Diabetes

Adrian Sanders Excerpts

Wednesday 9th January 2013 Westminster Hall

[Mr Adrian Sanders (Torbay) (LD)]

It is a pleasure to speak under your chairmanship, Mr Crausby.

I want to put on the record the difference between type 1 and type 2 diabetes, although the debate is about diabetes more generally. Type 1 diabetes develops when the body’s immune system attacks and destroys the cells that produce insulin. As a result, the body is unable to produce insulin, which leads to increased blood glucose levels and in turn can cause serious organ damage to all organ systems in the body. About 15% of people with diabetes in the UK are type 1s. I wish to declare my interest as someone who was diagnosed as type 1 nearly a quarter of a century ago, and I am still here. Type 2 diabetes develops when the body does not produce enough insulin to maintain a normal blood glucose level or is unable effectively to use the insulin produced. The long-term complications that challenge both type 1 and type 2 sufferers are much the same.

Diabetes remains one of the largest challenges to our health care system, with about 3.7 million sufferers in the UK; almost 1 million more are estimated to have the condition, although they do not know it. The numbers are expected to rise, which all makes for a significant challenge to the NHS, with an estimated spend of £10 billion a year on diabetes-related treatments. Much of that spend is unnecessary: people with the condition far too often suffer from late diagnosis, preventable complications and variations in care; they are often overlooked for specialist care when being treated for other conditions, particularly as in-patients; and they can be prevented from accessing treatment by the short-term financial ethos embedded in some primary care trusts.

None the less, we have made progress in recent years. I pay particular tribute to my right hon. Friend the Member for Sutton and Cheam (Paul Burstow) and the former ministerial team for the open and constructive way in which they pursued the issue and ensured that diabetes remained a high priority during the stormy times of NHS reform. The all-party group on diabetes, which I chair, has already met the new Minister, and I am confident that the good progress will be sustained, if not surpassed. I am already heartened by the new Secretary of State’s pledge to focus more on patient outcomes and the patient experience. Let us hope that that intention manifests itself in clear instructions for managers and commissioners.

One of the priorities on which Ministers can have a direct impact is the promotion of leadership by the Department of Health. In recent years, a problem has arisen from the apparent inability to disseminate best practice around the UK and the unwillingness of some NHS organisations to implement it.

[Keith Vaz (Leicester East) (Lab)]

I pay tribute to the hon. Gentleman for all his amazing work on diabetes over his parliamentary career. As he has done, I have tabled questions to ask simply how high the spend on diabetes was in individual PCTs last year, only to be told that the information was not available and so could not be given to me. Is not that kind of information vital for an effective strategy on diabetes?

[Mr Sanders]

That would certainly be extremely helpful and would complement the atlas of care by, in a sense, putting the actuality into the story behind the figures. It is extremely unhelpful not to be able to drill down to what is really happening on the ground; we could do that if such statistics were available.

Some of the problems of disseminating information have been offset by the work of NHS Diabetes. It has been instrumental, first, in monitoring variations in care and driving the collection of more robust data, which has culminated in an extremely important publication, the national atlas of variation; and, secondly, in working tirelessly to rectify the problems it uncovers, linking national policy intention with policy implementation on the ground, including support targeted on where the greatest improvements are necessary. It is important that that work continues, as much more could be done. I hope that the Minister will reassure me that, despite the upheavals in the commissioning architecture, NHS Diabetes will retain its central role.

[Rehman Chishti (Gillingham and Rainham) (Con)]

I, too, pay tribute to the hon. Gentleman for his fantastic work as chairman of the all-party group on diabetes. Does he agree that there need to be performance targets, like those for cancer, stroke and heart disease? At the moment, there are not the mandatory performance targets for diabetes that there are for those other diseases.

[Mr Sanders]

I am grateful to the hon. Gentleman for making that point. When one puts together speeches, they sometimes go on too long, and I had cut out that bit, so I am glad that he has raised it. The big issue is that the cause of death is sometimes recorded as stroke or heart disease when the underlying problem is diabetes. We have targets for cancer, heart disease and stroke. We really ought to look at diabetes as the root cause of other conditions for which there are targets.

The variation in care across the country is probably the largest worry for patients now, and the new implementation plan should focus on that. Failings in diabetes care cause an estimated 24,000 premature deaths each year. In 2001, the Department of Health published the national service framework for diabetes, which set out clear minimum standards for good diabetes care. Those standards include nine basic care processes that aim to end preventable complications by looking for early warning signs. Despite those targets, much of the country has seen little progress towards improving detection of type 2 diabetes and reducing the number of preventable diabetes complications. In 2009-10, results from the national diabetes audit showed wild variations in inputs and outcomes for both type 1 and type 2, including the astounding figure that the proportion of type 1s receiving the recommended nine care processes ranged from as low as 5% to 50%, with an average of 32% in England. The figures were only marginally better for type 2s. It really is not good enough.

The point about the condition is that people treat themselves 364 days a year and see a practice nurse or sometimes a general practitioner—more rarely, these days, a consultant—only once a year, although they should receive the nine care processes. The chance of developing diabetic complications can be reduced by keeping blood pressure, blood glucose levels and cholesterol levels low. Regular monitoring, backed up by periodic checks, is the key. The results from the national diabetes audit demonstrate that more needs to be done to end the postcode lottery of care for people with the condition. When as few as 5% of people with type 1 diabetes are receiving all nine care processes in some areas, there is a definite failure of care. If all health care trusts followed the national service framework, such complications as blindness and kidney disease—as well as stroke, heart and other diseases—could be prevented.

I hope that we will explore a range of best practices, but I want to highlight a couple that have scope to bring immediate improvement at very little cost. An acute issue is the provision of insulin pumps for type 1s. That is an example of where the UK should look abroad for best practice. Type 1s in other developed countries, such as France, Germany or the US, can expect to benefit from a pump if that is required for their diabetes management. Somewhere between 15% and 35% of type 1s in those countries have pumps, which enables them to lead normal lives, but in the UK the figure is less than 4%. That is clearly a failure of the commissioning structure as it is now. Will the Minister address how that is likely to improve? The Work Foundation has estimated that, if pump usage reached 12%, the NHS would save about £60 million a year.

Another example of where best practice is needed is surprisingly simple: good local leadership. Good leadership, as I have been fortunate enough to experience in my own area of Torbay, is essential to promoting effective and integrated services. Integration is key to reducing costs in the long term and, more importantly, to improving patient outcomes, which all too often get lost in the debate over health care services.

The move to clinical commissioning groups, with the potential for better scrutiny and criticism from patient groups, local authorities and health care staff could, in theory, lead something of a revolution in spurring innovation and creativity and in the striving to find best practice.

Just as educating the commissioners is crucial, so, for diabetes, is patient education, which has the happy side effect of making patients far more aware of whether they are receiving a good service and enabling them to become better advocates for their condition. I have no doubt that the great knowledge possessed by volunteers for Diabetes UK, the Juvenile Diabetes Research Foundation, INPUT and the many other groups involved in diabetes will be a considerable asset in shaping good services at a local level now that we have better scope for patient scrutiny and involvement.

In the wider sense, patient education is the core to preventing complications, which diminish the quality of life for patients and which, all too often, reduce life expectancy and increase the costs to the NHS in the long term. Good patient education programmes may require some investment, but they would pay for themselves many times over.

On a broader level, work needs to be done on detection and prevention. The number of people suffering from type 2 diabetes is set to reach a staggering 5 million by 2025. However, what many people do not know is that type 2 diabetes is a largely preventable disease. At the very least, its onset can be delayed and complications reduced.

NHS checks are vital to the detection and prevention of diabetes. In theory, such checks are available to all 40 to 74-year-olds who are seen to be at risk of developing diabetes. Shockingly, a number of primary care trusts in the UK failed to offer a single person an NHS health check last year, which demonstrates the dangerous variations in provision in the NHS. The Government can look to rectify that if they create a new national implementation plan for diabetes. Indeed they may even take up the suggestion by the hon. Member for Gillingham and Rainham (Rehman Chishti) to set targets for diabetes.

This year, the current national framework for diabetes comes to an end. It is important that we build on the successes of the framework, that we focus on reducing discrepancies in diabetes care and that the new framework emphasises the importance of health checks and prevention of the disease through simple means such as diet management. Indeed, it is essential for the Government to spell out to commissioners and to patients what services can be expected and to provide a road map to show where we want to be in a few years’ time and how to get there.

[John Pugh (Southport) (LD)]

My hon. Friend analyses the fair degree of regional variation that exists and talks about a postcode lottery. Does he think that that is primarily down to a lack of leadership at PCT level, or to the qualitative variations that we get anyway in primary care practice among GPs across the country?

[Mr Sanders]

It is a combination of both. We cannot prescribe from the centre precisely what must happen in every area. Of course local areas must reflect their own demographics and their own health picture and be able to apply priorities accordingly. However, there is something to be said for ensuring that local areas have the tools that they need, which is where NHS Diabetes did such a good job on the back of the NHS framework for diabetes.

It is equally important that health checks are used to detect diabetes in its earliest stages, as early detection and appropriate treatment can prevent the severity of the condition and the risks associated with complications such as amputations.

[Rehman Chishti]

On health checks, the hon. Gentleman must have seen the report that says that, according to Diabetes UK, nine out of 10 people do not know the four main symptoms of type 1 diabetes. Surely, therefore, the education should look at ways in which people can identify for themselves the symptoms that can lead to type 1 diabetes.

[Mr Sanders]

That is a very good point. There is the 4 Ts campaign on diabetes. If I remember correctly, the four Ts are thirst, tiredness, toilet and one other— I always remember three, but not four. Anybody who feels thirstier or more tired than usual or is visiting the toilet more often should see their GP. A simple test—it is not an invasive test—can be conducted and after an appropriate early diagnosis a patient can start to feel better very quickly. An ancient fear of great big hypodermic needles being stuck in their skin deters many people from going to a GP, but only 15% of diabetics are put on to an insulin regime on diagnosis and that is because they suffer from type 1. Most type 2 sufferers never have to take insulin via an injection device, and, in any case, those devices are subcutaneous and really nothing to fear. I speak as someone who has to inject four or more times a day, and it really is not as bad as people fear. People should see their GP. If they do not, matters will get worse, complications will set in and they will rue the day that they did not sort out the problem early on.

[The Parliamentary Under-Secretary of State for Health (Anna Soubry)]

I know that it is unusual for a Minister to intervene at this stage, but will the hon. Gentleman help me in this matter? Is it not right that there have been huge advances in the administration of insulin? A constituent of mine showed me the pump on his stomach that gives him the right amount of insulin. He even had a device on his mobile phone that could calculate from a photograph of a particular meal the amount of insulin that should be administered to his body. He clicks on the app and the insulin is given to him at the appropriate time, before or after he has his meal. Does the hon. Gentleman agree that those are wonderful devices that should be prescribed to people as much as possible?

[Mr Sanders]

I cannot fail but to agree with every word that the Minister has said, and I am absolutely delighted that she has said that. Children in particular benefit from pumps, because they can go to school and lead normal lives alongside their school friends. It is difficult for them to find the space and time to inject, and these little devices are doing the job for them all the time. The technological advances are such that we may well reach a point in the not too distant future where there is a device that both tests a person’s blood sugar level and then injects an appropriate level of insulin, without them having to check what they are eating. The little device is like having a pancreas attached to the side of the body. That is where we are going. At the moment, however, pump usage is very low in the UK. It is about having not just the pump but the services behind the pump—the trained nurses who can train and educate the person to use the pump properly, the technological support that needs to be there to back it up and the medical expertise to understand the difference between a pump regime and any other regime. That is the detail, and I am really glad that the Minister is on the ball here.

The provision of education about diabetes seems to be somewhat of a lottery in terms of who is actually receiving information and advice. There needs to be a standardised programme of education on the condition that is accessible and effective for all.

We must not miss the opportunity to encourage healthier lifestyles as a consequence of the Olympic legacy. It is essential that funding and provision for sports facilities and physical education continue to be given priority in the coming years to capitalise on increased interest in active sport. The Olympics have given people who have perhaps never before enjoyed individual or team exercise a new drive and desire for sport, which needs to be harnessed and nurtured. Gym membership and even one-off sessions for swimming still seem to be extremely pricey, which makes those forms of exercise inaccessible for many who could perhaps benefit from them. However, I am aware that some inner-city areas have set up programmes that allow residents to use facilities at a reduced rate or even at no charge. I wonder whether that idea should be taken hold of by more UK communities, and whether the Government could assist all local authorities to find ways to subsidise it, perhaps by working in partnership with private sector organisations.

Having facilities and making them affordable is an issue, which is why I find it unbelievable that some local authorities, including my own, give permission for building on sports facilities; in Torbay, the only public grass tennis courts in the local area are about to be built on. Andy Murray won his Olympic gold medal on grass and generated more interest in the sport last year, and my area has produced some of the great British tennis players down the decades, including British men and women No. 1s in Mike Sangster and Sue Barker. That makes that act by my local authority one of unforgivable short-sightedness.

I have outlined many of the issues surrounding diabetes care, but I will concentrate now on some of the things that I hope the Minister will focus on delivering in the coming years. There needs to be a comprehensive national implementation plan, containing measures to ensure that local leadership is robust and long term in its thinking. Such a plan also requires measures to focus on detection and prevention, and it needs to ensure that best practice can be effectively disseminated. Three priorities face our NHS and other health care systems around the world: prevention; diagnosis; and care. We have a long way to go to meet the challenges of each one.

[Several hon. Members]

rose—

--- Later in debate ---

[Anna Soubry]

It could be, but I make it clear, as I said on Monday in various media interviews, that at the moment the responsibility deal is working, which is why we have some of the lowest salt levels in the world. Other countries are coming to us to find out how we have achieved that by working with industry, retailers and manufacturers to reduce salt levels. On the reduction of trans fats, under 1% of our food now has trans fats in it. Again, we have done that by working with the manufacturers and retailers.

My natural inclination is against legislation, and I say that as an old lawyer. At the moment, I am confident that the responsibility deal is delivering in the way that I want it to. I make it clear that, if there is a need to introduce legislation, we will not hesitate to do that. I am almost firing a warning shot across the bows of the retailers and food manufacturers and saying, “Unless you get your house in order and accept responsibility, we will not hesitate to introduce legislation or regulation, because we know that we in this country have an unacceptable rise in obesity, to levels that are second only to those in America.” I will therefore consider everything. I always have an open mind. I am currently content, however, that the responsibility deal is delivering, but it has a great deal more to do. I hope that those who are signed up to the calorie reduction scheme later this month will encourage more manufacturers and retailers to sign up to the responsibility deal on calories. I want to ensure that we make some real, serious and tangible progress.

Ultimately, however, as the right hon. Member for Leicester East and the hon. Member for Strangford (Jim Shannon) identified, the responsibility is ours. Nobody forces us to eat the sugar buns or whatever it may be. When we go into the Tea Room and we are faced with the choice between fruit or a piece of cake, my natural inclination might be for a piece of cake, especially since I have developed a sweeter tooth as I have got older and since I have stopped smoking. We all make the choice whether to eat a piece of cake. The ultimate responsibility lies with us as individuals and as parents, but I always have an open mind.

Diabetes is a growing problem and a major factor in premature mortality with an estimated 24,000 avoidable deaths a year—10% of deaths annually are in people with diabetes. A variation exists in the delivery of the nine care processes, with a range of 15.9% to 71.2% achievement across PCTs, which is not acceptable. However, 75% of diabetes sufferers receive eight out of the nine care processes, which is a huge improvement. In 2003-04, only 7% of sufferers received all nine care processes. In 2010-11, that figure was at 54.3%, but there is much more to be done. In the coming months, several documents will be published to guide the NHS in delivering improved diabetes care, including the response to the Public Accounts Committee report, the work undertaken on diabetes as a long-term condition and the cardiovascular disease outcome strategy.

We must ensure that people get an early diagnosis. I must commend again the work of Diabetes UK. Other hon. Members have mentioned how it is raising awareness of the early signs and symptoms of diabetes with its latest campaign on the 4 Ts, which has my full support. One in every two people diagnosed with diabetes already has complications. I thank the hon. Members for West Lancashire (Rosie Cooper) and for Blaenau Gwent (Nick Smith) for their contributions. I will not be able to answer their points specifically in my speech, but I hear what they say and will write to them if necessary to answer their questions. I am acutely aware of the complications and the devastating effects that those can have on people’s lives.

[Mr Sanders]

Can the Minister respond to the important point made by the right hon. Member for Leicester East (Keith Vaz) about pharmacists? Some private pharmacy groups offer diabetes tests, which other pharmacies should be encouraged to do. I hope that we can see the roll-out of more collaborative working between the private sector and the health service in order to identify people with diabetes, so that they start to get treated.

[Anna Soubry]

I am grateful for that intervention not only because I was coughing but, most importantly, because I was going to mention that subject only in passing. I will now expand on that a little. I absolutely agree with the points of my hon. Friend and the right hon. Member for Leicester East about the importance of pharmacies. They are important for so much of the NHS’s work, but here is a good example of where we can link them in far more with delivering the successes, outcomes and diagnoses that we need so desperately. There is absolutely a role for pharmacies, and I look forward to clinical commissioning groups, which are already thinking in new ways about how to deliver better health care at a local level and working in exciting and imaginative ways, collaborating with pharmacies far more than has been done before. It is a good point, and I hope to see more action on it.

When people get a diagnosis, we need to ensure they are managed according to the latest clinical guidelines. The quality and outcomes framework, introduced in 2003-04, has incentivised primary care to perform the nine care processes for people with diabetes, but we know that there are difficulties—I have given the figures—and not enough people are receiving all nine. The National Institute for Health and Clinical Excellence has been asked to review the quality and outcomes framework and diabetes indicators, and we await its response and findings.

Last year, the National Audit Office reviewed the management of adult diabetes services in the NHS. While that highlighted the progress made over the past 10 years, it also highlighted the unwarranted variation that exists across the NHS and the significant challenges that we face over the next 10 years. There is no excuse for poor diabetes care. No one with diabetes should lose a leg or their vision if it can be prevented. We know what needs to be done and we need to ensure that we meet the challenge head on.

The prime objective of the NHS Commissioning Board will be to drive improvement in the quality of NHS services, and we will hold it to account for that through the NHS mandate, which makes it clear that we expect to see significant improvement in the outcomes, diagnosis and treatment of diabetes. In addition, through the NHS outcomes framework, we will be able to track the overall progress of the NHS on delivering improved health and outcomes. Diabetes is relevant to all five domains in the outcomes framework, so when work programmes are developed it is important to consider diabetes and how optimising care can deliver improvements.

My hon. Friend the Member for Torbay asked specifically about NHS Diabetes and whether it will continue to play a central role. NHS Diabetes is one of six current improvement organisations that are being replaced by the new NHS improvement body in the NHS Commissioning Board. In the overall context of what I have said, I hope that he will take comfort, will believe and be sure that diabetes is something that the NHS Commissioning Board has put much higher up its list of priorities. It is aware that much more needs to be done and is the ultimate driver of all of that.

Many hon. Members have mentioned diabetes 2, which is largely, but not always, a preventable disease. I have already paid tribute to those hon. Members who have raised the issue both in their local communities and nationally.

I want to end my comments by discussing an undoubtedly serious problem in our society, which is that almost all of us eat too much. We are overweight. Some 60% of adults are either overweight or obese. As a society, we find ourselves in a situation where one third of our 11-year-olds—our year 6 pupils—are either overweight or obese when they leave primary school. Those figures should truly shock each and every one of us, and something can be done about the problem. We can all take responsibility for how we feed our children and for our own lives and diets and what we eat and drink. The Government, however, can also do things, especially at a local level. When health and wellbeing boards identify the needs of their communities, if it is not a unitary authority, they can work with borough councils.

My hon. Friend the Member for Torbay made a good point about leisure services. We are already seeing evidence in shadow form. In my constituency, GPs are issuing prescriptions for activity, and the borough council is offering real assistance. It is almost as if there are no excuses not to go along to the various leisure centres and take up a class or gentle exercise. We even have walking football in Broxtowe. The point of all this is that local authorities are beginning to knit together all the various services to ensure that we all live longer, healthier and happier lives. The ultimate responsibility is ours, but local and national Government can do so much. It is all coming down to a local level. When we see the roll-out in the spring, I am confident that we will see great progress.