(12 years ago)
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Lord Harrison
That this House takes note of the management of diabetic services in the National Health Service.
Lord Harrison
My Lords, as a type 1 diabetic of 43 years’ standing, I have received unparalleled support from the NHS and, in recent decades, from health professionals in Chester and Liverpool. I am ever grateful for their continuing expertise and engagement. However, recently I have witnessed a worrying decline in the care offered to me and other diabetics. First, my excellent local hospital no longer invites me for my annual diabetic check-up. Similarly, the regular check on my eyes at the hospital is being curtailed, blindness being a not infrequent complication of diabetes for one in seven of us.
My big concern here is that the onus is falling on the individual diabetic to repair to the GP at the first signs of disquieting changes in his or her health for referral to the relevant specialist. That is all well and good if you are alert and dedicated to preserving your health, as am I, but that is not true of all of us. I have sat in the waiting rooms of diabetic clinics next to other, less articulate and perhaps less personally organised patients, who have turned up at the wrong hospital, never mind getting the date and time of their appointment wrong. In a hospital that I know, missing an appointment means instant dismissal from the clinic, with all the morbid consequences for the diabetic involved. Moreover, the regular diabetic check-up uncovers trends and problems that patients may not have recognised themselves. Action can be taken. Potential blindness, the amputation of a septic foot or the continuation of an unhealthy lifestyle can be diverted by action, and a life or a limb can be saved.
Therefore, my first question to the Minister is this: does he recognise that there is folly in short-termism, such as the cutting of annual clinics, which brings in its wake long-term deleterious consequences for the individual and, in the end, greater NHS expenditure in administering to the diabetic at peril?
A very recent example of a laudable NHS innovation is the potential treatment and advice to be given to patients online to save GP surgery time. However, that may lead to a greater exposure to danger for diabetics. All such worthy changes and innovations in the treatment of diabetics must be tempered by acknowledging that penumbra of citizens afflicted with diabetes who are less accustomed to the computer cursor. How will the Minister ensure that the computer-averse are not left behind? Perhaps, too, the Minister, who is admired on all sides of the House for his deep knowledge of his brief, could roundly repudiate the Tory GP Back-Bencher who foolishly opined last week that type 2 diabetics were to blame for their condition and should be deprived of NHS services as a punishment. That kind of response to the diabetes epidemic is unworthy and unrealistic. Nevertheless, diabetes is the UK’s number one health threat. Some 3.7 million of us live with the condition and a further 7 million are at high risk of type 2 diabetes. Half of those diagnosed with type 2 already have serious complications, thereby incurring increasing costs for the NHS budget, which currently stands at £10 billion a year and is rising. Action now on this killer disease is imperative. There is a need for a matching application of enthusiasm, expertise and expenditure to be granted to defeating diabetes that have rightly been developed for heart disease and cancer treatment in recent decades.
The National Audit Office found that diabetic care in the NHS is poor, with low achievements of treatment standards and high numbers of avoidable deaths. Indeed, 80% of the NHS costs are spent on the complications stemming from the condition, which are largely avoidable. Can we tolerate the fact that 24,000 people die each year from the condition needlessly, avoidably and with attendant unsung misery to their families and friends? The excoriating report of the Commons Public Accounts Committee rightly demands, in the words of its chair, Margaret Hodge, “straightforward care and support” for diabetics. Can the Minister be equally straightforward and respond to the detailed shortcomings exposed in the PAC report on diabetes care?
The noble Baroness, Lady Young, the chief executive of Diabetes UK, who is on duty in New York today, notes the postcode-lottery nature of diabetes cover across the UK. Can the Minister guarantee the maintenance of high standards, as in the established “15 healthcare essentials” for diabetics, so woefully underpowered in application at the moment? As the PAC report shows, these essential desiderata are simply not being met. Tailored education about their condition is essential for individual diabetics but this ambition fails to be fulfilled. Can the Minister comment on the important work done by the DAFNE programme? This is already being delivered in 70 centres around Britain and helps to provide proper cholesterol control among other tasks, such as promoting healthy eating among diabetics. Given the imprimatur that it has received from NICE, can this programme not have wider reach and support within the NHS?
April is the cruellest month, for in April next year we are to come under the reformed regime of local commissioning in the NHS. Some of us quake in our boots at this prospect. The PAC report tells us that the current NHS accountability structures have palpably failed to hold commissioners of diabetic services to account for poor performance. Indeed, it details other failings. Only one in two patients receives all the basic tests to monitor their condition, and only one in five achieves recommended levels for blood glucose and blood pressure, as well as the vital cholesterol norms. Will the Minister respond to the charge that the department is failing to incentivise delivery of all these aspects of its recommended standards of care through the medium of the payments system and that it neglects to gather the cost information and to carry out general monitoring? These responsibilities of the department are vital for proper reform.
I do indeed stand in the Chamber before your Lordships today because of the excellent care that has been accorded to my feet. I suffer from severe neuropathy, where one has no feeling at all in the feet, and I have a minor debriding of part of one foot. My wife and I have become foot fetishists in constantly visually examining my feet for any minor changes that might presage drastic and draconian complications. Indeed, at the recent Putting Feet First reception, Diabetes UK and the College of Podiatry noted that 125 amputations are carried out each week, of which 80% are preventable, costing the NHS some £700 million each year. Can the Minister ensure that all diabetics become foot fetishists in assiduously committing to look at their feet twice daily? Can he also ensure that health professionals are aware of the imperative to so monitor feet and that the integrated pathway approach to the diabetic foot, which characterised the approach of the care I received from Broadgreen in Liverpool, is applied universally? Incidentally, that is where my shoes are made at a cost to the NHS, but it means that I can become economically productive, as can many other diabetics, because they can get on their feet and do a job.
I await with interest the speech of the noble Lord, Lord Kakkar, on the imperative of an integrated approach to the treatment of diabetes as a whole. I hope that the noble Lord might also offer us some insights into Britain’s ethnic groups, who suffer disproportionately from diabetes. Indeed, he and the Minister may know of the recent research findings from Imperial College London detailing the worryingly high incidence of type 2 diabetes among our Asian, black African and African Caribbean communities. At November’s south Asian health education reception in the Lords, we learnt of the courses run in temples, mosques, gurdwaras and community centres assessing diabetic risk among these populations. Perhaps our Christian church-based communities might take up that useful contribution. I note the presence of the right reverend Prelate the Bishop of Liverpool, who might communicate that to colleagues.
Beyond that, I ask the Minister what is being done at the European Union level to share best practice among health professionals and health Ministers on the treatment of diabetes—I sense that the desirable exchange of knowledge is piecemeal at best—and also about our engagement internationally on reducing the terrible toll of 4 million deaths each year round the world. Tragically the notion that diabetes is the rich world’s disease is sorely mistaken. I ask the Minister, if I may, when he last had a conversation with another Minister from the European Union on the question of diabetes. It would be intriguing to know.
Let us return home. In-patient care studies, according to the 2011 in-patient audit, reveal: stark problems in the referral processes; a decline in diabetic consultant availability; no fewer than one in three entities lacking diabetic in-patient specialist nurses and, more specifically, no essential podiatric provision; and diet advice to diabetics deteriorating. A diabetic nurse at the Countess of Chester replied to my inquiry, “How can we do things better in the NHS?”, by volunteering that she would like to visit all the wards in the hospital and peek under the bedclothes to see the feet of new patients. No, she is not another foot fetishist. The purpose of such inspections is to identify potential problems by scrutinising feet when there is a captive audience within the hospital.
The national Health Check programme which was introduced four years ago to promote early diagnosis has been patchily implemented. Many PCTs fail to offer such checks. Next year this responsibility falls to local authorities whose budgets are being negligently cut by the Government, who continue to pile responsibility on responsibility on local authorities with no additional compensating funding. Can the Minister give us some hope and allay this fear?
Recently the Minister kindly replied to some Written Questions that I posed on the incidence of the very frightening and life-threatening condition for children of diabetic ketoacidosis. Some one in five children is diagnosed with type 1 diabetes through a DKA episode. What improvements are being made in the early diagnosis of children’s typically type 1 diabetes, and also in the auxiliary help given to parents and carers who, untutored, have to face the heart-rending job of explaining to their child the necessity of insulin injections and renouncing chocolates? I celebrate all those parents and carers who so dedicatedly help bring their children to maturity by their love and unstinting work. I know that others will highlight the needs of the diabetic child but it is imperative that paediatric and adult services combine to offer effective, tailored care for the individual child. Does HMG support the so-called transition clinic to help the child come to terms with their diabetes? Transition clinics are characterised by their multidisciplinary approach.
Could the Minister also report on the work done by his department and the education services on the diabetic child’s exclusion in so many ways from PE, school trips and so on? They are denied access to necessary medicines for the lack of a nurse or private space to inject insulin or take a blood reading. They can experience bullying as a result of being the child excluded by a diabetic condition. These are all examples of plain discrimination that must be tackled head-on in the classroom. Sometimes there is also a need for children and adults to have access to appropriate psychological and emotional support services. To many diabetics their condition is inexplicable, frightening and paralysing socially. Given that some two in five diabetics suffer poor psychological well-being, can HMG assure us that resources will be found?
Finally, when he replies, will the Minister tackle the vexed question of giving appropriate help to diabetics in hospitals? Sometimes appalling food is served up. I well remember the very sweet puddings that I was offered in the two periods that I stayed in hospital. I am most grateful to colleagues here today and hope to hear a report from the Minister that will perhaps give us some hope of ensuring that diabetic services are maintained at a level that is appropriate for the population.
Lord Rennard
The 3 million people living with diabetes in the UK will share my gratitude to the noble Lord, Lord Harrison, for securing this important debate today. So, in particular, should the 850,000 people in this country who have the condition but are unaware of it, and the 7 million people he referred to who are at high risk of developing type 2 diabetes.
I wish, first, to declare an interest as the director of communications of the British Healthcare Trade Association, but my personal interest in diabetes is longstanding. My father was an insulin-dependent diabetic. It was possibly the shock of losing a leg when wounded in the First World War that brought on his diabetic condition. He was, therefore, one of the first people in the world to benefit from insulin, as far back as the 1920s. Without it, obviously, I would not be here today. My father went on to live a relatively long life. Indeed, he was 71 when I was born and 73 when he died.
I was myself diagnosed with type 2 diabetes at the relatively early age for this condition of 34, some 18 years ago, and I have been dependent on insulin for the past seven years. I am personally grateful to the staff at St Thomas’s hospital, just across the river from here, for their help and support in managing this condition, especially when I let it get significantly out of control for a long period several years ago. I had to work hard and change things in my life to achieve better control. However, the issues surrounding diabetes are of great concern not just to those who may be directly affected or those closest to them but to everyone because of the growing scale of the problem, its consequences and the costs of trying to deal with it.
The number of people with diabetes in this country is expected to increase by 23% to 3.8 million by 2020. This will have a huge impact on NHS resources unless the efficiency and effectiveness of existing services are improved. We all know about the commitment to £20 billion of efficiency savings under the Nicholson challenge. The biggest challenge in diabetes will be how to commission cost-effective care while at the same time improving the quality of services and delivering excellent outcomes for patients. To do this, we need to recognise the growing scale of the challenge. Since 1996 the number of people living with diabetes has increased from 1.4 million to 2.9 million. We need to look at the weaknesses in the system at present. In England, almost half of the people with type 2 diabetes—47 per cent of them—are missing out on the nine basic health checks recommended by NICE, such as foot care and retinopathy screening.
Fewer than one in five people with diabetes are achieving the recommended standards for controlling blood glucose, blood pressure and cholesterol levels. We have to recognise that variations in the quality of care for diabetes patients cannot be explained by need or spending alone, and are influenced by the way in which local health services are organised and managed. We have to look at the human cost of diabetes and the adverse effects of the disease. The mismanagement of diabetes can lead to heart disease, stroke, blindness, kidney disease and amputations that in many cases could have been prevented. More than 100 amputations take place in England every week due to diabetes, while 4,200 people in England are blind due to diabetic complications, and this figure increases by 1,280 each year. There are 24,000 people with diabetes in England who die each year from causes that could have been avoided through better management of their condition.
It is estimated that already almost 10% of the NHS budget is spent on diabetes, around £10 billion a year. When we factor in the loss of working days, early death and informal care costs, the cost of the condition to the NHS will rise to almost £40 billion by 2035. When we look at the current situation for diabetes patients, we learn from the Public Accounts Committee that NHS accountability structures have failed to hold commissioners of diabetic services to account for poor performance as they have no mandatory performance targets like those in place for other conditions such as cancer.
The committee also found that information on diabetes is not being used effectively by the NHS to assess the quality of care and to seek to improve it, and that many people with diabetes develop avoidable complications because they are not effectively supported to manage their condition.
So, what must be done? Inequalities exist in the quality of diabetes care across the country and they need to be addressed if we are to develop better outcomes for patients and improve efficiencies in the NHS. The National Institute for Health and Clinical Excellence quality standard for diabetes should act as a benchmark to improve the quality of diabetes care.
The National Audit Office report on the management of diabetes in the NHS called for a review of the current system of incentives, so that GPs are paid for diabetes care only if they ensure that all nine care processes are delivered to people with the condition. Other recommendations call for greater collaboration and co-ordination between the new organisations and levers of the reformed NHS, such as the NHS Commissioning Board and Public Health England.
I know that NHS Diabetes is developing an implementation guide for treating diabetes patients in the NHS, which, in contrast to the diabetes action plan, will examine how diabetes care is commissioned and its implications for patients. We need to ensure that it addresses the health and economic impact of diabetes-related complications. In particular, I hope that the implementation guide will address how to reduce the variations that exist in diabetes care and the outcomes across the country.
Raising awareness of the causes, symptoms and consequences of diabetes is also crucial for increasing understanding about the disease and improving outcomes. I know from my own experience that diabetes specialist nurses play an essential role in helping patients to manage their condition and are a key source of information and advice for patients. Their posts should be protected during the current transition and all patients should have access to a named diabetes specialist nurse during their treatment.
I hope that the Government will make a commitment to the delivery of a national approach to addressing diabetes from 2013, set out by clear milestones and procedures for delivery, and using the recommendations of the National Audit Office as a guideline. The development of integrated care pathways should be encouraged as a means of reducing the postcode lottery of care for diabetes patients and reducing adverse outcomes of the disease, including mortality. Local health and well-being boards should scrutinise local commissioning plans to ensure that the delivery of diabetes services is joined up across public health, the NHS and social care. Finally, local commissioners should implement the NICE quality standard for diabetes and, where commissioners are not complying with the standard, they must be made to set out their reasons in their commissioning plans.
Baroness Masham of Ilton
My Lords, I thank the noble Lord, Lord Harrison, for raising the issue of the need for good managed services for people with diabetes today. I consider the noble Lord to be the expert patient for diabetes in your Lordships’ House.
The All-Party Parliamentary Group on Diabetes is very active and effective, keeping parliamentarians from both Houses up to date with the many needs of people of all ages living with diabetes. Diabetes spans several government departments—first, the NHS—but it is also a serious public health issue. With many aspects of diabetes going over to local authorities, I hope Public Health England will take diabetes as a priority. Unless primary and secondary care services work closely together, the treatment of diabetes will suffer.
I cannot stress enough the importance of the diabetic nurse and I am glad that that has already been stressed by the previous two speakers. Diabetic nurses can be the important link between primary and secondary care. They teach patients and their carers about diabetes and also community nurses. They are a vital resource for the management of diabetic services. When there are problems with insulin and patient stability, the diabetic nurse is often at the end of the telephone to give advice.
Diabetes often causes extra complications. Some years ago, a well known and well liked television presenter, Richard Whiteley, from Yorkshire, who hosted the programme “Countdown”, went into hospital for a heart operation, but sadly died due to complications because he was diabetic. More research needs to be undertaken into the causes of type 2 diabetes. I read in the press yesterday of a link between type 2 diabetes and food sweeteners:
“A sweetener used in food manufacture could be partly to blame for rising rates of type 2 diabetes … Countries that use large amounts of high fructose corn syrup (HFCS) have higher rates of the disease than those that consume little, says a new study”.
Professor Stanley Ulijaszek from Oxford University, who co-led the study, said:
“This research suggests that HFCS can increase the risk of type-2 diabetes, which is one of the most common causes of death in the world today”.
The syrup is widely used in drinks and processed foods because it acts as a sweetener, helps to keep food moist and is cheaper than regular cane sugar. Tim Lobstein, director of policy for the UK-based International Association for the Study of Obesity, has said that,
“if HFCS is a risk factor for diabetes—one of the world’s most serious chronic diseases—then we need to rewrite national dietary guidelines … and foods should carry warning labels”.
Diabetes can be a very complex condition. During this time of change in the NHS, many people are unsure of where their services will be coming from. There is dismay when people hear of the closure of A&E departments and walk-in clinics. Evenings, weekends and bank holidays mean that for long periods it is impossible to see a GP. There are real risks for people living with diabetes when things go wrong. They may have a hypo and need urgent help. Diabetes has become a ticking time bomb with increasing rates of the condition in many places around the world. When we were on holiday in Barbados some time ago, a taxi driver told us that he took the day off every Sunday in order to bicycle from one end of the island to the other. But he also said that the sugar workers used to slash the sugar cane manually, using much sweat and energy. Today they sit on tractors and everything is done mechanically. Diabetes has hugely increased in modern life.
Recently we saw an interesting presentation about the diabetic leg. We were told that the West Country is the worst region for amputations due to infections in the leg as a result of circulation problems caused by diabetes. Specialist centres in London ensure that people’s legs can be saved through expert vascular surgery. There seems to be a postcode lottery in different parts of the country.
This week, international attention is focused on HIV and AIDS. When someone has HIV/AIDS and diabetes, sometimes along with other co-infections, treatment can be very complicated, and some HIV drugs can encourage the development of diabetes. I have discussed this with Dr Jane Anderson, a marvellously dedicated HIV specialist who works at the Homerton University Hospital. She has seen co-infected patients with problems. These patients need the expertise of endocrinologists and HIV specialists to sort out their complications.
For good management, all those who are involved with those who have diabetes must be well educated about the condition. They may be teachers, medical personnel, or those involved in sports and leisure or food and drink, but it is diabetics themselves and the people closest to them who are the most important of all. The aim should be to keep fit within the community and to lead happy and healthy lives.
Baroness Thornton
My Lords, I thank my noble friend Lord Harrison for bringing this important debate to the House. I am going to concentrate on one aspect of diabetes services today, and it is one that I have raised in the House at least once since 2010. I wish to examine the impact and efficacy of podiatry services for those with diabetes. The Minister may recall that in April last year I asked him about nail-cutting services, including his own, and on 4 November 2010 I asked,
“how the Government can ensure that both the teams and the technology are available and funded”—[Official Report, 4/11/10; col. 1828.]
to avoid amputations and deaths. So here we are a year later returning to what is a worsening situation. I thank the College of Podiatry for its excellent brief on this matter.
The starting point for my contribution is the undeniably shocking statistic that was mentioned by my noble friend. Each week, 125 amputations take place, and in many ways it is even more shocking that 80% of those are preventable. My contention is not only that something must be done, and done urgently, to bear down on this unacceptable state of affairs but that to do so would save the NHS money. There really cannot be any reason not to give this issue some real priority, end suffering and save money. Why can that not be the case?
We all know that 4% of the population currently suffers from diabetes and 15% to 20% of those will develop a foot ulcer at some time. It has been estimated that 61,000 people with diabetes in England have foot ulcers at any one time. It is certainly possible to manage foot ulcers but too many are being missed, not spotted in time or not being treated swiftly enough, unfortunately leading sometimes to complications, surgery and amputations. Amputation is not only devastating but significantly increases the likelihood of death. According to NHS Diabetes statistics, the mortality rate for those with diabetic ulcers and who have had amputations is greater than for those with breast or prostate cancer. Although the five-year survival rate for those with breast or prostate cancer is now about or above 80%, for those with diabetic foot ulcers it is worse, at just under 60%. In other words, two out of five people with foot ulcers that are not treated will not survive for five years or more. I am afraid to say that once someone has had a lower limb amputation their survival rate worsens considerably—after five years it has been estimated somewhere between 68% to 79% will die. Of these amputations, which lead to these deaths, 80% are preventable.
Ulcers and amputations also cost the NHS, according to the acknowledged expert Marion Kerr, between £600 million and £700 million each year. If better foot care was available and these amputations were prevented, that much money would be saved. However, as things stand, the number of amputations is going up not down, as the diabetic population increases. I invite the Minister to support the alliance that has come together under the Putting Feet First banner, which has already been mentioned and which includes NHS Diabetes and Diabetes UK as well as the College of Podiatry. Does the Minister think that it would be sensible to say—I will use the word “target” but I do not mind what terminology he uses—that there should be a 50% reduction in amputations by, say, 2018? How does he believe that could be delivered? It seems to me that surely an effort from everyone, from the national Commissioning Board to CCGs and from the Government to clinicians on the ground, is what is needed. Of course there is also a huge role for patients learning to manage their own condition and becoming, as my noble friend put it, “foot fetishists”, specifically by taking care to maintain their own healthy feet.
However, it is indisputable that better services are also needed and that this will require more podiatrists, more specialist nurses and more multidisciplinary teams. I wonder how this might be delivered with the urgency required at a time when economies, reorganisation and cuts in podiatry services are already apparent. What will the Government do to drive forward a programme that delivers across the country?
Currently there is, as has been mentioned, a staggering tenfold variation in amputation rates across former PCT areas. Such a variation, as an example of a postcode lottery, is surely unacceptable. However, it is not surprising if one knows that more than half of hospitals do not have a multidisciplinary foot care team, while 31% of hospitals do not even have an in-patient podiatry service, an increase from 27% in 2010. There is evidence that one of the current problems is that GPs have no incentive to refer their patients on to foot protection teams for education, follow up and so on. There is evidence that the number of posts is being frozen or reduced, which is not the way to deal with a preventable problem. With that, staff are also experiencing “de-banding”, leading to reduced morale.
The College of Podiatry, along with Diabetes UK and NHS Diabetes, believes that the time has come for this goal to be promoted by the Government, adopted by the NHS Commissioning Board and worked towards by every clinical commissioning group. The QIPP—quality, innovation, productivity and performance—agenda also provides an opportunity to redesign services along the best practice lines so that there is a multidisciplinary foot care team in each hospital as well as foot protection teams in every community. However, unfortunately at the moment there is evidence that the opposite is happening and that services are not improving. The danger of new arrangements is that this important issue falls between the cracks, is left to local decision-making and does not get the prioritisation it deserves.
The College of Podiatry tells me that it is,
“fearful that public expenditure constraints mean that rather than being prioritised through the QIPP agenda, current podiatric services are at best, being frozen and in some cases being reduced, with patient services including the diabetic foot service deteriorating as a consequence”.
We know that best practice exists. For example, the multidisciplinary foot care team approach for in-patients with diabetes in Southampton led to a reduction in the length of in-patient stays from 50 days to 18. Not only were patient outcomes improved but annual savings to the NHS of £889,000 were generated on the back of an investment of £180,000. Let us imagine if that were repeated everywhere.
To address this issue is wholly in line with the outcomes that the NHS mandate has identified for the NHS Commissioning Board; that is, reducing preventive mortality, improving care for the chronically sick and driving up patients’ experience of care. The Putting Feet First campaign has already produced guidance and circulated it to CCGs and existing PCT commissioners showing how savings and improved patient services might be achieved. What is required now is political prioritisation; what is required is a guarantee of an increased supply of podiatrists. Given that the number of those suffering from diabetes will have increased to 5 million by 2025 and that as diabetes increases so do preventable amputations, it really is imperative that action is taken now to end what is really nothing short of a scandal.
Lord Kakkar
My Lords, I join others in congratulating the noble Lord, Lord Harrison, on having secured this important debate and declare my own interest as professor of surgery and consultant surgeon at University College London Hospitals NHS Foundation Trust. We have heard during this debate about the profound burden of diabetes in our country. Some 24,000 excess deaths are reported in those with diabetes annually, some 13,000 strokes, 11,000 heart attacks and more than 4,000 minor and major amputations, in addition to the complications seen in the eye, the kidney and the nervous system. All have a profound impact on the individuals who suffer from this potentially devastating disease. As a result, and quite rightly, diabetes has received an awful lot of attention, not only in clinical practice and research but in government during the past 10 to 12 years, with the growing recognition that the burden of this chronic disease on society and the National Health Service will be profound.
The recent inquiry by the Public Accounts Committee in the other place failed to reach a consensus position with Her Majesty’s Government on the cost to the National Health Service of diabetes, but the figures range between some £4.6 billion and £10 billion, looking at the broad impact of the disease on NHS services. This is quite striking at a time when the service needs to spend its resources more efficiently and effectively. Among the issues raised in that report are: how diabetic services should be commissioned, why commissioning to date through primary care trusts appears to have failed patients and how looking at the new arrangements for the delivery and commissioning of NHS services as a result of the Health and Social Care Act 2012 might be used to improve outcomes for diabetic patients.
What we know in terms of reports and strategies such as the national service framework in 2001 and the production of NICE clinical standards in 2011 is that simple interventions provided annually for patients with diabetes can have a profound impact on improving their clinical outcomes. These include, for instance, annual examination of the eyes to determine whether patients are developing retinopathy; annual, or more frequent if necessary, examination of the feet to guard against diabetic foot complications; regular measurement of the blood sugar, particularly glycosylated haemoglobin, to determine whether the longer-term management of sugar is appropriate; the evaluation of blood lipids and blood pressure, because cardiovascular complications in diabetics can be more devastating and occur with greater frequency; and, of course, testing the urine for protein and testing the blood for creatinine to determine whether the kidney is being affected by diabetes and whether more careful clinical attention needs to be paid to protecting that important organ. In addition, it is well recognised that education of diabetics is vital. Of course, the preparation of women with diabetes for pregnancy is vital, too, to ensure that we do not see the devastating potential complications of diabetes during pregnancy.
These complications and the measures are well understood. What is often forgotten is the fact that diabetics entering hospital for management of other conditions will often have complications at a much higher rate and frequency as a result of having diabetes. One of the most important is, of course, the development of infection in hospital, which is seen more frequently in patients in whom diabetes is not appropriately controlled. It is quite right to say that multidisciplinary care is vital.
To return to the NICE care standards and processes described—simple, authoritative measures—if we ask how frequently and successfully those are being applied to patients with diabetes in communities around the country, the data are quite startling. For interventions that could prevent a heart attack, stroke, amputation or early death, we find that only 50% of diabetics have all nine simple care measures applied on an annual basis. In two PCTs, less than 10% of patients have those nine standards assessed on an annual basis, and in the best PCT only 69% have those measures conducted on a regular basis. The reality of the situation is that the Department of Health, giving evidence to the Public Accounts Committee in the other place, stated that 100% achievement of these nine care processes was unrealistic and a more realistic target was only 75%. That seems rather disappointing, bearing in mind the burden not only for the individual patient but for society more generally and the NHS in terms of its resources attending complications of diabetes.
It is clear that the current arrangements for holding commissioners to account have failed. Of course, we will see the disappearance of those arrangements—and of primary care trusts—on 31 March next year. The provision of these appropriate care measures to much larger numbers of diabetic patients would be a first, early and important test of the new commissioning arrangements through the NHS Commissioning Board and the clinical commissioning groups.
With that in mind, is the Minister able to say what progress has been made with regard to putting at the centre of diabetic care the provision of integrated care pathways? It is quite right for a chronic condition that the majority of care should be provided in the community setting but it is also very clear for diabetics that provision of or access to ancillary services is vital. We have heard about feet and eye services, but there is also access to specialists in hospital because diabetes is much more than a disease of blood sugar. It is a complex metabolic condition with profound cardiovascular, neurological and peripheral vascular implications. It is very important that any commissioning arrangements incentivise excellent care in the community but also make it mandatory for early referral to more specialist centres for early intervention on developing complications.
In this regard, will the quality outcomes framework in primary care be modified to incentivise integrated care? Will payment by results for secondary and tertiary care providers ensure that integrated care across multiple providers in the community and in hospital becomes the norm rather than the exception for the provision of the management of diabetes? In addition, if more care is to be given at the primary care level, it is vital that general practitioners are properly trained and continue to receive ongoing training and professional development to ensure that appropriate care is given to diabetic patients, and that we have an emphasis on ongoing research in both the primary and secondary environments if more patients are to be managed out of hospital.
Finally, the question of the role of Public Health England has been raised. This is a major societal problem with major public health implications. It is critical that Public Health England takes as one of its early priorities the question of screening for diabetes in high-risk populations—for instance, in certain ethnic minority communities, as we heard about from the noble Lord, Lord Harrison—and sees that every opportunity is used to ensure that patients who develop diabetes can be identified early rather than later and that intervention can be provided to avoid potentially devastating complications.
Lord Morris of Aberavon
My Lords, I am particularly grateful to my noble friend Lord Harrison for choosing to raise the subject of diabetic services. I will concentrate on type 1, in which I declare a family interest. I have had the advantage of consulting Professor Amiel of King’s College Hospital and hope to visit the research unit of Professor Johnson in Oxford in January for further discussion. I am grateful for the excellent briefing by JDRF.
The recently published report by the House Of Commons Public Accounts Committee, which has already been referred to, notes that the incidence of diabetes has doubled in the past five years. The report concentrates on type 2, which comprises the greater number, and is one of the most damning I have ever read. It states:
“There is no strong national leadership, no effective accountability arrangements for commissioners, and no appropriate performance incentives for providers. We have seen no evidence that the Department will ensure that these issues are addressed effectively in the new NHS structure”.
My simple question for the Minister is: are things going to get better after that damning report?
Type 1 diabetes is a chronic, life-threatening condition which has a lifelong impact on those diagnosed and their families. I hope that this debate will send a clear message that the cause of type 1 diabetes does not involve lifestyle factors such as obesity, poor diet or lack of exercise. There is currently no way to prevent the condition and no cure.
I have been trying for some time to get a complete breakdown of the cost of management of type 1, as opposed to type 2. I have had only modest success in the disaggregation of the figures. I firmly believe that when you have a clear idea of specific costs, you can start to prioritise and direct funds. It is estimated that the direct and indirect cost to the National Health Service of treating type 1 is nearly £2 billion a year; 400,000 people are affected, including 26,000 children; and the numbers are growing at 4% per year. The current spending for research on type 1 is inadequate and falls way behind that of other developed countries. In 2009, government spending bodies committed £51 million to fund research into diabetes. Of this, only £6 million was applicable to type 1.
When I was a young Transport Minister in 1966, just before the ark, I learnt of the methods of cost-benefit analysis. It must be painfully obvious that as 26,000 children are already affected and they are growing in number, the cost of lifetime care will be disproportionately high and merits the targeting of research funding. There is an immense issue of management to achieve a target of long-term blood glucose levels. The challenge for the family is that a child aged five faces 19,000 injections by the time he is 18, and will have pricked his finger to draw blood 50,000 times, according to the JDRF.
NICE recommends insulin pump therapy as a clinically and cost-efficient treatment option for type 1. A report by the Medical Technology Group points to significant inequality of provision of pumps across England and a lack of adherence to NICE guidelines. NICE recommends that 12% of people with type 1 should be eligible for a pump and that for children under 12 it should be 33%. The average rate of pump utilisation is 3.9%, which is still the lowest in Europe though substantially better than it was a few years ago. In the United States, provision is estimated at 33%. Mr Burstow, a Health Minister, was able to assure me on 25 April this year that we were generally in line with the United States. How he could reach that conclusion is beyond comprehension. Perhaps the Minister will be able to correct it. If the number of pumps was increased by seven percentage points to reach the 12% benchmark, additional savings on consultant visits and hospital admissions would add between £37 million and £62 million, hence my attachment to cost-benefit analysis.
I welcome the announcement of the publication of NHS scoreboards for availability, delays and access to treatment. Those PCTs not complying—a number of which have been indicated in the various reports—will have to explain themselves, I trust.
It has been emphasised to me by clinicians that providing a pump is part of a package, with structured education first. If injections do not achieve treatment targets, then there is a move on to the provision of a pump. Many achieve the required outcome without it. Evidence-based work is still evolving on how best to provide such education for children. Increasing the skilled force within the NHS to provide such structured education is not without cost. We need to raise the profile of this need if we are to achieve equity of access to such skilled healthcare professionals across the country and across the range for people with type 1 diabetes.
It would be a tragedy if the needs of those with type 1 were lost within the greater number of those with type 2. The current reorganisation of the NHS could be a great opportunity to improve the availability of treatment for those with type 1. I understand that representations were made to the Department of Health for recognition that type 1 people are a small group with a need for highly specialised support. However, the request that type 1 diabetes be commissioned separately, or at least differently, from type 2 has not been approved.
I welcome the work that is being done at King’s, Cambridge, Oxford and Sheffield on the artificial pancreas. It is vital that adequate funding is provided for what could be a welcome and major breakthrough and that, particularly in this period of change, the general issue of funding for type 1 will be addressed. I am told that there has never been a real budget for type 1 services, which have been developed on the back of academic interest and clinical recognition of need. Greater investment by the Department of Health in both the research still required to develop a viable artificial pancreas and in providing technology, as and when it becomes available, and on its role, benefits and limitations, would be very welcome to all concerned for those who suffer from type 1 diabetes. I hope that in my short remarks I have highlighted the separate needs of those with type 1 as well as type 2.
Lord Roberts of Llandudno
My Lords, first, can I say how much I appreciate the opportunity granted to me by the noble Lord, Lord Harrison, by his entering this area? I enter with tremendous humility as well as deep concern because many have spoken in a personal way. They know the problems while we on the outside—we are possibly not going to be there long on the outside—do not know in depth what the real problem is, while they face this situation day after day.
Last year, on a wet night, I was crossing Westminster Bridge. We had just finished here, so it must have been after 10 o’clock. On the other side, just where County Hall used to be, a man was lying in the pouring rain. What should I do? Was he bait? Would other men attack me and mug me? Or was he desperately ill and in need of attention? I did not know. Rightly or wrongly, I went on my way, but others might have been more Christian than me.
We need awareness of the various conditions that people face. There has been a series of television advertisements about stroke, and HIV/AIDS had a tremendous media and television presence. Do we not need something—television adverts—so that we, the ordinary public, are made aware of the emergency that some people might encounter? Low blood sugar can induce something that might be thought of as drunkenness, but we do not know that. We must learn. Some sort of advertising is necessary in order to make us aware because, as my noble friend Lord Rennard said, 3 million people are now suffering from diabetes. I tried to work out what that means in Wales. It means 150,000 people in Wales, or about 5,000 or 6,000 people in each parliamentary constituency. It is a massive number that we have to take great notice of. We could produce adverts for television about what to do if you see somebody ill and have some idea of what the problem might be.
A good place to start is with children in schools. I am told that most children who have diabetes have type 1 diabetes. Other children in their school should be made aware that there is a problem. Teachers must also be aware so that they are able to be confident in the way that they deal with children who have problems. We are told that there are 26,500 children under the age of 15 with type 1 diabetes. In the home, in school and in the playground, youngsters with diabetes have my tremendous admiration: little youngsters who need to inject themselves and check exactly how many carbohydrates there are in every meal they are eating. For some youngsters, it is extremely difficult, so they need all the support we can give them.
I am trying to pronounce a word here: ketoacidosis. I am glad I have got it right. Twenty-five per cent of newly diagnosed children of all ages suffer in this way, and it is a life-threatening situation, and 35% of children under five years of age. We know the consequences. They have been mentioned: amputations, kidney failure and blindness. To tackle them early, as has already been urged upon us, is essential. When we are looking at expenditure in the NHS, in the long term, we would deeply regret doing anything to undermine this. You can reduce taxes, but not at the cost of threatening health and life. The lives of children come first.
Children with diabetes are often excluded from school trips, physical education and sports. A school can be afraid of admitting children with diabetes, although I am told that 52% of schools have such children. Only this morning, I was told of the common assessment framework, in which every child, every individual, particularly those who might have problems, is assessed and has individual concern and treatment for whatever might be their particular need. It is important that fellow pupils as well as teachers and other staff can recognise children with these conditions.
Some schools hold assemblies in which the children and staff are informed as to exactly what the situation is. Some schools also issue help cards to children, information telling them that if their diabetic classmate is showing symptoms, they should please take some action. Of course, a certain number of teachers are given courses on what they have to do if any child is in diabetic difficulties.
The recommendation of Diabetes UK is that every school should have people who are well versed in the relevant needs, and that secondary schools should have a school nurse. I have heard recently of the cuts made in school nursing levels. Is this a cut that we can really justify? Is it not time that we should assess this according to the need of the particular school? It is also suggested that there should be a nurse for a cluster of smaller schools, such as junior and infant schools: somebody who is well versed in and able to tackle these problems. In rural Wales, you could not have a nurse who would reach a school in time. That means that it is even more important that teachers and other school staff know exactly what to do when an emergency arises. We must all find the best way possible to ensure that no child suffers without somebody being there who can help them.
I will be visiting on Wednesday of next week a school with disabled and disadvantaged children; that is, those who are not able to cope quite as well as others. These are a particular problem: a child who possibly cannot read, or inject him or herself. How are we helping them? I am sure that this needs to be another of our priorities.
School meals need to be labelled in such a way that their content is easily understood. How much insulin is going to be needed in order to cope with this meal? That information is often difficult to understand. A youngster of seven, eight, nine or 10 years of age is trying to work out this complicated arithmetic to know exactly how much insulin to inject. What is the sugar level? Is it low or high? Somehow we need to signify that on every meal, wherever it is.
I am glad that some of the fast food chains, like McDonald’s, are providing the necessary information on their food tray papers. Other shops, hotels and others should follow suit. We are glad about what is happening. There is a lot more to be done. I am at least grateful for the opportunity to contribute in some way to this debate.
Viscount Falkland
My Lords, I, too, am very grateful to the noble Lord, Lord Harrison, for this debate. Particularly after the long discussions that we had about the House of Lords and its future, this debate so far has shown how it combines expertise, such as my noble friend Lord Kakkar’s expertise as a doctor, experience, such as those of us who are here as diabetics, and those like the noble Lord, Lord Roberts of Llandudno, speaking with articulate concern. It has been a wonderful debate.
A light has been shone on this subject this week. It was unfortunate for the MP for Slough, who is apparently a doctor, to imply that diabetes is a result of a poor lifestyle, and that those who indulge in a poor lifestyle and have diabetes should be deprived of the funding for their medication. That was stupid and irresponsible. What has been said so far in this debate shows that this is a complex condition that we have; I know that I have a complex condition. As I hope your Lordships can see, I am relatively well. I have had diabetes for 13 years. It was diagnosed in this House and I fully admit that I had been in denial. My wife had suggested that I might have diabetes. A good friend of mine in this House asked me to join him for lunch with his guest. After about five or 10 minutes, he noticed that I had been drinking a lot of water, which is one of the signs of a surplus amount of glucose in the bloodstream. He asked me some further questions and said, “Look, I am a diabetic and I think you are too”. He asked me whether I had a doctor. I said that I had hardly ever seen a doctor and that I belonged to a National Health Service panel. He excused himself, saying, “You wait here. I’m going to make an appointment for you this afternoon”.
My friend got me an appointment for that afternoon, which was the last appointment with that particular private doctor before Easter—I did not have a private doctor at that time. The doctor conducted a simple test and said, “You’ve certainly got diabetes and I’m going to pass you on; I don’t feel capable of dealing with it and I think you need immediate attention”. He rang a specialist diabetes clinic and I got an appointment for the following day, which, again, was the last appointment before Easter. I have been with that clinic ever since. However, I use the National Health Service and I talk to the doctor about my diabetes when we have a regular discussion about my medication. I am very thankful to the National Health Service for providing me with my medication and I am very thankful for the nurses, who have been mentioned, in my practice. They often seem to be more on top of the developments than the doctors.
Being a diabetic has been an extraordinary experience. I have had to give up certain things, and I am not talking about just Mars bars and pastry: I have had to give up playing golf; I cannot play with the same concentration that I used to because the blood sugars alter the whole time in one’s bloodstream. For six years I have been an insulin-dependent diabetic, which makes it even more difficult to do certain things, although I can drive a vehicle because I am very conscientious.
I wonder how many diabetics are conscious of the fact that they should report their condition to the DVLA. The DVLA guidelines are rather strange but basically they point in the right direction. If you are an insulin-dependent diabetic, you should check your blood sugar every time you go anywhere near a vehicle. If you are caught in an accident with a low level, you are committing an offence and will pay a penalty.
Generally speaking, my life is pretty good. When I first saw the specialist, he said, “You are in a very bad condition, aren’t you? Do you realise what your blood sugar level is?”. I will not mention the technical term for it but for the average person—for those in this Chamber even—whose pancreas is working properly, the blood sugar level would be about 5.5 or 5.7. Mine was 29 and the specialist said, “You are one Coca-Cola away from a coma”. I said, “I feel perfectly all right”. He said, “That is odd. I have people with a quarter of your level who are almost crawling in through my door”. It is curious because I have a reasonable feeling of well-being most of the time, although not all the time. I think that diabetics can feel like that.
However, I am not convinced that the NHS generally, as has been mentioned today, gives the kind of service that allows people to have the lucky break that I had when my diabetes was spotted. The number of people who are undiagnosed has been mentioned. I think that the noble Lord, Lord Rennard, mentioned the cost and ramifications of that. If you have nearly 1 million people with diabetes all wandering around the streets not feeling 100%, they are likely to have complications without having had the original diabetes diagnosed. Finally, something may bring them to realise it, but it will be a serious business and they may not have long to live. The cost of dealing with that emergency to the NHS is out of all proportion to what would have to be spent on medication on a daily basis.
I do not want to decry the NHS—I am the first person to praise it—but diabetes is an extremely odd, and serious, condition; one’s requirements change the whole time. One very important thing that the noble Lord, Lord Rennard, mentioned, and which saved my life, is the specialist diabetic nurses. It is all that they do, and they are absolutely essential; if you have any stress or worry, they talk you through it and get you to make the necessary adjustments, such as going to see your doctor or changing your medication. So it is quite extraordinary what can be done on a personal level. That is where the NHS is in trouble, because it is really not equipped to deal on a personal level with all the people who have diabetes.
There must be a better interface between the NHS and the private sector. Education and training is essential and can be provided to the NHS, if it cannot handle the problem, by the private sector, and not expensively. In any case, even if it is expensive, it is going to save a lot of money in the long run by preventing the kind of complications that cost all the money. We have already mentioned amputations and heart disease, and all the rest.
That is my first suggestion and question to the Minister. Why can we not work towards closer co-operation on these services with the NHS? When I go to my NHS people, they are sent everything from the private clinic but they do not have a compatible computer, which seems strange. That would seem to me the first step. They get the written stuff, which goes into a file. So when I go in, nobody ever knows what has happened the previous year. I have taken to having just a brief summary of what happened at my last inspection. I go regularly and have all the things that have been mentioned—a carotid examination, a foot examination, everything. I am thankful for that and for the course that my condition has taken. Whether I shall be standing here much longer in this condition, I do not know; I shall not say that I do not care about it, but I am optimistic. I think that I will probably have a pump, in the long run; they have been mentioned for type 1 diabetes but I think that in the end, most people like me, with type 2, will also have pumps. Then perhaps I will be able to go back to the golf tee and play golf again. Who knows?
How can we reduce the number of people who do not realise that they have this condition? As long as it remains at this level, we are in trouble.
Lord Brooke of Alverthorpe
My Lords, I thank my noble friend Lord Harrison for putting this debate before us. I suspect that I come under the category that was just described as “articulate concern”. I am certainly concerned; whether I am articulate remains to be seen.
I was drawn to the report by the Public Accounts Committee. In particular, I want to address the recommendation where it talked about the projected increase in the diabetic population having a significant impact on NHS resources. It said:
“The Department and Public Health England should set out the steps they will take to minimise the growth in numbers through well-resourced public health campaigns and action on the risk factors for diabetes, such as the link with obesity, and the complications they can cause”.
It is to those that I wish to address my remarks. Before doing so, I offer the Minister, at the end of rather a hard day for him, with quite a battering, some words of encouragement and thanks. I thank the Government for announcing yesterday in a Written Statement that they will consult on the proposal to introduce a 45p minimum unit price for alcohol. That is a brave step forward, on which they are to be congratulated. The figure is different from that in Scotland, but that is the lesser of the issues. I hope that all will come together, including the BMA and the rest of the medical profession, and work with the Government to move forward on this front.
This process will not be easy. It has taken time to get to the consultation stage and plenty of people will try to prevent this new policy being put in place. I have recently spent some time with the drinks and retail industry looking at the Government’s strategic policy on alcohol, and have encountered little enthusiasm for this change. Indeed, we have already seen one legal challenge against the Scottish proposal. I understand that the Bulgarians have a great interest in this matter and will raise question marks and seek a legal challenge. I suspect that there will also be a legal challenge against the Government’s proposal.
As I say, the Government’s action is a step in the right direction. In the past, the important link between alcohol consumption and diabetes has in many respects not been addressed to the extent that I would have hoped. I shall speak primarily about type 2 diabetes, and alcohol consumption causes difficulties in that respect as well as the consumption of high-fat and sugary foods. Drinks, particularly alcoholic drinks, contain a significant amount of sugar, of which nobody who consumes them is aware. Although food and fizzy drink labels show fat and calorific content, alcoholic drinks are totally exempt from any requirement to show energy or calorific factors. This means that people who drink excessively are not only harming themselves in other areas but are particularly at risk of raising their sugar levels, which may lead to type 2 diabetes.
The Minister seemed surprised to hear about what has been going on at the other end of the Corridor, but Dr Phillip Lee MP has said this week that, as a doctor, he believes that type 2 diabetes is self-inflicted in many respects and that, due to cost factors, the department should stop providing free prescriptions for people with this type of diabetes. Like my noble friend Lord Harrison, I hope that the Minister will state very clearly this afternoon where the Government stand on this issue and will refute Dr Lee’s proposition. That is not to say that there may not be some fundamental issues behind Dr Lee’s comments regarding costs in the NHS that we need to address, and I will come to that.
I see a link between drinking, obesity, diabetes and alcohol abuse. I hope that the Government will be prepared to stick to their objectives on that front and resist any challenges that may arise in Europe. I have taken soundings, as that is what we can do in this amazing Chamber, from some of my learned counsel friends who tell me that, if we are challenged in Europe, there is an opportunity for us to fight that very vigorously indeed on the basis of our having a margin of appreciation—that is, because of the scale of the problem with diabetes in the UK, we should have the freedom to act differently on this issue from other countries in Europe, even though the Commission may initially oppose such action.
Similarly, with regard to alcohol labelling, which the Minister knows I have raised previously, I have been encouraged to wait until the Commission comes back to this issue in 2014 because we cannot move unilaterally. Again, noble counsel here tells me that we could use the exemption that I referred to as a means to press the industry to move quickly and require it to move forward and introduce labelling on alcohol products that would show the number of calories in them. We should also think about the energy side of that.
Opportunities are there for us to keep pressing ahead on this front. This links to where we stand on public education, on which I will spend a few moments. Last night I had the good fortune to go to a celebration that was held in the River Room by the Terrence Higgins Trust to celebrate its 30 years of existence and the work that it has done. We were addressed by the noble Lord, Lord Fowler. He is a former Health Secretary who is remembered particularly—this was discussed at some length last night—for the very effective and world-leading public campaign on HIV that he raised in the 1980s and 1990s, and which had such a great impact on public health in this country.
After seeing reference to the emergence of a strategy on obesity, I look to see what the Government will do on that front, too. There have been plenty of other campaigns in addition to the one on HIV. There were campaigns on alcohol and drinking and driving and a range of campaigns on smoking, and they have been very effective. However, we await a national programme to highlight the problems that arise from eating and drinking too much. When can we anticipate something moving on this front? Given the evidence that we face with obesity and type 2 diabetes, such a campaign should be on the kind of scale that we had in the past. In particular, I look to see a Government that will address some of these issues in relation to children. A phenomenal number of young children are now classed as obese, and a growing number in turn will be likely to fall into the group of the 7 million possible candidates for type 2 diabetes.
We must be honest and straightforward in such a campaign. We must recognise that not only must the food and drinks industry be socially responsible but we must seek to persuade people in all the ways we can to accept responsibility for their own health. That means letting people—particularly young people—see that if they do not care for their health in the way that is best for them, there is a distinct possibility that their lives will be shortened, their health diminished and their opportunities greatly reduced. We need to highlight some of the topics that we have been talking about today, such as the risks of amputation, blindness and so on. We should not run away from presenting them to the public at large in a wide-scale programme of action. I hope that the Minister will tell us when we can expect a campaign of major proportions to come forward.
Lord Collins of Highbury
My Lords, I, too, thank my noble friend Lord Harrison for initiating this very timely debate. Five years ago I stopped smoking and subsequently put on weight. I stress that this was not through drink; I had a weakness for sweets. I thank my noble friend for reminding me of that. I had an eye infection and had taken on a very stressful job. My infection got worse and, after using all the available creams from the local chemist, I was finally persuaded to drop into the walk-in centre in Victoria Street, which unfortunately, as we heard recently in a debate, has since closed. The centre nurses helped me with my eye and also gave me a quick check-up that covered blood pressure and heart rate. The result was an urgent referral to my GP for very high blood pressure. The GP undertook a series of tests that led to an early diagnosis of diabetes type 2. I am therefore acutely aware of the need to raise awareness of diabetes, not only to help prevent the condition but to promote early diagnosis.
My early diagnosis and the excellent response of the NHS have meant that I have a chance of avoiding the worst consequences of diabetes. Early preventive action saves not only lives but money. As my noble friend Lord Harrison was right to point out, there is a worrying tendency to put the onus on the individual—it was the Tory Back-Bench MP for Bracknell, not Slough, I must add to the noble Viscount, Lord Falkland. Instead, as other noble Lords have indicated, we should focus more on the food industry that since the war has pumped out high-salt, high-fat and high-sugar products without any proper warnings.
However, as we have heard in today’s debate, there is a genuine fear that, at a time when the priority of diabetes should be enhanced, the new NHS arrangements seem to be removing diabetes-specific leadership, dedicated staff and specific plans. Many noble Lords have referred to the National Audit Office investigation into diabetes care, which found that:
“Diabetes care in the NHS is poor, with low achievement of treatment standards, high numbers of avoidable deaths and annual spending reaching an estimated £3.9 billion”.
In its response, the Public Accounts Committee highlighted how barely half of people with diabetes get the nine basic checks they need to manage their condition, and fewer than one in five has the recommended levels of blood glucose, blood pressure and cholesterol, leaving an unacceptably high number at risk of developing complications, being admitted to hospital and costing the NHS more money. As we have heard from the noble Lord, Lord Kakkar, the Public Accounts Committee also criticised NHS accountability structures for failing to hold commissioners of diabetes services to account for poor performance. He expressed optimism about the future, but I wonder how the new structures will stand up to the challenge of diabetes.
As the noble Lord, Lord Rennard, said, both type 1 and type 2 diabetes can lead to costly and life-shattering complications, including kidney failure, blindness and amputations, which my noble friend Lady Thornton focused on. Amputation is not only devastating, it is expensive. In England between £500 million and £600 million is spent each year on foot ulcers and amputations. I am lucky to see a podiatrist at regular six-monthly intervals. Speaking to my podiatrist, I discovered that as a consequence of the service being moved from the PCT to the local hospital trust, recruitment was frozen. His concern, as he was looking at my feet, was that without sufficient staff regular check-ups would not be carried out, so that instead of preventive treatment, he would be dealing with an increasing number of ulcers and other serious infections.
My noble and learned friend Lord Morris also pointed out that although the major rise is in type 2 diabetes, type 1 is also rising. As was referenced in a Question I put down, the first ever report into mortality from the national diabetes audit was published just under 12 months ago. It found that up to 24,000 people with diabetes are dying in England each year from causes that could be avoided through better management of their condition. About three-quarters of those are aged 65 and over. However, the gap in the death rate between those who have and those who do not have diabetes becomes more extreme when comparing those who are younger. It was truly shocking to learn that so many young people are dying from diabetes. Type 1 is a particularly difficult condition to live with, as my noble friend pointed out, and we need to raise awareness in schools and workplaces. At the end of the day, we need a huge public awareness campaign to help both to prevent and to detect diabetes.
The focus of today’s debate has been on the need for action. As I said at the beginning of my contribution, early diagnosis is key to both saving lives and saving money. We have heard about the NHS Health Check programme, which can help to detect and prevent the onset of type 2 diabetes. As my noble friend Lord Harrison said, implementation of the programme has been poor, and patchy at best. A number of PCTs failed to offer a single person an NHS health check last year, and so far this year the poor performance has continued, with two PCTs having offered no health checks to date. There is considerable variation in the way that PCTs have delivered the programme, and overall its implementation has been poor.
As the noble Baroness, Lady Masham, said, in April next year the responsibility for commissioning the NHS Health Check programme will shift to local authorities as part of their new public health duties. She is right to be concerned about the impact of this transfer on the future sustainability of the programme and the potential for further variation in its implementation.
This morning, I said in my Oral Question on HIV services that supporting self-management is critical. This approach helps people to gain the confidence, skills and knowledge to manage their own health, with resulting improvements in quality of life and even independence. My personal experience of the DESMOND programme has taught me how important this resource can be. Proper care planning, structured education and access to psychological and emotional support are essential if we are to deal with the challenge of diabetes.
In conclusion, I have a number of specific points, many of which have been raised by noble Lords today, but there is one that I want to focus on in particular. Will the Minister ensure that diabetes is given sufficient priority? There is an absolute need for a clinical lead in, and function for, diabetes within the national Commissioning Board. As we have heard, multidisciplinary networks working across all aspects of diabetes care are vital, and local commissioning work is going well for diabetes care.
My final point concerns the health checks. Will the Minister ensure that there is national delivery and national promotion of this vital work to prevent people developing diabetes? Unless there is urgent action on diabetes, thousands more people a year will be condemned to debilitating complications and early death. The time for action is now.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I thank noble Lords and, in particular, the noble Lord, Lord Harrison, for an extremely interesting and knowledgeable debate. Given the range of comments and issues raised, if I do not cover all the substantive issues, I hope that noble Lords will allow me to write to them.
I do not need to repeat all the statistics. It is abundantly clear that diabetes is a major current and future challenge for this country. It has to be a priority for the National Health Service. Diabetes is a priority for the Government and, as a long-term condition, it has been prioritised in the mandate for the NHS Commissioning Board. It is also a key marker of improvements in the NHS. Diabetes affects every system in the body. There should be no hiding place for this condition, but as the noble Viscount, Lord Falkland, reminded us, it frequently remains hidden from the patient who does not realise he or she has it, and from healthcare services that treat the complications of diabetes without managing their cause.
This year, the National Audit Office reviewed the management of adult diabetes services in the NHS. This highlighted the progress that has been made over the past 10 years, but also the significant challenges that we face over the next 10 years. As a number of noble Lords have pointed out, there is unwarranted variation in diabetes care. The management of people with diabetes has not been optimised. There is no excuse for poor diabetes care. No one with diabetes should lose their leg or their vision if this could have been prevented. We know what needs to be done and we have to ensure we meet this challenge head on.
A Public Accounts Committee hearing followed the publication of the NAO report, and the PAC has recently published its report. The Government are currently considering the PAC’s recommendations and will prepare a Treasury minute in response, which will be published in the new year. The noble Lords, Lord Harrison and Lord Kakkar, stressed the importance of integration of the patient pathway. The NHS has clear statements of good-quality care, with the publication of the NICE quality standards and a range of NICE clinical guidelines. These were informed by the national service framework for diabetes published in 2001, which sets out the key areas of development required for diabetes services in the NHS. The NICE quality standards require integrated care. They will be used by the NHS Commissioning Board as a basis for describing what good-quality care looks like.
The Quality and Outcomes Framework—QOF—introduced in 2003-04 has incentivised primary care to perform the nine care processes for people with diabetes, even though the percentage of people diagnosed with diabetes has more than doubled since 2004. NICE has been asked to review the quality and outcomes framework and we await its response and findings. We have a wealth of information and data on the provision of services and where we need to improve. The national diabetes audit started in 2004 and is now the world’s largest published clinical audit. There has been a year-on-year improvement in a number of areas. The audit shows that 54% of people with diabetes receive all nine care processes; 76% of people with diabetes had eight of the nine, which equates to 1.4 million people. However, I agree with the noble Lord, Lord Kakkar, that much more needs to be done. We need to ensure that everyone with diabetes for whom it is appropriate receives these essential care processes annually. We aim to achieve nine processes for as many people with diabetes as possible. However, each person needs individual care and it may not be clinically appropriate to do the tests in everyone. Some patients decline blood tests or other procedures. Nevertheless, I take the noble Lord’s point that the variation in the number of people with type 2 diabetes receiving all nine care processes is completely unacceptable.
A lot of work is being undertaken to drive up improvements in care and outcomes for people with diabetes, and I must now commend the work of Diabetes UK in driving change and raising awareness of issues for people with diabetes. I part company, very respectfully, with my honourable friend Dr Lee in another place on this issue. We know what needs to be done. We have the data and the guidelines to support this, and we must ensure that in the future structure clinicians and commissioners come together to commission services that meet the needs of people with this condition.
I went to Huddersfield last week to visit a general practice which is doing just that. The Grange Group practice, which provides a one-stop clinic for people with diabetes, impressed me a lot. It has developed an integrated and multidisciplinary team approach to the management of people with diabetes. It is a great example of a CCG taking the lead on improving the management of diabetes. It is not a one-off: there are examples of this up and down the country and it should become the norm.
The prime objective of the NHS Commissioning Board will be driving improvement in the quality of NHS services and we will hold it to account for this through the NHS mandate. Following the reforms to the NHS, the NHS Commissioning Board will use accredited evidence, such as NICE quality standards for diabetes, to guide local commissioners to improve outcomes for people with the condition. Commissioners can use the Atlas of Variation to identify the areas in their community that need improving and there is a wealth of clinical guidance and commissioning support for diabetes services. All this means that people with diabetes can expect to see a better service, with improved outcomes, and an end to unwarranted variation.
In addition, through the NHS outcomes framework we will be able to track the overall progress of the NHS in delivering improved health and outcomes. For people with long-term conditions such as diabetes, this will be measured by whether patients are in good health and are able to live active, fulfilling lives. Diabetes is relevant to all five domains in the outcomes framework, so it is important that when work programmes are developed they consider diabetes and how optimising care can help to deliver improvements.
We face substantial challenges in the next five to 10 years due to the changing age and ethnicity structure of the population, increased numbers of people with multi-morbidities and the challenges allied with obesity and activity. In 2020, it is estimated that 8.5% of people over 16 years of age will have diabetes—that is 3.8 million people in England. While type 1 diabetes is not currently preventable—I will say more about that in a moment—we must ensure that those with this form of the disease have access to appropriate services and have the knowledge and support to self-manage their condition.
We are fully committed to the prevention of type 2 diabetes. All our work on promoting an active lifestyle and tackling obesity will support this aim. The NHS Health Check programme has real potential to prevent many cases of type 2 diabetes and to identify thousands earlier. The Government have an ambitious programme to improve public health through strengthening local action, supporting self-esteem and behavioural changes, promoting healthy choices and changing the environment to support healthier lives. The Change for Life national campaign is raising awareness around eating healthily and increasing activity. The National Child Measurement Programme is giving people the information they need to make informed decisions about their child’s risk of becoming overweight.
We launched a new national ambition in January this year for a year-on-year increase in the number of adults doing 150 minutes of exercise a week. The public health outcomes framework was published in early 2012 and has key indicators for Public Health England, including diet, excess weight and physical activity.
The NHS Health Check programme, which I mentioned a moment ago, is a universal and systematic programme for everyone between the ages of 40 and 74. It assesses people’s risk of heart disease, stroke, kidney disease and diabetes, and it then supports people to reduce or manage that risk through individually tailored advice. I can reassure the noble Lord, Lord Collins, that the NHS Health Check programme is a key performance measure in the NHS operating framework this year, and take-up of the NHS health checks by the eligible population is another indicator in the public health outcomes framework. Local authorities will be mandated to offer risk assessments to their eligible populations from April next year—and I stress the word “mandated”.
The noble Lord, Lord Collins, referred to the NHS reforms and what these will mean for diabetes commissioning and care. He particularly stressed the importance of clinical leadership in the NHS Commissioning Board. I agree that clinical leadership has been key in driving improvements in care in recent years. Diabetes is a very high priority for the domain directors of the NHS Commissioning Board, both from the perspective of reducing premature mortality and improving the quality of life.
The noble Lord, Lord Kakkar, was right to remind us of the costs of diabetes care. These costs are hard to pin down—he is correct—because people with diabetes can be found in every part of the NHS. The thing to remember is that the greatest cost of diabetes is to the person with diabetes himself or herself in terms of the distress, disability and premature death that can ensue.
The noble Lord, Lord Harrison, spoke about the risk of short-termism and he was concerned that annual checks might be cut and replaced with online advice. He rightly asked about those people who are computer-averse. Annual checks are required by NICE and the Quality and Outcomes Framework and they must be face to face. Online advice does not replace them and, when it occurs, it is an additional option for patients who might find it helpful.
A number of noble Lords, including the noble Lords, Lord Harrison, Lord Kakkar and Lord Collins, referred to the importance of self-management, and I agree with what they said on this subject. The department is working to promote self-management in the care of diabetes through patient education and support from appropriately trained service providers, including the DAFNE and DESMOND programmes. The NHS reforms present an opportunity for stronger and closer partnership working between GPs and specialists, ensuring that the right care is commissioned and that it is focused on the needs of each individual patient and carer.
The noble Lord, Lord Brooke of Alverthorpe, brought us to the subject of alcohol, and particularly calorie counts in labelling. People with diabetes most certainly should have access to dietary advice, and that should include advice on alcoholic drinks. It is a subject that he raises regularly and he is right to do so. Around a quarter of adult men and a fifth of women report drinking at levels that are above the NHS guidelines, and in fact some 2.2 million people have said that they drink more than twice the amount set in the guidelines. That puts them at most risk of illness and death from alcohol. The noble Viscount, Lord Falkland, talked about safe driving with diabetes. I welcome the reminder he gave us that people with diabetes should follow DVLA guidance, and that includes the need for blood glucose testing if the driver is on insulin.
The noble Lord, Lord Harrison, spoke about transitional care, and particularly about children with diabetes in schools, an issue also referred to by the noble Lord, Lord Brooke. There has been long-standing work between the national clinical directors for diabetes and children and young people on improving diabetes care in children and those in the younger age groups. There is now a best practice tariff for children’s diabetes care. NHS Diabetes has been supporting work with young people on transitional care and there are regional paediatric diabetes networks. My noble friend Lord Roberts of Llandudno rightly drew attention to the late diagnosis of diabetes and diabetic ketoacidosis. I agree that it is important that all parents, teachers and healthcare professionals should be aware of the symptoms of diabetes, and I particularly welcome the “Four Ts” campaign from Diabetes UK. He referred to hypoglycaemia and the awareness of diabetes and its consequences. Again, I agree how important it is that children, young people and their families are taught how to avoid unduly low blood glucose levels. Friends, schoolmates and especially teachers should learn about this. An example is the work being done in Essex by the local authority with schools and parents as well as children.
The noble Baroness, Lady Masham, referred to specialist nurses. The Government consider that diabetes specialist nurses are an essential part of the diabetes specialist team. They have a valuable part to play in supporting people with diabetes. It is local healthcare organisations, with their knowledge of the healthcare needs of their populations, that are best placed to determine the workforce required to deliver safe patient care within their available resources, but the reforms once again present an opportunity for stronger, closer partnership working between the new primary care commissioners and secondary care specialists so that evidence-based, multidisciplinary care is focused on the needs of the individual patient. Once again, I saw this for myself last week when I visited Yorkshire. The noble Baroness also drew attention to high-fructose corn syrup, which is used as a food additive. I will write to her on that very important subject, on which a lot of work has been done.
A number of noble Lords, including the noble Baronesses, Lady Masham and Lady Thornton, focused on the very grave issue of amputation of limbs among those with diabetes. The National Diabetes Audit and the Atlas of Variation have both shown that there are unacceptable levels of variation in the care received by people with diabetes, and the noble Lord, Lord Kakkar, gave eminently sensible and important advice. It is important that clinicians review data relevant to their practice and make improvements to the care that they provide to reduce variation. We have plenty of examples of excellent patient-centred services that have improved outcomes and provided value for money. NICE guidance was published in January 2004. The guidelines include recommendations for primary and secondary care settings.
The incidence of amputation among people with diabetes has been declining over time, but the absolute number of diabetes-related amputations is rising as the prevalence of type 2 diabetes increases, and I agree fully with the noble Baroness, Lady Thornton, that the numbers need to come down. Diabetic foot disease accounts for more hospital bed days than all other diabetes complications put together. In the UK, 100 people a week lose a lower limb because of complications from diabetes. One in 20 people with diabetes will develop a foot ulcer in one year, and up to 70% of people die within five years of having an amputation. That shows how important an issue this is, but once again there is evidence that rapid access to multidisciplinary foot care teams can lead to faster healing, fewer amputations and improved survival. Savings to the NHS can substantially exceed the cost of the team. The noble Baroness spoke extremely powerfully on this subject. We join her in supporting the Putting Feet First campaign by Diabetes UK and NHS Diabetes and good patient education. The ambitions for the NHS are set out in the NHS outcomes framework and of course include improving the quality of life. Good care costs less for everyone.
The noble and learned Lord, Lord Morris, and the noble Lord, Lord Collins, spoke about type 1 diabetes. I agree that it is important to provide high standards of care for the 250,000 with type 1 diabetes, and that it would be helpful to improve the costing data around that. The noble and learned Lord, Lord Morris, was right to mention insulin pumps in this context. NICE recommend pump therapy as an option for adults and children over the age of 12 with type 1 diabetes if multiple daily insulin therapy has failed. In May this year, NHS Diabetes launched an insulin pump network to ensure an effective two-way sharing of the most up-to-date guidance, tools, best practice and resources. An insulin pump audit, the first to be undertaken nationally, is currently under way, and provisional unpublished data suggest that 11,985 adults and 4,447 children are currently on insulin pump therapy. Some 8% of people with type 1 diabetes now have insulin pumps. That is an increase, but we still need to go further to achieve the 12% to 15% advised by NICE.
As regards research, the department is currently supporting more than 60 studies into type 1 diabetes through the diabetes clinical research network. The Juvenile Diabetes Research Foundation has spent £1 billion on research around the world into treatments and prevention of the condition. I also acknowledge the major contribution of Diabetes UK to type 1 diabetes research.
Time prevents my replying to the points made about in-patient care, HIV/AIDS and diabetes, and the points made very powerfully about ethnic minorities. The noble Lord, Lord Harrison, asked me about the European Union and sharing ideas. I will write on those topics but will just say that progress has been made. It has been good progress, but we are not there yet. It is encouraging to see that many of the building blocks for making real progress are there and that, in the new NHS structure, there will be renewed awareness and mandated responsibility to improve care and services for all those at risk of this devastating condition.
Lord Harrison
My Lords, I thank the noble Earl for his repudiation of the intemperate remarks made at the other end about type 2 diabetes. I share his acknowledgement of the width and the depth of this debate, in which so many interesting individual contributions were made. I thank colleagues who have joined us in the Chamber to hear my last words on this important day. As the warm-up act for the Leveson inquiry, perhaps I may just identify the point made by the noble Lord, Lord Roberts of Llandudno, that diabetes is not properly represented on radio and TV. If the press have nothing better to do in the future after Leveson, perhaps they could explore and investigate some of the problems that we have identified today in the care given to diabetics, and many of the exhilarating stories of diabetics who have resisted their disease and who should be celebrated in the press and the highest organs of the state.