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Health: Diabetes

Volume 744: debated on Tuesday 19 March 2013

Question for Short Debate

Asked By

To ask Her Majesty’s Government what is their assessment of the cost to the United Kingdom of type 1 diabetes; and what plans they have to improve treatment of that disease.

My Lords, the question for this debate on diabetes follows on from the debate on diabetes initiated by my noble friend Lord Harrison on 29 November, when the House had a caring, helpful and painstaking reply from the Minister—who of course is responsible for health only in England. However, since the preponderance of contributions then were on type 2, it was not surprising that the Minister’s reply on diabetes type 1 could be measured in half a column of Hansard.

I shall particularise again on type 1, about which I have already declared a family interest. In sheer numbers, the lion’s share of the diabetes problem is type 2, where some individual action can be taken by those who suffer. Not a great deal can be done for type 1 except a great effort to mitigate the problem by management of the disease, including the use of insulin pump therapy where appropriate. I make three points. First, 400,000 people are currently affected by type 1, of which 29,000 are children, and incidence is growing at 4% a year. Secondly, lifestyle intervention will not prevent the increase in the number: obesity is not the problem. Thirdly, only research will find a cure for type 1. It is at present incurable and can strike at an early age. My aim in raising the subject is to seek once again to disaggregate the cost of diabetes type 1 from type 2, both in the cost of treatment and the provision of funds for research to find a cure. I have so far failed. The Department of Health does not currently calculate the cost in the way I would hope. Why can it not do so in future? That is my first question. Specifically, what are the obstacles?

We have estimates. The direct and indirect cost of treating type 1 is said to be of the order of £1.9 billion. With the projected increase of sufferers, the cost will be even more astronomical. Until the department is able to tell us what, in its view, is the order of expenditure, we cannot hope to make good decisions as to what expenditure is appropriate. We now have the opportunity of the shortly-to-be-born National Health Service Commissioning Board to look afresh at the two different types of disease. Aggregation of expenditure under the general figure of diabetes will not help the boards, as the Minister said, to,

“guide local commissioners to improve outcomes for people with the condition”.—[Official Report, 29/11/12; col. 333.]

I rely on those words. I am advised that representations were made to the Department of Health that type 1 sufferers are a small group—though not so small at 400,000 people—with the need for highly specialised support. However, the request that type 1 sufferers be commissioned separately or at least differently has not been approved. How is that decision justified? That is my second question. Since this is the second time that I have raised this matter in debate, perhaps the Minister could expand his reply tonight by writing to me with the department’s detailed reasoning. I would like that.

It can be of enormous material help to type 1 sufferers to provide insulin pump therapy and its monitoring as an option. There is immense international variation in the provision of pumps. In this country, as with the management of diabetes type 1 care there was a postcode lottery in the past. I was encouraged by the Minister’s reply that 8% now had pumps here in this country. He went on that,

“we still need to go further to achieve the 12% to 15% advised by NICE”.—[Official Report, 29/11/12; col. 336.]

I welcome what he said.

Specifically, what are the obstacles to enable this and why have we been so slow? It is estimated that the savings to the National Health Service that could be achieved by reaching the NICE benchmark would be £30 million and £60 million a year. We are talking about big sums of money. I am told that in the United States, probably 40% use the subcutaneous infusion. Norway, Austria, Germany and Sweden have higher figures of use than us, while of course other countries have lower ones. I have already questioned why the then health Minister, Mr Paul Burstow, was able to write to me on 25 April last year saying, “that we were generally in line with the United States”. That was a significant reply which took a great deal of wind out of my sails as I had relied on anecdotal accounts of disparity. It was a crucial response. How could the department have advised him to write as he did? Given the evidence that has emerged, that is now my third specific question for the Minister.

I come now to research. In addition to government funding, a great deal of work is done by charities, and I welcome the work of the Juvenile Diabetes Research Fund. I understand that the Wellcome Trust is also active in Cambridge, Oxford, UCL, Leeds and Hanover in Germany. Since the last debate, I have been to Oxford to discuss with Professor Paul RV Johnson, the director of the Oxford pancreatic islet transplantation team, its work on an artificial pancreas. JDRF believes that research into closed loop glucose control stands on the cusp of a breakthrough that will represent the first step towards improving the lives of millions of people with type 1 diabetes. They will be provided with an artificial pancreas. This is where we are and that is what they believe.

Progress can be achieved by a partnership between experts in various disciplines and industry for development, along with the regulatory agencies to ensure safe management. The need for disaggregation is exemplified by the fact that in 2009 the government spending bodies committed £51 million to fund research into diabetes, but of this only £6 million was applied to type 1 diabetes. I was encouraged by the progress being made at Oxford and the successes achieved with adults so far. I am sure I shall be further encouraged when I visit Cambridge and discuss the matter with the team led by Dr Roman Hovorka. While both the Government and the charities have to exercise care in the funding of projects, I hope that the Minister will himself examine whether there are any bureaucratic problems over the supervision of the spending of research funds, both public and private. It would be a pity if researchers had to spend an undue amount of time meeting overprescriptive requirements regarding the minutiae of how money is spent.

I made this point in the last debate, but I shall repeat it. There has never been a real budget for type 1 diabetes services. They have been developed on the back of academic interest and the clinical recognition of need. What has been done so far is a great tribute to the professionals. I earnestly hope that the commissioning boards will not miss the opportunity properly to recognise that type 1 diabetes is a disease with many different causes and characteristics from those of type 2 diabetes. We should ensure that the good research work now in hand is encouraged and adequately funded so that fresh hope is brought to the 400,000 sufferers of type 1 diabetes—and their number is growing each year.

My Lords, it is a great pleasure to follow the noble and learned Lord, Lord Morris, who is a distinguished member of the All-Party Parliamentary Group for Diabetes, so admirably led by our colleague in the Commons, Adrian Sanders.

The noble and learned Lord highlighted the amount of money being spent on type 1 and type 2 diabetes, which is familiarly known as some £10 billion a year, but evidence from a European study that I am going to quote in a minute suggests that it could be nearer £14 billion a year. This illustrates the theme of the noble and learned Lord, Lord Morris, that there is a large degree of uncertainty about the knowledge and facts that we have in this field and it is something we need to repair, which I will turn to shortly.

Having said that, we should have an update on the debates we have had in the past with regard to the treatment of diabetes. It is an odd circumstance that as diabetes becomes an epidemic in this country it has been largely neglected. Much more concentration has been on the repair of cancer or the attack on heart diseases and so on. I do not know whether the Minister has a reply to that but it is something that we need to turn our attention to.

I am very grateful that the Government have reiterated their desire to maintain the same levels of health spending as in the past. Nevertheless, cutbacks are beginning to happen. One of the most worrying themes, which I hope the Minister will address, is the decline in the cover of diabetics. We are beginning to lose the annual check-up, which is typical of what we have had. There is a tilting over to relying on the patient to bring to the attention of the GP a problem for the GP to refer on. The problem with that is that it is the middle-class, knowledgeable patient who understands that—so often at the cost of neglecting those who do need the annual check-ups and the variety of check-ups that were put in place by the previous Labour Government.

I encourage the Government to spend wisely. For instance, I have made this plea before about the DAFNE programme, which provides structured educational courses for type 1 diabetics. It is claimed, and I believe it may be true, that it pays for itself in four to five years, but it is not generally applied throughout the United Kingdom and that is a bad thing.

The general rush to do away with bureaucracy sometimes has a fatal element to it. I saw one of my many health advisers on Monday and at the end of the consultation she looked at the screen and said, “We no longer have the appointments done elsewhere and a paper notification for you”. She has to do it. It took her about six minutes, typing away. Of course, she is taking on administrative duties that take away from her skills at the coal face. I hope that the noble Earl, Lord Howe, will ensure that we leave the bureaucracy to the bureaucrats and that the health specialists have the opportunity to do what they do best.

I want to turn to a study by LSE Health at the London School of Economics, Diabetes Expenditure, Burden of Disease and Management in 5 EU Countries, which was published last year. It makes very informative reading. Noble Lords will know that I am a passionate pro-European. One reason for that is the ability to compare and contrast the practice of the 27 countries of the European Union. This is a study of the five biggest countries, but it offers us insights that we can adopt and adapt here, or which they can adopt and adapt in their countries.

I was surprised to note that the study firmly declared that blood glucose monitoring is a cheap and hugely effective way of ensuring the health of diabetics. The Minister will recall arguments we have had in the past over testing strips, for instance. He will remember that he responded to a debate in which I tried to highlight diabetic foot care, which I have always thought was quite expensive. I am clad in shoes which are appropriate for my very strange feet as they give protection which enables me to continue to do the kind of stuff I am doing, as is the case with thousands of other diabetics throughout the United Kingdom. I know that the noble Earl is familiar with these debates. I sometimes think that he has been answering them since the time of Galen.

The study looks at Germany, the UK, France, Italy and Spain and quantifies evidence and data. It notes:

“There is increasing concern amongst government officials and public health agencies about diabetes care in Europe. Both diabetes prevalence and spending appear to be increasing. … Diabetes prevalence has been increasing steadily over the past two decades, along with an aging European population, increasing, high obesity prevalence and changing ethnic make-up. This study estimates that Germany has the highest diabetes prevalence at 8.9%, followed by Spain (8.1%), France (6.4%), the UK (6.1%) and Italy (4.8%)”.

It is interesting to ask why these differences arise. The study continues:

“Only three countries have national diabetes programmes”.

I am glad to say that that includes the United Kingdom, along with Italy and Spain. The study notes that France’s programme,

“has not been operational since 2005”.

It continues:

“Germany has Diabetes Disease Management Programmes (D-DMP), however, not all patients with diabetes are registered. None of these strategies have hard targets to achieve ideal diabetes management”.

It would be interesting to learn more about that. In 2009, the United Kingdom introduced screening for high-risk patients. We have done well in regard to screening for retinopathy. It is imperative to maintain that momentum.

The study states:

“All countries have care guidelines, the UK’s being the most prolific, but none have guidelines written for patients”.

That is interesting. I wonder whether we can elaborate on that as I am not sure that that has been adequately dealt with. I have mentioned the DAFNE and DESMOND training protocols. The study continues:

“None of the governments collect diabetes spending accurately”.

There is no doubt about the difficulty of doing that because it is such a complicated matter. The study estimates that,

“in 2010, the direct cost burden of people with diabetes was highest in Germany … at €43.2 billion, followed by the UK (€20.2 [£13.8] billion), France (€12.9 billion), Italy (€7.9 billion) and Spain (€5.4 billion)”.

There are some strange discrepancies there which might be worth looking at.

I would like to draw your Lordships’ attention to other facts and figures but we need improved diabetes data so that we can construct more useful policy initiatives. The study has very little information on the indirect costs of diabetes. Can the Minister provide information on that?

I am coming to a close and should say that only France, Italy and the UK regularly collect and publish monitoring data. France did so intermittently, in 2001 and 2007. Thankfully, Italy and the UK do so annually but that is apparently not the case in Germany. Other elements in the collection of data are missing or overlooked and ought to be repaired. My general plea is—to embellish what the noble and learned Lord, Lord Morris, has said about spending—let us look and learn from our neighbours and improve what we can, but there has to be a fundamental drive towards better knowledge and data on type 1 and type 2 diabetes; otherwise, we will fail and misdirect the funds available to us in battling a disease that has become of epidemic proportions.

I am pleased to join in this debate. Like the noble Lord who has just spoken, I have had diabetes that has responded to treatment. It is possible to treat diabetes, and I thank my noble and learned friend for bringing about this debate. I have supported him in previous debates and am pleased to support him on this important matter because there are some 300,000 people with type 1 diabetes in this country and no one is sure what causes it. My noble and learned friend is right to say that more research is needed and the Minister, when he replies, can perhaps give us some assurances on that.

Most type 1 diabetes occurs in people before they are 40 but I am extremely concerned about the rate at which it is increasing in children. That in itself is causing problems because people whose children have diabetes very often find that they have to give up their job in order to attend school. I hope that the Minister will come in on this: there surely ought to be more collaboration between the health service and education. I tabled a Question to the Education Minister and I must say that the reply did not provide any more information. He said, “Yes, there ought to be programmes”, but there must be more collaboration because unless that happens, help will not be available to people with children.

We have said this because the cost of types 1 and 2 diabetes to the NHS amounts to £10 billion every year; and the direct patient costs of type 1 alone is £1 billion. Indeed, care for the illnesses induced by diabetes that make it necessary for people to take time off work if they are not treated properly—all sorts of things occur to them—costs £0.9 billion. We ought to be doing a lot of things about diabetes, and that is why it is important to have debates such as this which attract attention to the issue and raise its profile. As my noble friend said, there is no reason why people who are well treated cannot live healthy lives. Not enough of them are getting direct help and care. As I have said before, that often affects their work and their careers. They need a little more help from the health service.

How many people are receiving the nine tests that are available to them? In particular, how many children are receiving their annual tests? These tests should be given annually. Why is that not occurring? I say again that this matter should be given the priority that is needed. There is no doubt that if people are given the special care that should be available to them they can continue to hold down a job and have a career and a healthy life.

The other big concern that I have is with some of the side effects that occur from diabetes. There is no doubt that people are not receiving the education that they need; it is very patchy in relation to how many get it, but if they do get the education programmes, it helps them enormously. The 2009 data that I have seen show that of 6,500 people diagnosed with diabetes—the Minister may dispute my figures—only 180 received offers of help with education, and only 30% of those diagnosed attended a course. Surely we can do better than that—I should think so.

I would like to refer to the mental health side, because the figures show that people with diabetes are more likely to suffer from depression. Poor mental health has a very negative effect on people, as we know, and it is likely to need more care and attention from the NHS. Surely, we could offer people psychological care as well. That is a very important part of the treatment, and I do not know whether the Minister has any figures to show how many people are receiving that, or not. Like other noble Lords, I am disturbed by the idea that diabetes may be pushed further down and may not be receiving the attention that it should receive in the NHS. I was interested to see that there has been a new appointment of a national clinical director for obesity and diabetes. I welcome that appointment, but I hope that it is not only going to be about obesity, which is very important—but so is diabetes. I would like an assurance from the Minister that this new director will be concerned equally with diabetes as he is with obesity. Having said that, I welcome and look forward to the Minister’s reply.

My Lords, I have no doubt that my contribution will be interrupted very shortly. I, too, thank my noble and learned friend Lord Morris for initiating this important debate. As a type 2 diabetic, I am acutely aware of the possible causes of my condition and how lifestyle changes can improve matters. That is not the case with type 1 diabetes, which is a chronic, life-threatening condition with a lifelong impact on those diagnosed and their families. It cannot be prevented and there is no cure. No one is quite sure what causes it; possibly it is triggered by an auto-immune disease. It does not involve lifestyle factors such as poor diet or lack of exercise, as my noble and learned friend has said.

Although the major increase is in type 2 diabetes, type 1 is also rising. As my noble and learned friend said, estimates suggest that between 300,000 and 400,000 people living with type 1 diabetes in the UK, which accounts for around 10% of all people with diabetes. People with type 1 diabetes are at greater risk of dying younger. The first ever report into mortality from the National Diabetes Audit was published just over 18 months ago, and I referred to it in the previous debate. It found that up to 24,000 people with diabetes are dying in England each year from causes that could be avoided through better management of their condition. About three-quarters of those are aged 65 and over. However, the gap in the death rate between those who have and who do not have diabetes becomes more extreme when comparing younger people. It is truly shocking to learn that so many young people are dying from diabetes. Type 1 is a particularly difficult condition to live with, as my noble and learned friend pointed out. We need to raise awareness and campaign to help to prevent and detect diabetes, as my noble friend Lord Hoyle said. I am therefore sorry that the Government decided not to accept the Public Accounts Committee recommendation on this particular aspect of its report about mounting public campaigns.

According to the 2012 Impact Diabetes report, the current cost of direct patient care for those living with type 1 diabetes is estimated at £1 billion, along with indirect costs of just under £1 billion related to increased death rates and illness, work loss and the need for informal care. Last year’s Public Accounts Committee report also recognised that while the department had improved information on diabetes, it was not being used effectively by the NHS to assess quality and improve care. It recommended that the department should work with the NHS to ensure that the costs of diabetes are fully captured and understood in order to promote appropriate services and better outcomes for patients. In their recent response, the Government agreed with the committee’s recommendation. I would therefore like to ask the noble Earl what progress has been made in implementing it, especially on the further work required to improve the underlying financial information collected at both the local and national level, and how quickly this will be made available to commissioners.

As we have heard, people with type 1 diabetes can live long, healthy lives if their condition is well managed. However, too many are not getting the help and care they need, leading to devastating complications, avoidable deaths and greater costs to the NHS. Everyone with diabetes should receive the nine agreed care processes recommended by NICE as part of their annual review. However, two-thirds of those with type 1 diabetes do not receive all nine. Can the noble Earl give more detail on how the target of 80% coverage by 2018 given by the department in the PAC response will be met? The concern is that the disbanding of NHS Diabetes may result in a number of established work programmes either not continuing or being suspended. It is really important that these programmes continue. They include integrated care supporting self-management, clinical safety, paediatric care and education, specialist foot care, older person’s care, inpatient care and, as we have heard from my noble and learned friend, insulin pump networks. Will the noble Earl support further development of these work programmes with the input of clinicians and patients to drive quality improvement?

Data from the National Paediatric Diabetes Audit show that only 6% of children and young people whose checks are being recorded are getting all of the recommended diabetes care, services and support that they are entitled to. Over 85% of children and young people over the age of 12 have blood glucose levels higher than the recommended targets. As many noble Lords here will know, on 13 March, Diabetes UK launched its type 1 essentials for children and young people campaign. In seeking to help end the variation in levels of diabetes care, the organisation wants to see specific diabetes leadership and a diabetes service improvement function in the new NHS improvement body. Assuring the effective commissioning of integrated models of diabetes care across primary and specialist services by working closely with clinicians and patients is vital.

Despite the fact that type 1 diabetes is a condition which people have to live with every day of their lives, my noble friend Lord Hoyle pointed out that education for people with diabetes is not universal or guaranteed. NICE guidance recommends that people with type 1 and type 2 diabetes should be offered patient education programmes to help them understand more about their condition and develop the skills needed effectively to self-manage their diabetes. An economic analysis performed by the York Health Economics Consortium, referred to by my noble friend Lord Harrison, revealed that DAFNE, a structured education course for people with type 1 diabetes, would pay for itself within four to five years due to the reduced complication rate expected from improved management of an individual’s diabetes.

As my noble friend Lord Hoyle said, the National Diabetes Audit has been collecting data on structured education in England and Wales since 2005. However, the completeness of the data is limited and therefore has not previously been reported nationally. The 2009 data show that of the 6,444 people who were diagnosed with type 1 diabetes during that year, just 180 recorded offers of education. In Diabetes UK’s 2009 membership survey, only 36% of people had attended a course to help them manage their diabetes since diagnosis. All people with diabetes, whether recently diagnosed or those with pre-existing diabetes, should receive access to the education and support they need to enable them to manage their condition. It should be available in their local area and be accessible and flexible enough to meet their individual needs. Like other noble Lords today, and like Diabetes UK, I welcome the appointment of Dr Jonathan Valabhji as the National Clinical Director for obesity and diabetes for England. However, I would seek from the Minister an assurance that type 1 diabetes will not be forgotten and that it will remain a core part of the new director’s responsibilities. I have completed my speech without interruption.

My Lords, I congratulate the noble and learned Lord, Lord Morris of Aberavon, on securing this debate and on his authoritative speech and major contribution to raising the profile of diabetes, especially type 1. Diabetes is a major challenge for this country and that is why it is a key priority in the mandate for the NHS Commissioning Board. We are clear about the need to improve diabetes outcomes through better care, and we regard diabetes as a key marker of improvement in the NHS as a whole.

We are helped by having strong advocacy, as has been mentioned. I would like to commend the work of Diabetes UK in raising awareness of the early signs of diabetes in children, and support its new Ten out of Ten campaign: Type 1 essentials for children and young people.

Sitting suspended for a Division in the House.

Type 1 diabetes is an autoimmune condition that causes failure of insulin production. It cannot be prevented or cured. Individuals usually develop the condition in childhood or early adulthood and require lifelong insulin treatment.

I therefore commend the Juvenile Diabetes Research Foundation for funding international studies in type 1 diabetes, having spent over £1 billion on research that seeks a cure or better treatment. It is a mark of the international standing of diabetes research in the UK that JDRF spends a relatively high proportion of its funding on type 1 diabetes research in this country.

We know that diabetes has a significant cost to society. The current payment systems in the NHS do not differentiate between the costs associated with type 1 and type 2 diabetes. The National Audit Office estimates that the NHS spends at least £3.9 billion a year on diabetes as a whole and its complications.

The noble and learned Lord asked what the obstacles were to counting the costs of type 1 diabetes separately. It is simply current accounting practice that prevents this. There will be new opportunities, with the NHS Commissioning Board and CCGs taking responsibility. I understand that as we speak work is under way that looks at the coding of diabetes care in primary care and how this is collected via computer systems.

The noble Lord, Lord Harrison, mentioned the indirect costs of diabetes. We know very well what those indirect costs look like in personal terms. One in 20 people with diabetes require support from social services. People with diabetes are twice as likely to be admitted to hospital than those without it. Complications increase the cost of NHS care fivefold. People can lose a leg, or their vision. Their kidneys can fail, they are vulnerable to infection, and their hearts can fail. These are serious complications. Diabetes is also a major factor in premature mortality.

We need more proactive management of the condition and its complications, starting with prompt diagnosis. Once diagnosed, people must have access to the best care and support in living with and managing this long-term condition. We need to make sure that management is in line with the latest clinical guidelines. To that end, the department has taken a number of steps to improve diagnosis and management of type 1 diabetes. We have collaborated with NHS Choices so that its website now has clear advice for parents on identifying the signs of diabetes and the actions required.

The NHS has clear statements of good-quality care for people with type 1 diabetes. These include the NICE quality standard and NICE clinical guidelines for all ages, which are being updated. The NHS is expected to follow NICE guidance as part of its general duty to secure continuous improvement in quality.

From April 2013, the best practice tariff for paediatric diabetes will ensure that the NHS offers all children and young people with diabetes appropriate education, support and management. All paediatric diabetes centres must belong to regional paediatric diabetes networks. Those paediatric networks will continue to function.

Like all pupils, children and young people with diabetes deserve full educational opportunities unhindered by their condition and their daily medical care. It is worrying that so many pupils experience preventable problems at school because of their diabetes, whether through barriers to insulin administration or even being banned from school trips. I am glad to hear that the honourable member for Yeovil and my honourable friend for Central Suffolk and North Ipswich have considered this in the context of early years and the minimum health offer in schools.

From April 2013 we will also introduce a best practice tariff to ensure good specialist care for severe insulin lack, called diabetic ketoacidosis, and for insulin excess or hypoglycaemia. These are potentially fatal crises if you have diabetes and can usually be avoided.

The Quality and Outcomes Framework, or QOF, rewards general practitioners for providing the nine care processes for people with diabetes. Since 2003-04, QOF has encouraged steady improvements in these annual checks. At the same time, the percentage of people diagnosed with diabetes has more than doubled. We want this improvement to go faster. For this reason, NICE has been asked to review the Quality and Outcomes Framework and diabetes indicators within it, and we await its response.

Last year, the National Audit Office published its review of the management of adult diabetes services in the NHS. While this report acknowledged the progress made over the past 10 years, in particular in the information we have about diabetes, it also highlighted the extent of variation in services across the NHS and the significant challenges that we face over the next 10 years. The Public Accounts Committee subsequently made a number of recommendations. The Government accepted all but one. We also set clear objectives for the NHS.

For the last few years, this work has been led by Dr Rowan Hillson as national clinical director for diabetes. Since her appointment in 2008, Dr Hillson has made enormous strides to improve the care and management of all those with diabetes. She retires at the end of this month from this role and I take this opportunity to pay tribute to her and thank her for all she has done, which is a very great deal. From April, Dr Jonathan Valabhji will take up the challenge on behalf of the NHS Commissioning Board as the new national clinical director for obesity and diabetes. I wish him every success in his new role. I can tell the noble Lord, Lord Hoyle, that Dr Valabhji is a consultant diabetologist and fully aware of the needs of people with diabetes. He will give them appropriate attention in the balance of his work.

I also thank the NHS Diabetes team for all their hard work. NHS Diabetes has made a major contribution to improving diabetes care nationally. The team will be absorbed into NHS Improving Quality in the NHS Commissioning Board next month. It is good that the excellent work of the National Diabetes Information Service will continue in Public Health England. The prime objective of the NHS Commissioning Board will be to drive improvement in the quality of NHS services. The board will be held to account through the NHS mandate. Diabetes is relevant to all parts of the NHS outcomes framework, through which we will track progress. In the NHS, diabetes is everybody’s business.

I agree with the noble Lord, Lord Collins, that structured diabetes education is essential. NICE has specified this and I support its guidance. The noble and learned Lord, Lord Morris, asked what we were doing to increase the use of insulin pumps. The national clinical director chairs the Insulin Pump Working Group, which met today. It exists to increase pump use and provided the insulin pump audit showing that 8% of adults and children in the UK have pumps. Within that figure, it is 6% of adults and 19% of children, but the work of that group continues. I am happy to write with a full and detailed response, as the noble and learned Lord asked.

The noble and learned Lord also quoted from a letter he had received from my honourable friend Paul Burstow, which indicated that we in this country were in line with the United States. I confess that I am puzzled by that, as he is. The figures that I have are that the United States has around 30% coverage. That compares to Spain, Finland and Portugal at around 5%. We are, as I say, at 8%. I will look further into that situation and write to him as appropriate.

The noble Lord, Lord Harrison, referred to blood glucose monitoring, which is, of course, essential to managing type 1 diabetes safely and well. The national clinical director and the chief pharmaceutical officer wrote to all doctors to remind them of that this year. Dr Hillson recently wrote to the NHS on behalf of the Minister for Public Health, highlighting the Minister’s concerns, and reminded the NHS of the importance of appropriate prescribing and management.

The noble Lord, Lord Harrison, also asked about guidelines for type 1 patients. NICE produces patient-friendly summaries which I believe are very helpful, while NHS Choices includes information about type 1 diabetes. The National Clinical Director for Diabetes has worked with Diabetes UK to produce its guidance and we support the organisation’s 15 healthcare essentials checklist. He also asked why everyone with diabetes does not get an annual check. In the Government’s response to the Public Accounts Committee we set clear objectives for the NHS Commissioning Board and we will monitor them closely.

The subject of research was raised by the noble and learned Lord and the noble Lord, Lord Hoyle. Recently, the Government announced that £775 million would be invested over five years through the National Institute for Health Research to drive innovation focused on major diseases, including diabetes. The department is currently supporting more than 60 studies into type 1 diabetes through the Diabetes Research Network. Diabetes research in the UK punches well above its weight and the results are seen prominently in international diabetes meetings. The noble and learned Lord also asked why type 1 is not included in specialised commissioning. I will write to him with an explanation on that point.

I would like to support very strongly the remarks made by the noble Lord, Lord Hoyle, about children with diabetes. Children with the condition should have equal opportunities in schools. Collaboration between children’s diabetes services, children’s carers and education services is absolutely key to allow children to achieve their full potential. All local authorities and schools should be encouraged to read the Managing Medicines in Schools and Early Years Settings booklet. He asked how many people are getting the nine care processes. The answer is 54% of adults, but I regret to say that it is fewer than 10% of children. However, as I mentioned, we now have the Paediatric Diabetes Best Practice Tariff, which demands better care in regional paediatric diabetes networks.

My time is up. I have more to say and I will write to those noble Lords whose questions I have not answered. There is good and bad here. We have vast amounts of data for this condition. We know what needs to be done and where. The challenge is for clinicians and commissioners to ensure that everyone with diabetes has good care.

Committee adjourned at 7.37 pm.