Niamh Quinlan examines the ‘First report of the Structured Chronic Disease Management Programme in General Practice’ and speaks to doctors about future expansion.
The HSE structured chronic disease management (CDM) programme was a key development arising from the GP agreement between the IMO and health management in 2019. In addition to €120 million in FEMPI reversals (plus €10 million in pension contributions), €80 million was to be provided for the management of patients with chronic disease in the community as part of the agreement.
The programme commenced in 2020 and aims to reach full implementation in 2023. It was designed on an opt-in basis for GPs to treat eligible patients, with general medical scheme (GMS) or doctor visit cards.
The CDM programme allows 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 cardiac diseases.
During the roll-out of the programme, various cohorts of patients, determined by age, qualify for different components.
It also now includes the opportunistic case finding (OCF) 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. Both of these elements were introduced this year.
In October 2021, the programme won an award from the United Nations Interagency Taskforce (UNIATF).
The UNIATF awards recognise “outstanding contributions to multi-sectoral action in the prevention and control of non-communicable diseases” at local, national, regional or international level.
The award recognised the CDM programme’s work to develop the “GP chronic disease contract and rolling it out despite the Covid-19 pandemic”.
More recently, the First report of the Structured Chronic Disease Management Programme in General Practice, which was published on 5 August, showed positive results, feedback and uptake from GPs and patients alike.
At the beginning of the Covid-19 pandemic, there were concerns the roll-out of the programme would be hindered by the virus and the restrictions in place.
However, HSE Clinical Lead for the Integrated Care Programme for the Prevention and Management of Chronic Disease, Dr Orlaith O’Reilly, told the Medical Independent (MI) that the pandemic actually aided the implementation of CDM within community care.
As a result of Covid-19, a modified CDM (MCDM) programme was introduced in June 2020, which facilitated early expansion of the programme to eligible individuals over the age of 70 years. According to the recently published report, MCDM is in line with the 2019 GP agreement and “supports GPs in their delivery of chronic disease preventative and management activities through the use of telehealth”.
“We accelerated the implementation because we knew that… older people that had been cocooning with chronic disease were in need of care more than ever,” Dr O’Reilly said. “Back in 2020, in the first wave of Covid, the original plan had been [to introduce the programme] to the over-75-year-olds. But, in fact, we pulled it back to over-70s to include the full cohort of people who were cocooning.”
The first CDM report analysed two cohorts of patients who had consultations from 4 January 2020 to 11 September 2021: The initial cohort were seen during the first year; and the second cohort were from the next phase of the programme, which commenced in January 2021 to include individuals aged 65-to-69 years.
This amounted to total of 166,147 patients who were treated by 2,218 GPs across 1,080 practices.
The programme has a target uptake of 75 per cent among the eligible population. As of 11 September, the programme was open to those aged 65 and over, with an estimated uptake of 74.7 per cent among the group.
The report also stated 91 per cent of GPs are signed up with the CDM programme. Dr O’Reilly said she is “not sure we will ever get 100 per cent” uptake among GPs, as some smaller, single-handed practices may not have the IT infrastructure or nursing support necessary for the programme.
She told MI: “It is very difficult for doctors who aren’t computerised to participate in the programme…. But clearly, we would encourage everybody to get computerised and partake.”
In January 2022, the treatment programme opened to eligible patients over 18. In March, the OCF programme and prevention programme began for eligible patients over 65 years. According to Dr O’Reilly, these are “gaining momentum”, with the eligible age reducing further to 45 years and over next year.
Dr O’Reilly also said: “We would like to include a few of the other smaller numbers of people with other cardiovascular conditions in the programme [as the] next step.”
For Budget 2023, the HSE’s integrated care programme for chronic disease management submitted a proposal to the Department of Health to expand the CDM programme to include conditions such as familial hypercholesterolemia, peripheral arterial disease, and all severities of hypertension.
Dr O’Reilly added: “I suppose the other big issue here is [that] it is only relevant for patients with medical cards or doctor visit cards. Whereas, of course, the other half of the population needs this too.
“We are giving a perverse incentive for people without medical cards to continue to show up in the hospital for this type of care…. It would be wonderful if this was made universally available. But that is a significant budgetary issue.”
Asked if expanding the programme beyond GMS patients was a higher priority than inclusion of more chronic diseases, Dr O’Reilly said: “It depends what sort of money is available. If a lot of money was available, I would love to see it universally available. If a smaller amount of money was available, I would like to expand it to the rest of the cardiovascular diseases that we didn’t manage to do the first time.”
Drogheda GP Dr Amy Morgan said the CDM programme provides a “comprehensive template” that could be applied to other patients and support a more structured form of community care, “notably” for mental health.
Dr Morgan noted: “We would have patients who are on their psychiatric medications and would be at risk of developing metabolic syndrome, or complications of diabetes and weight-related changes.”
Patients on certain medications must already undergo monitoring tests twice a year, she added. “So there is already an agreed clinical care pathway for these people. But the problem is there is no actual dedicated resourcing [for it] in general practice.”
“This should be a priority to bring these people into the net… because as it stands, we would have a certain amount of patients who are on these medications and I feel their care is, for a variety of different reasons, quite fragmented. And obviously this can lead to poor outcomes.”
In its pre-Budget submission for 2023, the IMO recommended “building on the success” of the CDM programme and investing in structured programmes within general practice for mental health, women’s health, and nursing home residents.
Chair of the IMO GP committee Dr Denis McCauley also told MI the CDM offers a “very useful template” in terms of how systems should be devised and rolled out in general practice.
He acknowledged that there have been discussions to add mental health to the programme.
“But really, it is inappropriate to talk about that because the access we have to mental health services in the primary care are so negligible that [new services] would be there in name only.”
He added: “Any talk of introduction of such measures would be totally premature because irrespective of our capacity issues, the ability for us to introduce services other than medication is absent.”
Capacity within general practice is the biggest obstacle to expanding services within CDM, according to Dr McCauley.
He said: “It is a good template when capacity becomes available…. We [general practice] are having capacity issues with an increased workload for a whole lot of reasons, one of which is the chronic disease management and that has to be accepted.”
Dr McCauley said it was important that the OCF and prevention programmes, launched this year, become embedded “before we start getting overexcited and losing the run of ourselves [in terms of expansion], particularly because of the capacity issue”.
According to the ICGP data from March 2022, some 25 per cent of GPs are over the age of 60, many of whom will retire in the coming years. In its pre-Budget submission, the College stated it “may not be possible to train enough to meet projected demand”.
Speaking prior to the significant expansion of GP care announced in Budget 2023, Dr McCauley commented: “We are the vaccinators, we are the people who look after chronic disease management, we are the people that look after prevention. We can do all this when there are enough of us about and the resources follow the requests.”