Health: Diabetes

Lord Harrison Excerpts

Thursday 4th November 2010 Lords Chamber

Tabled By

[Lord Harrison]

To ask Her Majesty’s Government what is their response to the Diabetes UK report Putting Feet First and its implications for the treatment of diabetes.

[Lord Harrison]

My Lords, as a serial killer, diabetes is getting bolder, accounting over the past year for some 150,000 newly diagnosed diabetics, adding to the 2.8 million known diabetics in the country, with perhaps another half a million undiagnosed. It also absorbs 10 per cent of the NHS budget—that is, some £9 billion a year—as well as immiserating the lives of many of our fellow citizens, often needlessly, for with speedy diagnosis and treatment, the sickening complications of blindness, renal failure and amputation can be forestalled. Diabetics can lead long, healthy and productive lives. Dynamic public health programmes concerned with diet, obesity and exercise are crucial in preventing or staunching the rising incidence of diabetes. More recently, type 2 diabetes among schoolchildren, allied to the rising tide of obesity, places yet another challenge on the scarce resources provided in this direction. Indeed, these are desperate times of pressure on the NHS and of financial retrenchment and cuts.

Some additional spending now on upgrading diabetes therapy will save lives later and money and resources for the NHS in the long run. An example of the success of the long decade of Labour’s investment in the NHS and diabetes care is the increased incidence of retinopathy screening, saving the eyesight of many a diabetic. I hope that that is retained. The recent reform and investment in diabetes management, principally designed to help us to manage our condition, has transformed the lives of diabetics.

I come to some questions for the Minister. There are two discretionary areas at the moment with respect to diabetes care. One area is that of insulin pumps and the allied use of insulin inhalation, which is currently not paid for. I wonder whether he has any comments to make on those points. Something that I have raised in this House before is the essential need for the availability of blood glucose testing strips for diabetics as part of caring for themselves, to ensure that they have good blood sugar levels. Does the Minister recognise that there can be a postcode lottery in the distribution of blood glucose testing strips, with four different health services and different practices throughout the nations and authorities dealing with diabetes?

I ask the Minister, too, about NICE, which recently concluded a consultation on diabetic foot care. I do not know whether he can give us any indication there. He was rather unclear, and I hope he can clear it up today, about the role of NICE, especially as diabetic drugs now form the second largest call on the NHS budget. Good innovations that are cost-benefit assessed must be made available. Would he comment, too, on the flanking policies of the Government? I give the example of sport for young people, which will help to set back the rise in obesity and type 2 diabetes. We need more of the self-management programmes that I referred to and more education of diabetics and diabetic professionals to ensure that they are helpful. Would he say more, too, about whether the focus of the previous Government will be retained on children, obesity in women—typically in pregnancy, when they are diabetic—but also the immigrant population, where there is a higher incidence?

Can the Minister reflect on our colleagues in the European Union? The Federation of European Nurses tells us that the incidence of diabetes in the United Kingdom is, surprisingly, recorded at 4 per cent, while in Germany it is 13 per cent and in most other countries typically 9 per cent. I do not know whether the data are collected inaccurately, and perhaps he would look into that, but we need better information in that area. Would he also note that we have had no pan-European research since 1999 on the cost of diabetes? There is so much that we should be doing with our European colleagues to do something about that.

My superb NHS diabetes care by outstanding healthcare professionals in Chester and Liverpool has kept me active and on my feet as a type 1 diabetic of some 41 years’ standing, and it is to that I now return. Diabetic foot care deserves the same focus as actions on diabetic retinopathy. It may not be very sexy but we need health professionals to come into this area. The 2010 DoH review, Six Years On: Delivering the Diabetes National Service Framework, says that in the key area of feet we still have poor clinical outcomes, resulting in amputations, extended lengths of stay in hospitals and concludes that we need effective management of diabetic foot care to reduce expenditure and amputations.

Last year, Diabetes UK published an excellent document, Putting feet first, summarising the optimal management of available resources to minimise the manifold complications associated with the diabetic foot. Diabetic foot problems are the most common cause of non-traumatic limb amputation in the United Kingdom. Some 100 are performed each week. Neuropathy, peripheral arterial disease, foot deformity, infections, ulcers and gangrene are just some of the nasty complications of diabetes.

In addition to the financial implications of the NHS—out-patient costs, increased bed occupancy and prolonged stays in hospital—diabetic foot problems adversely affect patients’ quality of life, reduce mobility which in turn leads to loss of employment and depression among other social and health consequences.

As outlined in Putting feet first, pivotal to diabetic foot care is, first, fast action within four hours of diagnosis. Then the second period, the following four to 48 hours, is crucial to saving the threatened foot. Delay in diagnosis and management increases the risk of amputation, morbidity and mortality. The third period is the continuing foot surveillance which is so vital for keeping us on our feet.

However, catastrophic trauma need not happen. Let us take peripheral arterial disease where some 100,000 people are diagnosed each year. Vascular specialists need to be swiftly available and treatment by appropriate technologies—the use of balloons or stents to widen or relieve arteries—can prevent the devastation of foot amputation. Unfortunately, the UK has one of the poorest rates of lower limb revascularisation in Europe. To avoid this, we need to encourage the proliferation of local vascular networks and I ask the Minister whether he has anything to say on that. Will the Government implement Putting feet first, emphasising the vital need to create active local networks of key health specialists working with others to ensure speed of response and quality follow-up?

I highlight one of the many useful suggestions in the pamphlet which has been put to me by my own hospital orthotist expert. She tells me that huge benefits are to be derived from examining all new in-patients’ feet. Such inspections typically uncover hidden foot problems, as well as undiagnosed diabetics whose problems may thereby be quickly treated. Helpful, too, are the regular ankle/brachial pressure index tests as a predictor of future PAD. Resources are of course the nub of the problem. I ask the Minister whether he will provide the resources and trained staff to enact the strategy outlined in Putting feet first. How many practice nurses are trained in diabetes management—the orthotists, chiropodists, specialist shoemakers, diabetologists and vascular cardiologists as well as specialist lower limb surgeons?

I want to say a final word on the continuing care of diabetics with foot problems. As I speak to you, I am wearing fashionable orthopaedic shoes made for me by experts who form part of the clinical team at Liverpool’s Broad Green Hospital foot unit. These shoes offer vital protection for my feet, moulded as they are to the ever-changing shape of my feet to preclude the onset of ulcers as a result of my diabetes-associated neuropathy—that is, I have no feeling in the nerves of my feet which warn me of a loose stone doing untold damage to my foot tissue. However, these shoes are expensive—perhaps £500 a pair—and unsurprisingly rationed on the NHS. But these shoes keep me and thousands of other diabetics protected and active in the community. They are an economic investment of the kind with which the Government must wrestle. The Government should heed George Bernard Shaw’s wise aphorism and great foresight:

“I marvel that society would pay a surgeon a large sum of money to remove a person’s leg—but nothing to save it”.

Finally, I welcome to the debate not only the noble Baroness, Lady Young, who has recently taken over as chief executive of Diabetes UK, but also the Minister, who I know will give us a sympathetic reply.