Melbourne Declaration on Diabetes

Jane Ellison Excerpts

Wednesday 18th June 2014 Westminster Hall

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

Thank you, Dr McCrea. I am aware that some colleagues who would normally be with us for a debate on this important topic have been speaking in the main Chamber. No doubt they will catch up with the debate online, at some point. I thank my hon. Friend the Member for Torbay (Mr Sanders), who opened the debate, and all those who have spoken. It has been another thoughtful debate on a topic that is very important, as he said. I congratulate him on his recent election as the first president of the Global Parliamentary Champions for Diabetes Forum. I am not sure whether he modestly did not mention that, but I give him credit for it. It is a tribute to his effective championing of the issue, and the global initiative is important.

As my hon. Friend said, we must not underestimate the global threat posed by diabetes. Other hon. Members have mentioned the numbers involved; the International Diabetes Federation estimates that by 2035 there will be 600 million people with diabetes worldwide, which is about one in 10 of the planet’s population. I think that the hon. Member for Strangford (Jim Shannon) described that as a ticking time bomb, but the debate has drawn out the fact that for the most part we do not have to accept that as inevitable. There are things that we can do, and it is right that we are beginning to talk about the issue as a global community, in global health terms.

In the UK, 3 million people are affected by diabetes. It is estimated that by 2025 the figure will be 4 million if we do not make progress. We estimate that around 850,000 people have undiagnosed type 2 diabetes. Diabetes is a priority for the Government. We have set clear objectives for the NHS and Public Health England to do more on prevention and to improve the care and management of people with diabetes. I accept that there is a challenge about the need for a national action plan. I have had meetings with Diabetes UK and it is one of the things mentioned in its briefing. We have set up clear objectives for the NHS and Public Health England and we ask them to deliver against those, so my contention is that we do indeed have a national plan, but that we may be carrying it out within a slightly different framework from the one advocated. The degree of priority we give it, and the importance that the Government accord to ensuring that the health and care system work together at all levels to give people with diabetes the care and support they need, should not be underestimated.

I hope that while I have been the Public Health Minister I have reassured colleagues about the personal priority that I give to the issue of diabetes. Indeed, my first public outing, slightly terrifyingly, was to speak to a meeting organised by my hon. Friend the Member for Torbay. Almost certainly, everyone in the room knew more than I did about the subject, but I attended to show, very early in my ministerial role, how important the issue was to me.

I have met the national clinical director. I try to have reasonably regular meetings with him, because the issue is such an important one. I have a continuing relationship with the all-party group on diabetes and the other diabetes campaigning groups and Members in the House. With respect to type 1 diabetes, I met my and other Members’ constituents at the JDRF event, which I have attended several times. It is always humbling to meet those fantastic young people who have learned very young to manage and live with a difficult condition.

What is NHS England doing to improve the management and care of people with diabetes? As I mentioned, I have several times met Professor Jonathan Valabhji, the NHS England national clinical director for obesity and diabetes. He has been generous with his time in attending parliamentary events, and is a great supporter of the work of groups and Members in the House. He regularly attends events focused on diabetes and is focused very much on improving outcomes for people with all types of diabetes.

Earlier this year “Action for Diabetes” was published, which describes the actions that NHS England is taking to improve diabetes care. It covers many areas, some of which have been highlighted during the debate, including developing GP contracts and incentives; working with primary care services to trial and roll out case-finding; and decision-support tools to help to detect and diagnose diabetes earlier. A national conversation is also going on about obesity and taking care of one’s own health. Hon. Members have touched on that with regard to the prevention of type 2. Every member of the public is a part of that conversation. We did not talk much about individuals during the debate, but I think we would all agree that we need constantly to emphasise personal responsibility in relation to preventable or avoidable type 2.

I sometimes worry—I talked about this with the head of Diabetes UK shortly after becoming a Minister—that, because few deaths are recorded as being due to diabetes, rather than its complications, there may be a slightly more relaxed attitude among people who think they might develop diabetes, which they would never in a million years have towards a disease such as cancer, which they would immediately identify as a threat. Through debates such as today’s, and the work that we all do, we can emphasise the fact that, although people may not know many people who can be said to have died of diabetes, they will know many whose diabetes contributed to premature death or a long period of ill health. There is more work for us to do, to get that message out. That is how we can empower people to help themselves.

[Jim Shannon]

The Minister could not have said a truer word, because many people see diabetes as a disease that they can manage—one that is not too bad. However, she is right: the complications are far reaching and can lead to consequences that are final. In my speech I talked about education, because people must manage the condition themselves, but they need to know what they have to manage. That is my point: some people need the information reinforced, with the seriousness that the Minister expressed.

[Jane Ellison]

That is right. We need to make sure of that. People cannot be empowered without information. We also know, having a duty to address health inequalities, that some people and groups in the community find things much harder. I was taken by some of what the shadow Minister, the hon. Member for Copeland (Mr Reed), said about deploying technology more. Work is going on, but I agree with him that we could go further faster with that, to find ways to empower people who may not have a good sense of what to do to take care of their health, and who find it harder than others to obtain the available advice. We must work harder to reach them and I shall talk about NHS health checks in relation to that.

As to the commissioning of integrated care, NHS England is working with other organisations to help to promote services that are integrated around patients’ needs across all settings. There has been much emphasis on that. That body is implementing what it calls a customer service platform to allow patients with diabetes to self-manage, through booking their own appointments, managing their prescriptions, monitoring the care they have received and being able to view their personal health records. That picks up on some of the shadow spokesman’s points.

NHS England has also produced a sample service specification for the management of type 1 and type 2 diabetes that is based on National Institute for Health and Care Excellence standards. It provides a model for commissioning integrated care for those with diabetes, and also highlights the specific needs of those with type 1 diabetes, where they differ from the needs of those with type 2. If the current trial of the service specification is successful, it will be offered as a tool that all clinical commissioning groups can choose to use to deliver high-quality care. That is therefore an important piece of work in progress.

There is always a challenge for any of us in making sure that the rest are as good as the best. Occasionally when we talk about the challenges of our current health infrastructure I worry about the assumption that there is a model out there, somewhere, that would absolutely guarantee the delivery of completely consistent care in a given area, across the country. In a country such as ours it is not possible to give such a top-down guarantee. Yes, we must find a way to drive care from the top, with a clear sense of direction from the strategy and mandate that we have given the NHS and Public Health England, but we must also put the tools in the hands of the clinicians, as I have been discussing. Most importantly, we must empower individuals and patients to know what they can expect and to demand good care. Nevertheless, I genuinely do not think that we could devise any system in which we could just issue a notice from the centre to say exactly how care will be delivered consistently across the country. We must find other ways to do it.

[Mr Jamie Reed]

I understand the Minister’s point, but we are talking about nine very simple, fairly cheap tests for people with type 1 diabetes that must be done in a primary care setting by medical professionals. We are talking about blood tests, the blood being processed and the resulting data being made available, all of which are critical to the self-management of the condition. Surely we can insist on those nine tests for every single type 1 diabetic patient.

[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.

[Jim Shannon]

In my speech, I called for a strategy that was not just regional but UK-wide, and I hope the Minister can respond to that. Other Members have spoken about the need for an English strategy, but there must also be one for Wales, one for Scotland and one for Northern Ireland. All four must work together so that we can address the issue together. The Melbourne initiative is very much worldwide, so although people refer to England, we must go further. What are the Government doing to initiate a UK-wide strategy?

[Jane Ellison]

As the hon. Gentleman knows, health is a devolved matter. That is not to say that I am not at all interested in what is going on in Northern Ireland—far from it—but it is nevertheless a devolved matter. As I have said to him in other debates, there is clearly an awful lot that we can learn from each other. People can learn from everything that I report to the House on innovation and the progress that we make in England, as well as, indeed, things that other Health Ministers report from other parts of the United Kingdom. Nevertheless, I currently have no plan for a UK-wide strategy because health is a devolved matter.

[Jim Shannon]

Will the Minister give way?

[Jane Ellison]

If the hon. Gentleman does not mind, I am going to make some progress.

Of course, the fact that health is a devolved matter does not mean that we cannot find areas of joint working, and the Melbourne declaration shows us the way forward on that. That is probably where we end up—the fact that it is devolved does not mean that we cannot share learning and knowledge, learn from one another’s initiatives, or operate in that global context.

[Jim Shannon]

I hope that the Minister will accept that I am not being argumentative, but we had a UK-wide strategy until 2013—last year—so we have shown that we can work together. All I am asking really is: why do we not initiate a similar plan to what was there before 2013—a 10-year plan that started in 2003—and have the four regions work together? That is exactly what the Melbourne initiative is about, and we could do it because we have done it before.

[Jane Ellison]

I will reflect on the hon. Gentleman’s comments and perhaps we will discuss the idea again.

[Jim Shannon]

Thank you.

[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?