While a brilliant group of researchers in Limerick might not have broken the law, they have certainly upended one, and their important findings may be as compelling as those that led to the smoking ban.
The law in question is “The Inverse Care Law” which states roughly that those who need medical care the most are the least likely to get it, and when they do it is of poorer quality. It is also known as the Tudor Hart Law, after the brilliant and caring British GP (Dr Julian Tudor Hart, 1927-2018) who first proposed it.
This law has been around for decades.
The exception, it seems, is the Irish GP-led chronic disease management programme, known as CDM.
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Prof Ray O’Connor and teams from the University of Limerick medical school and The Irish College of GPs mid-western training scheme have just published a paper in Family Practice, comparing the care received by patients who had GMS (General Medical Services) medical cards or Doctor Visit cards, and private patients with the same chronic condition who were ineligible to join the CDM programme.
I don’t think any GP who partakes in CDM, and we nearly all do, will be surprised at the findings.
Some of my patients are on the sixth or seventh round, and the CDM review is now one of my favourite parts of general practice. We identify those with a chronic condition – cardiac, respiratory, stroke or two type 2 diabetes – and invite them in for review every six months. We measure their health through a number of tests and then go through medication and findings. The discussion could take in lipids, lifestyle, exercise, inhaler technique, weight or blood-pressure management. We look at immunisations and education programmes, and a lot more. There is room to ask about what else bothers people, such as loneliness and anxiety. I have lost count of the number of times something came up that I could help to sort out.
The consultations take time, but it is time well spent. It is not only better for patient care and more human, but also saves money. You don’t want your patient to end up on dialysis or have a myocardial infarction which could have been avoided by regular check-ups and tweaks of their medication.
[ From 20 cigarettes a day for 55 years to finally quitting: ‘I took it up thinking I was the big man’ ]
The analogy would be that it is better to get the car serviced than wait for it to break down.
We now know that CDM has been a resounding success, and another HSE report found that the programme has had a high impact on 400,0000 patients, reducing hospital visits and emergencies, and 91 per cent of these now receive routine chronic disease care within the community.
The chronic care programme also has an application in identifying those at risk of developing a chronic illness or those who already have one and did not know about it. Since 2020, 51 per cent of new chronic disease diagnosis had been made through GPs in the programme. This prevents the need for more intensive hospital-based treatments, which transforms people’s health journeys and promotes sustainable healthcare practice.
There are a frightening number of people who don’t know that they have chronic illnesses which need proper management.
The aim of Prof O’Connor’s Limerick area study was to compare the CDM programme on the management of matched GMS patients with those without GMS cards. The first important and novel finding was that it found healthcare process inequities between the GMS patients who are eligible for the programme and private patients who are not. The standard disease monitoring is superior among participating GMS patients. Statistically significant differences emerged in vaccination rates and the monitoring of health parameters including blood pressure, smoking status, renal function, HbA1c, and lipids, with GMS patients consistently receiving more comprehensive care than fee-paying patients. Also, supplementary data collected from fee-payers’ records showed little evidence of chronic disease care being provided outside of the GP setting.
So what are the implications?
It seems that if the CDM programme was extended to patients without medical cards it would make medical and financial sense.
It would also be in the spirit of Sláintecare, which aims to create a universal healthcare system based on need, not ability to pay. The iniquity in the present system is that against the private patient. At the very least, there should be a feasibility study to see if we can extend the scheme to all.
Dr Tudor Hart would be delighted.
