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Volume 742: debated on Thursday 10 January 2013


Asked By

To ask Her Majesty’s Government what action they are taking to reduce the number of amputations due to diabetes.

My Lords, foot complications of diabetes are usually preventable. Early identification and prompt treatment prevent amputations. NICE guidelines recommend annual foot checks, which are included in the quality and outcomes framework for general practitioners. NHS Diabetes has established regional diabetes footcare networks. People with vulnerable feet require expert protection, while those with problems need urgent specialist care. Local national health services are responsible for commissioning podiatry services and multidisciplinary specialist footcare teams for people with diabetes according to local needs.

I draw the attention of the House to my declaration of interests in respect of Diabetes UK. One hundred and twenty-five amputations take place each and every week in England alone, and 80% of those are preventable. The record of the Department of Health is not good; the figures are going up, not down. If I asked this question in a year’s time, what progress does the Minister expect that his department would have made to reverse that trend?

The noble Lord is absolutely right that this is a major public health issue and one that impacts very seriously on the health and well-being of individuals, so it is a priority for us. We are committed to reducing the number of avoidable amputations among people with diabetes. In fact, progress is being made: although the number of amputations is going up, the rate is falling. However, we are under no illusion that this will be a growing problem because of the growing number of people with diabetes. All our work on improving completion of the NICE nine care processes for people with diabetes and improving timely access to specialist diabetic footcare multidisciplinary teams will support that aim, and the Diabetes UK Putting Feet First campaign has real potential to improve awareness of foot complications in diabetes.

My Lords, does the Minister agree that the real way to reduce the number of amputations is to reduce the incidence of diabetes and that the way to do that is to do something about the obesity epidemic, which is the main cause of diabetes and one of the main causes of amputation? What is he doing to try to prevent that quango, NICE, misleading the nation and politicians, as it did, into believing that the answer to the obesity epidemic was to take more exercise when, although exercise is important, the real answer is to eat fewer calories?

I agree with my noble friend about the importance of targeting obesity as a serious public health risk and one which leads to diabetes in many cases. I believe that, if my noble friend were to talk to NICE about its recommendations to prevent obesity, he would find that its line is slightly modified from the one that he has criticised. We should pay tribute to NICE for the good work it has done in the specific area of diabetes. The recommendations and guidelines it has issued have been very positive. There is, of course, a quality standard for diabetes, which is also excellent.

My Lords, people with learning disabilities and those with serious mental illness have a higher incidence of diabetes. They have a later diagnosis and are therefore more at risk of complications. Does the Minister agree that one way to reduce the number of amputations associated with diabetes would be to improve access to diabetic care for people with learning disabilities or mental illness?

My Lords, yes, I certainly do. There are a number of positive ways in which we can do that. One is the NHS health check, which should, if it is performed correctly, pick up those with undiagnosed diabetes. Early identification of diabetics is key in this area, particularly for those who are at risk of ulceration. Other ways are targeting preventive services at those most at risk, including those with learning disabilities; early management of foot infection and rapid access to multidisciplinary teams; and having good diabetic foot prevention and ulcer management services in local areas.

My Lords, the point at issue is surely this: that to prevent the four out of five needless amputations that currently take place, Her Majesty’s Government need to respond to the Question of my noble friend Lord Kennedy by saying how they will ensure that there are those multidisciplinary groups with specialist knowledge of feet and the ability to make sure that there is not a postcode lottery as there is now. They should be properly monitored by the Government to ensure that a proper service is offered to diabetics at a time of decline in the amount of money going into the National Health Service.

My Lords, there is no single magic bullet that will solve this problem, but undoubtedly better monitoring in general practice is one answer; the QOF incentivises that. The NHS outcomes framework will also incentivise clinical commissioning groups to ensure that those with long-term conditions—particularly diabetes—are properly looked after. The benefits of multidisciplinary teams are now proven. The evidence is there and, if we can shine a spotlight on the statistics—and there is, as the noble Lord knows, a wide variation in success rates across the country—that will be the key to driving better performance throughout the health service.

My Lords, does the Minister agree that part of the problem is that while the NICE guidelines, if implemented throughout the country, would reduce the variation rate in amputations, particularly of lower limb extremities, it is not mandatory to implement those guidelines? He may be aware that several nations, including Scotland, have recently reported a reduction of 30% in the amputation rate, following strict protocols in diabetic management.

My Lords, there are centres of excellence throughout the United Kingdom, from which I am sure the health service as a whole can learn. The noble Lord is absolutely right. He mentions the NICE guidelines; he is right that they are not mandatory, but they do point to best practice. By highlighting the data, we can ensure that commissioners and practitioners ask themselves the right questions about whether best practice is being followed.