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Diabetes Care

Volume 606: debated on Thursday 3 March 2016

Motion made, and Question proposed, That this House do now adjourn.—(Gavin Barwell.)

Thank you, Mr Deputy Speaker, for giving me the opportunity to debate this important matter. I begin by declaring my interests as a type 2 diabetic and chair of the all-party parliamentary group for diabetes. In 2007, I founded the diabetes charity Silver Star, and I am an active and passionate supporter of Diabetes UK and JDRF—the Juvenile Diabetes Research Foundation—both of which provide secretarial services to the APPG. I would argue that we currently have the best diabetes Minister we have ever had, and I am glad to see her on the Front Bench today. I would like to thank her and her diabetes tsar, Jonathan Valabhji, for all the work that they do.

Diabetes is one of the most important health challenges facing the NHS and indeed the world. Sometimes we get immune to the facts, even though they are so devastating: 3.5 million people in the UK have been diagnosed with diabetes; 700 people a day are diagnosed with the illness; by the end of this debate 15 more people will have been diagnosed with diabetes—that is one every 2 minutes; and it is estimated that by 2025 some 5 million people in the United Kingdom will have diabetes.

Despite the good intentions of the Government, the passion of practitioners and the interest of many Members of this House, I am worried that the prevention, diagnosis and treatment of diabetes is not high enough on the agenda. One in five hospital admissions for heart failure, heart attack and stroke are people with diabetes. Diabetes is responsible for more than 135 amputations a week, four out of five of which are avoidable. Diabetes is the leading cause of preventable sight loss and the most common cause of kidney failure. Every year, more than 24,000 people die prematurely due to diabetes.

I echo my right hon. Friend’s comments about the Minister. He cites statistics, and on the amount of money that is spent on diabetes, £7 billion of the NHS budget is spent on dealing with the avoidable complications to which he has just referred. Yet Department of Health spending on research into diabetes through the UK’s Medical Research Council is just £6.5 million, which is by far the lowest level of almost any developed country. Does he think there is a connection between those two things?

My right hon. Friend, who is a great campaigner on this issue, is right to have raised this, because we need to spend much more on diabetes research. One way of doing that is to make sure the funds are available for the excellent researchers and academics we have in this field, because research has indicated that there is an unacceptable and unexplained disparity in diabetes care in our country. We are failing the very people we are trying to help. Secondary complications are largely avoidable through better care, and we need to ask why this is not being provided. Although the NHS currently spends approximately £10 billion on diabetes, it is estimated that 80% of these costs are spent on dealing with complications. The time for conferences, seminars and good words is over—it is time for a new deal for diabetics.

Earlier this year, the Public Accounts Committee published a report on the “Management of adult diabetes services in the NHS”, and I would like to thank those on the Committee for their very hard work. The report found that astonishing variations still exist across clinical commissioning groups: the percentage of patients receiving all the recommended care processes ranged from 30% in some areas to 76% in others; and the percentage of patients achieving three treatment targets ranged from 28% to 48% in different areas between 2012 and 2013. As well as this postcode lottery, the figures were even worse for type 1 diabetic patients.

In response to my recent written question, the Minister acknowledged that there is no specific budget allocation for public health services related to diabetes. It is up to local authorities to

“assess local needs, prioritise and deploy available resources accordingly.”

I believe that is wrong. My own health and wellbeing board was unable to tell me how much it has spent on diabetes awareness. It should be able to do so. I welcome the Government’s inclusion of diabetes in their proposed clinical commissioning group improvement and assessment framework. That is a vital step in the development of a cohesive national diabetes strategy.

There has been much discussion about how effective the framework will be, and whether it will be released on time. We are already disappointed that the publication of the childhood obesity strategy has been delayed, a pertinent issue of concern for me and many other Members, including the Chair of the Health Committee, the hon. Member for Totnes (Dr Wollaston). We need an assurance from the Minister today that both the framework and the childhood obesity strategy will be published before the start of the summer recess.

The burden of care for diabetes is currently left overwhelmingly to one group: the GPs. It is unrealistic to expect GPs alone to manage this. We acknowledge that GPs are under increasing pressure, and the demand for their services far outweighs the supply. In some places, it takes weeks to get an appointment. The financial incentives given to GPs are clearly not working. Some 16% of GPs’ contracts is supposed to be spent on incentives, with 15% of this sum being directly allocated to diabetes testing. That equates to £94 million, yet an estimated 549,000 people have type 2 diabetes, but remain undiagnosed. A recent study by Pharmacy Voice found that 40% of GPs would like more support for their patients in managing diabetes. We need an action plan from NHS England that will assess the practical support that clinical staff need to care properly for their patients.

We are often told that it takes a village to raise a child. That phrase was recently given re-emphasis by Hillary Clinton. In my view, it takes a whole town of healthcare professionals to deal with the diabetes tsunami. Instead of placing the entire burden on GPs, we need to utilise a network of different professionals to attack the diabetes epidemic on all fronts in an efficient and cost-effective way.

At an international conference organised by the all-party group last month, we heard evidence to that effect from specialist GP Dr Paul Newman, endocrinologists Dr Sam Rice and Dr Abbi Lulsegged, diabetes nurse Sara Da Costa, diabetes specialist dietician Julie Taplin and lifestyle expert Emma James. However, we did not have time to hear from other parts of the network—the podiatrists, ophthalmologists and pharmacists. Their enthusiasm knows no bounds, but they are limited by the availability of funds and the lack of specialist staff. We must mobilise our political will to give them the support that they so desperately need.

Diabetes specialist nurses are vital in the fight against diabetes. Evidence shows that these nurses are cost-effective, improve clinical outcomes and reduce the length of patient stays in hospital. I am extremely concerned that the number of trained diabetes specialist nurses has stagnated. The latest national diabetes in-patient audit stated that one third of hospital sites still have no specific diabetes in-patient specialist nurses. With the predicted increase in diabetes cases to 5 million by 2025, it is alarming that forward-thinking plans to train such nurses are not being put in place now. We need a commitment from the Minister that there will be future provision for diabetes specialist nurses.

Community pharmacies are ideally placed to provide care at a time and in a place convenient to patients. The NHS diabetes prevention programme could be a great opportunity to get community pharmacies involved in supporting GPs and other healthcare providers. Janice Perkins, the pharmacy superintendent of Well Pharmacies, advised me that this could be done as part of a care plan package, where appropriate tests are provided to the patient based on their personal need, without their having to access numerous sites.

The proposed cuts to the community pharmacy budget could see the closure of up to 3,000 sites. My local pharmacist, Rajesh Vaitha of the Medicine Chest in Leicester, informed me that up to 60 out of 227 sites could close in Leicester alone. The closure of these pharmacies will have an adverse effect on patients and will place greater pressure on our already strained health infrastructure. Pharmacies are on the high street, and no appointment is needed to see the pharmacist. Like many patients, my late mother Merlyn, a type 1 diabetic, had great faith in her local high street pharmacist. I believe that the cuts to community pharmacies could be shelved if pharmacies were properly utilised in diabetes care.

Last Friday I visited the Steno Diabetes Centre in Copenhagen. Steno is a world-leading out-patient facility that cares for 6,500 diabetics a year. It is a one-stop centre for diabetics, with the main focus on prevention and secondary complications. The Steno centre is run by a team of remarkable diabetes specialist nurses led by Professor John Nolan. This is extremely cost-effective—the centre has an annual clinical budget for 6,500 patients of £9 million. Steno has reduced avoidable blindness in its patients by 90%—a service that is provided by a team of just six nurses and one ophthalmologist. The centre’s foot clinic has reduced avoidable amputations in the past 10 years by 82%. The savings from avoiding just two amputations funds the entire foot clinic’s annual budget. The Steno centre is an ideal model of how diabetes care should be facilitated. I urge the Minister—not that I want her to spend too much time abroad—to look at the incredible work that is being done there and bring a network of such centres to the United Kingdom.

In my own constituency, we are very fortunate to have not only the best football team in the country—many thanks to West Ham, Swansea and Liverpool for what they did last night—but the Leicester Diabetes Centre, a centre of true excellence in diabetes care. It is one of the largest facilities in Europe for clinical research into diabetes. Run by the dynamic duo of Professor Melanie Davies and Professor Kamlesh Khunti, it provides an innovative partnership between the NHS and academia—the very people in whom we should put more faith and behind whom we should put more funds, as my right hon. Friend the Member for Knowsley (Mr Howarth) said. We are extremely fortunate to have such experts, but we need more centres of excellence.

We need an holistic approach to public health, tackling the medical complications of diabetes and the contributory lifestyle factors that increase the prevalence of type 2. Other countries have taken a lead on this issue. Dr Francisco George, director general for health in Portugal, told me that data sharing is one thing we can do. I have also heard from Dr Pablo Kuri Morales, the Minister responsible for health promotion in Mexico, that a sugar tax actually works. Press speculation is that the Prime Minister has shelved the sugar tax until after the European Union referendum. In my view, the two matters are entirely separate, so why can we not have a sugar tax now?

I have been vocal in my support for a sugar tax and for clearer labelling of sugar content. Industry leaders such as Waitrose and Asda have made commitments to reduce sugar in their products, but I am afraid that the Government’s responsibility deal, which pledged to do all kinds of things, has not had much effect in reality, as recent reports by Professor Graham MacGregor and Action on Sugar have shown. We are, however, fortunate to have an NHS chief executive—Simon Stevens—who has imposed his own 20% sugar tax across the NHS, and that is an important start. I call on the Minister, when she returns to Richmond House, to ban high-sugar products from the canteens in her own Department.

I recently visited a brilliant juvenile diabetes centre in Tangiers, which was based in the Centre de Santé Saïd Noussairi. I nearly wept when I saw young type 1 diabetics having to rely on charitable funding just to get their daily insulin injection—something we can get absolutely free from our NHS. Yet, astonishingly, even in our country, whose healthcare system is the envy of the world, we have stark variations in diabetes treatment and unfocused resources.

We have world-leading medical professionals, nurses, healthcare professionals and researchers who are capable of doing, and willing to do, so much more, provided they get the funding and are backed by an iron political will. That is why we need to achieve a new deal for diabetics, and now is the time to start.

I should start by saying that, as a Spurs season ticket holder, I shall dwell on the kind words of the right hon. Member for Leicester East (Keith Vaz) about my time in office and ignore his cruel jibes about what can only be described as a disappointing night last night.

I thank the right hon. Gentleman for bringing this important issue to the House for another debate. He has rightly issued a number of challenges to me and the Government, and it is vital that we keep up the drumbeat of debate, which is key to making sure that we keep this serious and increasingly prevalent disease on the agenda.

Fantastic work has been done by the right hon. Gentleman and other members of the all-party group, by the right hon. Member for Knowsley (Mr Howarth), who is also in the Chamber, by the Silver Star charity and by so many others. There is very high awareness of the issue in Parliament, and I will come back to what more we might be able to do to mobilise Members even more on this important subject.

As the House will be aware, tackling diabetes is of great concern to the Government. The Department of Health is committed to preventing type 2 diabetes and to tackling the variation the right hon. Member for Leicester East highlighted in the delivery of care, because we, too, want the best possible care for those with diabetes.

There were encouraging signs from the latest national diabetes audit that progress is being made in some important areas of management and care. For example, there are clear trends of improvement in blood pressure control for people with type 1 and type 2 diabetes and in glucose control for type 1 diabetes. It is also reported that a far greater number of people are being offered structured education within a year of diagnosis. However, I will come back to structured education, because it is uptake, not offer, that I am interested in.

The report again highlighted a concerning and continuing issue of variation in care process completion and treatment target achievement for people with diabetes. I am particularly troubled by the statistics on younger people and those with type 1. The audit found that in 2014-15 just 39% of people with type 1 diabetes received all eight care processes compared with 59% of those with type 2. There is an even greater contrast with regard to age range.

As the Minister will be aware, because I have discussed it with her before, there is a specific group of young type 1 diabetics who manipulate their insulin intake to achieve rapid weight loss. Will she give some thought as to how that group, which is relatively small, can be supported to get out of that problem, which is life-threatening?

I will certainly take that issue away and reflect on it, and we will speak about it again.

For people under 40, only 27% with type 1 diabetes and 41% with type 2 received all care processes, compared with 58% and 65% respectively for those aged between 65 and 79. I have some sense of why that is, but it does highlight the challenge we face. Encouragingly, 77% of those newly diagnosed with type 2 diabetes were offered structured education, but again the percentage was lower for type 1. That is clearly unacceptable, because everyone with diabetes should receive the best possible care regardless of age, postcode or the type they have been diagnosed with. That is why, in our 2016-17 refresh of the mandate to NHS England, we have made tackling variation in the management and care of people with diabetes a key priority over the lifetime of this Parliament.

Does the Minister agree that we need consistently early diagnosis? Early intervention is particularly important in diabetes care, as it saves the NHS from unnecessary expenditure in the long run, and, just as importantly, saves patients from unnecessary suffering.

That is absolutely right. I am going to talk about the national diabetes prevention programme, which goes to the heart of the problem. When I spoke to the all-party group, I mentioned the conveyer belt that can start with weight in childhood developing into type 2 and go through to the serious complications that have been alluded to. At all points along that continuum, there are things we can do, and must be doing, to make life better for people with diabetes.

Because of the mandate, diabetes is now right at the heart of NHS England’s agenda. We want it to lead a step change in preventing ill health and supporting people to live healthier lives. Our 2020 goal is for a measurable reduction in variation in the management and care of people with diabetes. However, there is some way to go, so this debate is an opportunity to update the House on some of the areas where we are going to make progress.

We have increased transparency through the creation of the Healthier Lives website, which is a major online tool from Public Health England. I encourage Members who have not looked at it to do so. It highlights variation in the prevalence and treatment of diabetes, allowing clinical commissioning groups and GP practices to compare how well they deliver diabetes care and so drive improvements and iron out variation. I will come on to the support that we are offering them as well.

The CCG outcomes indicator set provides clear comparative information. As was said, it will soon be replaced by the improvement and assessment framework, which will have two diabetes indicators aimed at reducing variation in the achievement of the NICE treatment targets and the referral and take-up of structured education. Consultation on the framework has just closed, and we expect it be published in the summer. It goes to the heart of tackling variation and the cohesive approach that was spoken about.

The NHS Right Care programme is a very practical approach to tackling variation that uses the “Atlas of Variation”. In the case of diabetes, NHS experts help CCGs and other local health system partners to make the step change they need in some areas to improve care, because transparency alone is not enough if we do not offer people support and hands-on advice. In Slough, for example, huge improvements have been made through a clinical mentorship programme that has upskilled healthcare professionals in general practices. That has resulted in an increase in patients who have had their blood glucose, blood pressure and cholesterol controlled. The Right Care programme will be rolled out across CCGs nationally by 2018.

I urge the all-party group on diabetes and the right hon. Member for Leicester East to continue to engage colleagues. It is absolutely right that Ministers are brought to the House and scrutinised about what we can do, but the very nature of our health system and the variation under discussion are also highly susceptible to pressure at local level from well-informed Members and senior councillors. I encourage him to continue to engage Members in asking the right questions at a local level.

I will be brief, because I know that the Minister has a lot to tell us. When Members of Parliament write to local health and wellbeing boards, it would help enormously if they were able to tell us how much they spend on diabetes awareness. They cannot do that at present.

Part of the challenge is because much of the effort that is put in relates to the preventive agenda and the contributory factors. That is one of the challenges in teasing such figures apart. However, I will reflect on whether we can do more in terms of health and wellbeing boards.

To incentivise improvements in the treatment and care of children and young people with diabetes, the best practice tariff for paediatric diabetes provides an annual payment for every child and young person under the age of 19 with the condition, providing that 13 standards of care are met. One of those standards relates to structured education. As the right hon. Members for Leicester East and for Knowsley know, I am passionate about making changes to the way in which we do structured education. We know that it works and that it is very good when people do it, but we also know that a lot of people are not accessing it. I am looking really hard at how we could take a new and radical approach, including whether there are any tech solutions, and I look forward to reporting back on that.

Our ambitions extend further than creating a level playing field. We want the management of and care for diabetes to be driven up right across the board in order to improve outcomes. The NHS is working with a number of other organisations to help to promote services that are integrated around patients’ needs across all settings. It is implementing a customer service platform to empower patients with diabetes to self-manage by booking their own appointments, managing their prescriptions, monitoring the care they have received and viewing their personal health records.

I fear that time will not allow me to touch on prevention in as much detail as I would have liked, but I want to emphasise just how seriously we take it. The right hon. Member for Leicester East has outlined the reasons why it is important, including the escalating figures and how much the rising tide of type 2 diabetes associated with lifestyle will cost the NHS in the future. The factors can be modified, and one of the most powerful weapons in our armoury is the NHS diabetes prevention programme, which is the first national type 2 diabetes prevention programme to be delivered at scale. Its aim is to help people identified as at the highest risk of developing type 2 diabetes to lower their weight, increase physical activity and improve their diet through intensive lifestyle intervention programmes. I am pleased to inform the House that the first providers will be announced by the NHS shortly, and the programme will move ahead.

The programme will also link to the NHS health check programme. Almost 3 million NHS health check offers were made in 2014-15 and almost 1.5 million appointments taken up. That is vital for first awareness and my constituency knows how important early diagnosis can be as a result of the checks carried out by Silver Star when it visited us.

The right hon. Gentleman talked about other important referral routes, including engagement with pharmacists, and I will pass on his concerns to the Minister for Community and Social Care, my right hon. Friend the Member for North East Bedfordshire (Alistair Burt), who has responsibility for community pharmacies.

The right hon. Gentleman criticised the responsibility deal, but I think it has achieved a lot. We have made some important gains working in voluntary partnership with industry, such as the voluntary front-of-pack nutritional labelling scheme, which has greatly empowered consumers to know what is in their food. That accounts for about two thirds of the market for pre-packed food and drinks, but I accept that the challenge is to go further.

We will announce more about our childhood obesity strategy this summer. We will also monitor the impact of NHS England’s proposal for the introduction of a sugar tax on the NHS estate. It will be interesting to see the results of that consultation. The Sugar Smart app has empowered 1.6 million consumers to date to know more about what is in their food.

I thank the right hon. Gentleman again for bringing these important issues to the House. I am absolutely sure that we will discuss them again, because this vital agenda is right at the heart of the Government’s health programme.

House adjourned without Question put (Standing Order No. 9(7)).