The Chronic Disease Management Programme for General Medical Scheme (GMS) or Doctor Visit Card (DVC) patients was a key development included in the GP Agreement, which commenced in 2020, and is being rolled out to adult patients over a 4-year period with a target uptake rate of 75%. The Programme, which is comprised of three components, envisages an uptake of 431,000 patients. The focus of this report is the first phase of implementation of the CDM programme commencing in 2020. It also encompasses modifications to the programme which were implemented in the context of the Covid-19 Pandemic. These occurred within the wider context of working towards implementing a whole system approach involving the development of 96 Community Healthcare Networks (CHNs) and 30 Community Specialist Teams (CSTs) for Chronic Disease and 30 Community Specialist Teams for Older People to support the implementation of integrated care across community and acute settings, in line with Sláintecare and the National Service Plan 2020.

P.11 Alcohol
An alcohol risk score was calculated for 166,040 patients, with 266,446 measurements undertaken in consultations between January 2021 and September 2021. Non-drinkers accounted for 51.5% of patients, 43.2% of patients had normal alcohol consumption, 4% had increased risk patterns and the remaining 1.3% had high risk/harmful drinking patterns. The alcohol risk score was computed according to the Audit C scale. (see Table 12 in report) High risk or harmful drinking reduced as patients received more consultations with their Doctor i.e. 1.5% of patients on their first visit had high risk or harmful drinking, 0.9% at their second visit and 0.6% at the third visit. Similarly the proportion of non-drinkers or those with normal levels of alcohol consumption increased from 94% of those at their first visit, to 95.7% at their second visit and 96.9% at their third visit. The CDM Programme requires GPs to carry out an alcohol intervention on those at increased risk and those with high risk/harmful drinking patterns. Those at increased risk received 17,436 interventions (6722 individuals) and those at high/harmful risk received 5,447 interventions (2083 individuals) i.e. some patients received more than one intervention. (Table 13 in report). 22,883 interventions were carried out and recorded in these patients.

Brief interventions were carried out in a large proportion of those with increased risk. Much smaller proportions of interventions were referring to the confidential helpline or substance abuse service, though a higher proportion of those with high risk and harmful drinking were referred to these services. A significant proportion of interventions were declined by patients with increased risk, and this was particularly noticeable among those with high risk profiles. The assessment of alcohol risk behaviour is complex and intervening successfully, particularly with those at high risk is particularly difficult. However it is very encouraging that large numbers of patients in the increased and high risk categories have completed the full Audit assessments done by the GPs and very few of these patients had no action documented.  

P.8 Smoking
As of 11 September 2021 smoking status was recorded in 166,146 cases. The majority (51.2%) are reported as never smokers, with a further 37.0% classified as ex-smokers and 9.0% recorded as current smokers. (Fig. 4 in report) There were 34,633 interventions recorded for 15,003 current smokers. The proportion of patients with no action documented was 10.0%, while the proportion of patients declining or not interested in an intervention was 43.2%. Since January 2021 most patients have had a number of visits, 45.1% of patients that received a smoking intervention (all of which are current smokers) had a subsequent smoking status reported. Of those, 85.9% remain current smokers. However, 13.4% were subsequently reported as non or ex-smokers. Smoking status was not recorded for the remaining 0.7%