Managing chronic disease: ‘It is one of the most positive things that has happened in the health service’

When Victoria Buckley-Gallagher was expecting her first baby, she knew she had risk factors for gestational diabetes, such as high BMI (body mass index), family history of diabetes and a pregnancy by IVF.

Although she did not have any symptoms, she tested positive for the condition when tested at 31 weeks at the start of 2022. Her care was transferred to the diabetic team in the Coombe Hospital, Dublin, and she was given two weeks to see if she could manage her blood sugars through diet alone. Taking her own blood readings up to eight times a day and sending the results into the hospital, “I felt very supported through this”, she says. “I could maintain my food sugars, but my fasting sugars, which come from the placenta, could not be maintained and no amount of food controlling can bring that down.”

Initial medication did not work for her so she ended up having to give herself insulin injections five times a day, along with the regular blood testing. “Apart from having to take insulin, it didn’t impact massively on the pregnancy or the recovery.”

She and her wife, Hazel, had a healthy baby boy, Ezra, who turned two the day we talk. He was born weighing 3.2kg (7lb) and had normal blood sugar levels, as did Victoria within weeks of delivery.

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When she became pregnant again last year, her glucose levels were tested every two weeks from 14 weeks onwards, and this time she was positive for gestational diabetes at 27 weeks. Even though she was able to take medication this time, along with two insulin injections a day, everything was more difficult during this pregnancy.

The food management and exercise recommended to lower her blood sugars were much harder to do with a toddler to care for, as well as working a full-time job in a creche. It was a bigger baby, too, a typical feature of the condition, which made movement very uncomfortable for her much earlier on.

Their second son, Levi, weighed more than 4.5kg (10lb) when he was born last January and spent 24 hours in the Coombe’s neonatal intensive care unit. “Levi struggled to control his sugars once he was out because he had been having so much sugar through the umbilical cord. So when he came out he had low blood sugars and was kind of jittery,” she says. “He was tube-fed the first couple of feeds to make sure he could regulate his sugars.”

[ Pandemic leads to welcome innovation for women with gestational diabetes ]

But eight weeks later, mother and baby are “rocking it”, she says. “I don’t have gestational diabetes any more and have two beautiful healthy boys.”

Breastfeeding is going well and she knows it can help reduce the risk of developing diabetes in the future for both her and Levi. However, any woman who has had gestational diabetes carries not only a higher risk of developing diabetes in their lifetime, but are also a third more likely to have a stroke and twice as likely to have a heart attack as women who never had this condition. This is why they have become one of the latest group of patients to be added to the HSE’s Chronic Disease Management programme.

Uniquely for this scheme, all the estimated 7,000 women in Ireland a year who develop gestational diabetes and/or pre-eclampsia, from January 1st, 2023 onwards, are covered. Whereas for the other qualifying chronic conditions, eligibility depends on having a medical card or GP visit card.

What is the Chronic Disease Management programme?

The programme was launched in January 2020, and its roll-out was accelerated by the Covid-19 pandemic, when its aim of keeping people with chronic disease healthy and away from hospitals became even more important. Operated by GPs, the scheme is for patients with a doctor visit card or medical card who have one or more of these specified medical conditions: coronary artery disease, heart failure, atrial fibrillation, a history of stroke or transient ischemic attack (TIA), type 2 diabetes, asthma or chronic obstructive pulmonary disease (COPD). (In addition, there is universal eligibility for gestational diabetes and pre-eclampsia, as outlined above.)

The programme is all about prevention, says Dr Sarah O’Brien, HSE national clinical adviser and group lead for chronic disease: “Trying to prevent chronic disease. If you can’t prevent the diagnosis, it’s about preventing the complications.”

Latest preliminary data shows that 89 per cent of eligible over-65s and 80 per cent of qualifying over-18s are registered for the treatment programme. A measure of its success is that 91 per cent of patients are now managed exclusively for their chronic disease in the community by their GP. “That indicates how well the programme is working,” says O’Brien. “The patients are getting continuity of care.”

There are treatment and prevention strands within the programme. The former is for anybody over 18 who has been diagnosed with one or more of the listed chronic conditions. They will have two wide-ranging health assessments a year in their local GP practice, usually with both a nurse and a doctor. An ongoing care plan is devised to help the patient manage their condition and avoid complications. Under the programme, specialised hubs have also been created to which GPs can refer patients for further tests or to deal with health issues beyond their scope.

We are making huge inroads and all the evidence is that this is going to reduce complications. That is hugely satisfying

—  Dr Lisa Devine, a GP in Bray

The prevention strand is for anybody over 45 with clear risk factors for one of the conditions. They will have a lengthy annual review with their GP and be armed with a care plan aimed at reducing their risks.

“A key component of managing chronic disease and indeed preventing chronic disease is supporting self-management; empowering patients to live well with chronic disease if they have it and giving them the tools and knowledge to prevent disease,” says O’Brien.

There is a third strand, referred to as “opportunistic case finding”, where a patient attending a GP for another reason may be offered an assessment for chronic disease because the doctor sees that they have a risk factor, such as being a smoker or having a high BMI. If the person is then diagnosed with one of the chronic diseases covered, they go into the treatment programme. If they are not diagnosed but are confirmed through tests as having a high risk of cardiovascular disease or diabetes, they can be enrolled in the prevention programme.

“It enables the GP to capture these people and bring them in proactively and give them dedicated time, which normally doesn’t happen,” says O’Brien. “People come when they’re sick, not when they’re well.”

What is the GP view?

It is an “absolute game-changer”, according to Dr Lisa Devine, a GP in Bray, Co Wicklow. “From my point of view it is one of the most positive things that has happened in the health service.”

As one of the 97 per cent of GPs who have signed up to deliver the programme, she says there is clear evidence it is working. A review of the first two years of implementing the programme showed, for instance, that between patients’ first and third visits, 13 per cent had given up smoking and 14 per cent had achieved very significant weight loss. There were also marked improvements in blood pressure control, in reducing the levels of “bad” cholesterol and 40 per cent of those with diabetes had recorded much better control over blood sugar levels. “On those objective markers, we are making huge inroads and all the evidence is that this is going to reduce complications. That is hugely satisfying.”

A second aspect of this new way of managing chronic disease is the holistic overview a GP has, being aware of the broader social situation of a patient who may have several chronic conditions, she says. Instead of attending different specialists in hospital outpatients for check-ups on each condition, patients are receiving integrated care from somebody they know and who knows them.

It gives us a real chance to treat not just different conditions, says Devine, but to figure out the best way to manage their health in the context of their situation. “That is really unique to the GP.”

Increased physical activity is often recommended for a range of conditions, but telling a person who also has painful arthritis just to “exercise” is not helpful, she says. In a chronic disease review, it is possible to look at exactly how they could increase their rate of physical movement, be it looking at controlling the arthritis better or finding exercise that works for them. If they can’t go for a jog or attend a gym, chair-based exercises might be the answer. A third, less obvious benefit of the programme that she has found very rewarding as a GP is the detection of symptoms of other conditions that are not related to chronic disease.

“For example, we measure weight, often looking at intentional weight loss. I have had people attending with weight loss they never intended and when we have looked into that we have picked up other conditions, in particular cancer diagnoses, really early and treatable. If the person hadn’t been walking through the door for their chronic disease review, they would have presented at a later stage.”

While it takes a lot of administration work in a GP setting to keep track of those covered by the programme and to ensure they are called for appropriately timed reviews, once somebody comes in, it is to a familiar place.

“It is a real safe space for the person. I feel we are working in partnership,” says Devine, who finds patients appreciate the chance to have a proper discussion, which fosters a sense of empowerment. Doctors can come up with what they think are great plans, she adds, but it may not work for the person.

What role does a GP practice nurse have in this?

“I am very lucky that the practice I work in takes a great interest in the chronic disease programme,” says Insa Larkin, a nurse colleague of Devine at the Carlton Clinic in the Bray primary healthcare centre. Here patients on the treatment programme have two 45-minute appointments a year with a practice nurse, during which they will have body measurements taken and undergo a range of tests appropriate to their condition or risk factors.

This dedicated time “makes a huge difference”, says Larkin, who has had patients start to cry halfway through a consultation, saying “this is the first time I feel I can talk about this”. Even if they can’t “fix” something, such as grief, nurses can tell them about other supports in the community.

The idea is that patients take an active role in their disease management, she says. “We can signpost and refer patients but it is very much up to the patient. They take charge.” Addressing something that might come up during a consultation but is not yet a significant health issue, “is a lovely opportunity for preventive medicine as well”.

She encounters many private patients who do not know enough about the GP visit card, which is the gateway to “this amazing programme”. This card scheme was expanded last year, when the means-tested, net income thresholds, which take into account expenses such as rent/mortgage payments, childcare costs and commuting expenses, were increased in November. In addition, anybody over 70 is entitled to one, regardless of income.

Larkin, a former hospital nurse, says she is a “huge fan” of the programme, which enables her to foster a “meaningful relationship” with the patients she sees. “I would love to see more patients being included in it, especially private diabetics, who often fall through the cracks.”

In the long term, it is a huge resource saver for the hospitals, she adds. “Keep patients well, keep patients at home, that is exactly where our strength lies.”

What do patients say?

Paddy Chawke (77) from Kilmuckridge in Co Wexford is “on the top of the world” and enjoying good health, after years of living with constant pain. His first health issues arose in 2014, when he was referred to a consultant urologist in a Dublin hospital. After that consultant retired two years later, “I got lost in the system for four years and I suffered with pain during those years. Nobody knows what I went through.” He had been told it was cystitis of the bladder and neither the GP nor consultant had seemed alarmed, so he didn’t like to complain.

“I suffered in silence for that period of time,” he says. It eventually took seeing a new GP to start him back on the road to improved health. “Unfortunately, in December 2022, my waterworks gave up completely.”

He was referred to a hospital emergency department, where he was told he had a very serious infection and was prescribed a two-week course of a strong antibiotic.

“Lo and behold, all the pain I had suffered for four, five or six years before that disappeared. I couldn’t believe it.”

Dr Lisa Devine suggests that the inclusion of cancer survivors who may have lifelong effects from chemotherapy and radiation treatment should be looked at

The GP also spotted a possible heart issue during a review and referred him to a community specialist team. In January 2023 Chawke started attending the heart failure unit at St Michael’s Hospital, Dún Laoghaire, “every single week” for a number of months. Dr Matt Barrett and his team there discovered he had cardiac amyloidosis, in which deposits of an abnormal protein form on the heart muscle and can lead to congestive heart failure.

He was told they would apply to the HSE for permission to prescribe him a “high-tech” drug, and this was granted in June. “From that day to this, I never had one ounce of bother with either the waterworks or the amyloids on my heart, or anything like that. I have had 15 absolute magnificent months of good health.”

For Deirdre Conneely (79), who has been living with type 2 diabetes since 2002, the programme has meant an end to lengthy queues in hospital outpatients and the bother of getting transport there, as she does not drive. Now she can walk straight in to appointments at her GP, close to her home in Bray, always sees the same doctor and is happy that her diabetes is well under control.

“I visit twice a year and get bloods done. They keep an eye on my cholesterol too and they refer me to courses.” She also suffers from arthritis. “I use a stick walking; I haven’t had the courage to have my knees done yet.” Although a very slow walker, “it is very important to move”.

Courses recommended for her have included a six-week course for diabetes, others for arthritis and for exercise, and all “have been really helpful”.

What next for the programme?

The hope is, says O’Brien, that increased funding will be provided in 2025 to include more chronic conditions, namely peripheral vascular disease, heart valvular disease, chronic kidney disease and familial hypercholesterolaemia.

Devine’s “wish list” for expansion of the programme would include extending cover to everybody with diabetes, in the same way that all with gestational diabetes since January 2023 are now eligible. She also suggests that the inclusion of cancer survivors who may have lifelong effects from chemotherapy and radiation treatment should be looked at.

Meanwhile, Victoria Buckley-Gallagher thinks the programme is “a great idea” and will definitely be availing of it when her time comes to be called for a full health review – for free.

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