Melbourne Declaration on Diabetes

Lord McCrea of Magherafelt and Cookstown Excerpts

Wednesday 18th June 2014 Westminster Hall

[Mr Jamie Reed (Copeland) (Lab)]

It is, as usual, a pleasure to serve under your chairmanship, Dr McCrea, and it is a pleasure to follow the hon. Members for Torbay (Mr Sanders) and for Strangford (Jim Shannon). The hon. Member for Torbay, in particular, has been making a superb contribution across this entire policy area for many years. As someone who is also “blessed” with type 1 diabetes, I look to him for inspiration, and he readily provides it on a regular basis. I cannot thank him enough for introducing a debate in this House on this subject yet again. His work as chair of the all-party group on diabetes, as president of the Parliamentarians for Diabetes Global Network and in the Global Parliamentary Champions for Diabetes Forum is commendable. His position and work there mean that the UK can be a world leader in ensuring high-quality treatments and support for those with diabetes. I am very sincere in all those comments. They are heartfelt.

The hon. Gentleman spoke on this subject in April, in a debate to which I contributed. He raised some very important issues, not least of which was the importance of an approach that respects the distinction between causes and treatments of type 1 and type 2 diabetes. In opening today’s debate, he has again raised matters of the utmost importance and concern, which I will also touch on.

The Melbourne declaration on diabetes was formally adopted on 2 December 2013, as we have heard, at the first Global Parliamentary Champions for Diabetes Forum. The declaration contains eight action points for parliamentarians, including encouraging the creation and adoption of a national plan that acknowledges that diabetes is a national health priority and that leads to action. I will focus my remarks today on the need to create an action plan. I hope that the Minister, whom I welcome to her place, can confirm that the Government are committed to that, especially given the clear will of parliamentarians from those parties that have contributed today, although I know from discussions and conversations with colleagues right across the House that there is a clear understanding of the need to support an action plan as a way forward.

There are more than 380 million people with diabetes in the world, and that figure is expected to reach almost 600 million by 2035. That is deeply worrying. In the UK, 3.2 million people are living with diabetes. That includes almost 35,000 children. One pound in every £10 spent by the NHS is spent on treating diabetes and the complications that arise from it. We have heard an awful lot about the economic and financial modelling of the effects of diabetes on the NHS. I think that we need to spend more time on that as a country. Diabetes UK says that diabetes is responsible for 20,000 premature deaths each year, and that 80% of cases of type 2 diabetes could be prevented or delayed. Let us just think about that: 80% of cases could be prevented or delayed. The financial savings that we could make, irrespective of the improvements that we could make to the lives of those people who go on to develop type 2 diabetes, are phenomenal.

We must always be aware of the distinction between type 1 and type 2 diabetes. Type 1 is a chronic, life-threatening condition that affects 400,000 people in the UK, including 29,000 children. Type 1, as we have heard, is not caused by lifestyle factors such as obesity, lack of exercise or poor diet. I should know, and I never resist the temptation to remind people that I did the London marathon earlier this year. Thanks go to the Juvenile Diabetes Research Foundation, if its representative is in the room. I want to do it again next year, by the way. Whereas those with type 2 diabetes can sometimes be treated with a change in diet and exercise and modest medication, those with type 1 diabetes need multiple insulin injections or pump infusions every day. I did mine before the debate started. My blood glucose level was 14.7, which is not particularly good—I will be getting told off for that.

Each year, a person with type 1 diabetes will undertake more than 2,000 finger-prick blood tests, have 1,500 insulin injections and count the carbohydrates in more than 1,000 meals. It is clear that any action plan will have to develop coherent and effective strategies for both conditions. A one-size-fits-all strategy simply will not do, so I hope that the Minister can reassure us today that she will not be cutting corners. Any plan must be workable and tailored to meet the specific needs of both conditions.

Diabetes UK has done excellent work, as always, on this matter. Its briefing in advance of today’s debate was superb. It endorses the view that there is a clear need for a national action plan. It has identified five key areas that must be included. Those are improvement in support for self-management; integration of care; improving safety; a focus on children and young people with diabetes; and prevention of type 2 diabetes. I am sure that if the Government introduced a comprehensive action plan built on those five principles, it would receive the support of the entire House.

Starting with self-management, it is obviously crucial that individuals and their families can successfully manage their condition, and the keystone of that is effective care planning and education. Positive care planning and strong education can ensure that an individual is equipped with the tools and resources needed effectively to manage their condition. Diabetes UK calculates that each year, care in a clinical setting totals about three hours, whereas self-care accounts for almost 9,000 hours. Improving self-management is not optional—it is absolutely essential. I appreciate that it could be culturally difficult for us to achieve that as a Parliament and a country, but it is something we absolutely need to crack.

Opposition Members have long advocated the benefits of integrated care across the whole NHS. With diabetes, a person will routinely have contact with many parts of the wider health care system, such as primary, community and secondary care. To improve integration, Diabetes UK has identified five key points that would, in effect, provide an integrated diabetes care pathway. Such a pathway would require strong networks of clinicians, commissioners and patients, a more integrated system of commissioning services, better information-sharing across services and the improving of skills in primary care, all of which should be overseen by effective clinical governance. Those actions are not out of reach, and the Government could easily ensure that they are part of any action plan.

The third point I want to cover is patient safety. There are major issues regarding the safety of in-patients with diabetes in hospitals. According to research undertaken by Diabetes UK relating to the past year, about 40% of in-patients experienced at least one medication error, more than a fifth experienced one or more hypoglycaemic episodes and fewer than a third were seen by a member of the diabetes team. Those problems can, as the hon. Member for Torbay said, contribute to patients with diabetes having to remain in hospital more than three days longer than patients without diabetes. Again, we should consider the cost implications for the health service in these tough times. Any plan the Government introduce must surely address that, because it is bad for patients, clinicians and the health service.

There must also be space in the Government’s plan to address young people’s experiences. There are 35,000 children with diabetes in the UK, which has the fourth highest number of children diagnosed with type 1 diabetes in Europe. Many children and young adults experience a marked deterioration in their care as they make the transition from children’s to adults services. Adolescence is often a time when many lifelong behaviours are established, including those that are health-related, so it is essential that young people can complete the transition at a time that is right for them. A deterioration in care and a forced transition have been shown to disengage young people from the service, resulting in worse outcomes and complications. There is an acute need to address that.

In the last debate on this issue, in April, I referred to support and education for young people, which are key to ensuring that they can manage and cope with their condition. Being diagnosed with any form of diabetes can be overwhelming if the proper support is not in place.

My next point relates to a focus on preventing type 2 diabetes. Recent reports by the British Medical Journal have shown that a third of adults have higher than normal blood glucose levels, which is an indication of pre-diabetes, and many health professionals project that there will be a huge increase in the numbers of those with type 2 diabetes. I am sure that that worries policy makers on both sides of the House, whether on the left or the right or in the centre. As I said, any action plan must take into account the differences between type 1 and type 2. Critically, any strategy for type 2 must be based on prevention.

I would be grateful if the Minister could outline what the Government are doing on the points I have raised, and I would expect her to be able to give us some indication of when they are likely to introduce a plan to address the issue. Given the importance of such a plan, I hope she will make a statement to the House when any plan is published, to give Members who are not present the chance to scrutinise the Government’s proposals. Indeed, I would go further. Every time we have such a debate, it strikes me that there is a real wealth of experience and understanding of these issues across the House. It would, therefore, be a tremendous gesture—not for its own sake, but from the point of view of those living with this condition—if Members who understand type 1 and type 2 diabetes were allowed to contribute their knowledge and experience to the production of a better plan that would better suit those with this condition.

Through the Melbourne declaration, the International Diabetes Foundation makes the incredibly important point that

“disadvantaged people in every country carry the greatest burden”

with regard to diabetes. That is important when looking at the levels of clinical care for diabetics across clinical commissioning groups throughout England. Speaking to diabetics around the country, I have seen for myself that if we are to make self-management as effective as it can be—we have a long way to go on improving not only the culture but the clinical ability of CCGs and other primary care providers regarding self-management—we must make a concerted effort to look at the literacy and numeracy of some of the people with this condition. Every day, before every injection, people must undertake a fairly simple and routine mathematical calculation of their insulin to carbohydrate ratio, but many of them simply cannot do the maths. There is no assistance, tool or device on the market to help them make those calculations simply, so we need to look at that, because it is a big cultural issue. There is an issue with not just numeracy, but literacy, and there are also issues about social exclusion, which I am sure we are all aware of. We need to put some time and effort into understanding and resolving those issues if we are properly to increase self-management among diabetics.

NHS England published “Action for Diabetes” earlier this year, but Diabetes UK said that it was not sufficient and did not present a comprehensive strategy or action plan. I have read it, and I think that is a fair comment. Diabetes desperately needs a national service framework—there are no two ways about that. The service around the country is incredibly patchy when it comes to not just the nine key diabetic tests, but other diabetic support services. Perhaps the Minister can tell us how the Government will ensure that CCGs step up to the plate. We really need a detailed plan, and I hope she can tell us when one will be introduced.

Will the Minister also tell us how many diabetics are missing their checks? That information should be understood and collated centrally, because the issue is of strategic national clinical importance. What are the clinical and financial effects on the service of people missing their appointments? We are failing people with diabetes, and that did not begin in 2010.

I touched earlier on self-management, which is incredibly important, but so are innovation and the use of data. For me as a type 1 diabetic, the most important issue in managing my condition is having access to data about it, such as my blood glucose readings and my insulin ratios. We need a framework and a strategy for medical innovation that incorporates diabetes research—from not just a scientific point of view, but a patient’s point of view—in a profound way. How can we become the best country in the world, in terms of medical companies and other pharma-based industries developing new and innovative ways of treating diabetes?

I wear all sorts of devices to monitor my fitness and my sleep—whether it is a Jawbone, a Misfit Shine or a Nike fuelband, believe me, I have them all. The data they capture about the individual is of incredible medical importance. We need, on a cross-party basis, to establish a strategy under which this country can genuinely innovate and become a global leader, with a view to enabling companies to produce the best suite of devices, applications and so on to assist in dealing with type 1 and type 2 diabetics. I look forward to the day when my data can be captured in real time and shared with my GP and my pharmacist, so that I do not have to phone up, text or e-mail to get my insulin prescription. My GP and my pharmacist will have the information and the algorithm, they will know when my prescription needs to be ready and how much I am using, and my doctor will know how I manage my condition. We can hothouse innovation—my office and I are doing an awful lot of work on this—but we need to make that innovation part of not only a national diabetes strategy, but a biotech and medical innovation strategy.

Finally, I say to the Minister that we are here to help. Will she please use the experience that exists across the House and not miss this opportunity to act?

[Dr William McCrea (in the Chair)]

Before I call the Minister, I want to mention that several Members have apologised for not attending because they are taking part in another debate. They wanted to be here and asked me to pass on their apology to the hon. Member for Torbay (Mr Sanders) and the Minister.

--- Later in debate ---

[Jane Ellison]

I want to discuss another area in which we can make a difference by empowering patients. Colleagues might be interested to hear about the patient experience of diabetes services survey, part of the national diabetes audit, in which I know there is always great interest in the House—we regularly answer a number of parliamentary questions about it. The survey measures the health care experiences of people with diabetes in England and Wales. It collects information online from people with diabetes by asking questions about their care using a short, validated questionnaire, and it is being tested.

Any diabetes service in England and Wales should be able to use the survey to get feedback from patients. We want to publish the first results this month or this summer. That is going to be an interesting extra tool in the box, not only to help to drive excellence and drive out variation, but to empower local services to understand at a local level what is going on and how satisfied their patients are with the service being provided. That can lead only to upward pressure to improve services, not least from patients.

Let me talk a little about the NHS health check programme. Alongside the work being done by NHS England to improve the management and care of people with diabetes, the Government are working on prevention and earlier detection, which all Members mentioned. We are continuing to roll out the NHS health check programme, which identifies those aged between 40 and 74 who are at risk of diabetes and other vascular diseases and helps them to reduce that risk. More than 15 million people are currently eligible for an NHS health check. Our economic modelling has shown that the programme has the potential to prevent more than 4,000 people a year from developing diabetes and to detect at least 20,000 cases of diabetes or kidney disease earlier. It is all about helping people to better manage and improve their quality of life.

In the past year, almost 3 million NHS health check offers were made and almost 1.5 million appointments were taken up, during a time of great change across the health system. We are now looking to challenge the system to go further and faster and to continue to increase the number of people who participate in the programme. I have been out and about and seen some great local initiatives. I visited an NHS health check team in Southwark and witnessed the important conversations they were starting with people in their local area.

Another example is Bolton, where health trainers have worked with 134 people identified as being at risk of diabetes through the NHS health check. The health trainers have supported people to make lifestyle changes such as eating more healthily and increasing physical activity levels, and they have helped almost half the group to return their glycaemic level to normal. That is really good evidence of effective intervention.

In Tower Hamlets, where more than 50% of the population are from ethnic minority groups, the prevalence of type 2 diabetes has been growing rapidly. To help to combat that, Tower Hamlets has incorporated the health check programme into its managed practice network scheme. I have talked to staff about that and heard about how they are approaching it. Tower Hamlets has worked hard to ensure that all diabetic patients have a care plan, and that focus has resulted in a 70% increase between 2009 and 2012. There has also been a lot of focus on the take-up of retinal screening for people with diabetes, and, again, there has been a significant rise.

We are seeing that such local interventions can really work. I firmly believe that a localist approach is important in some of these areas, because there is no one-size-fits-all approach that we can devise in Westminster that will work for every community. Such local innovations are important. I constantly challenge myself to think about how we can ensure that we spread the word about some of this great local action. We have started initiatives in that regard, but Parliament has a great role to play, and I encourage Members to tell us of effective local initiatives, so that we can spread the word.

Research on the NHS health check programme carried out by Imperial college London and Queen Mary university of London is under way. That research will improve our understanding of who is taking up the opportunity, their risk of cardiovascular disease and the incidence of diseases such as diabetes in those groups. When that work comes back, it will help us to understand how we can make those interventions count more.

We have already talked a little about obesity and sedentary lifestyles. Physical activity is a big priority of this Government, and I have had a couple of meetings in the past couple of days alone on the cross-Government action we are taking to try to hardwire physical activity into all aspects of life. We have a long way to go yet because, for too long, physical activity was left in a silo marked “health” when it is more important than that. We know that all parts of local and national Government need to address inactivity; that is one of the factors that can help to prevent diabetes.

I also want briefly to address the responsibility deal. The Government have been working with business—the hon. Member for Strangford mentioned this—on its responsibility to consider calorie reduction and clearer labelling of food. We are starting to see calories and other contents displayed on the packaging of many more foods, as we roll out consistent food labelling on a voluntary basis across the country.

The Change4Life social marketing campaign, which is one of Public Health England’s flagship programmes, is encouraging individuals to make simple changes, and it is trying to work with people in the way that the shadow Minister mentioned. The campaign is trying to talk to people in language that makes it straightforward and easy for them to understand the good choices they can make for the health of both themselves and their family.

The national child measurement programme’s findings on childhood obesity are encouraging. We know that far too many people are overweight and obese, but we are seeing signs of encouragement. In 2012, childhood obesity rates fell for the first time since 1998, so we must not despair over the actions we have all taken and advocated over many years. We are beginning to see that such action can have an effect, but we must never underestimate how far we have to go.

In 2013, the global burden of disease study showed that the UK has the lowest rates of early death due to diabetes of the 19 wealthy countries included in the analysis. The last data on diabetes care showed a 60% completion rate for all eight care processes recommended by the National Institute for Health and Care Excellence, which is a five percentage point improvement on 2010. We see progress, but we know there is much more to do. The Melbourne declaration is a timely reminder of the serious threat posed by the disease across the world, as well as here in the UK. I assure the House and my hon. Friend the Member for Torbay, who led this debate and leads the all-party group in such an exemplary way, that diabetes is a priority on which we continue to work hard. We are pleased to see progress, but we do not underestimate how much more there is to do. Such debates are welcome opportunities to keep the issue firmly on Parliament’s radar.

[Dr William McCrea (in the Chair)]

Mr Sanders, we still have a few moments. Do you want to make a few closing remarks?