Diabetes

John Pugh Excerpts

Wednesday 9th January 2013 Westminster Hall

[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.

--- Later in debate ---

[Rosie Cooper (West Lancashire) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Crausby, for this debate.

I congratulate the hon. Member for Torbay (Mr Sanders) on securing the debate on such an important issue, which affects a growing proportion of our population. Indeed, having listened to the contributions that have already been made, it is very clear that there are many facets of diabetes that could be covered during this debate, but I think that we will all probably concentrate on amputation. I will spend a few minutes focusing on the importance of podiatry services, which can reduce preventable amputations for those with diabetes.

Currently, 4% of the population live with diabetes, and a fifth of those people will develop a foot ulcer at some point. At any one time, there are 61,000 diabetics in England who have foot ulcers. A foot ulcer may not sound like a very serious condition, but for a diabetic the consequences of foot ulcers can be severe, and even fatal if the appropriate treatment is not given. Statistics for England alone show that, of those diabetics with foot ulcers, 6,000 people—that is 10% of the total number—had leg, toe or foot amputations in 2009-10. Based on current trends, that figure is projected to rise to 7,000 people by 2014-15. An amputation is devastating. If any individual loses a limb, it will have a far-reaching impact on their life. For many diabetics, an amputation can increase the likelihood of premature death.

Let me put those figures for diabetes in context. The five-year survival rate for those with breast cancer is just over 80%, but for those with a diabetic foot ulcer the five-year survival rate falls to just under 60%. For those people who have a lower limb amputation, their survival rate worsens after five years. The consequences are even more horrific when we consider that 80% of those amputations are preventable. In 2012, that is simply incredible. We are not doing everything we can to rectify that and to ensure that people have the information and services that will help them protect their limbs.

It is scandalous that with our 21st-century health care we are allowing people to go through the completely unnecessary, torturous and miserable experience of amputation. Prevention is supposed to be the watchword of the modern national health service; through prevention, people can enjoy a better quality of life and the NHS can save itself millions.

It is therefore hard to understand why better prevention is not deployed with diabetes and amputations. Why is more effective use of podiatry services not a priority for the health service? At a time when the number of diabetics is growing, and with it the costs of treatment, podiatry could be a means of improving a diabetic’s quality of life and saving the NHS money. Amputations cost the NHS considerable sums, which are estimated to be in the region of £600 million to £700 million each year.

Results from pilot projects can demonstrate the positive impact of investing in good podiatry services. A multidisciplinary foot care team for in-patients with diabetes in Southampton led to a reduction in the length of in-patient stays from 50 days to 18 days. Not only were patient outcomes improved but annual savings to the NHS of £900,000 were generated from an investment of £180,000. That savings ratio of £5 saved for every £1 invested was bettered in another example. In James Cook hospital in Middlesbrough, a multidisciplinary foot care team generated annual savings of some £250,000 at a cost of £30,000, which is a ratio of £8 saved for every £1 invested. Those figures show how it would be not only the Government and the NHS that reaped great rewards from a small investment, but diabetics and those who need podiatry care. Based on the pilot evidence, logic would suggest that even in these straitened times we should be investing in podiatry services, because that could save even more money and improve health.

There is evidence, however, that the opposite is happening and that services are not improving. The danger of the new arrangements is that important issues fall between the cracks, are left to local decision making and do not get the prioritisation they deserve. More than half of hospitals do not have a multidisciplinary foot care team. In fact, 31% of hospitals do not even have an in-patient podiatry service, according to data from the national diabetes in-patient audit in 2011. That reflects a worsening service, because in 2010 only 27% of sites had no provision. The amount of provision has dropped, and nearly a third of hospitals no longer have that service.

There is also evidence that there is a problem with GPs having no incentive to refer their patients on to a foot protection team for education or follow-up. Why is that? Why is this woeful situation tolerated? If more referrals were made, we would see a beneficial reduction in ulcer and amputation rates.

[John Pugh]

Will the hon. Lady explain why a GP would need an incentive to do what is clinically desirable in the first place?

[Rosie Cooper]

I absolutely share that concern, which is why I cannot understand the current view that doctors do only what they get paid for and if there is no money attached to something, it may not be the first thing they do. As I pointed out in Westminster Hall yesterday, when we had a debate on the Liverpool care pathway, financial rewards to clinicians should not be the driver of what happens or the pathways that are followed. That is good clinical practice. Surely to goodness, if a referral to podiatry is required, that is what should happen. It could also be said that if the services are not there or are being reduced, the GP has less incentive to refer, knowing that it will take so long to get an appointment.

The College of Podiatry is

“fearful that public expenditure constraints mean that rather than being prioritised through the QIPP”—

quality, innovation, productivity and prevention—

“agenda, current podiatric services are at best, being frozen and in some cases being reduced, with patient services including the diabetic foot service deteriorating as a consequence”.

That has massive implications for the NHS budget and for the patients themselves. During a debate in the other place on 29 November 2012, the Under-Secretary of State, Earl Howe, accepted that

“rapid access to multidisciplinary foot care teams can lead to faster healing, fewer amputations and improved survival. Savings to the NHS can substantially exceed the cost of the team.”—[Official Report, House of Lords, 29 November 2012; Vol. 741, c. 336.]

My question for the Minister is whether the NHS, which is in the throes of a reorganisation and being more localised through clinical commissioning groups, as well as being put under increasing financial pressure, will move towards or away from having more multi- disciplinary foot care teams, given that fewer than half of hospitals currently have such a team. Investment in more podiatry services would result in improved foot screening, appropriate follow-up services, enhanced care when required, better outcomes—including fewer amputations—reduced length of stay in hospitals, increased quality adjusted life years and reduced morbidity. We would all win; we would have a healthier nation and significant financial savings.

--- Later in debate ---

[Jim Shannon]

That is an excellent point, and I am sure that the Minister will address it in her response. There are groups in the whole of the United Kingdom in which diabetes is more prevalent, and we need to look at those target areas.

There are 3.7 million people in the UK diagnosed with type 2 diabetes. I was diagnosed four years ago. With me, it was down to bad eating habits, stress and the fact that there were no set hours to my job. I ate whatever was quickest, and that was Chinese, usually with two bottles of coke, five nights a week. That was why I was 17 stone. I am now down to 14 and a half stone because I no longer do that. The issue is eating and living styles—eating what is quickest rather than what is best.

Edwin Poots, the Minister at the Department of Health, Social Services and Public Safety in Northern Ireland, is very aware of the ticking time bomb that is diabetes. I am aware of the key initiatives in operation in Northern Ireland, and I know that the Minister here today has had discussions with the Minister in Northern Ireland. They are doing a great job, including setting aside funding to employ additional diabetic staff—specialists, nurses, dieticians and podiatrists. That is providing all the help that a diabetic needs, but it is still not enough.

We need a concerted effort across the United Kingdom, through the media, and even perhaps through the TV soaps. I am not a soap watcher. I could not tell anyone what happens in “Emmerdale” or “Coronation Street”, but my wife could. She knows everyone in them—what they are doing this week and what will happen to them next week. Could we not perhaps use the soaps to make people more aware of the issue? I understand that plenty of issues are brought up in them regularly, so perhaps we should try this one.

It is great that our children are taught about diabetes in school. It is surprising what a five or 10-year-old knows about food that their mum and dad do not. Who is educating the mums and dads at home who are making the dinner and buying the shopping? The hon. Member for Blaenau Gwent (Nick Smith) made a point about how the food coming into the house is controlled by the parents. Diabetes UK Northern Ireland is taking part in an organisation-wide campaign entitled “Putting Feet First” to raise awareness of amputations among people living with diabetes and to work to prevent unnecessary amputations.

The Minister might want to comment on the new medications that are available. In the press this week, there was talk about a new diabetic medication in tablet form that could replace—not totally but partially—type 1 injections. The figure used was a cost of £35 per month. It would be good if we could get some feedback about whether the new medications will be available across the United Kingdom and whether everyone will be able to take advantage of them.

In Northern Ireland last year, 199 diabetes-related amputations took place, and the “Putting Feet First” campaign highlights that an estimated 80% of lower- limb amputations are preventable. There must be a UK strategy to reduce diabetes-related amputations by 50% over the next five years. What can we put in place in this Chamber to highlight and support the campaign? How can we use our influence to see the number of cases of type 2 diabetes dropping, instead of this steady rise?

The links between type 2 diabetes and obesity are firmly established, and it is clear that, without appropriate intervention, obesity can develop into diabetes over a relatively short time. For instance, the risk of developing type 2 diabetes is about 20 times more likely in obese, compared to lean, people. A newspaper recently stated that academic sources have estimated that the predicted rise in obesity rates over the next 20 years will result in more than 1 million extra cases of type 2 diabetes, and that is really worrying. Can that go unchallenged, when it is within our power, as parliamentarians, to do something about it, at least by putting a strategy in place or by beefing up the ones that we already have? When the current UK-wide strategy ends, it will perhaps be time to do something more.

I live the life, as do many others, of testing my blood every day, of feeling unwell when my blood sugar is out of control and of worrying that the next visit to the doctor will bring worse news, which can be the case if we do not discipline ourselves and ensure that we do things right. That is not the life that I want to have, or the life that I want my family, friends or constituents to have. The way to take on the issue is to continue with the UK-wide strategy, with dedicated funding and with all the regions working together, which will save money in the long run and, more importantly, improve the quality of lives across the United Kingdom.

I urge the Minister to take the initiative. I believe that she will and that her response will be very positive, because she understands the issues. I urge her to work with the devolved bodies, in coming together to disarm the ticking time bomb of diabetes—the cost of which some people indicate will be £10 billion—before it explodes. Type 2 diabetes is preventable, and we must do all that we can to prevent it. Education, with attention paid by everyone in this Parliament and the regional assemblies, is the way to do that.

[John Pugh]

rose—

[Keith Vaz]

rose—

--- Later in debate ---

[John Pugh (Southport) (LD)]

I am happy to give way to the right hon. Member for Leicester East (Keith Vaz)—in any case, I will make just a few remarks. I pay tribute to his efforts in the House of Commons in this area, as well as those of my hon. Friend the Member for Torbay (Mr Sanders).

I am provoked to make a few remarks by things that other hon. Members have said. I think that we all recognise that diabetes is a major problem. Rates are increasing—it is almost a worldwide epidemic—and it is a killer, linked to a series of other sorts of organ failure. We all recognise and it has been clearly stated that type 2 diabetes is rampant in our society and is lifestyle-related. Diagnosis is important, but I got the sense that that is fundamentally not the problem. We can get diagnosis right. There are clearly failures in general practice, in not picking up the condition early enough, but we do tend to find out who has it and who does not.

The issue appears to be treatment, as has been phrased by most Members. From events that I have attended from time to time in the House, I am aware that the treatment of diabetes is becoming increasingly sophisticated. A series of technology is attached to that nowadays, and we also have the advent of telehealth. All the major practitioners of telehealth are keen to provide better services for diabetics.

Additionally, there is the expert patient initiative, about which I was slightly sceptical when it was launched. The initiative is becoming very effective in connection to diabetes. The charities are playing along with that, too. A lot of good things are going on, but we are recording a variation in practice. There is something of a postcode lottery. I wonder what will prevent that. In which direction will we go?

My hon. Friend the Member for Torbay voiced concerns about the future of NHS Diabetes, but, like the hon. Member for West Lancashire (Rosie Cooper), I wonder how that will play into the new system. There seem to be two ways in which things could go. Without the local primary care trust, there may be, temporarily at any rate, an absence of leadership, because one of the PCTs’ jobs was to manage GPs, to keep them up to the mark and to assess how well they were performing. Clearly, part of the problem that we are addressing today is the failure of GPs, first, to diagnose diabetes early enough and, secondly, to treat it as effectively as they might. It is a fact that, although they are slow to admit it, GP practices in this country can be something of a lottery; they are extraordinarily variable in quality and character. Such features may be more manifest in the new structure.

My hon. Friend the Member for Torbay sketched a more optimistic scenario, however, in which the health and wellbeing boards will become ever more vigilant and keep GPs up to the mark. GPs themselves have suggested to me that one of the best ways to produce good and more standardised practice is peer review, with every GP knowing what other GPs are doing.

I am not sure which of those two outcomes is more likely, but there is great concern that the Department of Health ensures that the right one results.

I am uncomfortable with the thought, as raised by several Members today, that we could simply impose targets and that that would somehow get things right. The hon. Member for West Lancashire and I attended a debate not 24 hours ago on the Liverpool care pathway, in which we considered the corrosive and dysfunctional effects of targets. Once targets are set, we do not always get the results that we want. What, for example, would a target to reduce amputations do? Would it mean people do not do amputations in circumstances where an amputation might be desirable for the patient?

We come back to the perennial dilemma of many of our debates, particularly on specialist conditions, in that we can identify good practice—we can see it, and we miss it when it does not occur—but the national health service has never successfully found the secret of spreading good practice fast enough, which is happening again with diabetes.