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Lord Harrison
To ask Her Majesty’s Government what is their response to the Diabetes UK report Putting Feet First and its implications for the treatment of diabetes.
Lord Harrison
My Lords, as a serial killer, diabetes is getting bolder, accounting over the past year for some 150,000 newly diagnosed diabetics, adding to the 2.8 million known diabetics in the country, with perhaps another half a million undiagnosed. It also absorbs 10 per cent of the NHS budget—that is, some £9 billion a year—as well as immiserating the lives of many of our fellow citizens, often needlessly, for with speedy diagnosis and treatment, the sickening complications of blindness, renal failure and amputation can be forestalled. Diabetics can lead long, healthy and productive lives. Dynamic public health programmes concerned with diet, obesity and exercise are crucial in preventing or staunching the rising incidence of diabetes. More recently, type 2 diabetes among schoolchildren, allied to the rising tide of obesity, places yet another challenge on the scarce resources provided in this direction. Indeed, these are desperate times of pressure on the NHS and of financial retrenchment and cuts.
Some additional spending now on upgrading diabetes therapy will save lives later and money and resources for the NHS in the long run. An example of the success of the long decade of Labour’s investment in the NHS and diabetes care is the increased incidence of retinopathy screening, saving the eyesight of many a diabetic. I hope that that is retained. The recent reform and investment in diabetes management, principally designed to help us to manage our condition, has transformed the lives of diabetics.
I come to some questions for the Minister. There are two discretionary areas at the moment with respect to diabetes care. One area is that of insulin pumps and the allied use of insulin inhalation, which is currently not paid for. I wonder whether he has any comments to make on those points. Something that I have raised in this House before is the essential need for the availability of blood glucose testing strips for diabetics as part of caring for themselves, to ensure that they have good blood sugar levels. Does the Minister recognise that there can be a postcode lottery in the distribution of blood glucose testing strips, with four different health services and different practices throughout the nations and authorities dealing with diabetes?
I ask the Minister, too, about NICE, which recently concluded a consultation on diabetic foot care. I do not know whether he can give us any indication there. He was rather unclear, and I hope he can clear it up today, about the role of NICE, especially as diabetic drugs now form the second largest call on the NHS budget. Good innovations that are cost-benefit assessed must be made available. Would he comment, too, on the flanking policies of the Government? I give the example of sport for young people, which will help to set back the rise in obesity and type 2 diabetes. We need more of the self-management programmes that I referred to and more education of diabetics and diabetic professionals to ensure that they are helpful. Would he say more, too, about whether the focus of the previous Government will be retained on children, obesity in women—typically in pregnancy, when they are diabetic—but also the immigrant population, where there is a higher incidence?
Can the Minister reflect on our colleagues in the European Union? The Federation of European Nurses tells us that the incidence of diabetes in the United Kingdom is, surprisingly, recorded at 4 per cent, while in Germany it is 13 per cent and in most other countries typically 9 per cent. I do not know whether the data are collected inaccurately, and perhaps he would look into that, but we need better information in that area. Would he also note that we have had no pan-European research since 1999 on the cost of diabetes? There is so much that we should be doing with our European colleagues to do something about that.
My superb NHS diabetes care by outstanding healthcare professionals in Chester and Liverpool has kept me active and on my feet as a type 1 diabetic of some 41 years’ standing, and it is to that I now return. Diabetic foot care deserves the same focus as actions on diabetic retinopathy. It may not be very sexy but we need health professionals to come into this area. The 2010 DoH review, Six Years On: Delivering the Diabetes National Service Framework, says that in the key area of feet we still have poor clinical outcomes, resulting in amputations, extended lengths of stay in hospitals and concludes that we need effective management of diabetic foot care to reduce expenditure and amputations.
Last year, Diabetes UK published an excellent document, Putting feet first, summarising the optimal management of available resources to minimise the manifold complications associated with the diabetic foot. Diabetic foot problems are the most common cause of non-traumatic limb amputation in the United Kingdom. Some 100 are performed each week. Neuropathy, peripheral arterial disease, foot deformity, infections, ulcers and gangrene are just some of the nasty complications of diabetes.
In addition to the financial implications of the NHS—out-patient costs, increased bed occupancy and prolonged stays in hospital—diabetic foot problems adversely affect patients’ quality of life, reduce mobility which in turn leads to loss of employment and depression among other social and health consequences.
As outlined in Putting feet first, pivotal to diabetic foot care is, first, fast action within four hours of diagnosis. Then the second period, the following four to 48 hours, is crucial to saving the threatened foot. Delay in diagnosis and management increases the risk of amputation, morbidity and mortality. The third period is the continuing foot surveillance which is so vital for keeping us on our feet.
However, catastrophic trauma need not happen. Let us take peripheral arterial disease where some 100,000 people are diagnosed each year. Vascular specialists need to be swiftly available and treatment by appropriate technologies—the use of balloons or stents to widen or relieve arteries—can prevent the devastation of foot amputation. Unfortunately, the UK has one of the poorest rates of lower limb revascularisation in Europe. To avoid this, we need to encourage the proliferation of local vascular networks and I ask the Minister whether he has anything to say on that. Will the Government implement Putting feet first, emphasising the vital need to create active local networks of key health specialists working with others to ensure speed of response and quality follow-up?
I highlight one of the many useful suggestions in the pamphlet which has been put to me by my own hospital orthotist expert. She tells me that huge benefits are to be derived from examining all new in-patients’ feet. Such inspections typically uncover hidden foot problems, as well as undiagnosed diabetics whose problems may thereby be quickly treated. Helpful, too, are the regular ankle/brachial pressure index tests as a predictor of future PAD. Resources are of course the nub of the problem. I ask the Minister whether he will provide the resources and trained staff to enact the strategy outlined in Putting feet first. How many practice nurses are trained in diabetes management—the orthotists, chiropodists, specialist shoemakers, diabetologists and vascular cardiologists as well as specialist lower limb surgeons?
I want to say a final word on the continuing care of diabetics with foot problems. As I speak to you, I am wearing fashionable orthopaedic shoes made for me by experts who form part of the clinical team at Liverpool’s Broad Green Hospital foot unit. These shoes offer vital protection for my feet, moulded as they are to the ever-changing shape of my feet to preclude the onset of ulcers as a result of my diabetes-associated neuropathy—that is, I have no feeling in the nerves of my feet which warn me of a loose stone doing untold damage to my foot tissue. However, these shoes are expensive—perhaps £500 a pair—and unsurprisingly rationed on the NHS. But these shoes keep me and thousands of other diabetics protected and active in the community. They are an economic investment of the kind with which the Government must wrestle. The Government should heed George Bernard Shaw’s wise aphorism and great foresight:
“I marvel that society would pay a surgeon a large sum of money to remove a person’s leg—but nothing to save it”.
Finally, I welcome to the debate not only the noble Baroness, Lady Young, who has recently taken over as chief executive of Diabetes UK, but also the Minister, who I know will give us a sympathetic reply.
Baroness Hussein-Ece
My Lords, I thank the noble Lord, Lord Harrison, for securing this debate on a very important health issue, and I also pay tribute to him for the eloquent way in which he has shared his extensive experience and knowledge.
We all know of someone affected by diabetes. Those alarmingly high numbers of people who are more likely to develop type 2 diabetes are over three times more likely to go on to develop serious complications of diabetes which include stroke, kidney damage and heart disease. People living in deprived areas who are socially disadvantaged are two and a half times more likely to develop diabetes. They are more likely to have problems with late diagnosis and have poor lifestyles and poor care, which often compound the difficulties in managing their condition. That, of course, includes poor foot care.
The overwhelming evidence demonstrates that reducing health inequalities in deprived areas and for people from disadvantaged backgrounds, including those with mental illness, would almost certainly lead to more prevention and better management of diabetes. I want to talk about how this condition disproportionately affects people from black and minority ethnic communities, which was mentioned earlier.
Diabetes is increasingly recognised as a public health problem of potentially enormous proportions. This poses significant clinical and economic challenges for the NHS. According to UK studies, the prevalence of diabetes is significantly higher in some minority ethnic groups, which are six times more likely to develop diabetes. Figures suggest that up to 20 per cent of people from south Asian backgrounds and 17 per cent of people who are black African-Caribbean are living with type 2 diabetes, compared with some 3 per cent of the general population. I know from my own background that people from the Turkish community are also at greater risk of developing diabetes. Both my parents developed type 2 diabetes in later years and I confess that that has given me greater first-hand experience in caring for someone with diabetes and the importance, which I never realised before, of good foot care and healthcare generally.
Whereas within the general population type 2 diabetes usually occurs over the age of 40, people from black and minority ethnic communities can get it from the age of around 25. Getting treatment early can reduce the risk of developing complications such as stroke, blindness, heart disease and amputations. There are a number of factors why it impacts disproportionately on black and minority ethnic communities, which include genetic differences in how the body processes fat, but poor knowledge of services, poor housing and social deprivation are huge factors. I was pleased to read how in some parts of the UK with significant numbers of ethnic minority communities, the health services are responding and proactively working with organisations such as Diabetes UK to address some of these unmet needs.
For example, in the past few months NHS Haringey, in partnership with Diabetes UK, has developed the community champions training courses. People from minority ethnic communities, health trainers and religious and community leaders attend sessions about what type 2 diabetes is, who is at risk, signs and symptoms, myths and misconceptions—of which there are many—complications and the NHS services that are available. After qualifying, the community champions then spread the word about diabetes in their local communities by organising stands, talks and healthy-living days. To date, more than 30 community leaders, nutritionists and NHS health trainers in Haringey have qualified as diabetes community champions and they are keen to raise awareness at community events. Several more training projects are planned in other parts of London. When I was working in the NHS in north London in the 1990s, projects on simple foot care such as nail clipping for older people were done at daycare and health centres. They were simple and cost-effective, and helped many vulnerable people with their foot care.
We know that prevention is often better than cure. That is why we need a more consistent public health strategy across areas with the greatest need and risk. Early diagnosis of those at greatest risk and better management would prevent the acute conditions that far too many people go on to develop, which result in greater risk to the individual and their families, the need for more intensive health services and hospital admission.
The problems are often not just about diagnosis, but about continuing care and managing the condition after diagnosis. Unfortunately, people from deprived backgrounds, including people from ethnic minorities, are less likely to have annual or regular health checks for blood pressure and cholesterol, for example, and, worryingly, many primary care trusts have not had strategies in place to deal with this.
I would like to see more consistent work to raise the profile of diabetes care within minority ethnic groups; strengthen leadership at national and local levels, particularly with GPs; improve practices and change general attitudes through the delivery and uptake of effective and appropriate training; and support a wider community development approach by going out into communities to listen to and involve people in the pathways of their diabetes care. The level and type of services should not necessarily rely on where you live or how involved your GP may be. There should be consistency and equal access to support and services regardless of your background or where you live.
Lord Kennedy of Southwark
My Lords, I thank my noble friend Lord Harrison for putting down this Question for debate today. He is well known in this House and elsewhere for his campaigning for greater understanding of and improved care for people with diabetes. I congratulate the noble Baroness, Lady Young, on her appointment as chief executive of Diabetes UK and I look forward to her contribution later today. I should like to declare an interest: I have type 2 diabetes. I am a member of the charity Diabetes UK. I support its activities and the campaigns it undertakes.
As my noble friend Lord Harrison said, more than 2.8 million people in the UK have diabetes, of whom 300,000 have type 1 diabetes and 2.5 million have type 2 diabetes. That equates to almost one in 20 of the UK population being diagnosed with this condition. Add to that the estimated 500,000 people who have undiagnosed diabetes and you see the truly worrying numbers we have to deal with.
The report that my noble friend Lord Harrison refers to specifically looks at the commissioning of specialist services for the management and prevention of diabetic foot disease in hospital. It is an excellent piece of work and the authors and the working group are to be congratulated on its production. Diabetic foot complications leading to nerve damage, foot ulcers and amputations are, in the majority of cases, avoidable with good care and proper management. That is obviously better for the patient and for the NHS. Amputations clearly have a major impact on a person's quality of life, and there is also the cost to the NHS of the amputation and the ongoing aftercare. Noble Lords who have read the report will have seen in the appendix the poster setting out best practice in integrated healthcare in hospital and the information card for people with the condition.
Noble Lords will also be aware that foot disease is not the only complication that people with diabetes have to tackle. Other long-term complications include how diabetes affects your eyes, heart, kidneys and nerves. I am very lucky. My care at the Morden Hill surgery in Lewisham, led by my GP, Dr Gostling, is excellent. But all too often the reports are that it is a bit of a lottery out there and care varies tremendously from place to place. This is a truly serious condition for patients, the NHS and the country. Parliament and government working with health professionals and patients have to make significant strides in the coming years to deal with this growing problem. The cost to the patients and their families, the NHS and the whole country is far too great.
As I said before, with good care, this is a wholly manageable and controllable condition. People with the condition of course have to take responsibility for their own diabetes control. Noble Lords may find it hard to believe, but I like the odd chocolate bar or Jaffa Cake at home watching the TV, and that is fine, but I am working to bring my condition under control and to improve my own health. Patients need ongoing support to help them to take control of the condition, as well as access to cutting-edge treatments, as they are developed, to deal with the many complications that they have to face: the regular visits to the practice nurse, the annual eye screening, and the advice from the dietician about what to eat and what to eat a little bit less of.
In his response, I hope the Minister can give the House a commitment to continuing a regular series of meetings and regular dialogue with Diabetes UK and other diabetes charities such as Silver Star, of which my right honourable friend Mr Keith Vaz, the Member of Parliament for Leicester East, is the founding patron. Such a commitment cannot just be between the department and professionals, however; it must include Ministers engaging in the discussion and the full involvement of people with diabetes.
In conclusion, I again thank my noble friend Lord Harrison for tabling this Question for debate.
Lord Rennard
My Lords, I, too, congratulate the noble Lord, Lord Harrison, on securing this debate on a topic that is so important to so many people. Like many noble Lords present, I am a diabetic, so I begin by thanking the diabetic team at St Thomas's Hospital, who have done so much to help me and from whom I have learnt a great deal about diabetic management.
Whenever I talk to some of my American friends about how our NHS has supported me in this regard, they agree that we have a wonderful and cost-effective system of providing healthcare to all our citizens, and they share my amazement at the hostility shown by some in the United States this week to the principle of universal healthcare and the option of the public provision of health services. These are things that we are right to regard as hallmarks of a civilised society, so we are rightly very proud of the NHS in the United Kingdom.
I want to use this debate to raise a number of points about the current NHS reorganisation that may be of concern to the millions of people in this country who know that they have diabetes, the millions who either have it but for whom it has not yet been diagnosed or who may develop it in the future, many people who have experience of diabetes in their families, and the health professionals who support them all.
The stark fact that Diabetes UK has drawn to our attention in its report Putting Feet First is that 100 people a week in the UK have a limb amputated as a result of diabetes. The costs of these amputations, which can be measured in very many ways, are very large. The noble Lord, Lord Harrison, referred to the total costs of treating people with diabetes, which amount to approximately 10 per cent of the NHS budget. And the prevalence of diabetes is growing rapidly, so all issues concerned with it must be addressed very seriously.
On the planned NHS reorganisation, I recently spoke to many NHS professionals who say that the advent of GP commissioning in particular both provides opportunities for and threatens better provision of support for people with diabetes. To promote best practice, when there could be a greater number of GP consortia than the current number of PCTs, will make information-sharing between consortia absolutely essential. We know that there is already a problem in that knowledge of the issues about diabetes and best practice vary significantly between GP practices. It will therefore be very important in future that all GP consortia are properly aware of the sort of issues raised in the Diabetes UK report if best practice is to be spread and every GP practice is able to respond appropriately.
The new consortia may need to work together along the lines on which many good primary care trusts work now, otherwise knowledge and efficiencies may be lost. I should be particularly grateful if the Minister could comment on how relevant information and best practice will be shared among the GP consortia in future. In the new arrangements, there may need to be incentives and guidance for GPs who are not experts in diabetic care to involve other health professionals in this aspect of the care of their patients. This is something that a GP recognised in my own practice when I was fortunate enough to be referred to St Thomas's. We need to ensure that the new arrangements do not provide disincentives for such referrals when they are desirable. In funding arrangements, there needs to be recognition that diabetes is significantly more prevalent in certain communities—often those that tend to be most unhealthy generally—and in many ethnic minority populations, to which the noble Baroness, Lady Hussein-Ece, has just referred.
The provision of insulin pumps varies greatly across the country and the United Kingdom lags behind many other countries in such provision. I believe that funding arrangements should recognise that there may be a much greater need for such provision in some areas. There may be significant long-term savings overall to be looked at because of the cost of poor control and diabetic complications, such as amputations and blindness.
We need to make sure that all the consortia recognise the value of diabetic specialist nurses. A specialist team can be the catalyst and driver for improved services and for involving patients properly. The consortia need to be informed about what specialist diabetes services and expertise are available to them. They need to make sure that diagnosis remains a key area for improvement. As Diabetes UK states:
“The delivery of high quality specialist foot care is an essential component of every local diabetes service”.
The human and financial costs of failing to do these things will be very great.
Lord Graham of Edmonton
My Lords, I am delighted to have the opportunity to speak in this debate. I am lucky in the sense that, out of the blue, two friends wanted to see me. They provided me with information which I believe, when I read it into the record, will be helpful. In declaring an interest, I am a type 2 diabetic and my son is type 1, so we are familiar with the problems. Looking at the speakers list for today’s debate—I congratulate sincerely the noble Lord, Lord Harrison, on securing it—and noting all the bodies which contributed to the report, I think that some may ask how the Government will respond. I know how the Government will respond. They will say, “We welcome the report”. That is because it is all good news.
The front page of the report lists the many organisations with sympathy for and knowledge of this matter. They have combined, which in itself is quite a feat. Today, the Minister, who I know is sympathetic on all issues which affect people, has been given an opportunity to put his case, but he will have problems. I will concentrate my comments on obesity which clearly is stark among the younger generation. There are the issues of money and will, as well as the question of how can we deal with it.
Camden is used as an illustration. It is seeking to invite bids for weight management programmes for children between the ages of two and 18. That is laudable. In its publicity, its target groups include:
“Young carers; Homeless children: Children who are not in education; People from low socioeconomic groups; People living in the 4 priority wards: Kilburn, Kentish Town, Gospel Oak, and St Pancras and Summers Town; People of Irish, Black African, Black Caribbean and South East Asian backgrounds”.
From our knowledge, we know that all those groups are in danger of contracting certain aspects of diabetes. The document I have states:
“The maximum value of the contract is stated to be just in excess of £2m”.
We are not talking about small beer because £2 million is a large sum, but it is what the PCT in Camden is willing to put forward for this.
The worry is this. In children there is a weight measurement nexus, which is to the good. It starts when they are in the infant class and goes on until the changes are reported on in year six, which is the last year that they are in primary school. The problem is that, unless I am misinformed, the parent and child as the result of this weight measurement plan are meant to attend guidance meetings outside the school day. The document from Camden I have seen states that the programme will be delivered in community halls and other places. Single parents and others in the categories I have mentioned will be invited to give up their time, to bring their child along, to listen to advice and try to do things to improve the situation. But they have not got the time because they have other pressures on them. One might say that surely the greatest pressure is the future benefit of their child, but this would be much easier to deliver in the school day. If what we are after is value for money, we ought to have a programme of that kind.
I also have some information on a story that all noble Lords will have heard about, that of the mother of the five year-old child who appeared on BBC television news having received a letter saying that her child was overweight. The point to be made here is that she said that it would have been much better for her to have been given advice through a direct chat with a nurse than through a letter from a faceless central trust. There is a great deal more that we could say about that, and I am delighted to see my noble friend Lady Young. I wish her well and she will be heartened by the number of friends she will find in this House as she pursues her new interests.
This is not a knocking debate, but one for the Government to tell us what they are doing and listen to the problems as we see them. That will assist the Minister in delivering what has been in the national programme for years and years. The experience of many people, both in this Chamber and outside, can be tapped. I hope that the Minister will be sympathetic to the case that has been made.
Viscount Falkland
My Lords, I, too, thank the noble Lord, Lord Harrison, for the chance to speak on what is really a very important health matter. I am a type 2 diabetic of 10 years’ standing. Like many men, I hid my head in the sand for a while, although I knew that something was wrong. Curiously enough—it was actually 11 years ago—the condition would manifest itself most strongly when I was speaking in your Lordships’ House: I could not see as well, I used to feel that my voice was failing and I would feel an enormous thirst come upon me. Eventually another Peer asked me whether I was all right. He turned out to be another diabetic—he is still with us today, alive and kicking—and, having spoken to me at lunchtime, he made an appointment for me to see his doctor at 4 o’clock that afternoon. I went to that appointment and I was in a clinic by the next day, where the principal doctor dealing with me said, “It’s a good thing you have come, because things aren’t very good and you are about one Coca-Cola away from a coma”. Diabetes is an insidious disease because generally you feel perfectly well, apart from under certain stressful conditions. I am grateful to the noble Lord for his actions, although I have not been able to repay him other than by suggesting that he might like to move to France because he was unhappy with his rubbish collections. Apparently, in France his rubbish is collected on six days out of seven. I feel that that is a poor exchange, but I was glad to be able to do something for him.
I was on ordinary medication for half the time before it became necessary for me to depend on insulin and, during that time, I was lucky enough to receive expert advice from health professionals on how to deal with my condition. I have become increasingly aware from people to whom I have spoken that diabetics are in a kind of a club. For instance, the man who collects my rubbish that will not be collected by the local council has diabetes. He is an ex-cruiserweight boxer, whom I like very much, but even though he has been a man of physical action he does not understand how the body works. His doctor has not told him why his metabolism has changed—why he cannot metabolise carbohydrates and so on—even though he is an intelligent man. Broadly, in a population in which diabetes is becoming an increasing problem, far too little information is given by the authorities on the basics of how the body works and why the body might not be working normally. It is one of the wonders of the human body that it can do all the things that we know that it has to do. With diabetes, it is rather like moving from an automatic car to having to do everything manually. The control of diabetes is extremely difficult, so people need education and training to deal with it. I know that the National Health Service does not have the time—I am a great supporter of the NHS, which is second to none in dealing with serious conditions—but, where a serious illness is some way off but it is known that a present condition could lead to such illness, I think that there are serious deficiencies in the NHS.
Happily, over the 10 years in which I have had diabetes there have been a number of developments, many of them from the United States. I know that the United States has problems with healthcare, but most of the developments in technology—pumps, monitors and so on—come from there. Much of the development is costly but it is extremely effective. For example, the pumps that are now available for children with diabetes 1 are minute, and they do not have to inject. There has been an absolutely transformation of that scene.
I have managed to keep reasonable, but not perfect, control of my diabetes. The condition can lead to issues with your feet, nerve endings, eyes and so on, but if you do not control it and you do not have regular check-ups to make sure that what is called technically your HbA1c, which is inescapable, is under control—any doctor can tell from a blood test whether it is or not—you will be in serious trouble. The problem with the National Health Service is in part due to the short-termism that exists in Britain in many other respects. I have spoken about this before. Quite naturally, the NHS is concerned about costs, but the expense of dealing with diabetes is all about cost-benefit analysis. For example, to give a pump to a person with an HbA1c in excess of 9 per cent or 10 per cent, which is very dangerous but can easily be dealt with by some of the new technologies, costs about £5,000—the price will probably fall—but for someone who is almost bound one morning to wake up with a red mist in front of his eyes, or his feet not working, or a pain in his chest that is then diagnosed as heart disease, a proper cost-benefit analysis would show that, if the NHS paid for the pump, it would save money in the long run by preventing the person from developing these serious conditions. That is the serious point that I wish to make. It is curious how you can get the serious point over quite quickly when you have nine minutes, whereas it is very difficult when you have only three.
Diabetes is generally a self-treating condition, on which you know more than your doctor—although not all doctors. I asked a question in the House as a result of a disagreement that I had had with one of the doctors in my practice. It was answered by the noble Baroness, Lady Thornton. I was very grateful to her, because she gave me the answer that I wanted to hear, which was not in accordance with what the doctor had said. He had said in sum that people’s HbA1c was generally more satisfactory when they never tested themselves, to which I had said, “That’s nonsense. You’re talking from a cost point of view, because you think the National Health Service shouldn’t pay for the strips and so on”. The answer from the noble Baroness and from NICE was in my favour. It was published, quite wisely, in the specialist diabetes press. There is a lot of difference between relying on your doctor in the normal way—doctors always do their best—and learning about the thing yourself, dealing with it, getting expert advice and going for tests at the right intervals and so on. I hope that the noble Earl will be able tell us when he replies to this debate that the Government have it in mind to approve that.
Not coming from an ethnic community, I did not realise that only 3 per cent of the general population have my condition, but I am proud that I share it with all kinds of people from the different ethnic communities in our country. I know that Indian friends of mine have it, particularly in the feet—I do not know why that should be so. Diet is a very important factor. I can assure the noble Lord opposite that chocolate—as long it is 85 per cent cocoa and he has only three or four squares—is very good for him and he can have it every day. However, he should not have a piece of white bread every day, which is much worse than a bar of chocolate. Having had to spend money on some of the new technology, I have a gadget that measures my blood sugar and shows it on a graph. One piece of toast has a dramatic effect; four squares of chocolate is negligible. One can learn from the new technologies.
I have come to the end of my time, although I could go on for ever. I hope that the noble Lord will introduce a debate on this subject again, because there is much more to say about it. More education and more awareness on the part of the Government and the National Health Service of the cost of not dealing with the disease in its early stages will have immense benefits, not just for individuals but for the state and the economy.
Baroness Young of Old Scone
My Lords, I add to the thanks expressed to the noble Lord, Lord Harrison, for giving us this opportunity to talk about a subject as important as diabetes and foot care. I also thank other noble Lords for the broad sweep of diabetic issues that they have raised today. I did not quite expect chocolate to come into it, but the sweep was wide. I should declare an interest as the new chief executive of Diabetes UK. This is day four, so noble Lords should not expect too much of me at the moment.
When I was swotting for the interview for the job, one of the heart-stopping statistics that I learnt was that, every week, 100 people have a foot amputated as a result of diabetic complications. Even worse, 85 of those amputations are entirely preventable. The report and the issue that we are debating today are therefore extremely important for a variety of reasons.
Rather than go through the report’s recommendations, I shall highlight some of the principles. It is clear that early detection of potential foot complications, not only in patients with diabetes but in other patients where diabetes may as yet be undiagnosed, is vital on admission to hospital and throughout a hospital stay. It needs a proper history to be taken and a proper examination.
We also need to make sure that the threat of diseases of the foot is recognised by some of the key, non-specialist healthcare professionals. As the rise in the number of people with diabetes or potential diabetes is truly epidemic, we need to make sure that health professionals across the piece, not just the specialists, are capable of recognising complications before they get active. Once there is active foot disease, there needs to be a referral to a specialist team or to a professional with specialist skills. Last but not least, the noble Viscount, Lord Falkland, rightly said that this is a disease where the patient needs to be in the driving seat. People need to be at the centre of their own care and to have access to information and support from specialist teams. One in three people with diabetes is currently unaware of the potential problems that they could have with foot complications, which is a poor performance figure.
Those are the sorts of things we need to bear in mind, but I will talk about that particular complication of diabetes as just one of those indicative of a much wider issue in the care and management of diabetic problems in this country. As many noble Lords have said, diabetes is a big problem. It consumes 10 per cent of the National Health Service budget; that is, £9 billion. It is also a growing problem, as we have 2.8 million people with diabetes and a large number of people as yet undiagnosed. There is the potential for it to rise very shortly to 4 million people with diabetes in this country. Foot problems and amputations are only some of the complications. Others, which have been referred to, are blindness, stroke and heart disease. Those represent a huge cost, not just to the NHS but to the economy, because people with severe complications may be less able to work and more dependent on benefits and social care, apart from the huge human cost and misery that we are talking about.
We need to ensure that we somehow enable that 10 per cent of the NHS budget, which might have to become more, to be spent at an early stage in the pathway for diabetes—at a point where the prevention of type 2 diabetes and of complications in all types of diabetes can take place, avoiding the complications further down the line that are such a huge cost economically, socially and in terms of heartache. That needs collaboration between the commissioners of services, the providers of services and patients and their families but there is lots of guidance around; we are not short of guidance on what good practice might look like.
There is, for example, NICE guidance on the prevention of foot complications. Their subsequent management is currently being consulted on. NICE is going to work on quality standards for diabetes as one of the 150 quality standards that the coalition Government have asked it to develop. I gather that the diabetes standard will be an early one among those. Guidance for commissioners already exists, which Diabetes UK worked on some years ago. We are currently working on a kind of checklist for what an integrated quality diabetic service would look like. There is plenty of advice around and nobody is in any doubt about what the standard of the service should be. The problem is that its implementation is very patchy.
Diabetes UK, in the context of the NHS reforms, is very much going to put its shoulder to the wheel, as it were. Many things which the charity currently does will fit well with the principles of the health service reforms. There is considerable information and support for patients and their families and guidance for commissioners, as I said—we will be inputting very actively to the national standard-setting process. There is also our volunteer network, which will be active locally in fora where advice and decision-making about diabetes is taking place, both at the commissioner and provider level. We will very much want to work locally with the commissioners as the GP consortia emerge. I share the views of other noble Lords; we need to have larger commissioning consortia rather than smaller. I hope that we can learn from history, as the primary care trusts had to be clumped up and merged because they were too small to do a decent job. Let us not forget that lesson by having consortia that are too small. Another job that Diabetes UK will willingly turn to is monitoring the quality of services being received locally and their implementation nationally. We are very much there to play our part.
I want to ask the Minister two questions. First, how can the Government ensure that there is a change in the pattern of investment in diabetes care, to make sure that the services for early detection and for preventing complications are up front, as it were, and that the huge downstream costs of complications are not using up the NHS budget for diabetes inappropriately as well as generating the social costs and the personal heartache of complications?
Secondly—this reiterates the point made by the noble Lord, Lord Rennard—can the Minister let us know how the new arrangements with GP commissioning consortia will be able to ensure that people across the country with diabetes get the recommended standard of care, irrespective of where they live? We hear about localism and less central direction being very much a principle of the reformed NHS. I will not talk about the postcode lottery as a risk, although I have heard the phrase “postcode democracy”. We ought to hold the Minister’s feet to the fire to explain that before long.
I look forward very much to my new role and to hearing what the Minister has to say about this topic, which is hugely important not just for people with diabetes and their families but for the national economy.
Baroness Thornton
My Lords, I congratulate my noble friend Lord Harrison on initiating this debate and on his tireless work on behalf of those with diabetes. I also congratulate the noble Baroness, Lady Young, on her new post. She is indeed a multi-purpose Baroness. When I first got to know her she was working on behalf of birds. Then she seemed to cover the whole environment, with a quick diversion into health regulation. I am sure that she will now hold the Minister’s feet to the fire on behalf of those with diabetes. We can indeed look forward to that.
By the time we get to the point where someone with diabetes has had a limb amputated or is in serious trouble with their feet, we have failed them at several levels. In two-thirds of the 2.5 million people with type 2 diabetes, the disease was preventable, which means that prevention still has a long way to go in terms of smoking, diet, alcohol consumption and lack of exercise. As the noble Baroness, Lady Hussein-Ece, said, prevention is vital. My noble friend Lord Graham of Edmonton was right to look to the future in terms of tackling obesity in children. It seems crucial that any new regime which the Government introduce should have at its heart prevention and the levers that will make prevention work.
Let us consider, for example, the issue of smoking. We know that things such as the smoking regulatory regime are often—pardon the pun—slow burning. However, over time smoking must become something that people simply will not and do not do. In this regard, can the Minister confirm that the tobacco regulations on vending machines and points of sale are still on track? I keep hearing rumours that the decision is being reopened by the Minister’s colleagues in BIS. Perhaps the Minister could take the opportunity to inform the House of the situation, because smoking is a major contributory factor in diabetes.
We know, and it has been said today, that foot problems are one of the many complications associated with diabetes and the most common cause of non-traumatic limb amputation in the UK. As many noble Lords have said, it is a shocking statistic that 100 people a week have limbs amputated as a result of these complications with their disease. I am also shocked—although I suppose I should have known this, having been a health Minister—that the tariff system pays for a limb to be amputated but not for it to be saved. I ask the Minister to explore that and what can be done about it.
As with many chronic conditions, there are several co-morbidities that often accompany diabetes. If people who have diabetes and those associated with them do not have access to accurate information about the management of the condition, support in managing it and knowledge about what to look out for, the NHS will have failed them in both the provision of information and the management of their condition from the outset. It is very important that the Minister gives us an idea of how the proposed information initiatives involved in the reorganisation of the NHS will deliver this important aspect of diabetes care.
We should emphasise the importance of the need to invest in prevention and the earlier stages of diabetes management in order to prevent a deterioration of health that leads to devastating complications such as ulcers, limb amputation and blindness. If it is the case that 10 per cent of NHS funding is spent on diabetes care and that this is set to rise because of ever-increasing numbers of people with diabetes in our ageing population, it seems absolutely self-evident—as many noble Lords have said—that preventing people developing diabetes and providing quality care and support for those with diabetes are essential to reducing the far-reaching emotional and physical consequences of foot disease, amputation and other issues.
I was also startled to learn about the cost of the specialist shoes—to be absolutely honest, I wondered whether you could not buy a pair of Jimmy Choo’s for that. I have never bought a pair myself, but it seems to me that that sort of comparison illustrates the absurd world in which we live.
We also know that the presence of specialist nurses and tailored care for diabetics is very cost effective. I agree with the comments of the noble Viscount, Lord Falkland, on the cost-benefit analysis of this. There is anxiety regarding the proposed reorganisation of the NHS vis-à-vis the community of specialists and the expertise that goes with them. Therefore, like other noble Lords, I seek comfort that, as with many other long-term conditions, we will not lose the growing expertise in this field. We do not want to have to reinvent that expertise when the dust settles around the new arrangements in the NHS.
We have to ask whether people who find themselves in danger of losing a limb or part of one will inevitably do so. Indeed, Professor Cliff Shearman, president of the Vascular Society of Great Britain and Ireland, said:
“Amputation is a devastating occurrence. It is estimated that in some groups of patients, 85% of amputations can be avoided. Early recognition of the patient together with early involvement of a multidisciplinary team can reduce amputation”.
Those comments make the fact that 100 people a week are losing a limb very shocking.
The issue is not a lack of available treatment, as my noble friend Lord Harrison said, because the appropriate technologies are available now. These technologies are used in the NHS but patients would benefit from having access to a multidisciplinary team to make timely decisions on the best course of action to prevent amputation, or minimise the extent of amputation if it is necessary. We fail if those multidisciplinary teams are not activated and available.
Therefore, I conclude by asking the Minister how the Government can ensure that both the teams and the technology are available and funded. It must surely be more cost effective to deliver prevention in order to minimise the number of people who present with diabetes, to deliver information so that they can manage their condition, to provide properly resourced clinical management of their condition and to make a serious effort to avoid the final and horrible fate of the loss of a limb.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I begin by thanking the noble Lord, Lord Harrison, very much indeed for tabling this Question, and indeed other noble Lords for their contributions on such a very important aspect of care for people with diabetes.
As we have heard, the latest figures suggest that 3 million people—about 7 per cent of the adult population—now live with the disease. Many experience severe complications, most notably heart disease, stroke, kidney failure, loss of sight and limb problems. The growing numbers with the disease are a prelude to many more suffering the worst ravages of the condition. Already the human cost is truly awful. The noble Baroness, Lady Young, whom I warmly congratulate on her appointment, gave us the figures on amputations resulting from complications in diabetes, making it the single most common cause of non-traumatic limb amputation. As she reminded us, this will inevitably have a major impact on a patient’s life. They may lose their job, their income and status, have reduced mobility and suffer from depression. However, as the noble Baroness rightly said, with the right care, it is estimated that four out of five amputations could be prevented. Eighty-four per cent of all major amputations in diabetes are preceded by ulceration, with at least 49,000 people developing foot ulcers every year.
Regular foot reviews with advice on prevention and prompt treatment of ulcers are essential. If identified early enough, foot complications can be treated effectively. Therefore, it is vital that every person with diabetes has access to a multidisciplinary specialist diabetes foot team as soon as they need it. The noble Baroness, Lady Thornton, was right in all she said in that connection. Dr Rowan Hillson, National Clinical Director for Diabetes, considers diabetic foot care services and the prevention of amputations as a major priority.
The Department of Health welcomes the publication of Putting Feet First, produced in partnership between our service improvement team, NHS Diabetes, and Diabetes UK. The report highlights the importance of proper management of diabetic foot disease. The evidence shows that the introduction of multidisciplinary specialist diabetes foot teams has led to a significant reduction in the number of amputations.
In addition to the consequences to a patient’s quality of life, there is a significant financial impact on the NHS. This gets to the heart of the question of the noble Baroness, Lady Thornton, about how we can afford this. Diabetic foot care is part of the QIPP long-term conditions programme, which is the department’s programme to improve the quality of NHS care, while making substantial savings which can be ploughed back into the NHS. By reducing unnecessary amputations, money is saved—the noble Lord, Lord Harrison, was absolutely right—not only on the clinical procedure, but on the longer term rehabilitation and social care costs.
Reducing the amputation rate by half would save the NHS more than £10 million a year. The prevention and good management of foot ulcers could save considerably more. NHS Diabetes is working on the economic case for improving foot care services. It is currently facilitating 10 local projects specifically focused on improving foot care services. In addition and in partnership with several other organisations, NHS Diabetes has published a commissioning guide for diabetic foot care services. This responds to the need for nationally recognised minimum skills for the commissioning of diabetes foot care services. This will stand the GPs in good stead when they come to commission services for diabetes.
A number of Peers spoke about prevention. The NHS is starting to focus on preventing foot complications. In some parts of England, the amputation rate has been drastically reduced by establishing integrated multidisciplinary specialist foot care teams. In particular, Ipswich and the Imperial College Healthcare NHS Trust now have amputation rates among the lowest in Europe. However, the noble Baroness, Lady Young, was right to say that the NHS must do more to embed this approach across the country.
The noble Lord, Lord Harrison, asked about NICE. I am pleased to tell him that NICE is finalising guidelines, to be published in March next year, on the in-patient management of people with diabetic foot ulcers and infection. I can reassure the noble Lord on a more general level about diabetic medication. Prior to the introduction of value-based pricing, which is what we wish to move to, we will continue to ensure that the NHS funds drugs that have been positively appraised by NICE. I assure the House that NICE will continue to play an important role in advising on quality standards of treatment in the NHS—including after the introduction of value-based pricing.
Last year, the National Diabetes Inpatient Audit revealed that one-in-30 patients with diabetes in hospital developed a preventable foot ulcer. NHS Diabetes is making vigorous efforts to ensure that every in-patient with diabetes has a foot check and appropriate preventive care. We will repeat this audit of diabetes care in hospitals next week. More than 90 per cent of acute trusts in England will participate. The audit includes questions on foot checks, the management of complications, prescribing and patient experience. The results will help us to identify the places that need to improve and drive forward change in those areas. NICE clinical guidelines recommend annual foot screening for all people with diabetes and the targeting of prevention and treatment to those at high risk. We will continue to work to ensure that these guidelines are reflected by PCTs when they commission diabetes services.
As many noble Lords pointed out, patients have a role to play. They must learn to manage their condition effectively, and there is strong evidence that a healthy lifestyle—maintaining a healthy weight and so on—along with good treatment can prevent disability and reduce mortality. The noble Lord, Lord Harrison, was right again when he said that education is key to empowering patients to be partners in their own care. NICE has highlighted the importance of structured education in supporting people with diabetes to manage their condition. However, education across the country is patchy, so we are working with NHS Diabetes to see how we can spread these education programmes more widely across the NHS.
The noble Lord also mentioned diabetic retinopathy, which is another serious, preventable complication that can cause blindness. Screening is the responsibility of the national screening committee. Ninety-five per cent of people with diabetes were offered screening in the 12 months to June this year. The department is supporting the minority of primary care trusts that have not offered screening to all people with diabetes, to ensure that they do so as quickly as possible.
I could speak for some time about the importance of early diagnosis. The best way to avoid the complications of diabetes is to prevent people from getting it in the first place. We are committed to doing far more to prevent diabetes wherever possible. Here, I refer to type 2 diabetes, which often is related to obesity and lack of exercise. Around 80 per cent of cases could have been prevented if the person had led a healthier life. Much of that has to do with improving the general health of the population and educating people about good and healthy ways of living.
The noble Baroness, Lady Young, spoke about the need to pick up undiagnosed cases of diabetes. She is of course correct. The NHS health check programme will play a significant role in the early detection of diabetes. As noble Lords will know, the health check is a risk assessment and management programme for everyone between the ages of 40 and 74. It will assess an individual's risk of a variety of conditions, including diabetes, and will support them to reduce their risk. This could prevent more than 4,000 people per year from developing diabetes, and detect at least 20,000 cases of diabetes and kidney disease earlier, in order to allow better management of the condition. Most of the care for people with diabetes is delivered in the community and through primary care. The relationship between primary and specialist services is central to the management of complications and the prevention of admission for amputations.
I have a little time to answer questions. The noble Lord, Lord Harrison, asked about the number of specialist diabetes nurses and diabetologists. We do not collect these data, but we know from the 2009 Diabetes UK survey that 1,278 specialist diabetes nurses were working in the UK in 2007. The noble Lord also pointed to a number of international comparisons. It is often difficult to make international comparisons of prevalence because of the way in which data are collected. The Yorkshire and Humber Public Health Observatory published a recent estimate of the prevalence of diabetes in England that suggests that there are 800,000 people with diabetes who do not yet know it.
The noble Lord spoke about sport in schools and about targeting those who are most at risk from diabetes. The noble Baroness, Lady Hussein-Ece, also spoke in this vein. The key here is for Governments to work with local commissioners to promote the benefits of investing in physical activity and to ensure that local investment in that area is based on an assessment of need. We will set out a strong business case for investment in physical activity, which evidence shows is one of the best buys in public health.
I think that generally decisions taken locally are the way forward. In particular, local commissioners are best placed to target groups that are most at risk from inactivity. The Let’s Get Moving model, which implements brief interventions in primary care, is a good example of that approach.
Similar considerations apply when we reflect on the concerns of the noble Lord, Lord Harrison, about the postcode lottery of services. Healthcare organisations, with their knowledge of the healthcare needs of the population around them, are best placed to determine the services required to deliver safe and effective care.
The noble Baroness, Lady Hussein-Ece, as I mentioned, talked about high-risk groups. We are committed to reducing mortality rates from diabetes. Dr Rowan Hillson, the National Clinical Director for Diabetes, chairs the working group, Good Diabetes Care for All, which has brought together leading stakeholders and providers of diabetes services who are concerned with inequalities. I say to the noble Lord, Lord Rennard, that to support NHS organisations to design services that reflect the whole diabetes community, NHS Diabetes has produced a comprehensive diabetes commissioning toolkit to provide advice and support for commissioners.
Time prevents me from answering all the other questions, to my great regret, as I have copious answers in front of me. However, I shall just say that I believe that the principles that we have set out in the White Paper of pushing power downwards, paying for quality and strengthening the voice of the patient will bring fresh impetus to improving outcomes for diabetes. This is not an issue that the NHS can ignore. We need to strengthen both preventive action and treatment for diabetes. By doing that, we can have a huge impact on the quality of people’s lives.