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Diabetes

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Siobhain McDonagh (Mitcham and Morden): I am grateful for the opportunity to speak about a serious health issue that has never received the recognition that it deserves. Some 1.5 million British people of all ages, races and backgrounds have been diagnosed with diabetes and their lives are impaired and sometimes dramatically shortened by it. That figure does not include the further 1 million people with the condition who live their lives undiagnosed.

Treatment of diabetes is an urgent issue, as is the implementation of the Government's national service framework for diabetes, which is due to be published this summer. I wholeheartedly support the Government's intention to develop that national service framework. I was encouraged by the comprehensive scope of the document "Diabetes National Service Framework: Standards", published in December 2001. It was a welcome acknowledgement by the Department of Health of the importance of diabetes and its prevention, and of the distressing complications that many diabetics face, such as blindness, kidney disease, heart disease, angina, strokes, foot problems leading to amputation, and difficulties in pregnancy.

Such conditions, coupled with the devastating fact that diabetes can shorten life expectancy by as much as 30 per cent., and in the context of a projected increase of people with diabetes to 3 million by 2010, mean that diabetes is a problem that should be at the top of the health agenda. However, it is not. Simply, diabetes is a condition in which the body cannot turn the food that people eat into the energy that they need to survive. That is usually because of type 1 diabetes, in which the body does not produce the hormone insulin, or because of type 2 diabetes, in which the body does not produce enough insulin or the insulin that it produces does not work properly. There are other, much rarer forms.

The human cost of diabetes is devastating because it can seriously damage other parts of the body. In the United Kingdom, it is the leading cause of blindness in people of working age. It is a leading cause of end-stage kidney failure and of lower-limb amputation. If they have diabetes, people's chance of having a stroke is two or three times greater and their risk of heart disease two to five times greater. In ethnic groups in which the incidence of diabetes is higher—partly for genetic reasons and partly because of lifestyle—there is even more chance of such complications.

Estimates of the precise financial cost of diabetes vary, but according to one study, it accounts for £1 in every £10 of the annual national health service budget. That represents a total of £5.2 billion a year, or £14,245,367 a day—something like £165 every second. Diabetes has a huge impact on the NHS, and the costs are set to grow substantially because, owing to sedentary lifestyles and increasing obesity rates, the number of those with diabetes in the UK is likely to rise dramatically during the next decade and beyond.

Hon. Members will have seen and been alarmed by recent media coverage of the first cases of type 2 diabetes found in white children in this country, accurately reported as highly disturbing evidence of the threat to health posed by increasing obesity in the developed

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world. The potential long-term impact on those affected of what can only be described as a time bomb, and the extra burden on an already overburdened NHS, are frightening.

For too long, politicians from all parties have failed to take diabetes seriously. Last year, however, 375 MPs signed a Diabetes UK pledge calling on all politicians to begin to deliver on diabetes. The Government have listened: the 12 standards contained in the document cover the complete life cycle of diabetes from prevention and the prevention of complications for those with pre-existing diabetes to the management of complications once they are identified. If the 12 standards are implemented properly, the prospects for those with diabetes in the UK will undoubtedly improve, and the Government will have made a significant public health policy achievement. However, the document will be no more than tantalising paper if they are unable to support those charged with implementation with new money.

Although we are all acutely aware of the colossal and competing pressures on the Department of Health's budget and accept that many positive steps can be taken without throwing money at problems, there is a danger that the national service framework for diabetes will be unable to raise standards of care across the country without extra dedicated resources. As other comparable service frameworks have received dedicated funding to support their implementation, will the Minister take the opportunity to guarantee dedicated funding for the national service framework for diabetes? If she is unable to do that at this stage, will she provide further information on the Department of Health's time scale for decisions about the funding of the national service framework?

There is certainly a need for extra investment. The Audit Commission's report, "Testing Times: A Review of Diabetes Services in England and Wales", published in April 2000, found:


A continuation of the status quo could have a devastating effect on the national health service, which is already under severe pressure from diabetes and its complications. That burden is due to rise because an ageing population with increased rates of obesity will inevitably translate into an increase in the number of people with type 2 diabetes in years to come.

Mr. Adrian Sanders (Torbay): I first declare an interest as an insulin-dependent diabetic. Is the hon. Lady aware of the "missing million" campaign run by Diabetes UK, which estimates that 1 million citizens in the United Kingdom have that condition but have not yet been diagnosed? Screening is one part of trying to identify those people, but the consequence would be an increase in the bill for treatment. We need to track down the missing million.

Siobhain McDonagh : I am aware of the missing million. As a London MP, I am specifically concerned that a substantial proportion of those 1 million people will be based in London, given the higher prevalence of diabetes among people from the Asian and Afro-Caribbean communities. A parliamentary answer to my

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hon. Friend the Member for Inverness, East, Nairn and Lochaber (Mr. Stewart) showed that the Government accept that as many as 1 million people may have type 2 diabetes without yet knowing it.

The longer people with diabetes go undiagnosed, the more likely they are to develop life-threatening and debilitating conditions such as heart disease, stroke, kidney failure, blindness and lower limb amputation. On average, people have type 2 diabetes for between nine and 12 years before it is diagnosed, the devastating effect of which is that more than a third and perhaps as many as half of them are already showing signs of complications when it is diagnosed.

The Government are aware of the need to identify people with diabetes early, and I urge Ministers to tackle the problem of how those people are to be identified early enough to prevent the onset of complications. A screening programme that targets people who are subject to a high risk of developing type 2 diabetes would help to provide a structured identification process. Opportunistic screening is clearly not working because the Government have accepted that an estimated 1 million people have diabetes but do not know it. Given that the costs of screening are lower than the costs of dealing with the problems resulting from undiagnosed diabetes, there must be a strong and urgent case for reviewing the way in which we screen for it, particularly in London where levels are reckoned to be 10 times the national average.

We must surely rethink the way in which we educate people about the risk of diabetes. I should be grateful to know whether the Minister will look into those pressing issues after the debate. The national service framework for diabetes provides a wonderful opportunity to address the nightmare scenario of a future NHS proving unable to cope with the financial and human costs of diabetes. Expectation among patients and healthcare professions is extremely high, and has perhaps been raised by the delay of the implementation of the national service framework, which was initially due to begin in April 2002.

The 12-month delay came as a blow to diabetics and health care professionals. Will the Minister guarantee that there will be no further delays to publication of the crucial implementation strategy document, and confirm that it will be published in summer 2002, as she announced last December?

The Government must ensure that the months during the build-up to publication of the delivery strategy are used to the full to ensure that the momentum for raising standards for diabetes care is maintained. The requirement for all primary care trusts to undertake a local assessment of diabetes service provides the opportunity to prepare fully for implementation. The Government must ensure that once it is published, there is local ownership of the service framework, by health care professionals, and patients. I am aware of concerns that the standard document does not place enough emphasis on the need for partnership in service planning, or involving people with diabetes, despite the Government's stated priority to build


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Given that the delivery strategy is due to be published in September, well in advance of the implementation date of April 2003, what do the Government intend to do to encourage preparation for the national service framework between now and then?

Given that people of south Asian origin are six times more likely to develop diabetes than Caucasian people, and that Afro-Caribbean people are four times more likely to do so, I would like to assure ethnic groups in Mitcham and Morden—I am an honorary member of the Asian Diabetic Support and Advice group there—that they will be fully consulted on and their needs incorporated in the national service framework.

User involvement in service delivery and decision-making has to be central to support empowerment. That is the only way to bring about the more patient-centred NHS that the Government are building. Local diabetes service advisory groups exist throughout most of the UK, and they can help in that process. Those groups bring together managers, health care professionals from primary and secondary care, people with diabetes and commissioners to advise on diabetes care. The fact that such care cuts across so many parts of the system requires that joint planning and integration are facilitated through joint working and local advisory groups. If supported and recognised, they provide the means of carrying out that planning.

The cost to the NHS of treatment of diabetes and its complications is immense. Substantial financial investment to support the national service framework could deliver savings in the future—I appreciate that every hon. Member who has an Adjournment debate about health makes that point, whatever the disorder might be. To demonstrate the need for Government to find comprehensive funding, Abacus International's recent report "Diabetes: the Problems, the Issue, and the Future" found that for every £1 spent on such treatment, £1.38 would be saved on complications.

I began by welcoming the fact that politicians have started to take diabetes seriously, and to listen to such eminent figures as Sir George Alberti, president of the Royal College of Physicians, who commented on the Abacus report that there is as


The national service framework standards document suggests that the Government are committed to tackling growing health concern. Translating those good intentions into delivery on the ground will require the promotion of user involvement in local planning and delivery, an increase in staffing, and a commitment to providing financial resources.

The implementation of the national service framework for diabetes provides an unprecedented opportunity to improve standards of screening, diagnosis, prevention, management and care. It will transform the lives of millions of British people, and pave the way for better future lives. That opportunity may not come again for a generation. Now is the time to deliver for those with diabetes.

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The Parliamentary Under-Secretary of State for Health (Yvette Cooper) : I congratulate my hon. Friend the Member for Mitcham and Morden (Siobhain McDonagh) on securing a debate on the important issue of the treatment of diabetes. I welcome many of her points, and I agree that this is a great opportunity to make substantial steps in improving care for those with diabetes.

I pay tribute to the work of Diabetes UK, which will hold its annual professional conference tomorrow. It has done considerable work for those who suffer from diabetes. It has raised awareness of the condition and has worked with health professionals and the Department of Health on the national service framework.

My hon. Friend is right that diabetes is a serious and complex condition that can result in a raft of debilitating complications and increase the risk of developing other diseases, including coronary heart disease, stroke, kidney failure, impaired vision, lower-limb complications, and additional risks in pregnancy. She is right that those with diabetes die sooner—on average, by more than 20 years if an individual has type 1 diabetes, and by up to 10 years if he or she has type 2 diabetes.

Diabetes can have a profound effect on people's lifestyles, relationships, work, income, health, well-being and life expectancy. My hon. Friend is right that it also has a significant impact on health and social services. It has been estimated that around 5 per cent. of total NHS resources and up to 10 per cent. of hospital in-patient resources can be used for the care of people with diabetes. Those with the condition are twice as likely to be admitted to hospital, and, once there, their stay is likely to be up to twice the average.

Around 1.3 million people have diagnosed diabetes, and evidence shows that it is becoming more common as lifestyles and life patterns change, even among children. My hon. Friend made it clear that the burden of diabetes does not fall equally. Significant inequalities exist in the risk of developing diabetes, in access to health services of quality, and in health outcomes. For example, type 2 diabetes is up to six times more common in people of south Asian descent, and up to three times more common in those of African and African-Caribbean descent, than it is in the white population. Mortality and morbidity are also affected by socio-economic deprivation. Such serious inequality issues must be taken into account.

The Audit Commission report, "Testing Times", highlighted unacceptable variations in the standard of diabetes service provision. It found some excellent areas of good practice in which staff worked across sectors to improve patient care. However, such examples were not widely shared across the NHS, and considerable improvements can be made. Those variations and gaps in the organisation and quality of diabetes services prompted the Government to announce the development of the national service framework for diabetes in England.

The number of national service frameworks that have been announced has been limited. Only a limited number of conditions and areas have been identified for those frameworks, such as mental health, coronary

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heart disease and the cancer plan. The frameworks have tended to concentrate on generic approaches, such as those for children and long-term conditions, and one for older people is already in development. The identification of diabetes for a national service framework was a significant step for the Government and the NHS because it stated the importance of diabetes and the issues that must be addressed.

As my hon. Friend said, standards for the national service framework were published in December. The delivery strategy will follow later this year so that implementation can begin next year. The standards document provides the first set of national standards on the treatment of diabetes for the NHS. They cover prevention, identification of those with diabetes, empowering those with diabetes by improving self-care, and clinical care for adults, children and young people. They also address managing diabetic emergencies, care of people with diabetes during admission to hospital, issues surrounding diabetes in pregnancy, and the detection and management of long-term complications. Considerable supporting information has been made available on the internet, and that includes suggested service models, performance indicators, proposals for practice-based registers and information on diabetes research. We welcome comments on the diabetes national service framework.

My hon. Friend is correct in saying that we intend to publish the implementation plan during the summer, and we have set up an implementation group to consider it. The group will work openly with a wide range of stakeholders to provide information on the strategy of the diabetes national service framework to ensure that implementation is manageable and sensibly paced and that it can be fully delivered during the 10 years of the programme and reflects the key priorities for those with diabetes and for the health professionals involved in their care.

I take on board the points made by my hon. Friend concerning partnership with those with diabetes to consider the care, education and joint planning of services. Those matters are being considered by the implementation group, and I shall ensure that it is fully aware of the points raised by my hon. Friend.

The implementation group is chaired jointly by Professor Mike Pringle of the Royal College of General Practitioners and Dr. Sheila Adam, director of policy at the Department of Health. The group includes two people with diabetes as well as members of the medical, nursing and allied health professions, NHS management and Diabetes UK. The implementation group is keen to hear the views of people with diabetes, those in the NHS and health care professions, and other interested parties on the priorities for action, the time scale for implementing different standards and what the priorities should be during in the first few years of the national service framework. A strength of the framework is that it has worked hard to involve all those who deliver the service or use it. Its purpose is to provide the care that people want and need. Another strength is that it covers all aspects of care, including prevention and treatment. My hon. Friend is correct in saying that problems may arise when there is insufficient integration of the different aspects of care.

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The delivery strategy for the national service framework will set out the action to be taken by local health and social care systems, including milestones, performance management arrangements, service models, and national underpinning programmes to support local delivery. We have established a research advisory committee with the Medical Research Council and Diabetes UK to review current diabetes research in the United Kingdom and to identify the priorities for new research.

The National Institute for Clinical Excellence is developing clinical guidelines for type 1 and type 2 diabetes and is appraising a number of new technologies. We welcomed NICE's publication last week of the first two guidelines in its type 2 diabetes series, which cover diabetic retinopathy and diabetic renal disease. A diabetes information strategy is being developed because it is important to ensure that the right information is resourced to implement the national service framework. It will set out a vision for the information infrastructure, systems and services and what needs to be done to deliver it.

We have also set up a long-term conditions care group work force team to take a national overview of the challenges of delivering services to the diabetes national service framework standards and to identify innovative ways in which the skills and competencies needed in the work force can be delivered.

My hon. Friend mentioned the time scale for introducing the national service framework and publishing the implementation document. We must take account of the changing roles and responsibilities of NHS organisations and staff and recognise the current pressures on the NHS, especially in primary care but also in hospitals. That is why the decision was taken to have a proper debate on and examination of the implementation process once the standards had been published in order to engage closely with patients and clinicians and ensure that we can deliver the national service framework to the standard that we all want.

Developing the national service framework in two parts in that way will enable us to engage the NHS, partner agencies and those with diabetes more closely in planning and managing the framework's implementation. That is why publishing the standards in advance of finalising the milestones gave us an opportunity to be far more inclusive in developing the implementation programme. We aim to have a fuller process of communication and of raising awareness and agreement about priorities and practical implementation.

My hon. Friend mentioned resources. The national service framework implementation process will need to take account of resources currently being considered for the future of the NHS as part of the Government's spending review for the next three years. She will understand that it is not possible for me to pre-empt that or the discussions that will take place as part of the implementation group's work. However, I assure her that those matters will be considered not only in the light of discussions on the spending review and long-term investment plans for the NHS, but as part of the detailed discussions on the implementation time scale and milestones.

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It is important to bear in mind, as my hon. Friend is aware, that we are investing considerable additional resources in the NHS across the board. As we shift power to the front line, primary care trusts will increasingly have to take responsibility for joining up their resources around the person and not simply around individual diseases. The national director for primary care is leading an important project to look at implementation across the national service frameworks to ensure that we deliver milestones properly and that the right investment is in place.

In the meantime, we are keen to avoid a planning blight in diabetes services. One reason for setting out the standards was so that primary care trusts and the health service could be aware of the direction in which the national service framework would go. We have also asked primary care groups and trusts to undertake a baseline assessment of population need and service provision so that they are ready to begin implementation of the national service framework next year. We shall shortly publish a template to support that task. Those already planning and investing in local diabetes services on an ongoing basis can take account of the broad direction in the standards document.

Other work in progress supports the broad thrust of the diabetes framework, including four of the first wave of pilot training courses in self-management, under the expert patients programme, which cover diabetes. The Minister of State, Department of Health, my hon. Friend the Member for Redditch (Jacqui Smith), who spoke at the Diabetes UK annual professional conference, will say more tomorrow about the expert patients programme and its application to diabetes. NICE will evaluate patient education models for diabetes and issue guidance next spring.

We must take account of work that is changing and redefining traditional professional roles and boundaries. Two pilot sites of the changing work force programme, in Luton and Peterborough, are helping health and social care organisations to redesign staff roles and cover diabetes services.

My hon. Friend will be aware that much work progressing across the Government on the prevention of ill-health also applies to diabetes, including tackling obesity and improving nutrition and physical activity among children, as the prevention of diabetes is important too.

Diabetes is a serious condition but the future need not be bleak because evidence shows that the onset of type 2 diabetes can be delayed or even prevented and effective management of the disease can increase life expectancy and reduce the risk of complications. The diabetes national service framework builds on those foundations. As my hon. Friend said, the framework provides an important opportunity to improve patient-centred care delivered in partnership for those suffering from diabetes.


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