Health: Diabetes

Lord Rennard Excerpts

Wednesday 31st October 2018 Lords Chamber

[Lord Rennard (LD)]

My Lords, I refer to my interests in the register. I congratulate the noble and learned Lord, Lord Morris of Aberavon, on securing this debate and on his personal tenacity in pursuing the important issue of helping people with type 1 diabetes to secure access to new technologies that might help them to manage their condition better. My own interest in diabetes is long term and personal. My father was one of the first people to benefit from the development of insulin in the 1920s; he developed diabetes probably as a result of the shock he experienced having a leg amputated following injuries to it during the First World War. Because of insulin he was able to live quite a long life for someone born in 1889. I was born in 1960, when he was 71. His survival for so long was testament to the effectiveness of insulin in saving lives and helping people to live with a condition that, until then, had been known to have fatal effects for thousands of years.

I was diagnosed with type 2 diabetes at the relatively young age of 34, almost 25 years ago. My lifestyle, related to my work in politics, was extremely poor for a long period. By the time that I was 45, I was on insulin as well as tablets. In my late 40s, I was warned that even the maximum levels of every form of medication available would not sustain me into my 50s unless I changed that lifestyle fundamentally.

However, changes to lifestyle are not so relevant to people with type 1 diabetes, and not always achievable for those of us with type 2 diabetes. The consequences of poor diabetic control are the same for people with either type 1 or type 2 diabetes. My own poor diabetic control some years ago is probably responsible for the fact that both my feet now suffer from a condition called foot drop. This means that I need to wear ankle foot orthoses, known as AFOs, and, like all other diabetics, I have to take great care of my feet.

I have been fortunate to receive great support from the diabetic team at St Thomas’ Hospital. I was there yesterday and was pleased to be told that my long-term control, as measured by my HbA1c blood glucose level, remains very good at present. It has been helped by changes in lifestyle, including those that have resulted from a GP referral for some physical fitness training—which I certainly needed—the acquisition of my Fitbit monitor and recognition that I needed to eat more healthily and consume fewer products filled with sugar, which for many people is a very addictive ingredient.

I know from friends with type 1 diabetes how much harder it is for them to maintain good control, whatever they do. They have to test their blood with finger-prick tests eight or more times per day and can observe their blood sugar levels increasing rapidly or falling dramatically, sometimes without any apparent explanation. The emergency services all too often have to pick up someone who has collapsed, with many people thinking that they are perhaps drunk when in fact they are suffering from a “hypo”. I experience hypos rarely, but type 1 diabetics are much more vulnerable to them.

The problems associated with both types of diabetes have grown rapidly in prevalence and are likely to do so even more in future. Diabetes UK said on Monday that some 500 people with diabetes die prematurely each week. I regularly read distressing accounts of how more than 6,000 foot amputations per year result from diabetic-related conditions, many of which are preventable. If not managed effectively, poor diabetic control results in loss of sight, kidney disease and a much greater prevalence of strokes and heart disease.

The most recent NHS National Diabetes Audit report on complications and mortality shows that men and women between the ages of 35 and 64 living with type 1 diabetes are three to four times more likely to die prematurely than those without the condition. Men and women in the same age range who have type 2 diabetes are up to twice as likely to die prematurely.

What can be done? Control is of course the key, and I have no doubt that wider use of FreeStyle Libre, a flash glucose monitoring system, is assisting a number of people, particularly those with type 1 diabetes, to improve their control. I have looked at the Medtech innovation briefing from NICE and the devices appear immediately cost effective compared with, let us say, the costs of 10 finger-prick tests per day. The evidence of benefit to long-term blood sugar control is not yet so clear, but I know from my own experience that behaviour is changed in a positive direction when you are regularly alerted to your blood sugar levels. This is, in my view, much more likely to be the case with such a flash monitoring device than with the more traditional blood glucose meter.

There was very strong evidence in the report suggesting that users of a flash glucose monitoring device suffered far fewer hypos, experiences that can be very unpleasant and quite dangerous. The fact that such devices can now potentially be prescribed as a result of their inclusion in Part IX of the England and Wales drug tariff a year ago is very welcome but, as the noble and learned Lord, Lord Morris of Aberavon, said, there is still far too much variation between CCGs in their provision, and the guidelines from NICE are very restrictive. In the recent Question that he referred to, he suggested that around 30% of CCGs are not yet considering prescribing these devices.

I know that the aim of reducing variation in the management and care of people with diabetes by 2020 is included in the NHS England mandate, but can the Minister tell us a little more this evening about exactly how this will be achieved? There are implementation plans to facilitate the wider provision of flash glucose monitoring systems; how are these progressing? We all know that we need to rely on NICE conducting some sort of cost/benefit analysis for any such product, but is the Minister satisfied that its processes for analysing the costs and benefits of new technologies aimed at improving diabetic control are sufficiently long term? Does he accept that any such analysis for public policy should factor in all the long-term costs to the NHS and the welfare system of poor diabetic control, as well as the wider benefits to the economy and to society of helping people to achieve good control?

Flash glucose monitoring, real-time continuous glucose monitoring and insulin pumps may all provide technological solutions to help people with type 1 diabetes live healthier and happier lives for very much longer. There is, for example, a much greater provision of insulin pumps in the United States than in this country, and this is not simply because the US has a greater love of technology than we do. Overall, the US healthcare system is known to be massively inefficient and ineffective compared to our own NHS but, with an insurance-based model, you know that the insurance companies evaluate the long-term costs to their businesses of dealing with the complications that arise from poor diabetic control. These insurance companies appear to have decided, on sound business grounds, that much greater provision of insulin pumps saves them money in the long run, to say nothing of the wider benefits to patients and everyone else.

I look forward to the Minister’s comments on these issues and what he has to say about how technological innovation may help some of the problems associated with diabetes.