Insulin Pen Needles (Hansard, 20 November 1997)

§ Mr. Adrian Sanders (Torbay)

Thank you, Mr. Deputy Speaker, for the opportunity to raise a very important matter. I declare an interest as an insulin-dependant diabetic and user of the pen needle system.

There is an irony about the timing of the debate. The last time that diabetes was raised in an Adjournment debate, by the hon. Member for West Lancashire (Mr. Pickthall), was in June 1996. The Minister responding at that time was Gerald Malone, who cannot be here today as he is quite busy—and I hope that he will not be here next week either. The debate was wide ranging and touched on the pen needle issue. The then Minister's reply was as follows:

The BDA"—

the British Diabetic Association—

submitted … a comprehensive document earlier this year, which is being considered by Ministers and officials in the Department. Although it was not my specific responsibility within the Department, I was interested to see the document in detail. It was a first-class effort in putting together a sound, economically based case as to why it might make sense to move in that direction. The hon. Gentleman will not be surprised that I cannot give any commitment about that tonight, but I can reassure him that the matter is being treated extremely seriously. Discussions are under way, and I hope that we can make some progress towards reaching a common position and an understanding of the facts and economics that underlie the case made by the BDA."—[Official Report, 5 June 1996; Vol. 278, c. 697.]

I hope that the present Minister will be able to confirm that further progress has been made in the past 18 months.

Diabetes is a common condition in which the amount of glucose in the blood is too high because the body is unable to use it properly. This is because the body's method of converting glucose—sugar—into energy is not working as it should.

The British Diabetic Association estimates that 1.4 million people in the United Kingdom have diabetes, and there might be as many as 1 million more undiagnosed. Diabetes is the single biggest cause of blindness among people of working age in the United Kingdom. Men with diabetes are two to three times more likely to suffer from coronary heart disease than the general population, while women have a four to five times greater risk. The risk of stroke is increased two to three times in people with diabetes. Half of lower limb amputations, other than those following trauma, are a consequence of diabetes. People with diabetes have a 15 times higher risk of amputation than the general population.

There are two types of diabetes: insulin-dependent and non-insulin-dependent. Today we are discussing the former, in which the condition is treated by insulin injections and diet. It is worth remembering that before the discovery of insulin such diabetics simply died; today they can lead normal lives, but the key is control of their condition. Well-controlled insulin-dependent diabetics will test their blood sugar levels regularly and take appropriate action in the light of the results.

525 The health service provides a number of items on prescription to help diabetics to maintain control: insulin, in both vial form for syringe injections and cartridge form for the pen needle; tester strips so that people can test their blood in glucose meters; lancets, the little pricking devices to enable the blood to be drawn for the blood test; and syringes—but not pen needles. Although general practitioners and hospitals are free to supply pen needles, it is unfair for health professionals to be placed in the position of determining needy cases. It is also unfair that access to free pen needles depends on where the diabetic lives or who is consulted for advice.

My hon. Friend the Member for Somerton and Frome (Mr. Heath) showed me a letter today from one of his constituents who lives in a part of the country where free pen needles are not available. His constituent—who was progressing from non-insulin-dependent diabetes, treated by tablets and diet, to insulin-dependent diabetes—was offered the pen but was aghast at having to pay for the needles. All hon. Members should be aware of that problem, because we all have constituents in that position. Pen needles cost patients around £10 per box of 100. Unlike syringe needles, pen needles can be used more than once; consequently, some diabetics will need only two boxes a year, while others require four or five and a minority will use slightly more.

Using a pen device is much more convenient as it is self-contained. There is a stigma attached to hypodermic needles, whereas the pen is a well-disguised object that enables people to inject themselves discreetly—sometimes when other people are around, but without their noticing. That is not possible with a syringe, which has to be drawn up, thereby broadcasting all sorts of connotations to those who witness it. The pen is discreet because it looks like a fountain pen; it is quicker than having to draw up a syringe; and it is much easier to use, especially by children, people with arthritis, the elderly and the visually impaired. Instead of drawing up the dose of insulin, one simply clicks the pen and one can hear the dose of insulin as it goes in. That is a significant benefit to the groups I listed. Many people need mixed insulin, in which case they have to carry two vials and draw from both before injecting themselves. With the pen, the insulin can be ready-mixed in the cartridge, thus avoiding the necessity of carrying around glass bottles in one's pocket or handbag.

The pen system encourages better control of blood sugar level and that is the key consideration. It reduces the chances of the onset of costly health complications. Yet despite all that, three quarters of people still use a syringe.

It is estimated that providing pen needles on prescription would cost the health service budget around £5 million a year. Diabetes as a whole costs the national health service about £2 billion a year, mostly from acute care. Poor control leads to complications, often involving acute care. The latest figures I have been able to get are for 1993–94, when 926 leg, 155 foot and 812 toe amputations took place in England with diabetes as the main diagnosis—each and every one a costly operation, necessitating a hospital stay.

In addition, a considerable amount of money would have to be spent on adaptations to housing and equipment; and consequent loss of employment might lead to almost 526 complete—in some cases complete—dependence on the welfare system. Poorly controlled diabetes can also lead to blindness, kidney failure, heart disease and strokes, with all the associated additional costs to the state. When the savings to the NHS acute care costs from better control of diabetes are taken into account, the overall cost of supplying pen needles on prescription is much reduced—or could even result in savings.

Other savings add weight to the economic case for free pen needles: for example, district nurses would no longer have to visit at home those people who need assistance with injections through a syringe; improved control would lead to fewer days off work for those who are sick as a consequence of poor control; and the nation's welfare bill would be reduced.

A total of 370,000 people in this country inject themselves with insulin in order to stay alive. Too many of them are discouraged from using a proven method of reducing their risk of complications. To sum up, the current system is unfair: access to free pen needles depends on where one lives, not on one's medical needs. Children, the elderly, people who have arthritis or are visually impaired will benefit the most. It makes good economic sense and it is logical. A decision from the Government is long overdue and I trust that the Minister will be able to respond positively today.

§ The Minister of State, Department of Health (Mr. Alan Milburn)

I am grateful to the hon. Member for Torbay (Mr. Sanders) for raising such an important issue. I am aware of his close interest in diabetes as the chairman of the all-party group on diabetes. I know that the group is due to meet my noble Friend Baroness Jay, a Minister of State in the Department, in the new year, and I am sure that the subject will be discussed in detail during that meeting.

The subject is an important issue for patients and one on which I am determined that we should make substantial progress. The hon. Gentleman asked whether I was able to report progress and I hope that, towards the end of my speech, I shall be able to reassure him that progress is being made.

Before I respond on the specific issue of insulin pen needles, it might be a helpful if I put it into the wider context of what the Government are doing to tackle diabetes more generally. We take the matter very seriously. In its different forms, diabetes is estimated to affect 2.4 per cent. of the adult population in this country—more than 1 million people—and 10 to 15 per cent. of those with diabetes are dependent on regular insulin injections.

As the hon. Gentleman rightly pointed out, diabetes and its complications often cause severe problems for those affected, their families and their carers and, inevitably, the disease imposes heavy burdens on the health services. If diabetes is not properly managed, it can cause terrible long-term complications such as blindness, renal failure and cardiovascular disease.

Obviously, the Government are concerned to tackle these problems. I shall briefly outline five important signals of the priority that we attach to improving services for people with diabetes. First, let me point out that we spend over £1 billion a year on the various services and drugs to help those with diabetes and associated problems. 527 That is over 5 per cent. of the budget for the NHS. It is useful to bear that in mind in considering the issue of pen needles.

Secondly, my right hon. Friend the Secretary of State for Health launched new guidance to the NHS last week, to coincide with World Diabetes Day. The guidance, entitled "Key features of a good diabetes service", was developed by a small group involving the Department of Health, patients, GPs, nurses, NHS managers and the British Diabetic Association. It is important to put on the record the value that the Government accord to the BDA's work on behalf of people with diabetes, in its roles as adviser and advocate.

The new guidance sets out to the NHS how health authorities working with GPs can secure and deliver a good diabetes service. It places special emphasis on partnership: the organisation of diabetes services can involve many parties—primary and community care teams, secondary care teams, carers and people with diabetes, who, of course, have a pivotal role in managing their care. We want to make sure that services for people with diabetes are better tailored to the needs of individuals.

The guidance emphasises prevention and the need to raise awareness of diabetes. It has long been recognised that the education of people with the disease is vital for promoting effective self-care. The guidance was welcomed by the British Diabetic Association, which described it as "a major step forward". It is significant that the association gave it such a positive response.

Thirdly, the Government have endorsed the international St. Vincent declaration, which highlights the scope for reducing the complications resulting from diabetes, and proposes a number of outcome targets, which include the reduction of cases of new blindness due to diabetes by one third or more; the reduction in the numbers entering end-stage diabetic renal failure by at least a third; and the reduction of lower limb amputations for diabetic gangrene by a half.

Those are challenging targets and are widely recognised as such. It is important for us to make progress on them. Indeed, I was pleased that the follow-up conference to St. Vincent, which was held in Athens last year, accorded this country the honour of being in the vanguard in Europe of improving diabetes services. We have done well, but we are not complacent, as there is still much progress to be made.

We must continue to strive to improve the care of people with diabetes and the quality of their lives. We are pledged to work in partnership not only with the NHS and health professionals, but with the British Diabetic Association and the all-party group on diabetes. We are always happy to discuss these issues in the House or in private meetings, if that is helpful to the hon. Gentleman.

Fourthly, the Government support much vital research into diabetes. The Medical Research Council, which is the main agency through which the Government support medical and clinical research, spends about £3 million a year in this area. The Department of Health is funding three important studies at a total value of £1 million, which is on top of the Department's research and development programme.

Finally, there is a whole programme of work in support of diabetes, such as clinical audit and monitoring. We have recently commissioned new national clinical 528 guidelines for non-insulin-dependent diabetes and other clinical effectiveness materials, which will ensure that the very best practice in the NHS is shared better in the future.

I hope that the hon. Member will forgive me for sketching some of the general developments in the treatment of diabetes that the Government are intent on promoting. We are considering the specific issue of pen needles in the context of that broad programme.

For some time, we have been discussing the merits or otherwise of listing insulin injection pen needles and the pens themselves in the drug tariff. That would allow the needles to be prescribed on the NHS by family doctors. At present, insulin injection syringes, and their related needles, are listed in the drug tariff, so are prescribable on the NHS by GPs.

The issue of the availability of injection pens is slightly more complex: perhaps even more complex than the hon. Gentleman suggested. There are two types of pen. The disposable pen is prescribable only because it is a container for the insulin, and the prescription for the insulin automatically includes its container. The reusable pen, on the other hand, does not come pre-filled with insulin, so it is not automatically prescribed when the insulin is prescribed. That may be as clear as mud, but that is the position. Indeed, there is less need to prescribe reusable pens, as they usually last two to three years. I understand that reusable pens are made widely available to patients by the manufacturers, which often distribute them free, sometimes through diabetic clinics.

Needles for injection pens fit either type of pen, but are not interchangeable with the needles used with syringes. They are not currently listed in the drug tariff, and may not be prescribed on the NHS by family doctors. That sets out the rather complicated current position.

The Government are considering whether pen needles should be placed on the drug tariff list, so that they could be prescribed with the insulin. We are giving the issue serious consideration, as I have made clear to the hon. Gentleman in parliamentary answers or when he has written to me. It is said that many people find the pens more convenient and comfortable to use than syringes. We do not dispute that, and we acknowledge that convenience and comfort are important considerations when people have to inject themselves frequently.

The major stumbling block is quite simply the cost. The NHS is not a bottomless pit, and we have to use taxpayers' money responsibly. We must ensure that it is used as efficiently and wisely as possible. Pen needles cost about four times as much as syringe needles. Our estimate is that the costs of placing the reusable pen on the drug tariff could range from £10 million a year at the lower end to £30 million a year at the upper end, depending on the uptake. If people switched from syringes to pens, or from reusable pens to disposable pens, costs would range towards the upper figure.

I shall be frank with the hon. Gentleman. The problem at the moment is that we are unclear about whether, or to what extent, such switches are likely to occur, and whether the cost of listing injection pen needles would be significantly higher than the British Diabetic Association's 1995 estimate of £9.5 million over two years.

However, costs cannot be the only consideration when such important issues affecting so many people are involved. The Government are committed to ensuring that 529 we try to improve the care of people with diabetes and their quality of life. For that reason, I have asked officials in the Department of Health to examine, in discussions with interested parties if necessary, whether we can be more certain on the cost points. They have held a number of meetings with the major suppliers, and negotiations are currently under way.

It is still a little early to place a precise time scale on this work, particularly given the delicate nature of our discussions with the companies concerned. We do not want to delay decisions unnecessarily and, equally, we do not want to take premature decisions if costing issues still 530 have to be resolved. Nevertheless, this is an important issue on which we are determined to make progress in the interests of patients and of the NHS more generally.

The hon. Gentleman was right to seek this debate. Ministers have signed many letters in response to hon. Members who have expressed concern about the issue. The Government are aware of the concerns in the House and in the country. Many people suffer from diabetes, and many people have relatives, friends and neighbours who have diabetes. We want to make progress, and I shall be happy to update the hon. Gentleman in due course when we have advanced a little further.