Diabetes-related Complications

Tuesday 7th June 2016 Westminster Hall

[Mark Pritchard in the Chair]

00:01

[Paula Sherriff (Dewsbury) (Lab)]

I beg to move,

That this House has considered diabetes-related complications.

It is a pleasure to serve under your chairmanship, Mr Pritchard. I am particularly pleased to have secured a debate on this topic because of its profound importance to all those with diabetes, and because support for those with long-term conditions is vital to the future of the NHS.

There are 4 million people living with diabetes in the UK today, and it is estimated that more than half a million people are undiagnosed, living with the condition without being aware they have it. Since 1996, the number of people diagnosed with diabetes in the UK has more than doubled, from 1.4 million to almost 3.5 million. About 700 people a day are diagnosed with diabetes, which is the equivalent of one person every two minutes. The NHS spends about £10 billion on diabetes every single year, which equals around 10% of its budget. Critically, it is estimated that 80% of that cost is spent on complications that are largely avoidable through better care.

[Ms Margaret Ritchie (South Down) (SDLP)]

I congratulate the hon. Lady on securing this important debate. She referred to the fact that 80% of NHS spending on diabetes is on avoidable complications. Does she agree that a greater focus on early intervention is needed, to ensure that the budget, resources and staffing are better targeted?

[Paula Sherriff]

I thank the hon. Lady for her intervention, and I absolutely agree. As with so many other conditions, early intervention is crucial.

The total direct and indirect costs associated with diabetes in the UK are estimated at £23.7 billion. That is predicted to rise to £39.8 billion by 2035. Earlier this year, the Public Accounts Committee said that the cost of diabetes to the NHS would continue to rise.

[John Howell (Henley) (Con)]

I thank the hon. Lady very much for the speech she is making and for securing the debate. I want to take her up on the point she has just made. There is a belief that diabetes is not curable; actually, diabetes is curable. It is curable by the individual going through a process of losing fat around the liver, which takes away the—

[Liz McInnes (Heywood and Middleton) (Lab)]

indicated dissent.

[John Howell]

The hon. Lady is shaking her head. I am a living example of someone who has cured diabetes. I wonder whether more patient-centred education would be a big help to the NHS.

[Paula Sherriff]

I thank the hon. Gentleman for his contribution. While I acknowledge that some people may be cured of the condition, we must not be complacent about the causes of it or, indeed, the impact it can have on many people’s lives.

[Liz McInnes]

I wish to make the point that the hon. Member for Henley (John Howell) is talking about type 2 diabetes, which can be cured by weight loss. Type 1 diabetes, which is insulin-dependent, cannot.

[John Howell]

I did mean type 2 diabetes.

[Paula Sherriff]

I thank hon. Members for their contributions, and I will now try to make a little progress.

Earlier this year, the Public Accounts Committee said that

“the costs of diabetes to the NHS will continue to rise. In order to control these costs, the Department and NHS must take significant action to improve prevention and treatment for diabetes patients in the next couple of years.”

The wider impact on people’s health is significant. One in five hospital admissions for heart failure, heart attack and stroke are among people with diabetes. The condition is responsible for more than 135 amputations per week. It is the leading cause of preventable sight loss in people of working age and the single most common cause of kidney failure.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Lady on securing the debate. I declare an interest as a type 2 diabetic. I lost almost 4 stone and I am still a type 2 diabetic. I still need tablets to keep me right, and many type 2 diabetics are the same. Experts at Queen’s University Belfast are spearheading a new major research project aimed at ascertaining why thousands of diabetics around the world suffer kidney failure, which she referred to. They have examined DNA samples from 20,000 diabetics to help identify the genetic factors in diabetic kidney disease. The project could enable personalised procedures for those at risk. Does she agree that such research is the key to unlocking life-changing advances for diabetics?

[Paula Sherriff]

I absolutely agree, and it is encouraging to learn that such research and development is being carried out. I will later share details of a visit that my hon. Friend the Member for Heywood and Middleton (Liz McInnes) and I undertook recently, which proved very interesting.

[Julian Knight (Solihull) (Con)]

The hon. Lady has been most generous in taking interventions. I congratulate her on securing this vital debate. Does she agree that education is a key part of ensuring that individuals with diabetes can manage their condition and limit the complications that she mentions? In my constituency we have a diabetes support group that was established way back in 1994. It meets nine times a year, often hears from experts, and provides advice and support. Will she reflect on the role of support groups in helping people to combat diabetes?

[Paula Sherriff]

I thank the hon. Gentleman for that relevant contribution, and I absolutely agree. It is worth noting that, as with many conditions, education is often the key, and I will allude to that later in my speech.

[David Simpson (Upper Bann) (DUP)]

Will the hon. Lady give way?

[Paula Sherriff]

I will make some progress and then take further interventions.

The starkest figure of all is that every year, more than 24,000 people die prematurely due to diabetes and its complications. However, there is significant room to improve diabetes care, which would reduce the risk of diabetics developing complications and tackle the rising costs of diabetes to the NHS. First, we could take action to reduce avoidable amputations. There are more than 7,000 diabetes-related amputations every year in England alone, and foot ulcers and amputations cost £1 of every £150 spent in the NHS. I am sure hon. Members will agree that that is quite an incredible statistic. In 2013, the Secretary of State for Health committed to reducing the rate of diabetes-related amputations by 50% over five years, but the national amputation rate has since remained steady.

Action could be taken to meet that commitment. For example, the Government must ensure that clinical guidance is properly implemented and followed. The National Institute for Health and Care Excellence recommends that all people with diabetes have their feet checked every year, but in the worst-performing clinical commissioning groups, one in four people still are not receiving that annual foot check. There also appears to be a significant disparity in what the annual foot check actually means. Those at increased risk of foot problems should be referred for an assessment by a foot protection service. Having multidisciplinary foot care teams in place can reduce the risk of amputation, but almost one third of hospital sites do not have one.

That is of particular significance to me, because along with my hon. Friend the Member for Heywood and Middleton, who will no doubt have more to add during the debate, I recently visited King’s College hospital diabetic foot clinic here in London, which provides some of the best diabetic foot care in the country, if not the best. Care such as that provided at King’s is unfortunately not universal. There are currently no national drivers to lower the rate of amputations across the country, of which we believe about 80% are avoidable. With the right care in place, such as acute multidisciplinary foot teams and a robust care pathway, amputation rates could be significantly reduced. Not only would that have significant cost-saving benefits for the NHS, but more importantly, the people involved would not need to go through such a life-changing experience.

I will briefly reflect on a gentleman my hon. Friend and I met during our visit to King’s College hospital. He was due to have an amputation at another hospital within 48 hours. He was then referred to King’s College for a last chance to have his condition reviewed, where he was told that he did not need any surgery, nor an amputation. When we saw him, he was almost completely cured of his foot problems. A huge amount of money and a huge amount of distress to that man were saved. Will the Minister please confirm that the Government are still committed to the 50% reduction that the Secretary of State spoke about and tell us when they expect to see figures showing year-on-year decreases? Will she tell us what they are doing to ensure that CCGs meet the NICE guidance, and how they can ensure that multidisciplinary teams such as that at King’s operate much more widely across the NHS? The benefits we saw that morning were absolutely clear.

There is a similar need to improve in-patient care. One in six people in hospital now have diabetes, but one in three hospitals have no diabetes specialist nurse and an unacceptable number of in-patients experience diabetes-related harm while staying in hospital. Diabetes UK has pointed to evidence showing that specialist diabetes in-patient teams save three times what they cost the NHS to provide. Specialist teams make fewer prescribing errors and deliver better outcomes for their patients, so there are fewer expensive complications in hospital and shorter stays. Although most hospitals report increasing referrals and patient contacts, there has been no increase in staffing levels in diabetes teams.

I do not think that the number of in-patients who suffer diabetes complications while in hospital is acceptable, and I hope the Minister agrees. The national diabetes in-patient audit showed that 38% of in-patient drug charts had at least one diabetes medication error and 22% had at least one prescription error; that 30% of in-patients had one or more hypoglycaemic episodes, with nearly a third being severe; that 33% of people with diabetes did not think the staff looking after them knew enough about the condition; and that one in 10 hospital sites did not have any consultant time for diabetes in-patient care. Will the Minister tell us what action she intends to take to reduce those figures, assuming that the Government do not think they are acceptable?

[David Simpson]

We have heard education and early intervention mentioned. Does the hon. Lady agree that in order to help patients, and especially children—there is a reluctance for teachers to give insulin to young people within nursery provision and at primary school level—the mindset needs to change? We need to make sure that there is preventive medication as well as early intervention for children.

[Paula Sherriff]

I thank the hon. Gentleman for that intervention; once again, I agree with those points.

It makes sense both clinically and financially to improve access to diabetes self-management education. Managing diabetes well is time-consuming and can be complicated, but 69% of diabetics said they did not fully understand their condition. On average, people with diabetes spend only three hours a year with a healthcare professional. For the remaining 8,757 hours they manage their diabetes themselves, for which they need the right skills and knowledge—not to mention confidence. Diabetes self-management courses empower people with diabetes to take charge of their own care. Nine out of 10 people with diabetes who attended a course stated that they felt more confident about managing their diabetes afterwards.

Evidence collated by Diabetes UK shows that diabetes education courses reduce an individual’s risk of developing serious and costly complications and prove very cost-effective. However, more than a third of CCGs do not currently commission specific courses for people with type 1 and type 2 diabetes, despite national guidance, and less than 2% of people newly diagnosed with type 1 diabetes—and just 5.9% with type 2 diabetes—attend a diabetes education course. Investing in diabetes education is the big missed opportunity in diabetes care. Will the Minister agree to look at what can be done to ensure that we do not continue to miss it?

[Mr Jamie Reed (Copeland) (Lab)]

My hon. Friend is making a fantastic case. I speak as somebody who is a type 1 diabetic, the father of a type 1 diabetic and the uncle of a type 1 diabetic. Does she agree that when we look at providing the education that she has talked about, we also need to give regard to the fact that such courses require a basic level of numeracy and literacy, so provision needs to be made for people accessing those courses to be given help in those disciplines in some cases?

[Paula Sherriff]

I thank my hon. Friend for his contribution; he speaks with a great deal of experience, having experienced diabetes himself. That is an incredibly interesting point, and I hope that the Minister will give her views on that issue.

Finally, we must tackle the significant variations in the care and support received by people living with diabetes. The postcode lottery is exacerbated by additional differences according to age and the type of diabetes. People of working age with type 1 diabetes receive considerably worse routine care than other people with diabetes. For example, although 41% of people with type 2 diabetes achieve the three treatment targets—on blood pressure, HbA1C, or haemoglobin A1c, and cholesterol—less than 20% of people with type 1 diabetes achieved them in 2014-15. Because of that variation, far too many people are experiencing short and long-term complications that have a huge impact on their health and quality of life and prove incredibly costly to our NHS.

The universal provision of healthcare is one of the founding principles of the NHS, and we have warned of the impact of wider Government policies on that, but there is also a specific issue in the case of diabetes. We should acknowledge that the Government have recently made some steps to improve care and address wider problems through the new improvement and assessment framework, but those measures will require sustained resources and national leadership. I hope that the Minister will outline not just a commitment, but some detail on how she will ensure that those intentions result in long-term action. In particular, will she tell us more about what support will be provided to CCGs that are identified as poor performers as part of the new improvement and assessment framework?

As well as better care to reduce complications and enable people with diabetes to live long and fulfilling lives, urgent action is needed to tackle the rise in type 2 diabetes. Nearly 12 million people are currently at increased risk of developing it. As obesity accounts for 80% to 85% of the risk for type 2 diabetes, the main strategy for reducing the rising prevalence of type 2 diabetes must be to tackle the rise in obesity. I welcome the NHS diabetes prevention programme—a joint commitment from NHS England, Public Health England and Diabetes UK—which will identify those at high risk of developing type 2 diabetes and refer them to evidence-based behaviour change programmes to help reduce that risk.

The first wave of 27 areas in that programme covers 45% of England’s population, with the aim of supporting 20,000 individuals to reduce their risk of type 2 diabetes. Can the Minister give us any assessment of the programme’s record to date? Will she confirm that it is due to cover the whole country by 2020 and that she still expects a full 100,000 places to be available on the programme each year?

The Obesity Health Alliance identifies three other priority areas for action that should be fundamental components of the forthcoming governmental childhood obesity strategy. They are restrictions on unhealthy food marketing, including a 9 pm watershed for TV advertising of junk food; the implementation of independent and mandatory reformulation targets to reduce the sugar, saturated fat and salt content in our foods; and the implementation of a levy on sugary drinks manufacturers. We have, of course, recently had some progress on the last of those, although the levy that the Chancellor of the Exchequer is implementing perhaps does not quite match up to that envisaged by public health campaigns. Perhaps the Minister can tell us more about that strategy and about the Government’s views on the other policies put forward by the alliance.

The Government have also promised to take action to reduce childhood obesity, with the aim of publishing a childhood obesity strategy. The strategy was initially due for publication in autumn 2015 but has been delayed. The latest indication is that it is to be released in summer 2016, but quite frankly, they have been holding off for far too long already. Can the Minister give us a specific date for exactly when the strategy will be published?

I know that other hon. Members are keen to speak, so I will conclude by saying that, both as a former NHS worker for many years and as a member of the Select Committee on Health, I see this issue as absolutely critical for the future of our health service as a whole, as well as for the many thousands of my constituents who live with diabetes. There are a disproportionate number of diabetics in my constituency, so this is a big issue for the people of Dewsbury, Mirfield, Denby Dale and Kirkburton. I hope that the Minister has some answers today for them and for everyone who relies on our NHS.

14:06

[Derek Thomas (St Ives) (Con)]

I congratulate the hon. Member for Dewsbury (Paula Sherriff) on securing this vital debate on diabetes and related complications. This is important to me because my constituency, in particular, has a high level of diabetes-related amputations. As we have heard, diabetes is a significant problem for the UK, and it is right that the Government and the Department of Health have identified tackling diabetes as a priority for this Parliament.

The cost to people’s quality of life is dramatic and an increasing number are having to manage the condition, which can make holding down a job or going about their normal daily business very difficult. Some 3.5 million people have been diagnosed with diabetes and a further 500,000 may have it but have not yet been diagnosed.

Diabetes costs the NHS approximately 10% of its budget, with one in five hospital admissions for heart failure, heart attack and stroke involving people with diabetes. However, the cost of supporting people with diabetes goes far wider when we start to consider the costs associated with adapting people’s homes and workplaces following amputation or sight loss, for example.

The UK is a civilised, wealthy country and if more can be done, there is no real excuse for not doing it. We know that for many people, the risk of developing diabetes can be reduced through good diet and exercise, but this message must be communicated positively and early. Much more must be done to encourage outdoor physical education and activity from an early age. We will not be forgiven for having a nation of children who accomplish good results in year 6 SATS, only for many of them to live with life-limiting conditions. For me, physical education is as valuable as numeracy and literacy.

[Mr Gregory Campbell (East Londonderry) (DUP)]

On childhood obesity, does the hon. Gentleman agree that we need a generational change so that from this generation on we will raise young children with clear knowledge of the issues and the unfortunate and inevitable consequences of a sugary diet—so that we can try to prevent diabetes and make sure this is the last generation to suffer from this horrible affliction.

[Derek Thomas]

That is true, and I welcome that intervention. It is right to make the distinction between type 1 and type 2 diabetes. Type 1 often occurs in younger people and there is little, if anything, we can do about it other than manage the condition well. General practitioners in my area have teenagers and adolescents presenting with type 2 diabetes. The hon Gentleman is right that to address the issue in the long term we must be positive and provide information and education that is sensitive, but honest and truthful. We cannot pussyfoot around when people’s lives are at stake.

We have a responsibility to ensure that both those with type 1 diabetes and those with type 2 diabetes that cannot be avoided have easy access to the best treatment available and the best support, and can access modern devices that manage diabetes and reduce the development of further complications. Since arriving in this place in May 2015, I have attended several meetings and seen all sorts of innovations and devices that can be used, particularly by young people, to help them to manage their condition better.

In the past, I spent some time as a youth worker and I know it is a huge challenge to help young people with diabetes to manage their condition through finger prick tests and regular injections, and parents are frustrated that young people often do not realise the consequences of not looking after their condition well. New innovations and new devices must be made more available to them now because I believe they will embrace smart technology, which could be life-changing for children and young people who are managing a life-limiting condition.

We know that when diabetes is not well managed, it is associated with serious complications. I have referred to the cost of health and social care for diabetic patients. The tragedy is not just that 80% of these costs are spent on complications that are largely avoidable through better care, but that people’s health and quality of life are unnecessarily deteriorating because sufferers are not always able to access the care that we know they need.

I was keen to take part in this vital debate and I appreciate the opportunity because the situation in Cornwall and the Isles of Scilly gives cause for concern. One of the most serious diabetes-related complications is amputation. Nationally, an average of 2.6 diabetics in every 1,000 have a diabetes-related amputation. In Cornwall and the Isles of Scilly, the average is 4.4 amputations per 1,000 people with the condition. This suggests that in my constituency alone, eight people each year have a lower limb amputation as a result of diabetes. Last year, 40 people in Cornwall had a lower limb amputation as a result of diabetes. We know that four in five of these amputations could be prevented through better care, so six people in my constituency today could have avoided having a lower limb amputation in 2015 if everything we know about managing diabetes had been correctly applied. Six people’s lives have been changed dramatically and their outcome is grave indeed. It is essential that we reduce the number of amputations, not least because we know that up to 80% of people die within five years of having a lower limb removed.

As the hon. Member for Dewsbury said, NICE is very clear about what CCGs should do to improve treatment for diabetic patients. Earlier this year I wrote to my clinical commissioning group in Cornwall, Kernow CCG, to argue that it should ensure the NICE recommendations are properly implemented. I am encouraged by the action it is taking, which it set out in its response to me. It says that figures to be released this month demonstrate that its efforts have reduced the level of amputations in Cornwall and the Isles of Scilly. That achievement would be a phenomenal and significant success, and something to celebrate.

However, there is a role for the Government in improving patient outcomes and it is not fair to leave everything to the CCGs. I have referred to the need for a positive message about how to improve our own health to reduce the risk of developing diabetes, but those who have diabetes and are at risk of a lower limb amputation need to benefit from a cultural shift in the profession. We need to get to a place where major lower limb amputation associated with diabetes or vascular disease is considered a failure of treatment rather than a treatment choice. A functioning foot with minimal surgery should be a success.

The Government must do more to ensure that patients with a diabetic foot are diagnosed earlier and are on the right patient pathway. More must be done to ensure the right professionals are in place. If patients are seen by podiatrists, diabetologists and interventional radiologists as early as possible, patients can be treated appropriately and their leg can be saved. This means ensuring everyone with diabetes gets good quality annual foot checks. We have talked about what that might mean and perhaps we need clarity on what an annual foot check entails. Everyone with a foot infection should be urgently referred to those specialists.

The best way for patients to have access to those specialists is through a multidisciplinary team, where healthcare professionals meet to discuss patients and treatment choices. That sounds simple, but too often different parts of the healthcare system operate in silos and that is particularly the case in some parts of the healthcare profession in Cornwall. It is crucial that the right members of the team meet regularly and that multidisciplinary teams are fit for purpose. It must not be just a tick-box exercise for NHS trusts.

Clinicians also need access to the right technologies when they intervene on patients with advanced forms of diabetic foot and critical limb ischaemia. Data show that the use of drug-eluting technologies, when used by vascular specialists, can improve outcomes for diabetic patients to the equivalent of those patients without diabetes. NICE is about to review its clinical guidelines for peripheral arterial disease and I hope the updated guidance will include recommendations for the use of drug-eluting technologies for critical limb ischaemia and intermittent claudication.

In conclusion, the Department of Health has said it will assess CCGs on their provision of structured diabetes education as part of the new CCG improvement and assessment framework. I would like the Minister to say today what support the Department will provide to ensure that CCGs identified as underperforming are able to improve access to structured education, and thereby increase the number of people with diabetes who have the skills and confidence to manage their own condition. As was said early in the debate, many people with diabetes across the UK could manage their condition with the right support, education and resources. It is absolutely right that we do everything we can to give every person with the condition the support that should be available to them and that they deserve to have.

15:06

[Chris Evans (Islwyn) (Lab/Co-op)]

It is an honour to serve under your chairmanship, Mr Pritchard. I, too, congratulate my hon. Friend the Member for Dewsbury (Paula Sherriff) on securing this debate on diabetes-related complications. Diabetes is a huge public health issue in highly developed countries such as ours, and the complications of diabetes, if left unchecked, can be life-changing and, ultimately, fatal.

Approximately 4 million people live with diabetes in the UK—that is one in 16 of us—and more than half a million of those are undiagnosed and unaware that they have a potentially life-threatening condition. About 700 people are diagnosed with diabetes every day and it is estimated that, by 2025, 5 million people will have the disease.

Although we are not quite sure what causes type 1 diabetes, which affects approximately 10% of those with the disease, we know that the far more common type 2 diabetes can be caused by lifestyle factors. In 2014, Public Health England said that 90% of adults with type 2 diabetes are overweight or obese, and that men are five times more likely to develop type 2 diabetes if they have a waistline of more than 40.2 inches, while women with a waistline of more than 34.7 inches are three times more likely to develop the disease.

The link between unhealthy lifestyles and a higher risk of diabetes is clear and very well established. Is it any wonder that diabetes is on the rise when it is easier to live a sedentary lifestyle and eat unhealthily? We have more temptations, in terms of food, than ever before. The principle that prevention is always better than cure is particularly apt when we are thinking about diabetes and the serious complications that can arise from the disease.

In the first instance, it is imperative that everything that can be done is done to ensure that children and young people who have not yet developed the disease or become overweight are encouraged to lead healthy lifestyles. Schools have a very important part to play in that. They must ensure that pupils and parents are made aware of diabetes, including the causes of the disease and what might happen if they develop it. Sport in school is a fantastic way to get young people active, yet a University College London study in 2013 found that, of the 6,500 seven-year-olds included in the study, only 51% achieved the recommended hour of physical activity every day. That situation simply has to improve.

Although physical education lessons in schools often focus on competitive sports such as football, hockey, rugby and netball, they should also put emphasis on general fitness training. Schools should also be given the tools and resources that they need to encourage after-school sports clubs in addition to community-run sports clubs. The Rhymney Valley athletics club, based in my constituency, is a fantastic example of a community-run sports club for children and young people. On the occasions when I have had the opportunity to visit it, I have always been impressed by the enthusiasm of the coaches and the positive atmosphere that they create, which is impressed on the children. The number of children taking part is growing quickly, simply because they enjoy going. Whether they know it or not, by taking part in physical activity, they will be reducing their risk of type 2 diabetes and, more importantly, having fun along the way.

However, parents must bear much of the responsibility for ensuring that children lead a healthy and active lifestyle. It may be easier for parents to allow children and teenagers to eat sugary, high-fat treats with low nutritional value and drink sugary pop, but that puts their health at risk in the long term. The new tax on high-sugar drinks that was announced in March is a welcome step in the direction of tackling child obesity, and I hope that parents will take the message on board by encouraging children and teenagers to drink and eat more healthily. One of the most important skills taught to me by my mother was the ability to cook my own food—not to rely on ready meals, a takeaway or the fish shop, but to go home of a night and make myself a meal.

If young people do not develop a healthy lifestyle while they are at school, it is reasonable to expect that they will find it much harder to do so once they have left. If we make a serious effort to point children in a healthy direction from an early age, we will give them the best possible chance to avoid becoming overweight. It follows that, if they do not become overweight, they are less likely to develop diabetes and, as a result, less likely to suffer health complications caused by the disease.

Adult obesity in the United Kingdom is showing a sustained upwards trend. By 2014, more than 28% of adults were considered clinically obese, and that is expected to rise to one third by 2020. Overall, 62% of adults in the UK—a significant majority—are classed as overweight or obese. That is the third highest level in western Europe, and it is not a league table we particularly want to be at the top of. It is clear that, if we are to tackle excess weight and obesity to tackle diabetes, radical public action must be taken to reduce the UK’s average waistline.

A key reason for increasingly sedentary lifestyles is the rapid growth of office and desk work during the past few decades. Employees stuck behind a computer screen for most of the day do not get the opportunity to exercise, which we know is vital to maintaining a healthy weight. Perhaps great benefit would be gained if employers were incentivised to incorporate physical activity into office work or to set aside time during the working day for the desk-bound to exercise. The expansion of accessible after-work exercise clubs for all would also be a huge and radical step forward.

Incentives should be given for healthy eating. When living on a budget, as so many people are, it is often cheaper to eat unhealthily than healthily. That extraordinary situation must be turned on its head. Equally, disincentives such as the sugar tax should be used to discourage unhealthy eating. Only once we as a country have truly got to grips with our weight and obesity problem will we be able to prevent the very serious health complications caused by diabetes.

15:06

[Liz McInnes (Heywood and Middleton) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Pritchard. I am grateful to my hon. Friend the Member for Dewsbury (Paula Sherriff) for securing this important debate. We both have a background of working in healthcare and we share an interest in health issues, particularly when it comes to health inequalities and postcode lotteries of healthcare provision.

As my hon. Friend said, we recently visited the excellent diabetic foot clinic at King’s College hospital. I will be honest: when I received the invitation, it was only my interest in diabetes that led to my accepting it. I did not expect to come away from a diabetic foot clinic feeling inspired, but inspired I most certainly was. I spoke to the doctors, nurses, healthcare assistants, researchers and, most importantly, the patients. I heard from patients whose limbs had been saved from amputation by the amazingly skilled, dedicated and knowledgeable staff—patients who had arrived at the foot clinic clutching letters from their doctors that stated, “There is no alternative other than to amputate this limb.” Those patients were lucky because they had talked to people such as diabetes specialist nurses, who had suggested that they consult the diabetic foot clinic to get a second opinion.

We spoke to a farmer from Kent who had been kicked by one of his cows. He had a wound on his foot that would not heal and he had been advised by the hospital that a below-knee amputation was the only solution. The farmer talked to us about his family farm, about how he would have been unable to carry on working had the amputation gone ahead and about how grateful he was for his referral to the foot clinic. The staff there had been able to treat the wound and it was well on the way to recovery by the time we saw it. They had saved his limb and consequently his business and his family’s livelihood, with all the concomitant savings to the NHS. So many of the people we spoke to told us stories like that; he was just one of them.

I was absolutely blown away by the incredible work done by that clinic, but, as has been pointed out, the care provided there is not universal and there are currently no national drivers to lower amputation rates across the country. It has already been stated that four out of five of these amputations are avoidable. I particularly liked the comment by the hon. Member for St Ives (Derek Thomas) that we should aim to get to a point at which amputation is seen as a failure rather than as a form of treatment.

My hon. Friend the Member for Dewsbury has quoted quite a lot of my speech. [Laughter.] So I will be brief. She referred to this, but it deserves repetition. In 2013, the Health Secretary committed to reducing the rate of diabetes-related amputations by 50% over five years. The amputation rate has in fact remained steady. Little progress appears to have been made towards the commitment. I do not think it does any harm to repeat that point and to hope for a response.

[Mr Jamie Reed]

My hon. Friend is making an excellent point. Does she agree that there is a regional dimension? There is a GP shortfall of 40% across the north of England. If the gateway treatment for type 1 and type 2 diabetes is through primary care and accessibility is limited in certain parts of this country, clearly, we will get much worse outcomes.

[Liz McInnes]

I thank my hon. Friend for that intervention. He is absolutely right. In my own constituency of Heywood and Middleton, I have also come across the problem of people being unable to get access to GPs. I am a member of the all-party group on diabetes and we have come across the problem time and again.

Patients have told the APPG that, when they first went to see the GP with the full-blown symptoms of diabetes, the GP took weeks to diagnose them. We have a real problem with GPs’ awareness of the condition of diabetes, even though it is common. Perhaps it is just the patients who come to our APPGs, but they all seem to come with the same tale, so perhaps there is a job of work to be done to standardise GPs’ education on diabetes.

We have touched on the subject of variations in care around the country. Because of the regional variations, far too many people are experiencing short and long-term complications, which can have a huge impact on their and their family’s quality of life. It is also very costly to the NHS.

I want to talk about a major clinical audit that is going on at the moment, the national diabetes audit, which measures the effectiveness of diabetes healthcare against NICE clinical guidelines and NICE quality standards in England and Wales. That audit provides an overview of the quality of diabetes care at national, clinical commissioning group, acute trust and GP practice levels. Through the collection of the data, the national diabetes audit can produce reports for a range of stakeholders to drive changes and improve the quality of services and health outcomes for people with diabetes.

Again, we see regional variations in participation in the national diabetes audit. The latest NDA report produced in January this year showed that participation in the audit had dropped to 57%; it is thought that that can be attributed to a change from an opt-out to an opt-in system for GP practices, plus variations in the ease of use of the three different IT systems used by GP practices. I am very disappointed to say that, in my constituency, which is covered by the Heywood, Middleton and Rochdale CCG, not one GP practice is participating in the national diabetes audit. It is really important that participation be improved; better data help CCGs to more effectively set priorities and evaluate improvements. If we are not collecting the data, there is no way we can plan for improving the outcomes for people with diabetes. NHS England should make participation in the national diabetes audit mandatory as an important step towards improving diabetes care.

Several Members have already talked about the importance of education. An important aspect of avoidance and prevention of complications of diabetes lies in educating diabetics to help them to better understand and therefore manage their condition. With 69% of diabetics saying they do not fully understand their condition, there is clearly a need for education to be made available and accessible.

As has already been pointed out, more than a third of CCGs do not currently commission specific courses for people with type 1 and type 2 diabetes, despite national guidance. In my own constituency, only about 20% of people with diabetes are offered a course, and the take-up is alarmingly low, at around 6% to 7%. One reason that people give for not taking up the offer of a course is that their employer will not give them time off to attend. There is a real job of work to be done to persuade employers that supporting their employees to attend the courses will have all-round benefits for the employer and the employee in terms of reduced sickness absence and a healthier and more productive employee.

I know that the Minister shares my interest in promoting diabetes education, which is key to preventing the major complications of diabetes. I am interested to hear her views and whether she has any plans to improve access to education.

15:06

[Ronnie Cowan (Inverclyde) (SNP)]

It is a pleasure to serve under your chairmanship, Mr Pritchard. I thank the hon. Member for Dewsbury (Paula Sherriff) for securing this debate.

I unashamedly turned to a much more informed source of information than me while putting this speech together. My sister, Linda Irvine, has been an insulin-dependent diabetic for 36 years. She knows the system inside out and has experienced the good and the bad of the NHS. In that time, she has seen many changes in the treatments provided. In 1980, she was fortunate to be diagnosed on what she considered the cusp of change. She had been subjected to horror stories of painful injections and severe restrictions in diet, along with a lack of understanding from doctors and nurses not familiar with the medical condition. In those days, injections were delivered in glass syringes with barbaric steel needles, which had to be kept steeped in methylated spirit and which obviously restricted away from home activities. Insulin was bovine or porcine and the peak effect of it was three to four hours after administration, making the timing of meals a bit of guesswork.

Shortly after my sister’s diagnosis, a new synthetic form of insulin, termed human insulin, was laboratory-developed. That made it cheaper to produce in larger quantities. From 1982, human insulin started to replace animal insulin as the primary treatment. It was developed further in the 1990s and now starts to take effect within 30 minutes of injection, making control of blood sugars more predictable. Syringes also became plastic, smaller and had finer needles: much easier to carry on you if you were out. Syringes have now been replaced by pre-loaded pens that are much more convenient and easier to draw up.

The introduction of insulin pumps is also an increasingly available initiative that Linda benefited from during her last two pregnancies, but she was unable to keep them because of an allergic reaction to the needle. She was not born lucky. Food was also a big problem in those days, with no light or sugar-free options on the market and diabetic drinks or biscuits available only in chemist shops. They were overpriced and frequently unpalatable. Nowadays, there are many options and most are readily available in high street stores.

We might think that nowadays it is all plain sailing, but unfortunately it is not. Diabetes complicates life immeasurably. It takes the spontaneity out of everyday activities, particularly with children and grandchildren. “Can we go to the park?” “Wait till I’ve checked my blood sugar.” “Can we go swimming?” “I need something to eat first.” “Why do we have to leave? We’ve only just got here.” “I’m due a meal soon.” On occasions, after she had injected, usually in a public toilet, and when the restaurant service was very slow, she would slip into a hypo. “Why are you sliding down the seat, mum, and heading for the floor?” It is not only mums who suffer from diabetes. All four of my sister’s children were able to dial 999 and tell the operator that she was diabetic by the age of three.

If we are leaving the house now, Linda carries a large bag with two insulin pens, needles, blood monitor, testing strips, lancets, a bottle of Lucozade—other drinks are available—and some kind of carbohydrate such as a packet of crisps or a sandwich to have in case her blood sugars go too low. She always carries a card explaining that she has diabetes and two emergency phone numbers in case she collapses.

Travelling abroad through different time zones can really complicate matters, too—not to mention the embarrassment of carrying syringes through airport security. As for dietary requirements on airlines—don’t go there. Of course, another area of concern is driving. As with most medical problems, insurance is always steeper and more complicated, DVLA requirements more stringent, and licences harder to acquire and keep.

What does my sister have to look forward to? The long-term problems of diabetes are well documented: cardiovascular disease, kidney damage, foot problems, eye disease, nerve damage, tooth and gum disease, thyroid problems, skin problems, constant infections and, unsurprisingly, mental health issues. It is therefore a cause close to Linda’s heart that the treatment of children with type 1 diabetes should be as up-to-date as possible, to ensure that their exposure to long-term problems is minimised.

Linda is now waiting for a kidney and pancreas transplant. Current research involves stem cell transplantation and chimera pigs where embryos are created with organs hopefully compatible for human transplant. Of course that is controversial and raises all kinds of ethical questions. But what if it was your child? What if it was your sister?

15:06

[Martyn Day (Linlithgow and East Falkirk) (SNP)]

It is a pleasure to serve under your chairmanship, Mr Pritchard. I congratulate the hon. Member for Dewsbury (Paula Sherriff) on bringing forward this timely debate. It is encouraging to hear such consensus across the Chamber today. She gave an informed and comprehensive presentation, and I was grateful to hear it. I speak, obviously, as a Scottish Member, and many things are devolved there, but the scale of the problem is remarkably similar in Scotland; 10% of our NHS budget is likewise devoted to treatment of preventable diabetes-related conditions, and those costs continue to rise, as has been noted for England.

I was somewhat shocked by the figure for the number of deaths, which I had not considered before. I am sure that that will strike many people. We think of the life-affecting changes that people go through, and the fact that lives are shortened, but not necessarily of the resulting deaths. The hon. Member for South Down (Ms Ritchie) summed things up in her short comment about the need for early intervention; she hit the nail on the head. That, undoubtedly, is what we need. I was impressed, also, by the remarks of the hon. Member for St Ives (Derek Thomas). I thank him for the figures he gave about the one in five heart and stroke-related admissions to hospital, and for what he said about costs, adaptations that are required, and effect on quality of life. It is important to consider those things together. One of the few optimistic comments that I have taken from the debate is the statistic that four in five amputations are avoidable. I hope that that message will get out to people.

I have not been diagnosed as diabetic, but my lifestyle is somewhat appalling, and perhaps I should get myself checked. Obviously people of both genders should be checked, but perhaps males in particular should take more care. Maybe there are lessons for other people. I was somewhat cheered by the comments of the hon. Member for Islwyn (Chris Evans). It made me slightly more optimistic to hear about the 40.2 inch waistline. I thought, “I’m a bit below that.” However, it does not fully mitigate the diet. I think perhaps that there are many others who will not consider 40.2 inches as a particularly large waistline. When we think about the connection to obesity, which is important, we tend not to think of ourselves as obese even when there is an issue. Several years ago, I was 6 inches bigger than I am now: I did not think I was large at the time. My mother, of course, always commented that I was, and she was probably proved correct. If those figures got through to the wider public they might think, “Yes, that does affect me”—or whoever they know who is in that position. It is important that people see that.

We can probably agree that diabetes is the fastest growing health threat of our time. That is certainly how it appears. The Scottish National party is committed to ensuring that in Scotland people with diabetes have access to the best possible care, and it aims to reduce the risks of complications. There have been a number of reports, an action plan in 2010 and an improvement plan in 2014. The statistics are very similar to those we have heard. One in 16 people has diabetes—diagnosed or undiagnosed. Since 2008 we have seen a 25% increase in the number of Scots with the condition, which accounts for 5.2% of the population. That is largely in line with figures from England and Wales. However, a more frightening aspect of the Scottish dimension is the fact that a further 500,000 are at high risk of developing type 2, and a further 1.1 million are at an increased risk as a result of their waist circumference. I am grateful that I now have a set of statistics to put that in perspective. That figure represents one in five adults, which seems typical, going by figures for elsewhere in the UK. Of course, the connection with obesity cannot be underlined strongly enough. Similarly, 80% of our NHS spending on diabetes is invested in treating avoidable complications—amounting to the same 10% of the budget.

One of the keys to avoiding manageable complications through diabetes is, as has been said, early prevention. Approximately 80% of complications in Scotland are estimated to be preventable, or can be significantly delayed through early detection, good care and access to appropriate self-management. That involves reaching the people who are at risk and supporting them in knowing the risks of poor diet and low levels of physical activity. Among the positive things that are happening are volunteer groups, including the Diabetes UK West Lothian group in my area, which supports people living with the condition through several different schemes. It has NHS support through St. John’s hospital in Livingston. Exercise groups are provided, and they include a session of seated exercise for people who have limited mobility. There is also a GP referral service entitling people to free or heavily discounted memberships at Xcite West Lothian gyms. Again, that is probably not well enough known about in my area and it could be taken up more. That is all part of the push to support people, and to further prevent complications arising from diabetes.

There is much we can agree on, and much good practice, as well as many frightening statistics out there.

15:06

[Justin Madders (Ellesmere Port and Neston) (Lab)]

I congratulate my hon. Friend the Member for Dewsbury (Paula Sherriff) on securing this important debate and on the eloquent and powerful way she set out the issues in her opening speech. Several hon. Members have echoed what she said, and I will no doubt repeat it to an extent. After just a year as an MP she has established herself as one of the most effective campaigners in this place, and she is a passionate advocate on a range of issues—particularly public health matters. She spoke of her visit to King’s College with my hon. Friend the Member for Heywood and Middleton (Liz McInnes), and described the excellent care there, as well as mentioning the fact that, sadly, that experience is not replicated throughout the country. She highlighted the cost of diabetes and described education as a missed opportunity to reduce complications. That is a theme that has come through in several of the contributions today.

I also want to mention the contribution from the hon. Member for St Ives (Derek Thomas), who made a powerful point about what kind of future the next generation is heading towards, if we do not put more focus on the issue now. He gave us constituency-specific figures on amputations. I wonder whether all hon. Members would be interested to find out the specific figures for their constituencies. They really bring the issue home. I agree with the hon. Gentleman that the matter should not just be left to CCGs, and that there is a need for more co-ordinated national support. He was also right to say that we should aim to reach the point where amputation is seen as a failure and an exception.

My hon. Friend the Member for Islwyn (Chris Evans)—I hope that is the right pronunciation of his constituency—

[Chris Evans]

Someone once said it as “insulin”.

[Justin Madders]

We could have been forgiven for making that error today, but we will talk more about pronunciation afterwards. My hon. Friend spoke with great sincerity about the benefits for children of taking part in sport, and about how once they get into it they can enjoy the physical activity. I know from experience that dragging kids off the Xbox can be a difficult challenge, but once they actually get out there they enjoy themselves, and that contributes to a healthier lifestyle. He also made a valuable point about the world of work, in that so many more jobs are now sedentary in their nature. Of course, a healthy workforce is a more productive one, and productivity is a challenge for the whole country.

My hon. Friend the Member for Heywood and Middleton spoke with great experience of health. It was great to hear that she had been inspired by her visit to King’s College. She spoke about the national diabetes audit, and the importance of using the data collected to drive improvements. Again, she highlighted the need for more education. It was interesting to hear that some of her constituents have difficulty attending some education courses because employers are not agreeing to give them the time off. It will be interesting to hear the Minister’s reflections on that and it comes back to the point about a healthy workforce being a more productive one. We really need to get that message across to employers.

The hon. Member for Inverclyde (Ronnie Cowan) spoke about his family’s experience and gave us a useful personal insight into the everyday challenges faced. We can all reel off the figures but hearing from someone who has had a close relationship with the condition for a considerable length of time brings home some of the practical challenges that people face.

There is a consensus, as the hon. Member for Linlithgow and East Falkirk (Martyn Day) said. All hon. Members acknowledge that diabetes is one of the most significant healthcare challenges, given the impact that it has on NHS resources and, more importantly, the impact it has on people. We heard very powerful details of that today.

To put the condition in perspective statistically, 45 people in the UK will have been diagnosed with diabetes in the time it takes to complete today’s debate. In that time, one person will have undergone a diabetes-related amputation and four people will have died prematurely due to diabetes-related complications. According to figures produced by Diabetes UK, there are currently 4 million people living with diabetes in the UK, of whom 549,000 are undiagnosed.

The number of people with diabetes is increasing, as various hon. Members have said, and it has more than doubled since 1996. More than doubling the number of people with any condition in 20 years is bound to lead to serious questions about how our society is operating. Indeed, several hon. Members have given some good examples of the challenges we face. Part of our role is to question and support, where possible, how the Government respond to those challenges, particularly when we are talking about something that can be preventable. The level of interest shown by hon. Members today shows that there is at least recognition and agreement that the issue demands significant attention.

The number of people with a diagnosis is huge, as is the cost to the health service. The NHS now spends about £10 billion on diabetes each year, which is equivalent to about 10% of its budget, and £8 billion of that is estimated to be spent on complications, which, as we have discussed, are largely avoidable. Diabetes is an important issue to tackle at any time but, when we have such financial pressures on the NHS, it becomes even more pressing to really get on top of trying to avoid the complications it can cause.

At the heart of the issue are the people involved. Although many are able to manage their diabetes effectively, it is still a life-changing condition that has an impact on those living with it on a daily basis. We heard from the hon. Member for Inverclyde about how it really has an impact not only on the individual, but on their family. For somebody with type 2 diabetes, managing their condition means learning how to treat it with diet and exercise, and possibility coming to terms with the need to take medication and insulin. For someone with type 1 diabetes, it means constant diet management and carefully working out the correct amount of insulin to take. However, for everyone living with diabetes, it means being aware of the potential complications that can occur, and keeping a careful watch not only on blood glucose levels, but on cholesterol, weight, blood pressure and the conditions of eyes and feet.

Put simply, living with diabetes means becoming an expert on the condition. Despite that, less than 2% of newly diagnosed individuals with type 1 diabetes, and just 5.9% of those newly diagnosed with type 2 diabetes, attend a diabetes education course, which is a theme that has been mentioned by various hon. Members. Those figures alone are disappointing, but they are even more so given that there is clear evidence that the courses reduce the risk of individuals developing complications, and given the fact that a worrying 69% of people say that they do not fully understand their diabetes. The very nature of the condition means that self-management is the only practical way to reduce the risk of complications.

We welcome the publication of the Government’s new improvement and assessment framework for CCGs, which will assess CCGs on the attendance of structured education schemes and on the NICE recommended treatment targets. Will the Minister tell us what steps the Government are taking to improve access to diabetes self-management education, what steps she envisages taking against CCGs that perform poorly in the improvement assessment framework, and what support will be available to those identified as poor performers in order to bring them up to what is considered best practice?

[Mr Jamie Reed]

Does the shadow Minister agree that some consideration ought to be given to the funding allocation for CCGs with particularly large concentrations of people with type 2 diabetes, which is, after all, linked to obesity and lifestyle, especially considering that obesity is increasingly statistically linked—there is a clear correlation—with the incidence of poverty and socioeconomic disadvantage? Does he agree that CCGs with those significant populations should have their funding allocation reviewed?

[Justin Madders]

I agree that that needs due consideration. In some written answers, the percentages of people with diabetes per constituency are shown, and there are some definite peaks and troughs. If we are to get the issue under control, we must think more strategically about where the resources are put.

At the moment, a third of CCGs do not commission specific courses, which is contrary to national guidance. I hope that the Minister will be able to tell us what she will do to try to end the current postcode lottery. One of the most convenient and effective sources of education for many people with diabetes is their local pharmacy. There is a need—possibly, a demand—for expanding the role that pharmacies play in supporting people with diabetes. What are the opportunities and possibilities for thinking again about the Government’s plans to slash the community pharmacy budget, which may lead to the closure of up to 3,000 sites?

More significant than the variation in education is the variation in the levels of care and support offered depending on location, the age of the patient and the type of diabetes. There is evidence of markedly different routine care throughout the country, which has a huge impact on the quality of life of diabetics, as well as being costly to the NHS. One in six people in hospital has diabetes, yet one in three hospitals has no diabetes specialist nurse. The national diabetes in-patient audit paints a worrying picture of the variations in the way in which the condition is managed by hospitals, and the unacceptable number of in-patients suffering avoidable complications.

Some of the most serious diabetes-related complications are avoidable amputations and foot ulcers. We have heard that £1 in every £150 that the NHS spends is in that area, and such action has a dramatic, life-changing impact on individuals and their families. As my hon. Friend the Member for Dewsbury said, in 2013 the Health Secretary committed to reducing the rate of amputations by 50% in five years. Will the Minister tell us what progress has been made towards achieving that goal, particularly given that Diabetes UK has said that no progress has really been made? Will she confirm that she still hopes to meet that target?

NICE recommends that all people with diabetes undergo an annual foot check but, in the worst performing CCGs, one in four people are not receiving a foot check at all. Part of the reason for that is the shortage in the number of podiatrists, particularly following a recent reduction in the number of students from 361 to 326. I am concerned that the plan to scrap bursaries for podiatry students and to push them into about £50,000 of debt will make the situation even worse. I ask the Minister to reconsider the direction of travel on this policy. Will she advise us what assessment has been made of the likely number of podiatrists who will be trained each year under the new funding regime?

I will close by making a few remarks about prevention. As I said at the beginning of my speech, the number of people suffering from diabetes continues to rise. The primary driver of that is, of course, lifestyle. Some 11.9 million people are currently at an increased risk of developing type 2 diabetes as a result of their waist circumference or weight. Two in every three people in the UK are now overweight or obese. As other Members have said, people might not necessarily feel that that relates to them, but we must reflect on those figures. Obesity accounts for 80% to 85% of the risk of developing type 2 diabetes, and therefore we need to focus on education and treating the condition. The main strategy to address the prevalence of type 2 diabetes has to be to address the rise in obesity, particularly at a young age, as the hon. Member for St Ives said.

We welcome the Government’s announcement of a sugar tax in the Budget, but that measure will only be effective as part of a wider strategy to address childhood obesity. I do not know whether the Minister will be able to tell us, but what is holding back the publication of the strategy? Is there disagreement on what will be in it? Is it at all possible for her to give us a date for when it will be published? [Interruption.] I suspect I have my answer from the grin on her face.

Both sides of the House are alert to, and supportive of, the need to get on top of this challenge but, as with all such matters, the Government will be judged by the results, on which we will keep a close eye in the coming years.

15:06

[The Parliamentary Under-Secretary of State for Health (Jane Ellison)]

It is a pleasure to serve under your chairmanship, Mr Pritchard. What an excellent debate we have had, and I thank the hon. Member for Dewsbury (Paula Sherriff) for securing it. She is a passionate health campaigner and has made her mark in a very short time in the House. This is the second time I have seen her today, as I gave evidence to the Select Committee on Health this morning. It is excellent to see so many colleagues from both sides of the House in the Chamber today.

Diabetes-related complications are a vital issue and, sitting here, I agreed violently with much of what was said about the scale of the challenge, the need to step up and, indeed, some of the things that we need to do. I hope to use my time, as much as possible, to update the House on practical measures that the NHS and the Government are taking, as well as to hint, where I can, at policy yet to come. There is more to be said later in the summer on some areas. One reason why it is so important to have such debates is to keep up a drumbeat of discussion. One thing I have realised as a Minister is that momentum is a funny thing in politics.

[Mr Jamie Reed]

It certainly is.

[Jane Ellison]

I make no comment. Political momentum is important because it drives change in a way that is hard to pin down. We now have momentum on obesity and diabetes in a way that we did not a few years ago. The level of interest in this House is a good measure of that, so it is vital that we have such debates. It is also a measure of how seriously we take diabetes that we have included reducing diabetes care variation and preventing diabetes in the NHS’s mandate—it is right at the heart of our big asks of NHS England.

Before I continue, I take this opportunity to pay tribute to the many NHS staff who provide invaluable support to patients. Inevitably, in a debate where we are rightly stress-testing the system and asking where we can improve, it is easy to forget that masses of people out there are doing brilliant work. We have heard inspiring words today from two colleagues about their visit to see real specialists in action. Across the country there are people supporting patients with diabetes. There are also excellent third sector organisations such as Diabetes UK, with which we work closely, and JDRF, which does such great work on type 1. They both work with and independently challenge the Government, all with the aim of improving the lives of those with diabetes or at risk of it.

[Paula Sherriff]

Although I appreciate that the Minister undoubtedly has an incredibly busy schedule, I encourage her to contact the diabetes foot clinic at King's College hospital in London to arrange a visit. As my hon. Friend the Member for Heywood and Middleton (Liz McInnes) said, our visit was inspiring. I came away with much knowledge and real hope that we can make improvements.

[Jane Ellison]

I sat here thinking how interesting the visit sounded. My team has made a note of that. We had heard about the visit and how it had gone well, so it is great to hear that first-hand from the hon. Lady.

I will not repeat the shocking facts on diabetes, which have been well rehearsed and explained by Members in this debate, but suffice it to say that the impact is huge. My hon. Friend the Member for St Ives (Derek Thomas) and others have made notable contributions drawing out the human cost of diabetes. People tend not to understand how devastating diabetes can be for patients and families, as well as the cost to the NHS, which in England we estimate to be £5.6 billion a year.

We have to work together to address diabetes. Before I talk about the action we are taking now and the progress we need to make, it is worth noting that we have come a long way. I have discussed that in some detail with our national clinical director, Dr Jonathan Valabhji, over the past year. The progress we have made through the quality and outcomes framework over the past decade has driven a step change in delivering better management and care for people in GP practices. Last year’s National Audit Office report showed that the relative risk of someone with type 1 or type 2 diabetes developing a diabetes-related complication has not changed, and indeed has fallen for most complications, despite the growing number of people with diabetes, so we have made progress. Clearly, the question now is how we can go much further. Diabetes is a key priority for us, and we want to see a measurable difference in the lifetime of this Parliament. There are four main areas in which we are taking action.

[Mr Jamie Reed]

Before the Minister moves on to the progress that is being made—she is right that we have come a long way over the past 10 years—will she undertake that the Department will consider not just the cost to the NHS of all diabetes-related complications, because we have been talking about this from a very NHS-centric point of view, but the cost to the economy of such complications?

[Jane Ellison]

We have been preparing and working on the childhood obesity strategy for some months, and I assure the hon. Gentleman that we have been looking at the wider cost to society and, obviously, projecting that forward, as has been done by many other economies in the developed world. There is an interesting piece by the McKinsey Global Institute on the cost to the developed world.

Specifically in the NHS, and going to the heart of the debate, there are four main areas in which we are taking action that we expect to deliver reductions in complications: reducing variation in the delivery of the three NICE treatment targets for blood pressure, blood glucose and cholesterol control; improving the take-up of structured education; improving foot care; and improving in-patient care. Reducing variation is always a theme of health debates and, frankly, it is a constant challenge in any system. The question is how we drive out variation, and Members have made a good point about how we support people to drive out variation. One of our goals for 2020 is a reduction in such variation in the management and care of people with diabetes.

The newly established CCG improvement and assessment framework has been mentioned by a number of Members. Diabetes is one of the clinical priorities in that framework, which will play a key role in delivering the challenge to variation. The chief executive of Diabetes UK is the chair of the panel of independent experts who are involved in the assurance process for that rating system. Diabetes is high on the IAF agenda. The framework will identify CCGs in need of improvement, and then NHS England will work with those CCGs to identify the nature of the changes needed and the type of support required to facilitate those changes.

To give some idea of the support available, we will be working with CCGs to consider the nature of the tasks they need to address. A key focus will be to help CCGs to map how their services compare with those in similar areas, to help them look at best practice from which they can learn and to introduce specific peer support through other programmes. CCGs will be supported in practical, hands-on ways. As we build the data picture of what is going on, we obviously need to support CCGs as they discover that they have variation, of which they may not even have been fully aware.

There are other areas not covered by the IAF that the Public Health England “Healthier Lives” website addresses. I encourage people to look at the vast amount of publicly available data for their local area. NHS Right Care is an important programme that has reducing variation at its core, and it is there to help CCGs and other partners to make step changes in the way they improve care. It will be very focused on diabetes care, and it has been improving services. It will be rolled out to all CCGs over the next 18 months, with practical support and sharing best practice at its heart.

The hon. Member for Heywood and Middleton (Liz McInnes) and I have discussed structured education, and I share her frustration. Essentially, we know that structured education works and that it is being offered to far more people, but that take-up is low. We cannot keep doing the same thing; we must look at things differently. For example, working people with diabetes straight away pose a challenge involving the amount of time that they can take to attend a course. We want to improve take-up. We know that structured education makes a difference to people’s quality of life and, importantly, reduces their risk of developing complications, but we also know that we are not where we need to be.

It is one of my personal priorities to change that. The Department is working with NHS England and Diabetes UK on ways to improve the take-up of structured education, particularly by considering more diversity of provision through digital and web-based approaches, as well as what can be done to improve access to more traditional forms of support. Again, the improvement and assessment framework includes an indicator for the number of newly diagnosed diabetes patients who attend a course. However, we have to make it possible for CCGs to refer people to a course that they think is likely to be taken up. There is something in why such courses are not commissioned as much as they should be: people are aware of low take-up and it is a vicious circle. We need to address that. Next week, an expert round table is taking place with the national clinical director. It will consider options to update structured education, potentially including working with employers, and practical actions that we can take to overcome barriers. I expect to be able to say more about it in due course.

We regularly discuss improving foot care. Particularly for people with late-stage diabetes, it is a challenge and a threat, for reasons that have been well explained. The number of amputations is unacceptably high, and we want to reduce it. NHS England is working with a number of key stakeholders to publish a new framework to improve the delivery of hospital-based diabetic foot services. The framework makes it clear that all patients with diabetic foot problems should have rapid and equal access to services, and describes for commissioners what key elements are in place that they need to commission. The new national diabetes foot care audit provides data on all diabetic foot care services so they can measure their performance against the NICE clinical guidelines.

I note the concern expressed about the survey and the lack of take-up. NHS England is taking action on the issue of GP participation, but I might ask NHS England to write directly to the hon. Member for Heywood and Middleton to say specifically what it is doing, because I share her concerns about having the fullest possible picture. Again, transparency of information, along with improvement support through initiatives such as Right Care, will drive improvement. Interestingly, the variation on amputations does not follow many of the traditional patterns in terms of the burden of disease that we see in some other areas. We need to be able to examine the information at quite a local level, as support for patients is variable even within local areas, and we must expose that.

On inpatient care, the NHS’s focus is on ensuring that all hospitals have inpatient specialist teams to assess and help to manage inpatients with diabetes. Again, if we get that right, it can lead to a significant reduction in complications.

I will say a few words about prevention, as it is at the heart of any public health Minister’s agenda. Preventing people from developing type 2 diabetes in the first place helps to take them off the conveyor belt that can lead ultimately to complications and all the burden of disease that we have been discussing. At all points along that conveyor belt, there are things that we can and must do, and are doing, to make life better for people with diabetes. For example, I welcome the increasing focus of our major charities on prevention and explaining the role of prevention in fending off some of the most serious diseases from which people suffer.

Healthier You, the NHS diabetes prevention programme, goes to the heart of tackling the rising prevalence of diabetes. Around 90% of adults with diabetes have type 2, and an estimated 80% of cases of type 2 are related to lifestyle; as Members have said, it is a huge factor. The national diabetes prevention programme is, we think, the first at-scale diabetes prevention programme to be delivered anywhere in the world. This year it will refer at least 10,000 people to an evidence-based behaviour change intervention that has been proven through randomised controlled trials to reduce the risk of type 2 diabetes.

I can confirm that the programme will be made available to up to 100,000 people by 2020. I know that there is great interest in it. We are learning from the seven demonstrator sites, which tested different approaches over the past year. Although the nature of the intervention is essentially common, there are different ways to deliver it, and we have learned a great deal. We are taking a phased approach, and the first wave of 27 areas covering 26 million people, or half the population, will open their doors to patients in the next few months and throughout 2016.

We are building up at pace. The interventions offer tailored, personalised help to reduce risk, including education on healthy eating and lifestyle and bespoke physical exercise programmes. If there is one thing that I ask of Members, it is to encourage their constituents to attend their NHS health check when invited to do so, as it is one of the gateways into the national diabetes prevention programme.

Of course, that is only part of a wider public health programme of preventing disease in the first place. Members have mentioned children. It is absolutely right that we should go way upstream to consider what we can do to tackle overweight and obesity in children. We will be launching our childhood obesity strategy in the summer. It will examine everything that contributes to children becoming overweight and obese and set out what can be done by all. We are looking at the entire environment around a child, so everything that Members have said that they hope will be considered as part of the strategy is being considered.

All parts of society, the public health system, Government and local government and industry have a part to play. The soft drinks industry levy announced by the Chancellor in the Budget is an important first step, and it has turbo-charged our discussions on the childhood obesity strategy. Its introduction in 2018 is driving reformulation of product, which every expert identifies as a key way to tackle obesity at population level. That is why there is a delay. I cannot comment in detail, but I assure hon. Members that we care about the same things that they do, and that all are being considered extensively.

[Mr Jamie Reed]

There are approximately 500,000 type 1 diabetics in the UK. Will the Minister undertake to ensure that continuous glucose monitors, flash glucose monitors and other emerging diabetic technologies are made available as a right on the NHS for people with type 1 diabetes?

[Jane Ellison]

Yes, I should say that many of my remarks have addressed type 2 diabetes, but that is not to say in any way that type 1 is less important. I will undertake to write to the hon. Gentleman on that, because there is work going on. As I said, many of my comments have dealt with type 2, but that is not to say that we are not also interested in addressing the challenges of type 1.

I am hugely heartened by the continuing parliamentary interest in this important subject. We will introduce the childhood obesity strategy and I have described all the other work on diabetes. It is good to know that there is so much parliamentary support from all parties for doing more, and particularly on investigating how to prevent diabetes from developing, to ensure that the next generation does not carry the same burden of disease as this one. It is a big challenge, but an unprecedented level of activity is taking place across our health system and the wider public health system, and in government at all levels. I look forward to updating Parliament further.

Question put and agreed to.

Resolved,

That this House has considered diabetes-related complications.