‘Highly successful’ chronic disease scheme leads to lifestyle improvements for over 180,000

Reduced smoking rates and weight improvements among the benefits identified in report on GP programme

Significant lifestyle improvements have been recorded among more than 180,000 older people whose chronic diseases are being managed by their GP rather than in hospital.

Reduced smoking, better weight control, less problem drinking and greater physical activity were observed in many of the patients enrolled in the chronic disease management programme in general practice, a report has found.

In 2020, GPs were funded for the first time to manage many chronic diseases in the community rather than have patients attend hospital.

Since then, 91 per cent of GPs have joined the programme along with 83 per cent of eligible over-65s, the review of its first two years has found.


About 800,000 reviews of patients were carried out by doctors over this period, and they note an improving trend for lifestyle risk factors.

Thirteen per cent of patients had given up smoking between their first and third visit to the doctor. Among patients who were obese initially, 1 per cent had achieved normal weight and a further 13 per cent had moved to the overweight category.

Of those reporting inadequate physical activity on a first visit, there was a 48 per cent reduction by the third visit and 30 per cent had achieved adequate levels of exercise.

And among those with risk alcohol behaviour, 67 per cent were either normal drinkers or non-drinkers by the third visit.

Improvements in patients’ blood pressure, cholesterol and blood sugar levels were also observed over time.

“The implementation of the programme over the first two years should be considered highly successful,” according to Dr Orlaith O’Reilly, HSE national clinical adviser chronic disease. “As it is rolled out it will result in a reduction in hospital attendance by patients with these conditions.”

The programme supports GPs to provide structured treatment for patients with one or more of four chronic diseases: asthma; type-two diabetes; chronic obstructive pulmonary disease; and cardiovascular diseases.

Two further conditions – high blood pressure and gestational diabetes/pre-eclampsia in pregnancy – are being added this year. The report recommends other conditions, such as chronic kidney disease and pre-diabetes in young adults, also be added.

It is estimated that 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.

Paul Cullen

Paul Cullen

Paul Cullen is Health Editor of The Irish Times