HSE publishes second report into the implementation of the Structured Chronic Disease Management Programme in General Practice

  • 91% of GPs participating 
  • 83% of eligible patients (65 years and older) enrolled 

Today, (Wednesday, 22nd March 2023) the HSE publishes the second review into the implementation of the Structured Chronic Disease Management (CDM) Programme in General Practice

The report focuses on the first two years of implementation from January 2020 to January 2022. It largely describes a population aged 65 years and over due to the age-based phased introduction of the programme and it aims to reach full implementation in 2023.

Key Information:

  • 91% of patients with chronic disease were not attending hospital for the ongoing management of their chronic condition, which was now fully managed routinely in primary care
  • 91% of General Practitioners signed up for the CDM contract
  • 83% of eligible patients (65 years and older) enrolled   
  • Around 800,000 reviews have been carried out by GPs and practice nurses
  • Improving trend self-reported lifestyle risk factors - 13% of patients had given up smoking between first and third visit; of patients who were obese at their first visit, 1% of these had achieved normal weight and a further 13% of them had reduced weight and are now be in the overweight category rather than obese.

This reports refers to patients treated by GPs for the first two years of the programme and comprises 186,210 patients in total. It focusses particularly on patients (43,600) who have had at least three reviews in the first two years of the programme to describe trends in outcomes.

Commenting on the launch of the report, Dr Orlaith O’Reilly, HSE National Clinical Advisor Chronic Disease said: “The Chronic Disease Management Programme is an example of the HSE’s commitment to enhancing healthcare in the community and bringing care closer to people’s home.

“The implementation of the CDM Treatment Programme over the first two years should be considered highly successful. Promising trends in lifestyle and medical risk factors behaviours have been shown with increasing numbers of reviews.

“As the Chronic Disease Management Programme is rolled out it will result in a reduction in hospital attendance by patients with these conditions. This report, which includes mostly patients over 65 years, shows that only 9% of patients were attending hospital for ongoing care of any of the conditions for which they were attending the GP under the CDM Programme.”

Commenting on the launch of the report, Dr Shane McKeogh, ICGP/HSE Clinical Lead for Adult Respiratory Disease said: “As a GP, I’m very aware that patients living with these conditions are often some of the most vulnerable people in society. It is wonderful to be in a position to provide this programme of structured reviews for our patients right in their community through their GP and practice nurse twice a year.  Designed by the HSE and working with the ICGP and IMO, this important programme reaches large parts of our population and represents an excellent initiative highlighting once again how General Practice properly resourced can deliver for large sections of the population. At ground level, feedback from the programme has been hugely positive from patients and GPs alike. 

Tina Maria Morrison, a patient under the Chronic Disease Treatment Programme, explains how the programme is making a difference in her life: “Anyone thinking of going on the programme, I would talk to your GP or your nurse, and get on the programme because it’s very beneficial. Personally, I find it’s great because I know my levels of bloods that you need every six months. I can keep an eye on that then. Generally I know I’m on the right path. I can set goals then for the next six months, so it’s very good.”

The CDM programme was designed on an opt-in basis for GPs to treat eligible patients, with general medical scheme (GMS) or doctor visit cards. The programme supports GPs to provide a structured treatment programme for patients with one or more of four chronic diseases: asthma; type-2 diabetes; chronic obstructive pulmonary disease; and cardiovascular diseases.

During the roll-out of the programme, various cohorts of patients, determined by age, qualify for one of three elements of the programme. This includes opportunistic case finding programme, which provides surgery-based assessments to identify patients with an undiagnosed chronic disease or at risk of development; and an annual CDM prevention programme for patients at high risk of cardiovascular disease or diabetes and the Treatment Programme for patients with the diagnosed chronic conditions.

It is estimated that approximately 430,000 patients with chronic disease, or at high risk of chronic disease, will be registered as participants when it reaches full implementation in 2023.

The report’s major findings include:


It is extremely encouraging to note that the vast majority of multi-morbidity patients did not attend hospital for the routine management of their chronic conditions and their conditions were reported as being fully managed routinely in Primary Care.

  • Multi-morbidity increases with age (defined as two or more chronic conditions); 51% of over 85 year olds had two or more chronic conditions compared to 42% of the cohort overall
  • 20% of over 85 year olds had three or more chronic conditions compared to 14% of the cohort overall
  • Patients with heart failure tend to have more comorbidities than patients with other chronic conditions e.g. 87% of heart failure patients have at least 1 other chronic condition.

Lifestyle Health Behaviour Improvements

The report shows improvements in all the modifiable risk factors concerned between the first and third visit, including patients who had higher risk profiles at the first visit.

  • Of those that were smokers on their first visit 13% had become non-smokers by their third visit
  • Of those who were obese at their first visit 1% had achieved normal weight and 13% had reduced weight to be in the “overweight” category by their third visit
  • Of those who had inadequate physical activity on their first visit there was a 48% reduction by the third visit and 30% had achieved adequate levels by their third visit
  • Of those who had risky alcohol behaviour (Audit C Scale) on their first visit 67% had become either normal drinkers or were non-drinkers by their third visit.

Bio Metric Risk Factor Improvements (Medical)

There is an improving trend in in biometric measurements such as blood pressure, LDL cholesterol and HbA1c, over time in this cohort.

  • Both systolic and diastolic blood pressure had dropped by 1 mm Hg for the whole cohort of patients who had three visits to their GP.  (This population scale reduction is linked to very significant reductions in future CVD events i.e. reduction in heart failure of 13.3, in Coronary Heart Disease of 9, and in stroke a 4.8 events per 100,000 person years).

Blood test results

The Chronic Disease Treatment Programme requires a series of blood tests to be carried out at specified intervals, some in common across all conditions and some specific to the condition concerned.  Overall the results for LDL (low-density lipoprotein) cholesterol show important improvements against target for all sub categories, between their first and third visit to their doctor, indicating a raised awareness among doctors and patients and tighter control either by diet or medication in combination.

Patients with Diabetes also showed important improvements against their targets for Hba1C levels.

Diabetic Foot Examinations

Diabetic foot disease is a major cause of hospital admission and surgery for diabetic patients, hence early identification and management is essential.  The Chronic Disease Treatment Programme requires the GP or the Practice Nurse to carry out a number of tests on diabetes patients’ feet to identify foot complications.

  • 98% of diabetic patients had a detailed foot examination
  • 21% of diabetic patients had an abnormal foot exam and should be continued to be monitored twice yearly, and referred to the ambulatory care hub podiatry service if necessary. 


The CDM programme requires that General Practitioners develop, discuss and record a care plan with each of their patients and that this plan is updated at each visit. The care plan includes anticipatory care, recommended actions for when the patient deteriorates and facilitates the development of patient-centred goals for treatment and behaviour change to be agreed and documented between patient and their GP. 

  • 53% (i.e. 98,494) of patients had a comprehensive patient centred care plan by January 2022, this had risen to 71% of patients by January 2023.  

Hospital attendances

GPs participating in the Treatment Programme are asked to indicate whether their patients are also attending hospital for the care of each of the chronic conditions included in the Treatment Programme. A major objective of the Chronic Disease Management Programme and the Enhanced Community Care programme is to enable patients to be managed in primary care as much as possible.

  • 91% of patients with chronic disease were not attending hospital for their chronic condition, which was now fully managed routinely in primary care.

The full report is available on the HSE website here.

Last updated on: 22 / 03 / 2023