The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I congratulate the noble and learned Lord, Lord Morris of Aberavon, on securing this debate and on his authoritative speech and major contribution to raising the profile of diabetes, especially type 1. Diabetes is a major challenge for this country and that is why it is a key priority in the mandate for the NHS Commissioning Board. We are clear about the need to improve diabetes outcomes through better care, and we regard diabetes as a key marker of improvement in the NHS as a whole.
We are helped by having strong advocacy, as has been mentioned. I would like to commend the work of Diabetes UK in raising awareness of the early signs of diabetes in children, and support its new Ten out of Ten campaign: Type 1 essentials for children and young people.
Earl Howe
Type 1 diabetes is an autoimmune condition that causes failure of insulin production. It cannot be prevented or cured. Individuals usually develop the condition in childhood or early adulthood and require lifelong insulin treatment.
I therefore commend the Juvenile Diabetes Research Foundation for funding international studies in type 1 diabetes, having spent over £1 billion on research that seeks a cure or better treatment. It is a mark of the international standing of diabetes research in the UK that JDRF spends a relatively high proportion of its funding on type 1 diabetes research in this country.
We know that diabetes has a significant cost to society. The current payment systems in the NHS do not differentiate between the costs associated with type 1 and type 2 diabetes. The National Audit Office estimates that the NHS spends at least £3.9 billion a year on diabetes as a whole and its complications.
The noble and learned Lord asked what the obstacles were to counting the costs of type 1 diabetes separately. It is simply current accounting practice that prevents this. There will be new opportunities, with the NHS Commissioning Board and CCGs taking responsibility. I understand that as we speak work is under way that looks at the coding of diabetes care in primary care and how this is collected via computer systems.
The noble Lord, Lord Harrison, mentioned the indirect costs of diabetes. We know very well what those indirect costs look like in personal terms. One in 20 people with diabetes require support from social services. People with diabetes are twice as likely to be admitted to hospital than those without it. Complications increase the cost of NHS care fivefold. People can lose a leg, or their vision. Their kidneys can fail, they are vulnerable to infection, and their hearts can fail. These are serious complications. Diabetes is also a major factor in premature mortality.
We need more proactive management of the condition and its complications, starting with prompt diagnosis. Once diagnosed, people must have access to the best care and support in living with and managing this long-term condition. We need to make sure that management is in line with the latest clinical guidelines. To that end, the department has taken a number of steps to improve diagnosis and management of type 1 diabetes. We have collaborated with NHS Choices so that its website now has clear advice for parents on identifying the signs of diabetes and the actions required.
The NHS has clear statements of good-quality care for people with type 1 diabetes. These include the NICE quality standard and NICE clinical guidelines for all ages, which are being updated. The NHS is expected to follow NICE guidance as part of its general duty to secure continuous improvement in quality.
From April 2013, the best practice tariff for paediatric diabetes will ensure that the NHS offers all children and young people with diabetes appropriate education, support and management. All paediatric diabetes centres must belong to regional paediatric diabetes networks. Those paediatric networks will continue to function.
Like all pupils, children and young people with diabetes deserve full educational opportunities unhindered by their condition and their daily medical care. It is worrying that so many pupils experience preventable problems at school because of their diabetes, whether through barriers to insulin administration or even being banned from school trips. I am glad to hear that the honourable member for Yeovil and my honourable friend for Central Suffolk and North Ipswich have considered this in the context of early years and the minimum health offer in schools.
From April 2013 we will also introduce a best practice tariff to ensure good specialist care for severe insulin lack, called diabetic ketoacidosis, and for insulin excess or hypoglycaemia. These are potentially fatal crises if you have diabetes and can usually be avoided.
The Quality and Outcomes Framework, or QOF, rewards general practitioners for providing the nine care processes for people with diabetes. Since 2003-04, QOF has encouraged steady improvements in these annual checks. At the same time, the percentage of people diagnosed with diabetes has more than doubled. We want this improvement to go faster. For this reason, NICE has been asked to review the Quality and Outcomes Framework and diabetes indicators within it, and we await its response.
Last year, the National Audit Office published its review of the management of adult diabetes services in the NHS. While this report acknowledged the progress made over the past 10 years, in particular in the information we have about diabetes, it also highlighted the extent of variation in services across the NHS and the significant challenges that we face over the next 10 years. The Public Accounts Committee subsequently made a number of recommendations. The Government accepted all but one. We also set clear objectives for the NHS.
For the last few years, this work has been led by Dr Rowan Hillson as national clinical director for diabetes. Since her appointment in 2008, Dr Hillson has made enormous strides to improve the care and management of all those with diabetes. She retires at the end of this month from this role and I take this opportunity to pay tribute to her and thank her for all she has done, which is a very great deal. From April, Dr Jonathan Valabhji will take up the challenge on behalf of the NHS Commissioning Board as the new national clinical director for obesity and diabetes. I wish him every success in his new role. I can tell the noble Lord, Lord Hoyle, that Dr Valabhji is a consultant diabetologist and fully aware of the needs of people with diabetes. He will give them appropriate attention in the balance of his work.
I also thank the NHS Diabetes team for all their hard work. NHS Diabetes has made a major contribution to improving diabetes care nationally. The team will be absorbed into NHS Improving Quality in the NHS Commissioning Board next month. It is good that the excellent work of the National Diabetes Information Service will continue in Public Health England. The prime objective of the NHS Commissioning Board will be to drive improvement in the quality of NHS services. The board will be held to account through the NHS mandate. Diabetes is relevant to all parts of the NHS outcomes framework, through which we will track progress. In the NHS, diabetes is everybody’s business.
I agree with the noble Lord, Lord Collins, that structured diabetes education is essential. NICE has specified this and I support its guidance. The noble and learned Lord, Lord Morris, asked what we were doing to increase the use of insulin pumps. The national clinical director chairs the Insulin Pump Working Group, which met today. It exists to increase pump use and provided the insulin pump audit showing that 8% of adults and children in the UK have pumps. Within that figure, it is 6% of adults and 19% of children, but the work of that group continues. I am happy to write with a full and detailed response, as the noble and learned Lord asked.
The noble and learned Lord also quoted from a letter he had received from my honourable friend Paul Burstow, which indicated that we in this country were in line with the United States. I confess that I am puzzled by that, as he is. The figures that I have are that the United States has around 30% coverage. That compares to Spain, Finland and Portugal at around 5%. We are, as I say, at 8%. I will look further into that situation and write to him as appropriate.
The noble Lord, Lord Harrison, referred to blood glucose monitoring, which is, of course, essential to managing type 1 diabetes safely and well. The national clinical director and the chief pharmaceutical officer wrote to all doctors to remind them of that this year. Dr Hillson recently wrote to the NHS on behalf of the Minister for Public Health, highlighting the Minister’s concerns, and reminded the NHS of the importance of appropriate prescribing and management.
The noble Lord, Lord Harrison, also asked about guidelines for type 1 patients. NICE produces patient-friendly summaries which I believe are very helpful, while NHS Choices includes information about type 1 diabetes. The National Clinical Director for Diabetes has worked with Diabetes UK to produce its guidance and we support the organisation’s 15 healthcare essentials checklist. He also asked why everyone with diabetes does not get an annual check. In the Government’s response to the Public Accounts Committee we set clear objectives for the NHS Commissioning Board and we will monitor them closely.
The subject of research was raised by the noble and learned Lord and the noble Lord, Lord Hoyle. Recently, the Government announced that £775 million would be invested over five years through the National Institute for Health Research to drive innovation focused on major diseases, including diabetes. The department is currently supporting more than 60 studies into type 1 diabetes through the Diabetes Research Network. Diabetes research in the UK punches well above its weight and the results are seen prominently in international diabetes meetings. The noble and learned Lord also asked why type 1 is not included in specialised commissioning. I will write to him with an explanation on that point.
I would like to support very strongly the remarks made by the noble Lord, Lord Hoyle, about children with diabetes. Children with the condition should have equal opportunities in schools. Collaboration between children’s diabetes services, children’s carers and education services is absolutely key to allow children to achieve their full potential. All local authorities and schools should be encouraged to read the Managing Medicines in Schools and Early Years Settings booklet. He asked how many people are getting the nine care processes. The answer is 54% of adults, but I regret to say that it is fewer than 10% of children. However, as I mentioned, we now have the Paediatric Diabetes Best Practice Tariff, which demands better care in regional paediatric diabetes networks.
My time is up. I have more to say and I will write to those noble Lords whose questions I have not answered. There is good and bad here. We have vast amounts of data for this condition. We know what needs to be done and where. The challenge is for clinicians and commissioners to ensure that everyone with diabetes has good care.