Leveraging Partnerships to Deliver Preventive Care, Early Detection and Treatment Services for Patients with Chronic Disease Across the Whole Population

Background: The Chronic Disease Prevention and Treatment General Practice Programme in Ireland (CDM) was co-designed with General Practice, Health Service, Health Ministry and Patient Voluntary Groups working in partnership.  It commenced implementation in 2020 with older patients from the more disadvantaged sectors of the population first.

It was adapted during Covid in 2020 in response to patient and general practice input, to facilitate care of "cocooning" older patients.  The UN Interagency Task Force on Prevention and Control of Non-Communicable Diseases presented the programme with a national award "in recognition of outstanding contribution towards the Non Communicable Disease related sustainable development goals". 

Approach: The service focuses on the more deprived and excluded sectors of the population nationally.  The service continued to be developed and adapted using patient and health sector partners stakeholder input. The Early Detection (Opportunistic Case Finding) Programmes and the Prevention Programme were launched in 2022.

Results: Clinical outcomes from the programmes are excellent, and have led to Health Service, Health Ministry, Health Union and the GP Association partners agreeing to further investments, enhancements and extension of the programmes to include additional at risk and marginalised groups in 2023, 2024 and in 2025.  For example the Early Detection Programme showed over 50% of those assessed had hypertension, stakeholder feedback advocated for hypertension to be included in the programme and this was included from 2023 onwards.  Recent opportunistic case finding results in 2024 identified chronic kidney disease as an unmet need, identifying over 26,000 patients with undiagnosed chronic kidney disease, corroborating the Irish Kidney Association’s ( patient group) advocacy to have this included in the programme.  This is now to be included in the programme from 2025. 

The Prevention Programme results show large numbers of people with newly identified hypertension, elevated CVD risk (Qrisk) and prediabetes, these patients are now receiving a preventive service.  The Treatment Programme continues to show clinically significant reductions in blood pressure, LDL cholesterol and HbA1c levels as well as improved lifestyle behaviour profiles.  Audits from General Practice partners show that the more deprived patients, currently funded by the state for GP care now have better chronic disease clinical results than the more affluent sectors of society, due to the CDM Programme.

Implications: Recent engagements have included partners from the private health insurers, with a view to enabling patients not eligible currently for the state funded programme to avail of the service and hence ensuring full population coverage and full benefits to all population groups.

The programme demonstrates that prevention, early detection and treatment services for patients with chronic ambulatory care sensitive conditions can be successfully delivered by General Practice at population scale. 

The programme is now the major service in the prevention, early detection and treatment of chronic disease in Ireland.  It has resulted in reduced ED and hospital attendance and contributes to the UN sustainable development goals.