Diabetes

Debate between Keith Vaz and Paul Burstow

Friday 23rd March 2012 Commons Chamber

[The Minister of State, Department of Health (Paul Burstow)]

I congratulate the right hon. Member for Leicester East (Keith Vaz) on securing this debate and on making such an effective and compelling case for raising awareness of diabetes and preventing, postponing and better managing the condition. I know of his personal experience and the leadership that he has shown in his constituency and in the House on these issues over many years. The centre of excellence that he talked about is there as a testament to his determination to make this happen, and I pay tribute to him for that. He rightly paid tribute to the work of the all-party parliamentary group and, in particular, my hon. Friend the Member for Torbay (Mr Sanders), who has proved an excellent chair of the group and has done some excellent work, as the right hon. Gentleman described.

The case for action is absolutely compelling. As the right hon. Gentleman said, the number of people with diabetes is rising, with profound effects on their quality of life. As he rightly said, there are huge health inequalities, for which some of the most deprived and excluded pay the highest price. It is therefore a big responsibility for any Government to tackle these issues. The costs to our society and to the NHS are substantial.

We currently have the most accurate picture ever of the state of diabetes care in England, with the national diabetes audit, the detailed analysis by the national diabetes information service and the atlas of variation, all serving to expose an unjustifiable variation in the levels of care and treatment from one postcode to another—the classic postcode lottery. We now plan to go further in providing more information than ever before by publishing a specific themed atlas on diabetes, which will prove to be an invaluable tool for commissioners and campaigners, and patients and carers, to use to make sure that we get the very best diabetes care in every part of England.

The data show that there has been significant progress, but, as the right hon. Gentleman says, there are still shocking, inexplicable and unjustifiable variations that we have to bear down on. We know what works at three levels—population-level interventions, targeted interventions, and what can be done better to manage the condition. Let me go through what we are doing in those contexts. First, it is vital to raise awareness among the population. The right hon. Gentleman and other hon. Members, the NHS, and other organisations—including, in future, Public Health England—have an important role in raising overall awareness. Supporting healthy behaviours that improve the population’s health is absolutely key to successful prevention. We need to tackle the main risk factors that are particularly relevant to type 2 diabetes.

One of the key strands from the Government’s point of view is the work done through Change4Life, which has a clear focus on maintaining healthy weight and increasing levels of physical activity, as that is very important in addressing obesity. That also requires much more effective collaborative working between local authorities and the NHS to ensure that we exploit the full range of levers that local authorities have in making a real difference in those two areas. Our planned health and wellbeing boards will provide a new and important lever for driving improvement on the public health side.

The right hon. Gentleman talked about other interventions. We are addressing this through our public health responsibility deal. Some of these issues are not about regulation but getting the relevant industries to move further and go faster, and that has already borne fruit, not least in reducing trans-fats in products. I appreciate his welcome for the comprehensive approach that the Home Secretary outlined today with regard to reducing alcohol harm—the harm that it does to the individual and the harm that its effects can have on others on our streets—and the decision to move, after consultation on the details, towards minimum unit pricing. The right hon. Gentleman is right that that can have a profound effect, not just on liver disease, but on many of the other aspects that we are discussing.

The second area is targeted interventions. The right hon. Gentleman rightly raised the importance of NHS health check and of targeted interventions for high-risk people. We can reduce and even reverse the worst effects of diabetes if we are effective in identifying at an earlier stage those who are at risk. That is why risk assessment and diagnosis are essential to the strategy that has been in place for some time. It is important to identify more people at an earlier stage and to give them the messages and support that can enable them to mitigate the worst effects of diabetes. The national roll-out of NHS health check is a key component in that. We have signalled our determination, through the NHS operating framework, to ensure that that continues.

The proactive identification of people who are at risk of vascular diseases, including diabetes, is key. The right hon. Gentleman mentioned that that covers a population of people from 40 to 75 years of age. I can tell him that in some parts of the country, high-risk individuals are being targeted specifically—for example, those in the south Asian population, where there is a greater risk of type 2 diabetes. We know that the risk in that population is four or five times greater than that in the European population. That will be reinforced shortly by the guidance that the National Institute for Health and Clinical Excellence is finalising on the detection and prevention of diabetes in high-risk individuals.

[Keith Vaz]

Will the Minister write to me, because he probably does not have the list with him, to tell me in what areas people are being targeted below the age of 40?

[Paul Burstow]

I will gladly do that.

Accurate and timely diagnosis is key, but diabetes can be hard to spot and some of its symptoms, such as extreme tiredness and weight loss, can be attributed to other diseases. Again, NICE has produced advice on preventing adult pre-diabetes and on early detection. It is key for GPs and others to be more effective at early diagnosis. The national clinical director for diabetes, Rowan Hillson, has been supporting that work to raise professional awareness, which is critical.

The third area is long-term management and self-care. There has to be a team effort across primary and secondary care, and the patient has to be at its centre. A person with diabetes must know how to spot and report changes in their health that might result in serious complications with life-changing or even life-shortening consequences. Integrated multi-disciplinary care is crucial to delivering the best outcomes in diabetes.

I will give a couple of examples that pick up on the right hon. Gentleman’s references to the scandalous picture in respect of amputations in England. He rightly rehearsed the variations from one part of the country to another, which are inexplicable and shocking. On average, 73 amputations take place every week, but eight out of 10 of those operations are unnecessary because they could be prevented simply by following what we know works. It is critical that we get that message out and translate it into practice by clinicians. For example, we know that when a foot care team is established, which is a relatively modest investment, it can cause as much as a 50% drop in the rate of amputations. Such investments can release resources. That is why they are part of the quality, innovation, productivity and prevention work and the Nicholson challenge, which the right hon. Gentleman talked about.

There is also room for further progress in the use of insulin pumps, which are particularly relevant to type 1 diabetes. They provide for the slow release of insulin. The NICE guidance clearly recommends the use of insulin pumps for type 1 diabetes when daily injections are not working, and yet many primary care trusts are dragging their feet and not making pumps available. That is why we have established the NHS Diabetes insulin pump network and why it is oversubscribed for its first meetings, with more than 270 members. I think that it will prove an invaluable way of beginning to drive out unacceptable practices. We are also auditing the availability of insulin pumps so that we can identify where use is not adopted properly.

[Keith Vaz]

I obviously welcome what the Minister says about pumps. Will he also deal with the issue of the shortage of medicines?

[Paul Burstow]

I am coming to that almost straight away.

I welcome the fact that there will be a type 1 diabetes parliamentary lobby by the Juvenile Diabetes Research Foundation in the next month or so to highlight some of the relevant issues.

Population levels, targeting, and management and self-care are all critical, and I want to say a bit about what we are going to make happen. First and foremost, NHS Diabetes leads on improvements, spreads best practice, supports professionals and develops professional networks of the type that I have described. The national service framework for diabetes is reaching the end of its life, and we now need to set new ambitions and new directions towards making the further progress that the debate is highlighting the need for. That will be reflected in both the new cardiovascular strategy and the long-term conditions strategy, which the Department is working on in collaboration with many other stakeholders.

We also need the system to be supported by incentives such as payment by results. That was why we rolled out new tariffs last April to recognise paediatric diabetes care as a discrete specialism, and why we will continue to develop tariffs to support best practice.

The right hon. Gentleman asked about Eucreas, which is a glucose-lowering drug. It is composed of two drugs, metformin and vildagliptin, and I understand that although there may well be supply problems with the combined drug, the industry is not aware of any supply problem with the two separate tablets. I will gladly write to him about that in further detail, but that is what I have learned about that drug so far.

More generally, the Department is working to address the issue of parallel exporting of UK medicines in conjunction with the Medicines and Healthcare products Regulatory Agency and the pharmaceutical supply chain, to ensure that medicine supplies are not compromised and we do not have the tragedies to which the right hon. Gentleman referred. I will write to him about the progress of that work.

The right hon. Gentleman also asked about Copenhagen. I look forward to the opportunity to meet colleagues to share best practice and learn about it from others.

As the right hon. Gentleman says, diabetes is a complex, lifelong, progressive condition. When it is well managed, with the right education and support, it is possible to prevent the most severe, sometimes fatal complications. We have the data to guide us and the evidence of what works, and we have the economic case. We are setting our strategy with the ambition of making even more progress. Now, we need commissioners and clinicians to act so that the best is not the exception but the norm across the national health service.

Question put and agreed to.

Health

Debate between Keith Vaz and Paul Burstow

Wednesday 21st March 2012 Ministerial Corrections

[Keith Vaz]

To ask the Secretary of State for Health what proportion of diabetes patients in Leicester City Primary Care Trust did not have a foot check in 2011.

[Official Report, 13 March 2012, Vol. 542, c. 185W.]

Letter of correction from Paul Burstow:

An error has been identified in the written answer given to the right hon. Member for Leicester East (Keith Vaz) on 13 March 2012. The exception rate in Leicester City was reported as 5.5% for DM09 and 5.5% for DM10. The correct figures were 5.2% and 5.2%.

The full answer given was as follows:

[Paul Burstow]

There are two sources of data for assessing the extent to which foot checks are provided: the National Diabetes Audit and the Quality and Outcomes Framework (QOF) achievement data.

The National Diabetes Audit shows that, from data received by 92.3% of practices, 18.3% of diabetics registered in Leicester City Primary Care Trust (PCT) did not have a foot check.

The QOF indicators for diabetic foot care in 2009-10 were as follows:

DM09: The percentage of patients with diabetes with a record of the presence or absence of peripheral pulses in the previous 15 months; and

DM10: The percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months.

According to Leicester City PCT's QOF data for 2009-10, for DM09 the average underlying achievement for practices in the PCT was 89.5% and for DM10 89%. Underlying achievement means the percentage of eligible patients (excluding those who were excepted from the indicator) who received the checks. This indicates that for DM09, 10.5% and for DM10, 10.6% of patients (excluding those who were exception reported) did not receive the checks. The exception rate in Leicester City was reported as 5.5% for DM09 and 5.5% for DM10.

The differences in results between the audit and QOF may be ascribable to variations in scope and data assessment methodology. We are working with stakeholders to understand the reasons for the differences and to identify what needs to be done as a result.

The correct answer should have been:

Oral Answers to Questions

Debate between Keith Vaz and Paul Burstow

Tuesday 26th April 2011 Commons Chamber

[Keith Vaz (Leicester East) (Lab)]

4. What his policy is on funding for a national framework and quality of service guidelines for diabetes patients.

[The Minister of State, Department of Health (Paul Burstow)]

To support the NHS in improving outcomes, the National Institute for Health and Clinical Excellence has published a quality standard for diabetes building on the existing national service framework, which provides an authoritative definition of good-quality care. Under proposals in the Health and Social Care Bill, quality standards will have a central role within the new system’s architecture.

[Keith Vaz]

May I declare my interest as someone who has type 2 diabetes, and remind the Minister that we currently spend 10% of the NHS budget—£1 million an hour—on diabetes-related illnesses? Does he agree that what is central to this framework is providing funding for prevention? If we can prevent and assess diabetes, we will save a great deal of money in the long run.

[Paul Burstow]

I certainly agree with the right hon. Gentleman that prevention is undoubtedly the right way forward, but earlier diagnosis is also very important. That is why we continue, as a Government, to support the roll-out of NHS heath checks for people aged 40 to 65 as a way of ensuring that we detect more readily and earlier so that we can provide the appropriate support.

Diabetes

Debate between Keith Vaz and Paul Burstow

Wednesday 8th September 2010 Commons Chamber

[The Minister of State, Department of Health (Mr Paul Burstow)]

I am grateful to the right hon. Member for Leicester East (Keith Vaz) for taking the opportunity to apply for this debate, and congratulate him on his good fortune in securing it. It follows on from the questions he asked at Health questions yesterday. I know that he has an enduring, personal interest in pursuing this cause, and I pay tribute to his work, effort and leadership in raising awareness of diabetes among the south Asian communities in his constituency. He rightly paid tribute to the work of the Silver Star organisation.

Let me first address his final point, which was on his discussions with Ministers in the previous Administration and the intentions to create a centre of excellence. I need to be honest with him. I cannot give him an undertaking tonight other than the most important one that any Minister should give at the Dispatch Box, which is that I will go away and properly consider the matter and come back to him as speedily as I can. If that means a further discussion face to face, I would be happy to do that as well.

I also look forward to the debate that I will have with the right hon. Member for Knowsley (Mr Howarth) on type 1 diabetes, and I hope that we will get the opportunity to explore some other issues on that topic. While these are not prime-time debates, they are an opportunity to air issues that affect the lives of our constituents, so I am grateful to the right hon. Member for Leicester East for raising this matter tonight. He is right to highlight the disturbing rises in the rates of diabetes in this country, because it is placing a huge strain on the NHS, and has a profound effect on people’s long-term health, with the most deprived and excluded groups often paying the highest price.

Diabetes could be described as a head-to-toe condition. Complications—many extremely serious if poorly managed—can affect every part of the body. I was particularly shocked, as I prepared for the debate, to discover that 73 lower limb amputations occur every week due to complications from diabetes. More shocking still, 80% of those amputations could have been prevented, some by lifestyle changes and others by changes in the approach of the NHS. Every preventable amputation is an appalling human tragedy, and something we need to improve on, which is why I am so pleased that we are discussing these issues tonight.

There was plenty in the right hon. Gentleman’s speech that I supported and much common ground between us. I wholeheartedly agree that we must do more to prevent diabetes across all age groups and all social backgrounds. The Government’s approach therefore has three levels. The first is the population level, and in diabetes, this is about improving general health across the population at large, recognising—as the right hon. Gentleman rightly said—that diet and lifestyle are key risk factors in diabetes. Then come targeted interventions for people at risk, which recognise that we can reduce and even reverse the worst effects of diabetes if we intervene early enough. Finally, there is the long-term management of established disease, and people with diabetes and clinicians must work together to delay, reduce or prevent complications. We need to get all three aspects right in order to secure the better results in diabetes care that all hon. Members would wish to see.

On the population level, rises in diabetes are closely linked to lifestyle and behaviour, which makes this a considerable public health challenge. Much of this is about individuals taking responsibility for their own health—for example, choosing not to have some of the sweets that the right hon. Gentleman mentioned—by changing what they eat, drink and how much exercise they take. We are clear that the Government and the NHS, while they have their parts to play, cannot and should not do everything. But what we can do is educate people about the risks, and give them the information to lead healthier lives and understand and change the influences that govern their behaviour.

I can confirm that the Change4Life programme will continue to be a focal point, as it has been successful in putting the issue on people’s radar. The Change4Life brand will continue, but we will need to change it, as it can no longer be about glossy, national advertising campaigns directed from the centre. We need Change4Life to become less an old-style, centrally directed campaign, and more a genuinely social movement, owned collectively by communities, families, voluntary organisations and industry, and driven locally. Hand in hand with this, we need a much more targeted and community-led approach to health improvement as a whole. In the White Paper, we said that local councils will be given a central leadership role on public health, and we would expect local authorities to work with the NHS and other services to develop the appropriate strategies and approaches.

[Keith Vaz]

Some of the key people in this are GPs. I welcome everything that the Minister has said so far, but we need to get guidance out to GPs to tell them that they need to be proactive, as my GP Dr Farouki was. When they have a patient who matches the criteria and is therefore at risk, they should perform the test, which takes only five minutes. Such guidance could be very effective.

[Mr Burstow]

I am grateful for that point. I will say a little about guidelines in a moment, because good news is on the way in that regard.

I was talking about the public health role of local authorities that we are developing. It will be supported by a dedicated ring-fenced budget and the implementation of a new health premium, which will allow local areas to target reductions in health inequalities, including inequalities associated with diabetes and other cardiovascular diseases. We are also committed to working with industry on a new public health responsibility deal to ensure that business takes action together with others to support the nation’s health.

On early intervention and diagnosis, the right hon. Gentleman is right to emphasise the importance of identifying pre-diabetes. There are two developments that relate to the role of GPs. First, the National Institute for Health and Clinical Excellence is developing guidance on preventing adult pre-diabetes in the first place. This will be published next year and will inform and support local public health strategies and others, as I have already described. Secondly, NICE is also preparing guidance on preventing pre-diabetes from progressing to type 2 diabetes. That will be a valuable tool in our fight against diabetes, and will help GPs and other health professionals to advise and support people at risk, hopefully to stop the disease in its tracks.

The right hon. Gentleman is right that earlier intervention and better diagnosis is crucial. NHS Health Check, which was introduced by the last Government, can prevent more than 4,000 people a year from developing diabetes, and could detect 20,000 cases earlier, so it can be, and should be, a very powerful means of detecting and supporting people at risk.

--- Later in debate ---

[Mr Burstow]

My hon. Friend is right, and I certainly pay tribute to him for his work as chair of the all-party group on diabetes. He has been a powerful advocate on these issues for many years. I applaud what he has done, and he is right—pharmacists and other health care professionals are part of what we need to do in order better to equip the whole service for detecting and intervening.

I was told that the right hon. Member for Leicester East was going to ask about extending the age range. That is an important point that needs to be discussed. At the moment, NHS Health Check starts at 40 and calls people every five years. The best clinical and most cost-effective case was made for doing it at that age. However, there is nothing to prevent primary care trusts from commissioning services that widen the age range. They should be considering that, particularly in areas with more susceptible populations, and clearly Leicester is one of those cases.

[Keith Vaz]

Last year, I wrote to the chief executive of every PCT asking how much they spent on preventing diabetes and on health checks such as the ones the Minister described. Some thought it was a freedom of information request and became very defensive. Will the Minister go back and get this information from his Department and place it in the Library of the House?

[Mr Burstow]

I will look into that. My view is that we need far more transparency when it comes to such issues, so that people can make comparisons of the performance of their local organisations and hold them to account over how they spend taxpayers’ money on these services.

I want to move on to long-term management. Once diagnosed, people need personalised support to manage what is a highly complex and changeable condition. A person with diabetes must know how to spot and report changes in their health, and how to get the right services to prevent more serious problems. That issue was raised by my hon. Friend the Member for Torbay (Mr Sanders) in Health questions yesterday. He was right to do so, because it is important to ensure that we have good care planning, embodying the principle of “No decision about me, without me”, which is vital in starting to transform the relationship between GPs and patients. Indeed, the diabetes year of care programme, led by Diabetes UK and the NHS, is already looking at how we can improve care plans for diabetes. Education goes hand in hand with that. I know that many NHS organisations offer patient-structured education programmes, specialist diabetes advice, care planning discussions and annual checks. We need more of that: it needs to be consistently applied and we need to ensure that good practice becomes the norm.

On treatment, it is no surprise to learn that the best results are achieved when there is a fully integrated, multidisciplinary team working across primary and secondary care, which picks up on my hon. Friend’s point. Programmes such as the excellent “Think glucose” campaign and the guidance produced by NHS Diabetes on in-patient management are already helping hospitals to discharge patients sooner and give them a better experience of care. However, there is more to do on that—as well as in other services, such as foot care and eye services—to ensure that problems are dealt with early on, and certainly long before amputations become necessary.

Meanwhile, in primary care the relationship with GPs is crucial, as the right hon. Gentleman rightly said. We need them to be alert to the signs of pre-diabetes in routine consultations and to play a key role in the ongoing management of existing conditions. How we incentivise GPs to do so is a key issue. Clearly the qualities and outcomes framework is one avenue that could be explored, but it is for the National Institute for Health and Clinical Excellence to determine what QOF indicators are ultimately introduced. My hon. Friend referred to pharmacists. I certainly agree that they provide another channel for reaching those at risk, which is precisely why they are one of the ways in which health checks can be used in various settings.

In conclusion, the right hon. Gentleman spoke about his experiences in Leicester and the important lessons that he has drawn. He is right to point to the financial climate, which is undoubtedly a constraint on what any Government can do. However, it is also correct to say that this is not just about beds and buildings; it is actually about services and where they matter most in identifying diabetes early and then providing the appropriate care. The issue is fundamentally about outlooks, attitudes and priorities in the NHS and beyond. The principles that we have set out in the White Paper—pushing power downwards, paying for quality and strengthening the voice of patients—will bring fresh impetus to improving outcomes for diabetes.

It is clear that this issue is not just for the NHS, but for all of us—for the society in which we live. We need to strengthen preventive action on diabetes. Let me conclude by saying that I share the right hon. Gentleman’s commitment and passion. I look forward to maintaining a close dialogue with him, and with my hon. Friend and the all-party group on diabetes, and to participating in next week’s debate on type 1 diabetes.

Question put and agreed to.

Oral Answers to Questions

Debate between Keith Vaz and Paul Burstow

Tuesday 7th September 2010 Commons Chamber

[Keith Vaz (Leicester East) (Lab)]

9. What steps his Department is taking to inform young people about diabetes prevention.

[The Minister of State, Department of Health (Mr Paul Burstow)]

I thank the right hon. Gentleman for his question, and for his tireless campaigning to raise awareness of diabetes. We know that being physically active and maintaining a healthy weight can reduce an individual’s risk of developing type 2 diabetes and cardiovascular disease. Our approach is to support families and young people to eat healthily and be physically active.

[Keith Vaz]

I thank the Minister for his comments. I declare an interest as one who has type 2 diabetes. As he knows, we spend £1 million an hour treating diabetes-related illnesses, and more and more people are now being diagnosed at a much younger age. What steps are the Government taking to alert parents and young people to the perils of diabetes?

[Mr Burstow]

The right hon. Gentleman is absolutely right to draw our attention to the rising rate of diabetes in our country. When it comes to diabetes in children, we have to bear in mind that the diagnosis for type 1 diabetes—which affects about 23,000 children in this country—is a genetically predisposed condition that cannot easily be prevented. We need to do more about type 2 diabetes, however, by tackling the obesity problems in this country. We need to deliver physical and healthy eating programmes through schools and other partners, and those things are much better done in the context of the local authorities, which will now have a new responsibility for public health that the last Government never gave them.