Melbourne Declaration on Diabetes

Adrian Sanders Excerpts

Wednesday 18th June 2014 Westminster Hall

[Mr Adrian Sanders (Torbay) (LD)]

It is a pleasure to speak under your chairmanship, Dr McCrea, for what I think is the first time.

Diabetes is the fastest-growing health threat in the UK, the EU and across the globe. I will first talk a little about what diabetes is. It is a condition in which there is too much glucose in the blood because the body cannot use it properly. That happens because the pancreas does not produce any insulin, or does not produce enough, or because the insulin it produces is unable to work properly. That is a problem because insulin is the key that unlocks the door to the body’s cells so that glucose can enter them. Diabetes means that the body is unable to use glucose as fuel; instead, it builds up in the blood.

There are two main types of diabetes, type 1 and type 2. They are different conditions with different causes; the treatments can be different as well. Both types are serious, lifelong conditions that can lead to devastating complications if they are not managed well, but with the right treatment and support people with diabetes can reduce their risk of developing such complications.

People with type 1 diabetes cannot produce insulin. About 10% of people with diabetes have type 1; I myself have had type 1 diabetes for nearly a quarter of a century, and I am still here. No one knows exactly what causes it, but it is not to do with being overweight and it is not currently preventable. It usually affects children and young adults, starting suddenly and getting worse quickly.

People with type 2 diabetes do not produce enough insulin or else the insulin they produce does not work properly. About 85% to 90% of people with diabetes have type 2. They might get it because their family history, age or ethnic background put them at increased risk. People are also more likely to get type 2 if they are overweight. It starts gradually, usually later in life, and it can be years before people realise they have it.

There are of course exceptions with both types: there are people who have got type 1 quite late in life and there are quite young people, including children, who have type 2, which is not always the consequence of the weight a person is carrying at the time of diagnosis. As with all things, the exceptions mean it is difficult to make a comprehensive diagnosis of what is happening, precisely why it is happening and how it can be prevented.

In the UK, around 3.2 million people have diabetes, and the condition costs the NHS over £10 billion a year. Within the EU as a whole, one in 12 adults have diabetes, and one in three people with the condition apparently do not know that they have it. In this country we have done a lot of work on trying to find what was referred to as the missing million—the people who have diabetes but had not been diagnosed. I believe the figure is now around 750,000, so around 250,000 people have been diagnosed as a result of greater awareness. I will be referring to that a little later.

According to the International Diabetes Federation, globally there are 382 million people with diabetes, a figure that is expected to rise to 592 million by 2035. The number of people with type 2 diabetes is increasing in every country in the world, and 80% of people with the condition live in low and middle-income countries. The greatest number of people with diabetes are between 40 and 59 years of age, and diabetes caused 5.1 million deaths in 2013. A really frightening statistic is that every six seconds a person dies from diabetes somewhere in the world. It is a global problem—a global pandemic—and requires a global response.

That is really what the Melbourne declaration on diabetes was all about. Parliamentarians representing 50 different countries came together to talk about what was happening in their countries and what the problems were, and to discuss how we could co-operate better. We recognised that many bodies work transnationally: patient bodies, medical professionals and pharmaceutical companies all meet regularly on a transnational basis. One group that does not is parliamentarians, yet it is the parliamentarians who can initiate debates, vote on budgets, raise awareness and put pressure on Governments in a way that other bodies cannot. In a sense, the parliamentarians are the missing link.

The aim was to bring those parliamentarians together to work together to commit themselves to be advocates in the fight against diabetes and to recognise the global challenge. Those who attended committed themselves to raising the profile and working for the benefit of people with diabetes wherever they live in the world. Since the declaration was signed, over 100 parliamentarians have signed up as members and many more have declared themselves supporters. Two newsletters have been published and are hosted on the International Diabetes Federation website, a Twitter account is now active, and debates have occurred in Russia, Bolivia, Malta, Kenya, Scotland and now here today in the Parliament of the United Kingdom.

There are so many issues to address. One is prevention. Far more needs to be done on that. We may have reduced the number who are missing their diagnosis, but there are still 750,000 people out there with diabetes whose condition will develop and whose cost to the health service will increase the longer they go undiagnosed. Health education is vital, to make people aware of the risks involved. We also need information out there to combat people’s fears that if they are diabetic they will have to inject themselves with needles all their lives. Only 10% of people with diabetes are type 1 and have to take insulin subcutaneously by injection—believe me, when someone is confronted with the fact that they have to inject themselves with a needle or they are going to die, they no longer worry about injecting themselves with a needle—so 90% of people with diabetes do not have to worry about that. They can be treated by diet and tablet, and different regimes.

There is still a stigma. There are Members of this place who have diabetes but do not want other people to know about it, although it is good that increasingly Members are prepared to come forward. The situation is the same in other professions. One great thing the all-party group on diabetes achieved was a change of policy in the police, the ambulance service and the fire service: people who admitted that they had diabetes were being retired immediately, but now instead they are given individual annual medical assessments to see what they can and cannot do. Sacking people simply because of a condition seems such an obvious injustice, especially as many of them can control that condition and hold down their job as well as any other person so long as they are monitored and have that medical assessment.

Prevention will save millions. There is no doubt that the bulk of the cost of diabetes to health care systems is at the point when the complications come in and a person with diabetes has to be hospitalised. It is an interesting phenomenon that people with diabetes stay longer in hospital beds than people without it. That includes people who have been admitted to hospital for something that has absolutely nothing to do with their diabetes, or who have come in for elective surgery. The change of environment on going into hospital disables them in terms of being able to control their condition. Increasingly now, many hospitals are saying that, as people with diabetes basically self-medicate 365 days of the year, if they go into hospital, they may as well carry on self-medicating, because they know their body better than the health service is likely to.

The savings to the health service from prevention are quite phenomenal. Early diagnosis is also important, as it reduces complications, so we need to encourage people to come forward and be tested. That is linked to the need for education and information so that people do not fear being tested or being diagnosed with the condition.

Sadly, many people with the condition are not getting the checks that they are supposed to get from our health service. Diabetes UK has taken that up and argues that everyone should be entitled to 15 checks whenever they go to their GP for an annual check-up. The fact that they are not getting all 15 checks suggests that something is not working correctly in the system. Some GP practices are excellent, but others are not so good and we must ensure that everyone gets the minimum 15 checks.

The pump device for those who are insulin-dependent is a small device about the size of a pager. It is attached to the patient and provides insulin doses, almost mimicking the pancreas. It is a very good regime, particularly for children who do not want the paraphernalia of injection pens and so on. They can enjoy a life in which other children do not recognise that the diabetic is different. They must still check their blood sugar, but we are looking and hoping for the development of a single device that both tests blood and injects insulin, completely mimicking the pancreas. It is out there, but it is not yet widely available. The cost must come down and more testing is needed, but that is the future. People must live with diabetes now and the level of pump prescribing here is well below that in other EU countries. Any child who is diagnosed with diabetes should be automatically put on a pump unless there is an objection. It is the obvious way to get a child to control their condition early and to enable them to enjoy their life along with other children of the same age.

The treatment of people in care with diabetes leaves a lot to be desired, and a lot more needs to be done in the various care inspection regimes to ensure that people with diabetes who go into residential or nursing care are properly looked after.

There are questions about research. Are we spending enough on research on a cure? Are we researching better conditions and finding the best treatment regimes for people with type 1 or type 2 diabetes?

Children with diabetes must be supported in school and I hope that the Children and Families Act 2014 will go some way to helping parents with some of the problems. Some schools have refused to deal with a child with diabetes or to help them to test their blood sugar levels and take their insulin. Some schools insist that a parent must be in attendance at the school, which often means taking someone out of a job to be a full-time carer of their child with diabetes in school. Surely that is not desirable.

There are complications with transition when children move from primary school to secondary school, and then to university. They often have to deal with three health care regimes: paediatrics, adult care and student care services. Problems often arise as a consequence of those transitions.

I mentioned discrimination in the workplace in relation to blue light services. We were able to campaign against that to help to tackle it. That discrimination is still out there. People must have the courage to come forward in cases where there has been discrimination on the grounds that they have diabetes. There is probably much better understanding now in the workplace about diabetes, but there are still pockets of ignorance that need to be tackled.

All that occurs in the UK, with its well-developed health care service, many aspects of which are the envy of other countries. The Commonwealth study that has come out this week shows that the UK health service is at No. 1. That is testament to everyone who works in the health care service. They deserve our congratulations on delivering such a fantastic service cost-effectively for the majority of people who need to access services. I may list a whole load of issues and problems, but it would be wrong to be all doom and gloom and to think that we are lagging behind. We are way ahead, but we want to be even further ahead and to bring other countries up to our level. We must and can do more.

Internationally, the 66th World Health Assembly adopted a global target to halt the rise of diabetes and obesity by 2025. Every nation needs a national strategy and action plan to prevent and manage the diabetes pandemic. It is unfortunate that we no longer have a national service framework for diabetes in this country. The Government should think again about that because without a national plan and national strategy, it is difficult to determine whether we are achieving what we want to achieve in terms of reducing the number of people with diabetes, diagnosing those who have the condition and ensuring that treatment is as good as the best anywhere in the UK.

The Parliamentarians for Diabetes Global Network, which was set up through the Melbourne declaration, can help to facilitate the objective that the World Health Organisation has laid down for health care systems around the world. The network’s priority in its early years will be to build a coalition of advocates for action to prevent the pandemic at local, regional, national and transnational levels, with the focus on raising the matter in Parliaments and Assemblies across the globe to spread better understanding and awareness of diabetes and the urgency with which it needs to be addressed.

Following the declaration and events in Parliaments around the world, the ExPAND Policy Toolkit for Diabetes has gone live and will greatly assist the aims of the declaration. It is a practical guide to help diabetes advocates to challenge national Governments and to raise the profile of diabetes. It is the first comprehensive resource aimed specifically at helping MPs and other policy makers to shape and influence national policy to ensure that we prepare our health care systems for the challenges of the 21st century. With input from parliamentarians for parliamentarians, it provides a one-stop resource covering the economic case for investment, evidence of what works and best practice from across Europe, as well as practical steps for leading and developing new policies on diabetes that are fit for purpose. Key topics include prevention, self-management, innovation and person-centred care. There are also dedicated chapters on the care and treatment of children and older people. It is hosted on the International Diabetes Federation’s website and is available for any parliamentarians who want to avail themselves of its usefulness. The toolkit was the result of more than a year’s work by a network of parliamentarians, patient representatives and other opinion formers from across Europe.

The Melbourne declaration is a clarion call for action across the world and the ExPAND Policy Toolkit for Diabetes is a resource to turn words into action, but we also need momentum to reach that tipping point where no one questions why the global pandemic of diabetes receives priority attention for resources to prevent, to diagnose and to treat the condition.

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[Jim Shannon]

I thank my hon. Friend and colleague for that comment. He is absolutely right, and I will come on to some issues that I feel the Government need to address early on. He is correct to say that vast savings will be made if there is early detection. The need for early detection was mentioned by the hon. Member for Torbay, and other Members will make the same comment.

Although it is great that money is available to treat this illness, we must not merely chase after it, putting a plaster on it after it has inflicted damage. That is clear. We need to ensure that money is spent not only on treating it, but on prevention methods—which makes me wonder whether my hon. Friend the Member for East Londonderry (Mr Campbell) was looking over my shoulder at my notes, because he made the next point that I was coming to. We cannot allow ourselves to accept the fact that 3.2 million people in the UK have been diagnosed with diabetes. Again, that is the magnitude of the problem. We must look to the causes and stamp them out at the root.

One thing that we can address is the preventive measures that need to be taken. We have talked many times in the House about the sugar content in food. The right hon. Member for Leicester East (Keith Vaz), who is not here today, introduced a measure, which I was happy to put my name to, addressing the issues of sugar in manufactured products that we eat. We need to take that issue forward, and in the future, I hope we will be in a position to take legislation on that subject through the House with the support of food manufacturers, so that we can address the issue of the food we eat. We do not need all the sugar or salt that is in food. There is a way of addressing issues outside the Chamber—issues that are outside Government control—but something needs to be done at a manufacturing level.

Our annual intake of sugar is 33.7 kg per capita. To put that in perspective, it is equivalent to eating nearly 34 average-sized bags of sugar each year. Imagine if the sugar was piled up on the table here; it would block my hon. Friend the Member for East Londonderry from sight completely. That is how much sugar we are all eating every year, and some people even eat more. Surely when discussing the Melbourne declaration on diabetes, the Government need to take another look at sugar levels in our food. What steps are the Government taking on diabetes prevention to ensure that the next generation is not blighted by diabetes in the way that this one is? Projections show that if current trends continue, in 2025, 5 million people in the UK will have diabetes. Again, the magnitude of the issue is clear, so what are the Government doing to ensure that that does not happen? What preventive measures are they putting in place to decrease that number?

The correlation between weight and diabetes has been made clear: 80% of people with type 2 diabetes are overweight or obese. The Government need to do more to increase education on the danger of being overweight or obese and tighten controls on how much sugar goes into our food. Those are all issues that I feel we need to take on board.

What is so frustrating is that up to 80% of type 2 diabetes could be delayed or prevented. I am not saying that in any judgmental way, because many in the Chamber will be aware that I am a type 2 diabetic, as I declared at the beginning of my speech. The truth of the matter is that I have to blame myself and my lifestyle choices for the onset of the disease. It was the Chinese carry-out five nights a week, with two bottles of Coke—not a good diet for anybody. That is the reason why I was almost 18 stone and had to lose weight very quickly. Aside from that, it was also a lifestyle with high levels of stress. When the two are combined, diabetes will knock on the door of nearly everybody, as most of us know.

While I am on the subject, many people can be diabetic even though they are not necessarily overweight. It can happen through them having a stressful lifestyle. How many others living the same lifestyle are not aware of the damage that they are doing to their bodies in the long term, and how can we do better in highlighting that? I have to take two Metformin tablets in the morning and two at night. That dosage could have to be increased; a doctor could come along, as he often does, and say “By the way, you just need a wee blood pressure tablet now to keep you right as well.” People wonder just how many tablets they will have to take before they reach the age of 65 and retire, if they are spared until that age.

What are the Government doing to diagnose diabetes early and treat it effectively, preventing or delaying the complications that cause so much human suffering, require costly treatment, and reduce life expectancy? Only one in 10 people who are newly diagnosed with diabetes are offered education on how to manage their condition, despite strong evidence that education is a cost-effective way of giving people the knowledge that they need to manage their condition. On managing diabetes, after someone is diagnosed as diabetic, what help is given to them to ensure that they manage that in a sensible way? I accept that the person also needs to acknowledge that they have to manage the condition. I remember Dr Mageean, my doctor, telling me when I was first diagnosed, “Jim, it is up to you what you do.” He was very clear and said, “You must manage this yourself,” but at the same time, I think we need a wee bit of help, perhaps from Government and from the health service in particular, just to ensure that we know what that all means for everyone involved.

It is estimated that in my small Province of Northern Ireland, 80,000 people have diabetes. That awful statistic worries me very much.

[Mr Sanders]

The point about education is interesting. According to the National Audit Office, the estimated amount that the NHS could save annually through people better understanding and managing diabetes is £170 million. That is just from improved awareness and education.

[Jim Shannon]

I thank the hon. Gentleman for his intervention. That reinforces the point made by my hon. Friend the Member for East Londonderry and by me: prevention saves money for the NHS. I accept that the Minister’s budget is restricted, and that we cannot spend outside of that, but if there are ways and means of reducing the money that is spent and ensuring that we can still deliver the NHS that we are all very proud of, we should try to do that as well.

On 12 February 2014, I asked the Minister what discussions had been had with the Health Minister in Northern Ireland on UK-wide strategies for diabetes, obesity, heart disease and rare diseases. The Minister said that there had been no discussions with the Northern Ireland Executive on those issues. I am asking that question again, as she is here. I respect her greatly—she knows that—and I value the work that she carries out in this place, but I honestly believe that a UK-wide strategy is needed. We had one until 2013, but then it was not carried on. I believe that it would be to the benefit of all the regions of the United Kingdom of Great Britain and Northern Ireland if that UK-wide strategy was started again, so I ask the question again.

There is cross-House approval of and support for the Melbourne declaration on diabetes, which pushed for an international effort in the fight against diabetes, and that is what this is all about. Are the Government willing to work with the devolved Administrations of Northern Ireland, Scotland and Wales to use resources wisely and create a UK-wide strategy against diabetes? They have done it before; let us do it again, and do it even better this time.

The director of Diabetes UK Northern Ireland, Iain Foster, has said:

“We are in the middle of a diabetes epidemic…With the numbers rapidly increasing it is now more important than ever that everything is done to prevent serious complications which cost the NHS millions”—

as the hon. Member for Torbay said—

“and are absolutely devastating for the individuals and families involved.”

Let us never forget that it is not just those with diabetes but the families around them who are affected by the debilitating effects of diabetes on the individual.

Will the Government commit to implementing fully the NHS health check, which should be offered to everyone aged 40 to 74, to help identify people at high risk of type 2 diabetes? I say with respect that that programme has been patchily introduced so far, so there could be a lot of improvement. The Government need to do more to ensure that those at high risk benefit from lifestyle interventions to help to prevent the disease. The National Institute for Health and Care Excellence has recommended increasing the proportion of people with diabetes who get the nine annual checks. That should happen as a matter of course when people are in their GP surgery, or in hospital for whatever reason.

Those checks help people to manage their condition and to identify any signs of complications early. However, there is a large geographical variation in the proportion of people getting them. Again, if we had a UK-wide strategy, we could ensure that there were no differences geographically in who gets the nine annual checks and who does not. Will the Government commit to increasing the number of people who receive the checks? That is a positive way forward. It is another way of doing the preventive work that we need, and will ultimately lead to the savings that we need.

In 1922, insulin was discovered by John Macleod, Dr Banting and Charles Best, yet 92 years later, in 2014, we are still fighting against the dreadful disease of diabetes. In the UK this year, 59,000 people will die unnecessarily from diabetes. I strongly urge the Government, in the wake of the Melbourne declaration on diabetes, to take serious strides in the UK in preventing and controlling diabetes.

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[Jane Ellison]

I think that the shadow Minister has slightly misunderstood what I said. Those are the tests and that is exactly the standard to which we want everyone to work. What I am saying is that there is no top-down guarantee. We cannot sit in Whitehall and say, “It must be done like this and that is the end of it.” We have said that that is the standard, and NHS England has set a range of other standards, but to deliver that and to drive that consistency of excellence throughout the country requires a range of tools. We must acknowledge that. That is not to say that we accept patchy service—far from it—but we cannot do it with top-down diktat only; we must drive change at all levels of the system and drive towards excellence.

[Mr Sanders]

On that point, there is a difference between a treatment, which must be down to the clinician and what is right for the patient, and tests, which should be the same for everyone. They are just tests that would then dictate the right treatment regime, if additional interventions are required. There ought to be a mechanism to ensure that the tests are consistent for every patient with diabetes in the country, otherwise what is the point of having them?

[Jane Ellison]

I agree. The Government, NHS England and Public Health England are all looking at how we drive that consistency. How do we drive consistent excellence? What tools can we use to do that?

Perhaps it would be helpful if I gave an example. Public Health England is developing a tool to drive improvements in diabetes care and iron out variation. It will be launched later this year, and although I am not able to give much detail now, I am sure that my hon. Friend the Member for Torbay will be interested when it is launched. It will provide a clear picture of how diabetes care and outcomes vary across the country and among practices, which will support decisions on how to make improvements.

The Government have made transparency of data a real priority, and being very transparent about what is being delivered and identifying variation is one of the ways in which we can drive the rest to be as good as the best. I suppose I am trying to explain that, although I could send out a memo tomorrow outlining my national diktat on diabetes, that is not how we drive change. It is crunchy, it is detailed and it is about getting to that local variation and ensuring that we drive up standards in every way possible. That is one of the tools we are developing, but there are others as well.

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[Mr Sanders]

When the Minister came to the all-party group, I do not think anyone recognised that it was her first meeting because she carried it off with distinction and quickly won over a lot of friends in the group. She has been a consistent friend throughout the period.

One of the challenges of a bottom-up approach, as has been highlighted in this debate, is getting people to use the information that is out there to drive up standards. People need to be aware of where the information is and how they can best use it, which is a challenge not only for diabetes but across the health service. I thank all hon. Members for their contributions.