NHS: Diabetic Services

Lord Harrison Excerpts

Thursday 29th November 2012 Lords Chamber

Moved By

[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.

--- Later in debate ---

[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.

Motion agreed.