§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Sainsbury.]
12.56 am§ Mr. A. J. Beith (Berwick-upon-Tweed)I now turn to a different subject. I must declare an interest in this subject as I am the parent of a diabetic child. I am in the fortunate position, like other hon. Members of the House who have diabetic children, that I can afford to buy the supplies which are the subject of this debate.
Experience has given me a vivid understanding of the problems of those who find it difficult to pay for these things. I am on record as having raised this matter as far back as 1976 before I found myself personally involved as a parent.
I will be interested to hear the response of the Minister. It may be her first reply to an Adjournment debate, in which case I hope that she will take the opportunity to give a most positive reply and set a good precedent for the future.
Diabetes mellitus, or sugar diabetes, affects more than 1 per cent. of the population of the United Kingdom and the incidence is increasing. It can develop in childhood or at any stage and almost invariably remains with a person for the rest of his life. Over 150,000 diabetics in England and Wales are dependent on injections of insulin, usually twice a day. They must also monitor their blood sugar level constantly through blood and urine tests. They must also follow a careful diet.
When the Minister is tempted to make controversial comments about healthy eating, she should remember that there is one group of people whose lives depend on healthy eating and who watch their diet very carefully — the diabetics. Because sugar-free jams and other items are often expensive and because they need to eat at frequent intervals—they often have to buy a snack when out in the middle of the morning or the afternoon when someone else would wait until lunch or dinner—they face higher costs for food.
It is therefore very important that they should not also have to face costs for essential medical requirements, but at present they do, because neither plastic syringes nor blood glucose monitoring strips are available on prescription from family doctors. At present the only syringe which GPs can prescribe is the cumbersome glass syringe, which has to be sterilised each time it is used.
The disposable plastic syringe is a far better alternative. It is much easier to handle and carry, and does not require sterilisation. In my experience it is extremely difficult to inject a small child with a glass syringe. Both hands are needed to hold the glass syringe and the plunger is apt to slip. If, however, one is holding and trying to reassure a child, one needs a spare hand for at least some of the time.
It is much easier for a child with small hands to use a plastic syringe for his or her own injections. We want to encourage children to do their own injections. The teenager is able to lead a much more normal life if he can carry with him a plastic syringe instead of all the equipment that is associated with the glass syringe. It is also much easier to obtain accuracy over small doses with plastic syringes. That is vital for control, which has become much more important since the introduction of the U100 insulin, where the marks to which one works are often very small.
1429 Given all the advantages of plastic syringes for many diabetics, they find it difficult to understand why the Government insist that their general practitioner should prescribe for them only the glass syringe. Could it be that an enormous cost is involved? The evidence suggests otherwise. There is now considerable experience which suggests that it may be cheaper to issue disposable syringes. A study in Southampton, reported in the British Medical Journal of 28 June 1986, put the cost of plastic syringes at less than half that for glass syringes and reported direct savings to the health authority as a result of issuing plastic syringes. Other work, by Dr. Arnold Bloom at Wittington hospital and Dr. N. R. Waugh at Dundee, also questions the Government's cost figures.
Several factors have to be borne in mind in assessing the cost of glass syringes, including the amount of insulin that is wasted in them because of "dead" space—insulin that is not used and that is washed out when the syringe is cleaned. However, there is one reason, above all, for the disparity between the Government's figures and those which are accepted by the medical profession. It is now accepted professionally that disposable syringes can be used more than once, and most of the diabetics who use them say that they use them several times. There is no evidence, if the syringes are kept in proper conditions—which usually means just putting them in the fridge—that this poses any risk of infection. Indeed, there is thought to be a greater risk from the use of glass syringes. However, the Department of Health and Social Security refuses to admit that re-use is acceptable, and it assumes that diabetics wish to be supplied with two new plastic syringes per day. They might like such a facility, but they are realistic enough to welcome a more limited supply of syringes that can be re-used.
This extraordinary obstinacy by the Department, in the face of overwhelming medical opinion, is causing real hardship to many diabetics. I plead with the Minister to bring about a change of attitude. If she is still worried about the cost and the number of syringes to be issued, there is one way out. She could allow diabetics to be issued with a voucher that is equivalent to the present cost of prescribing glass syringes. Then diabetics could choose for themselves whether to spend it on a glass syringe or on disposable syringes. At least they would be able to make that choice for themselves, with the advice of their doctor, at no extra cost to the Government.
There is another item of essential equipment that the family doctor cannot prescribe—blood glucose monitoring strips. If a diabetic is to avoid appalling complications, such as blindness, kidney failure or amputations, strict control is essential, and the only reliable way to achieve strict control is through blood testing. Urine testing is useful but it is not so reliable, because the time lapse is much greater. Many diabetics, therefore, are expected to take samples of their blood for testing, perhaps several times a clay; yet we also expect them to pay for the privilege of undergoing these very uncomfortable tests by buying their own testing strips at a retail cost of about £15 for a tube of 50 strips. The Government could make these strips available on prescription at a cost of less than £5 million a year.
If more diabetics carried out more frequent blood tests, there is no doubt that complications and hospital admissions could be greatly reduced. The cost of the admission of diabetics is about £90 million a year and the cost of treating complications is about £62 million a year.
1430 I emphasise that control prevents hospital admissions. A well-controlled diabetic will be admitted to hospital much less often and the likelihood of complications will be much less great. Five million pounds is a tiny figure to set against a massive potential reduction in human misery and in cost to the National Health Service.
The Minister will no doubt point out that it is possible for both disposable syringes and testing strips to be supplied free by hospital consultants to their patients, even though general practitioners cannot prescribe them. But that is not an adequate alternative. Many diabetics are not under hospital care, and it is the Government's policy that care of patients with chronic diseases should be increasingly undertaken by family doctors who are able to see patients more frequently and deal with all aspects of their health. I support that policy. I think that it is sensible in many cases. The family doctor should be entrusted with the regular week-by-week supervision of the chronically ill patient. It would relieve the hospital clinics of a great deal of pressure and, for many patients, it is the best way to receive care. Improving the standards of GP training and retraining make it a more satisfactory alternative.
However, it will not be possible to maintain that policy if there is a two-tier standard of service under which a consultant can prescribe what the diabetic patient needs but a general practitioner cannot. The patient, once he realises that he can get the supplies he needs by remaining under hospital care, will prefer to do so rather than transfer to the GP who he knows is restricted from prescribing what he needs.
Hospitals are under such pressure that the ability of consultants to make syringes and testing strips available to their patients may be under threat. It has been reported to me that in some areas, not my own, that difficulty is beginning to arise.
I urge the Minister to press the case as hard as she can with her colleagues, including her Treasury colleagues, who I understand are considering the specific issue. A number of hon. Members contacted Ministers, including Treasury Ministers, earlier this year. I have before me a reply from the Chief Secretary to the Treasury to the hon. Member for Strathkelvin and Bearsden (Mr. Hirst) in which the Chief Secretary said that he is aware of the case for making both blood test strips and plastic insulin syringes for diabetics available under the family practitioner service. He said:
Nevertheless, there are resource implications which both we and the DHSS have to consider—and set against other major demands on resources under the NHS. There could also be knock-on effects for other patients … the growing lobby in favour of issue of free syringes to drug abusers to help combat the spread of AIDS".I might say in passing that diabetics simply would not understand it and would find it extraordinary if the Government were to decide that syringes should be macle available to drug abusers because of the AIDS problem but not made available to diabetics. That would be a terrible slap in the face for people who have struggled so hard over the years to control a condition. The Chief Secretary continued:Norman Fowler and I will be considering this issue when we come to the Public Expenditure Survey in the autumn. I obviously cannot at this stage comment on the likely outcome; but I will certainly bear in mind your representations.I hope that that process of consideration is going ahead favourably and that the Minister, who has recently come to office, will add her voice to the pressure on Treasury 1431 Ministers to be helpful, especially regarding glucose monitoring strips. The British Medical Association has made representations to her Department, as have Government and Opposition Members. The hon. Member for Horsham (Sir P. Hordern) has asked me to make known his support for that, as well as for the issue of plastic syringes. The costs involved are small. The resultant savings in treatment costs are potentially large. The Minister could bring great relief to thousands of diabetics who seek, by rigorous self-control, to lead full, active, long and healthy lives. They deserve the Government's support.
§ 1.7 am
§ The Parliamentary Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)I congratulate the hon. Member for Berwick-upon-Tweed (Mr. Beith) on his success in the ballot and on his diligence in raising this important subject. I suspect that I share with him a degree of disappointment that we are debating it so late at night when many other hon. Members have expressed interest in and support for the points he made. I recognise also that he made his points from personal experience, having a diabetic child. He may not be aware that diabetes is also present in my own family—on my father's side. I took a close interest in the subject before I became a Minister.
As the hon. Gentleman rightly said, the condition diabetes mellitus is found in 1 to 2 per cent. of the population. With proper treatment, diabetic patients can be kept fit and in full productive work. Over the past 40 years, great progress has been made in the management of patients with diabetes and its complications. We have seen significant improvements in understanding the disease and its effects, in the development and evaluation of new forms of detection and treatment, and in enabling sufferers and their families to live their lives with the minimum of disruption and anxiety.
As the hon. Gentleman said, diabetics need to control their blood sugar level. Most can do that through diet or tablets. However, 150,000 to 200,000 diabetics in England and Wales need injections of insulin to manage their condition effectively. We have the greatest sympathy and indeed admiration for those people, especially children and their families. They must exercise self-discipline, monitor their condition, follow a controlled diet, and give themselves daily injections of insulin.
I shall deal in turn with each of the commodities that we have been discussing, the first of which is blood test strips. Personal blood glucose monitoring is an integral part of modern diabetic care. The urine tests which are available on the Health Service are adequate for diabetics whose condition is controlled by diet or tablets, as I am sure the hon. Gentleman will agree. They are quick and easy to use. For insulin-using diabetics, urine tests allow some measure of control and have been standard and available for many years. More recently, it has been recognised that blood testing has advantages over urine tests. First, they give an accurate and direct reading of blood sugar level at the time of the test and, secondly, that fact allows the patient to take action to keep blood sugar within normal levels immediately, if necessary.
That is extremely important, since too low a blood sugar level—hypoglycaemia—can lead to unconsciousness, even death, and too high a blood sugar level— 1432 hyperglycaemia—for a prolonged period increases the potential risk of long-term complications such as blindness and kidney failure. However, blood testing is not particularly pleasant. It involves pricking the finger, and some people will undoubtedly prefer urine testing, perhaps particularly for children.
I have some syringes with me. It is claimed that plastic disposable syringes are more comfortable. The needles are thinner and are lubricated. It is claimed that they are more convenient than re-usable glass syringes. We understand why many patients, especially children, prefer them. In some cases consultants may arrange for them to be provided under the hospital service because they are medically necessary, but in most cases they offer no medical advantage over glass and metal syringes and re-usable needles, which GPs can prescribe, as I am sure the hon. Gentleman will admit.
As the hon. Gentleman knows, both blood glucose testing strips and disposable syringes are available on the Health Service through hospitals when they are medically necessary. That is where a consultant thinks it advisable. The hon. Gentleman may say that that is not good enough, but that is a matter of fact. For some years we have seen sustained pressure from patients, doctors, hon. Members and all those interested for these items to be available on GP prescription.
The effort became more notable last year when the general medical services committee of the British Medical Association and the British Diabetic Association joined forces in making representations to the Department. That culminated in a meeting last November with officials of my Department and I shall return to what was said at that meeting.
Early-day motion No. 1070 attracted before the recess 38 signatures of hon. Members. A deputation of hon. Members came and saw my right hon. Friend the Member for Brentford and Isleworth (Mr. Hayhoe), who was then the Minister for Health, on 15 July. Since August we have received more than 300 letters from hon. Members on both sides of the House. Many constituents were undoubtedly encouraged to write by an article in the August edition of "Balance" magazine, which is published by the BDA, and which gave precise and accurate advice on how to lobby Members of Parliament.
I shall now turn to the drug tariff list of prescribable appliances, about which we are talking. I hope that it is obvious that the Government have considerable sympathy with the case put forward by the hon. Gentleman and other colleagues. So why are blood glucose testing strips and disposable syringes not prescribable by general practitioners? There has always been an approved list of dressings and appliances which a general practitioner may prescribe. The intention of that list was to ensure that the range of dressings and appliances commonly used in general practice were readily available through retail chemists. The list was never intended to be comprehensive. It would not be practicable or cost-effective to include all items which may be supplied through the hospital service.
It is also important to keep that list up to date. Changes are made in consultation with the medical and pharmaceutical professions in the light of the changing needs of general practice, the extent of demand, the availability and the cost. There is relatively little problem where new products are cheaper, or at least no more expensive, than products for a similar purpose already on the list. I hope that we keep the list up to date with more 1433 modern methods and materials. However, where the products have a high price they must be considered alongside competing priorities for the NHS.
I have some detailed figures which I hope will be of assistance to the hon. Gentleman. The comparable product for blood test strips is urine test strips. The family practitioner services currently spend over £2 million a year on urine testing. The drug tariff price for urine test strips is about £1.50 for 50, or about 3p each. A mail order company is advertising blood test strips in "Balance" magazine at £9.15 for 50, or 18p each, while another company is selling them at £13.50 for 50, which is 27p each. That is 27p compared with 3p, so we are talking about nine times the cost. Retail prices can be even higher.
Even assuming that we could arrange supplies at a substantially reduced cost, we estimate that the additional cost to the family practitioner services could be up to £10 million a year. There is the question of offsetting the saving, but at present we have insufficient information to estimate the saving to the hospital service from a reduction in the issue of blood test strips or the saving from reduced in-patient admissions resulting from better control of the condition. However, I am aware of the case that is being made.
The question of syringes is more complicated. Disposable syringes are a lot cheaper than re-usable glass ones. The most widely used brand advertised in "Balance" costs £1.17 for 10, or 12p each. The drug tariff price for glass and metal syringes is £6.25. Needles are about 16p each and the carrying case for the syringes and needles costs £.75.
Glass syringes and the needles that go with them can, of course, be used many times, but one does not need to be a mathematical genius to work out that they cost 50 times as much, or perhaps even more.
We are currently spending about £1.2 million a year on these re-usable syringes and needles. A simple calculation based on the number of times an average diabetic will use insulin and the number of diabetics w ho are likely to use these syringes shows that it would cost at least £8 million to supply disposable syringes to all insulin-dependent diabetics for use on this basis.
We accept that many diabetics who buy their own disposable syringes use them more than once, but there is a wide variation in the pattern of use. It is difficult to predict what would happen if disposable syringes were provided free, bearing in mind that diabetics do not pay prescription charges and would have no incentive therefore to re-use them.
The equipment is also supplied sterile and is not intended to be resterilised. It is clearly intended for single use. Manufacturers, bearing in mind product liability, make it clear that syringes are intended for single use. The packet that I have with me, imported from the United States, has "Single use" printed twice on the packet. It has "Use once and destroy" printed clearly on the packet, and that is printed on every syringe. The Department could be in a difficult legal position, we are advised, if we instructed people to ignore that advice, and something went wrong. It is also clear from our correspondence that many diabetics use them only once and discard them.
§ Mr. BeithWill the Minister consider the matter again? Will she take account of the strong, professionally qualified medical opinion that re-use is not only safe but 1434 is probably safer than the glass syringe? The Department really should find a way through these technical and legal difficulties.
§ Mrs. CurrieAs I said earlier, the Department is discussing closely and in great detail with the medical advisers and representatives of the British Diabetic Association. Many more of these goods are becoming available on the market, and perhaps that makes our life a little easier than it might have been some time ago.
Like diabetics, other patients, such as drug misusers, may get disposable syringe on the National Health Service through the hospital service. GPs may not prescribe them. Drug misusers attending special NHS drug dependence centres may get single use syringes for use with prescribed drugs. Doctors prescribe treatment in individual cases. The recommended practice in most cases is to prescribe an oral preparation for a short weaning-off period. Nevertheless, I take seriously the hon. Gentleman's argument.
Even record levels of spending on the National Health Service do not mean that we can afford to do everything that we would like. We take seriously, however, the issues that the hon. Gentleman has raised and those taken up by all other correspondents. We must hear in mind that testing strips and disposable syringes are available on the Health Service through hospitals when they are medically necessary. Provision may vary somewhat according to individual clinical decisions, and that would apply if general practitioners were to prescribe. It varies to sonic extent also according to health authorities' different views on spending priorities. We understand the arguments for supply on GPs' prescriptions.
I have taken further advice on which of the two different pieces of equipment we would regard as having the higher priority. I recognise that many patients would prefer to see syringes given a higher priority because of the comfort and convenience of use, but as a matter of simple fact the medical advice that has been received is that it would be the glucose blood testing strips that would be regarded medically as the higher priority. That course would enable an improvement to be made in the quality of information to the diabetic. The disposable syringes, while presenting more comfort, would make no medical change in the condition of the patient. This was accepted by the general medical services committee and the British Diabetic Association when they met the Department's officials in November.
I am unable to make the promises that the hon. Gentleman wants on making blood testing strips available on GP prescription, but that provision will have a high priority if and when resources become available. Price is an important factor, and the strips will not be made available unless a satisfactory price can be negotiated.
Disposable syringes are not likely to be available on GP prescription just at present. We are, however, keeping the comparative costs of disposable and re-usable syringes under close scrutiny. The BDA tells us that it intends to put proposals to the Department for a voucher scheme for hypodermic equipment along the lines that the hon. Gentleman has suggested, and this is a proposal that we shall consider carefully.
I know that the hon. Gentleman may not find my response wholly satisfactory, and I am sorry about that. 1435 I hope I have assured him, however, of our concern to ensure that all the necessary medical items are available to diabetics and other patients through the NHS.
1436 Question put and agreed to.
Adjourned accordingly at twenty-two minutes past One o'clock.