§ 11.19 p.m.
§ Mr. T. L. Iremonger (Ilford, North)The matter I have to raise tonight is the special needs of diabetic children and their parents. I have in the borough of Redbridge, of which my constituency is a part, a very active and energetic group of members of the British Diabetics Association, who form the Ilford and District Club Parents' Group, now known as the Young Diabetics. The group consists of parents of children who suffer from diabetes.
I know that my hon. Friend the Under-Secretary of State for Health and Social Security will wish to join me in thanking the association generally for the service it performs in keeping the problems of diabetics in the forefront of his attention. I am sure that he would like also to join me in thanking my Ilford Young Diabetics for the stimulus they have given us both to consider their problems. I know that my hon. Friend's attendance here tonight will be very much appreciated by those parents and thousands of others in other boroughs who are similarly unfortunately placed.
About one in a thousand children is diabetic—between 30 and 40 at any given time in the borough of Redbridge. In children the onset of diabetes is usually sudden. The condition is invariably severe from the outset. When I asked one of my constituents what was the first indication, she said that the child went into a coma. This sudden and inevitably very frightening happening is for thousands of children and their parents the beginning not so much of an illness as of a new way of life. The diabetic must conform to a certain exacting regime for life. "It's jabs for life", as they say, in two senses. The injections must go on for the entire life of the individual, and they must go on in order that life may continue.
There is no known cure, and without the regime of treatment, consisting of a 684 balance between diet and injection of insulin, death is inevitable. Therefore, this life regime is especially difficult and especially important for children. It is part of my purpose tonight to ask that we should make it as little difficult as possible for all children, without the extra expense now involved in the special kind of treatment appliances to which I want to draw my hon. Friend's attention. I shall submit that this may be done at a minimal cost, at most, to public funds.
The main feature, apart from the rigorous imperative of the diet, in the lifelong regime of the child diabetic is the daily—and in some cases two or three times daily—painful, irritating but vital ritual of injections. Without constant artificial injections of insulin which their own bodies will not produce, the necessary balance between just enough and a fatal surplus of blood sugar cannot be maintained. A peculiar misfortunate of child diabetics is that they can get their artificial insulin only by way of injections all their lives. They can never get it from tablets taken by mouth as can many of those who first become diabetics when they are already adult.
A parent—it is usually the mother—must get her, perhaps very young, child to administer the injections to himself or herself every day, day after day, for ever. Therefore, the actual process is something that matters very much, not only to the child who has to do it and to suffer it but to parents, and to brothers and sisters too.
The injections can be very much more difficult and painful and irksome than they need be; under the provision made free by the National Health Service it certainly is much more difficult and painful and irksome than it need be or ought to be. That is because the syringes and the needles supplied free by the National Health Service are not so good from the point of view of ease, painlessness, skin damage avoidance and convenience as the disposable syringes and needles which are available to those who are willing and able to pay for them privately.
My first request to the Minister is to make available free on the National Health Service the superior modern disposable packs of syringes and needles at least to children on general practitioner 685 prescriptions. The old kind of syringe and needle supplied free at present has disadvantages. The needle is used again and again and it becomes blunt. The jab is therefore painful. Its bluntness causes painful bumps and scars. The syringe degenerates with use and constant sterilisation. The piston becomes loose in the cylinder, causing it to stick. Further, the joint of the syringe with the needle becomes loose so that the needle detaches itself in the middle of an injection.
One mother told me that her little daughter had to have three jabs on one occasion before a successful injection could be achieved. That is just one extra part in the task of the family of a diabetic child of getting the family off to school in the morning. In contrast, the disposable syringe and needle is for use only once. The syringe and the needle are brand new every time. The syringe is invariably perfect in functioning. The needle is absolutely sharp so that the child does not feel it enter the skin.
To buy such disposable packs, which any parent is at liberty to do, would cost for an average regime upwards of £1 a month. It is not so much the sum as the principle and the priority which troubles many parents. The cost of £25 a year could be regarded as a very unwelcome extra tax. If a Chancellor of the Exchequer were for once to refrain from taking £25 in tax from a taxpayer he would expect that to be regarded as a mighty bounteous Budget dowry. But this is a matter of deciding the relative importance and priority which should be given to a need which strikes deeply into the hearts of thousands of families. If I were in their position my feeling would be that the quality of the need was of a high order and that the priority for meeting it out of public funds was correspondingly high.
I know it may be said that what I am asking for cannot be limited to children and that the cost to public funds would be the cost of providing free disposable needles and syringes for all diabetics, adults included. However, if general practitioners can make distinctions in other cases I do not see why they should not be able to do so when treating diabetics. I do not see why they should 686 not be able to distinguish between prescriptions for adults and for children.
But, even if it were not possible to make that distinction, I should urge that the provision should be made, if necessary at the cost required to supply all adults and children alike, for the sake of the children. Without in the least detracting from the plea which I make, it should be put on record, if only to preserve the position, that I do not believe that value added tax should be eroded as a universal consumption tax by exempting any and every useful and necessary article, no matter how worthy the priorities for which it is used.
I wish to ask the Minister for three more things which can be stated briefly and need little explanation but are none the less important for that. First, will the Minister take special steps to see that the Secretary of State for Education and Science alerts local authorities to the importance of warning heads of schools of the special precautions necessary in caring for diabetic children? Every teacher with a diabetic child in his care should know that the child is diabetic. He should know something about the child's diet and, most importantly, he should know and be able to recognise the symptoms of hypoglycaemia and be able to give the simple treatment necessary without delay.
A further useful routine for schools would be to print menus for school meals a week in advance so that they could be circulated to the parents of diabetic children and the parents and the child could agree in advance what the child should eat at school. This would also be helpful for mothers of families in planning family meals at home, which has to be done with a special eye to what the diabetic child has eaten elsewhere.
There is a need for area diabetic clinics to be established throughout the country. These need not be many, but they must be enough to enable any worried mother of a diabetic child, where-ever she might live or be staying, to have immediate access by telephone at any hour of the day or night to someone on whose advice she can rely with special reference to the needs of the diabetic child. All children get suddenly and frighteningly ill sometimes. Usually it is nothing terribly serious. Even if it is 687 serious doctors and hospitals manage marvellously to help, but there are special complications and dangers when a child is diabetic because the diabetes can be affected by the other illness—they react on one another—and special treatment may be required for both the specific illness and the diabetes. That may call for instant specialised advice, and many mothers may be diffident in demanding this, unable to explain exactly what is required and unable to be reassured unless they have someone in whom they have confidence to explain to the doctor who is treating the child for the immediate illness that the diabetic aspect is being properly taken care of.
Finally, I ask the Minister for a word about fundamental research into the cause and cure of diabetes. I discern a depressing note of fatalism and acceptance in medical attitudes in this respect. It may be that the miracle of insulin has acted against research into the cause and cure of diabetes. It is almost as though, having turned certain death into something that can be controlled, we have somehow exhausted our resources of endeavour.
I ask the Minister whether anything serious is being done specifically to examine the causes and possible cure. If nothing is being done—as I suspect—why should this be so? Need it be so? What, if anything, can be done? Will the Minister explain what is being done and how hopeful in his assessment is the prospect of finding a permanent cure for a disease which at the moment is bound to be lifelong?
§ 11.34 p.m.
§ The Under-Secretary of State for Health and Social Security (Mr. Michael Alison)I congratulate my hon. Friend the Member for Word, North (Mr. Ire-monger) both on securing the Adjournment and on choosing a subject which, although it is perhaps not so dramatic as some with which I am involved, is nevertheless one of real concern. Perhaps he will allow me to associate myself with the specific commendations he made about the family organisation, the parents in his constituency and elsewhere who are showing such a determined spirit to co-operate together and help themselves and the public good in this manner.
688 Fortunately, diabetes is uncommon in childhood. Below the age of five only 0.3 per 1,000 children suffer from it: in the age group five to 15 the incidence is about 1 per 1,000 school children.
Fifty years ago diabetics who developed the condition in childhood died soon after, usually within 18 months of diagnosis. The introduction of insulin has altered this but the average expectation of life is still less than 20 years from diagnosis.
Once a diagnosis of diabetes has been made and the acute metabolic disturbance has been corrected in hospital, the stabilisation of the diabetes and education of the child and the parents begin—as my hon. Friend said, the beginning of a lifelong process. Diabetes starting in childhood almost always involves lifelong daily or twice-daily injections of insulin.
The great majority of diabetics are able to lead reasonably normal lives. Once they have mastered the technique of managing the disease, many remain under the care of their family doctors. For those who need regular specialist medical supervision, this is provided at district general hospitals, most of which run special diabetic clinics for patients of all ages.
Most diabetic children go to ordinary schools. There is no doubt, however, that diabetes is a limitation on a child. I have already mentioned the need for injections. Meals must be assessed for carbohydrate content and the right amount taken at the right time to balance food, exercise and insulin. Some form of carbohydrate, such as lumps of sugar, must always be carried in case of emergency. Special physical exertion must be matched by taking extra carbohydrate.
The need for these precautions can lead to stress for the child—there is no doubt of this—for his parents and for teachers. Any child will break the diet rules sometimes and especially during the naturally rebellious period of adolescence: all will need help in keeping to the diet. Many diabetic children show some degree of emotional disturbance, and anxiety symptoms are more prominent in mothers of diabetic children than of other children.
All the health and social services need to co-operate in helping families who have these problems: family doctors, 689 hospitals, health visitors, district nurses, social workers, the medical and nursing staff of the school health service, and teachers. The reorganisation of the National Health Service will, we believe, open the way to the creation of a comprehensive child health service from which all children will greatly benefit. Allied to this reorganisation are arrangements for collaboration between the National Health Service and local authorities—local health authorities in particular—which will provide a frame-work for close working between social workers and the health service.
Clearly, there are many problems involved in the care of diabetic children. My hon. Friend has touched on several, and I think it would be to the benefit of the House if I now try to outline the Government's views on the points he has raised.
I take the question of disposable syringes and needles first. Disposable syringes are not available on prescription by a general practitioner under the National Health Service. They were developed especially to meet the needs of hospitals, where it is essential to have available, sometimes in an emergency, a supply of absolutely sterile syringes. This avoids the serious risk of cross-infection which can arise. For the same reasons they are available for use by general practitioners. But these reasons do not apply where a patient has a personal syringe for injections which he administers himself.
Most insulin preparations are to some extent self-sterilising, and where a syringe is used only by one person the dangers of infection are minimal. The non-disposable glass and metal syringes supplied on prescription are suitable for the vast majority of patients who need regular insulin injections.
Both the syringes and the needles must comply with the British Standards specification. Provided the needles are treated with reasonable care, I am advised that they normally remain sharp and can give nearly painless injections for quite a time. My hon. Friend described the condition into which some of them can fall with prolonged use, but general practitioners can prescribe these syringes in appropriate quantities, so that problems of 690 depreciation, as it were, can be dealt with within the normal prescribing machinery by family doctors.
In the exceptional case where the family doctor considers that only disposable syringes are suitable on medical grounds, he may refer the patient to hospital, where a consultant, if he agrees, can authorise a supply of them to last until the next visit. I appreciate that some diabetic patients who have no special need for disposable syringes may nevertheless prefer to use them and may find them a little more convenient. We naturally like to meet patients' preferences when we can reasonably do so, but the additional cost of providing disposable syringes and needles on prescription is estimated to be about £2 million a year.
In a sector such as ours with almost limitless demand for more facilities but where the supply of resources is inevitably limited—my lion. Friend, as the author of a book on economics, will know about this—this is not an insignificant sum. It would enable us to double the expenditure on the invalid vehicle service, or to introduce 10 major operating theatre suites. These are matters of great significance for the groups involved. We are faced with an appalling dilemma of priorities, and the sum of £2 million is critical for many projects which might have to be abandoned.
My right hon. Friend therefore feels that, as the existing arrangements are considered adequate to meet both general and medical needs, an additional annual expenditure of this order could not be justified while there are so many competing claims on the funds available for the National Health Service. It would not be possible to make special provision for general practitioner prescribing of disposable syringes limited to children, as my hon. Friend proposed. There is no power to restrict prescribing by general practitioners in this way, and even if we had such power I doubt whether an acceptable scheme could be devised.
If a general practitioner were able to prescribe disposable syringes and needles he would be under pressure to meet parent preferences and would find it very difficult to restrict this prescribing to cases of medical need. I am afraid, therefore, that we cannot meet the request that 691 disposable syringes should be made available on prescription by a general practitioner.
I return to the point made earlier, that if the GP feels that there is a medical case for disposable syringes in a family or for an individual he can take it to the consultant who can authorise a supply.
The arrangements I have described are generally adequate but if my hon. Friend has evidence that individual patients who need such syringes or needles on medical grounds are experiencing difficulty, and it may be that the groups to which he has referred have such difficulty, if he will send me details I will look into the cases.
I now turn to the suggestion that there should be area diabetic clinics for emergency consultation. On the face of it, this has considerable appeal, and my hon. Friend has eloquently outlined the fears which some parents face when their diabetic children contract one of the childhood illnesses. But I hope that my hon. Friend, on reflection, will agree that the family doctor is responsible for the medical care of a patient who suffers from diabetes, and it is to him that parents should look for advice on the health of their children.
This applies to emergencies involving patients with diabetes. It is for the family doctor to decide whether it is necessary for reference to be made to the specialist services of the NHS. While parents are naturally concerned when their children are I have seen no evidence that the existing arrangements for the treatment of diabetes need supplementing by special area diabetic clinics for emergency consultation by parents.
My hon. Friend has pointed out the enormous importance of informing schools of any of their pupils suffering from diabetes. I am happy to assure him that, in order that the school health services and the schools may play a full part in caring for the child who returns to school after the correction of the acute metabolic disturbance, the school health service and the school attended by the child are both informed. The way in which this is done varies. Usually the hospital or general practitioner informs the school medical officer and he, or an administrator in the school health ser- 692 vice or general local education authority office, lets the head teacher know. There may well be a part which social workers can play in informing the school of diabetic children and in keeping an eye on the progress of the child at home. On the whole, however, it seems more appropriate for the school health service medical officer, nurse or health visitor to undertake the liaison between health services and school, with social workers playing the equally important but non-medical rôles in welfare work. But we are confident that there is no possibility of a breakdown in the necessary communication between diagnostic and treatment services and what gees on in the schools.
The final major point raised by my hon. Friend was perhaps the most important of all—the extent of research into the cause and cure of diabetes. Government-sponsored research into the basic mechanisms of diabetes and applied research connected with it is carried out under the general aegis of the Medical Research Council. A number of research teams are working on different aspects of diabetes. For example, fundamental research is being pursued into the structure of the insulin molecule and the way in which it is made naturally in the body, into the mechanisms of its release from the pancreas and the point at which these mechanisms become deranged, thus leading to the clinical disease.
It is now becoming recognised that there are several distinct types of diabetes each with its own characteristics, possibly each with its own separate cause and differing in symptoms and prognosis. For several years drugs have been developed which can be given by mouth to patients with the less severe type of diabetes as a substitute for injections of insulin. Recently this form of treatment has been criticised on the ground of relative lack of effectiveness in the long term. Earlier this year this problem was referred to the Medical Research Council, which has as a result set up a working party under the chairmanship of Professor Sir Richard Doll at Oxford to conduct a thorough trial of these "oral agents". I shall await with interest the results of these trials.
I hope that what I have said will lead my hon. Friend to agree that we take 693 the problems associated with diabetes in childhood seriously, and that we are conscious of the wide-ranging needs of such children and their parents. If he has any evidence of particular cases where things are going wrong and a child appears not to be getting the help he needs, I would be more than happy to have them investigated.
My hon. Friend asked me to comment on the pessimism or optimism with which I view the general sphere of research and the possibilities of improvements. It is dangerous to be specific about an imponderable future. I can point out only what happened in the past and remind him that there was a dramatic improvement in the prognosis of the condition as a result of the insulin discoveries, and there is evidence, therefore, on the basis 694 of this precedent at least, that there may well be some possibility of a major step forward in the future.
I cannot be specific but I am optimistic that research will be pursued with vigour and with conscientious zeal by those who are involved in these questions because they know only too acutely what the problems are for those who suffer from the disease.
§ The Question having been proposed after Ten o'clock, and the debate having continued for half an hour, Mr. DEPUTY SPEAKER adjourned the House without Question put, pursuant to the Standing Order.
§ Adjourned at eleven minutes to Twelve o'clock.