During her first pregnancy, Victoria Buckley-Gallagher was aware she was predisposed to developing gestational diabetes due to her elevated BMI, a family history of diabetes, and her in vitro fertilisation (IVF) pregnancy. Despite exhibiting no symptoms, during a routine check-up, 31 weeks into 2022, she tested positive for the condition. Her care was consequently shifted to the diabetes unit of Dublin’s Coombe Hospital. She was then encouraged to regulate her blood sugar via dietary adjustments for two weeks.
While Victoria was successfully able to regulate her diet-initiated blood sugars, her fasting sugars, originating from the placenta, were uncontrollable irrespective of her dietary management. Despite initial attempts with medication proving unsuccessful, she resorted to administering insulin shots five times daily, coupled with regular blood monitoring. Even though this regimen involved insulin administration, it didn’t significantly disrupt her pregnancy or recovery phase.
Victoria and her spouse, Hazel, welcomed their healthy son, Ezra, who weighed in at 3.2kg (7lb) and displayed standard blood sugar levels like his mother did in the weeks following her delivery. Ezra celebrated his second birthday when this was recounted.
During her subsequent pregnancy the following year, her glucose levels were monitored bi-weekly from the 14th week and at 27 weeks, she received the diagnosis of gestational diabetes. Despite her ability to take medication, coupled with two daily insulin injections, managing the condition proved more challenging this pregnancy.
With a toddler to look after and a nursery job to attend, Victoria found adhering to the dietary regulations and exercising to reduce her blood sugar remarkably difficult. Furthermore, a common trait of the condition, such as carrying a larger baby, caused significant discomfort early in her pregnancy.
Last January, their second child, known as Levi, was born weighing in excess of 4.5kg (over 10lb). In the aftermath, he spent 24 hours under the care of the neonatal intensive care unit at the Coombe. The fresh-born encountered difficulties stabilising his sugar levels, stemming from excessive sugar received via the umbilical cord, resulting in noticeably lower blood sugar levels after birth. Feeding through a tube was initially necessary to assist in establishing control over his sugar regulation.
Despite the initial difficulties, mother and child are now heroically dealing with the situation. The mother no longer experiences gestational diabetes and is the proud parent of two robust and healthy boys. The breastfeeding process is proceeding smoothly, which she understands may help prevent the manifestation of diabetes in both her and Levi’s future. However, it is important to underline that any woman who has experienced gestational diabetes is not only at a heightened risk of developing diabetes later in life but also holds a greater chance of suffering a stroke by a third and a doubled probability of a heart attack, as compared to women who never had to deal with the condition. It is due to such reasons that they have become the newest addition to the group of patients eligible for the HSE’s Chronic Disease Management Programme in the country.
What sets this programme apart is that it provides coverage for all women, estimated at 7,000 annually, who develop gestational diabetes and/or pre-eclampsia starting from the 1st of January, 2023 in Ireland. Unlike other chronic conditions where the eligibility for the programme would be dependent on possession of a medical card or GP visit card, this isn’t the case here.
So what is this Chronic Disease Management Programme? Launched in 2020, the programme was given a boost due to the Covid-19 pandemic. Its principal objective is to preserve the health of patients with chronic diseases and reduce their interactions with hospitals. The scheme is operated by GPs and caters to patients equipped with a medical card or doctor’s visit card who suffer from one or more specified medical ailments such as coronary artery disease, hart failure, atrial fibrillation, history of stroke or transient ischemic attack (TIA), type 2 diabetes, asthma or chronic obstructive pulmonary disease (COPD). As stated, those with gestational diabetes and pre-eclampsia are also universally covered.
The initiative, according to Dr Sarah O’Brien, HSE national clinical adviser and group lead for chronic disease, places a strong emphasis on prevention. She stresses the importance of avoiding chronic illnesses or, if the onset of such conditions cannot be avoided, preventing additional complications from transpiring.
Newer preliminary figures indicate that 89 per cent of suitable seniors aged 65 and over, and 80 percent of appropriate individuals aged 18 and above are signed up with the programme for therapy. A noteworthy success of this initiative is reflected in the fact that 91 per cent of participants are now receiving exclusive care for their chronic illnesses in the community via their GPs. Dr O’Brien asserts that this continuous care showcases the effectiveness of the initiative.
The programme is comprised of two facets, focusing both on treatment and prevention. The treatment element is extended towards anyone aged 18 or over, diagnosed with at least one chronic condition listed in the programme. Each patient will receive two comprehensive health check-ups annually at their local GP practice involving both a nurse and a doctor. A continuous care plan will also be devised in order to help them manage their condition and ward off potential complications. The programme facilitates the creation of specialised hubs, to which doctors can refer patients either for additional testing or if they have health concerns exceeding their capabilities.
Dr Lisa Devine, a Bray-based GP, expresses satisfaction with the progress created and believes that complications will be reduced significantly with the help of the program.
The initiatives preventive aspect targets anyone aged 45 or older with evident risk factors for any of the listed conditions. These individuals will then have an extensive review with their GP annually and will be provided with a care plan designed to decrease their risks.
O’Brien states that a key facet of managing and preventing chronic diseases involves supporting self-management among patients, giving them the necessary knowledge and tools to prevent illnesses.
A third aspect of the programme, known as “opportunistic case detection,” provides for a situation where a patient can be evaluated for chronic diseases when they visit their GP for unrelated reasons. This is particularly the case when they display certain risk factors like being a smoker or possessing a high BMI. If diagnosed with a chronic disease covered by the program, they’ll be enrolled in the treatment plan. If, however, after tests it is confirmed they are at a high risk of cardiovascular diseases or diabetes, they can be inducted into the prevention plan.
O’Brien points out that the new approach allows general practitioners (GPs) to actively reach out to people, allotting them specialised attention which is a rarity in normal circumstances, as patients usually only seek medical help when they’re unwell, rather than when they’re healthy.
Dr Lisa Devine, Bray based GP, deems it to be a crucial development in healthcare, dubbing it a “game-changer”. Being one amongst 97% of GPs who implement the programme, Devine highlights its effectiveness through the statistics gathered over the initial two years. Remarkable progress was observed, for example, between the first and third consultations, 13% of the patients quit smoking, while 14% saw significant weight reduction. Recorded advancements were found in controlling blood pressure, diminishing levels of harmful cholesterol, and 40% of diabetes patients achieved superior blood sugar level management. Such objective progress indicates a reduction in future complications, which is enormously gratifying for Devine.
According to Devine, the second element of this innovative approach towards treating chronic disease lies in the fact that the GP gains a comprehensive understanding of the patient’s overall social context who might have multiple chronic illnesses. Rather than seeking advice from various hospital specialists for each condition, a patient is granted cohesive care from a person familiar with their medical history.
This system offers an opportunity not merely to manage multiple illnesses, but to figure out an optimal way to promote a person’s health in light of their circumstances, something Devine notes as a GP’s unique capability. Increased physical activity is a common suggestion for a host of conditions. But for someone suffering from debilitating arthritis, a blunt directive to “exercise” isn’t beneficial. A chronic disease analysis, however, can give a detailed view on how they can step up their movement rate, like managing arthritis more effectively or discovering suitable exercises. If conventional exercising methods like jogging or gym workouts are out of the question, sitting exercises might be the solution. As a third supplementary advantage, this programme has also opened the opportunity for GPs like Devine to spot symptoms of other conditions unrelated to chronic disease.
It’s often the case that our team in the medical practice, particularly within our chronic disease programme, becomes aware of serious health conditions such as cancer, due to unintended weight loss in patients. This discovery is often earlier than would otherwise be possible. Typically, these are incidents in which a patient hasn’t initially attended with a concern about weight. Uncovering conditions in this manner happens regularly, reminding us of the importance of the routine chronic disease reviews we conduct.
Although there is a significant level of administration required in the GP’s office to keep track of all the patients under the programme and ensure they are scheduled for appropriate reviews, the benefit is apparent. Not only is the practice environment familiar, but it is also a safe space for the patient to participate in discussions about their health. Our approach is very much built on partnership with the patient. Doctors might device what they perceive to be excellent healthcare plans, however, the success of any plan ultimately depends on whether it aligns with the patient’s needs.
Insa Larkin, my nursing colleague in our practice, also testifies to the profound impact of the programme. In her role as a practice nurse, she is privileged to have a significant role in our chronic disease programme. Her focus is on patients enrolled in the programme, taking body measurements and administering various tests relevant to their condition during the two 45-minute appointments held each year.
This dedicated one-on-one time with patients often results in emotional moments, underscoring its importance. While we may not always be able to provide solutions – in cases such as grieving, for instance – we can refer them to other support services within the community.
At the core of our philosophy, we work towards empowering our patients to take increasingly more responsibility for managing their health. We may provide guidance and reference to proper resources, but ultimately, it’s up to the patient to take the initiative. This proactive approach means we frequently deal with concerns that have not yet developed into significant health issues, providing an excellent chance for preventive care.
She meets various private patients who lack proper understanding of the General Practitioner (GP) visit card, a significant component of an incredible healthcare programme. The access to this novel programme was broadened the previous year when the net income limits, evaluated on a means-tested basis, were raised in November, considering outlays such as housing costs, child-rearing expenses, and travel costs. Plus, every individual above the age of 70 is automatically eligible for the card, regardless of their financial circumstances.
Larkin, a previous hospital nurse, highly appreciates this initiative that allows her to cultivate a significant connection with the patients she encounters. She would love to witness the inclusion of a larger number of patients into this scheme, particularly private individuals with diabetes who repeatedly slip between the gaps.
In her judgement, in the enduring scenario, it serves as a substantial utility saver for healthcare units. “Maintaining patient wellness, enabling patients to receive care at their residences is our primary forte,” she notes.
How do patients respond to this?
A 77-year-old Kilmuckridge, Co Wexford resident named Paddy Chawke is floating on cloud nine and is experiencing a healthy life after wrestling with continuous discomfort for years. His health complications initiated in 2014 when he was directed to a consulting urologist at a Dublin-based hospital. A couple of years later, when the consultant retired, he felt stranded in the system for about four years. Throughout these years, he endured intolerable pain. “Nobody could possibly comprehend the suffering I have gone through,” he expresses. A diagnosis of bladder cystitis had seemed about right to his GP and consultant, and since they didn’t appear too concerned, he didn’t feel right complaining about it.
“I tragically endured in silence during this period,” he shares. Eventually, a new GP was able to redirect him towards a healthier path. “Sadly, in December 2022, my urinary function became totally dysfunctional.”
He was immediately forwarded to a hospital’s emergency unit where he was identified with a severe infection and prescribed a two-week, potent antibiotic regimen.
“Surprisingly, the continuous suffering of four to six years that I had been undergoing vanished. It seemed unbelievable,” he said.
Dr Lisa Devine proposes scrutinising the possibility of cancer survivors with potentially permanent side-effects from chemotherapy and radiation therapy being included in the scheme.
During an assessment, the GP identified a potential heart issue in Chawke and recommended him to a team of local specialists. From January 2023, Chawke frequented St Michael’s Hospital, Dún Laoghaire, where he was diagnosed with cardiac amyloidosis by Dr Matt Barrett and his staff. This condition arises when an abnormal protein accumulates on the heart muscle, potentially causing congestive heart failure.
Following the diagnosis, an application was made to the HSE for approval to prescribe Chawke a high-end medication, which he received in June. Since then, he attests to having no health problems and has enjoyed 15 months of exceptional well-being.
Likewise, Deirdre Conneely (79), a patient with type 2 diabetes since 2002, has benefitted enormously from the programme. The initiative has freed her from long hospital waits and transport hassles as her GP, situated near her Bray residence, looks after her healthcare. Conneely visits twice annually for blood tests and cholesterol checks, and gets referrals to relevant courses. She also has arthritis, and appreciates the emphasis of the programme on getting mobile, despite her slow pace due to this condition.
Conneely highly recommends the courses she has undertaken for managing her diabetes and arthritis, and for physical exercise.
Looking to the future of the program, O’Brien hopes for increased investment in 2025 to accommodate additional chronic diseases, including peripheral vascular disease, chronic kidney disease, heart valvular disease, and familial hypercholesterolaemia.
Devine’s expansion aspirations for the programme also include amplifying the cover for all diabetic patients, similar to the eligibility now extended to all gestational diabetes patients since January 2023. Additionally, consideration for the inclusion of cancer patients experiencing long-term chemotherapy and radiation treatment side effects could be worth exploring.
Victoria Buckley-Gallagher is a strong supporter of the scheme and assured that she will surely utilize it at the time of her comprehensive health check-up which will be provided at no cost.