Diabetes

HC Deb 30 November 1999 vol 340 cc277-84

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Jamieson.]

11.55 pm

Mr. Adrian Sanders (Torbay)

Thank you Mr. Deputy Speaker, for allowing me to raise—[Interruption.]

Mr. Deputy Speaker (Mr. Michael J. Martin)

Order. An hon. Member is addressing the House, so other hon. Members should leave the Chamber quietly.

Mr. Sanders

Thank you, Mr. Deputy Speaker.

I am grateful for the opportunity to raise an important issue in the House. I have declared a relevant interest. It has been pointed out that some might take offence at a Member of Parliament addressing the House in a dinner jacket, but that is unavoidable: I came here straight from an event to which I hope to return at the end of business.

Currently, 140 million people throughout the world are known to have diabetes. That figure—

Rev. Ian Paisley (North Antrim)

On a point of order, Mr. Deputy Speaker. In the previous debate, you made a ruling in respect of something I said. May I draw your attention to column 605 of the Hansard of 24 November? At that time, the Secretary of State for Northern Ireland made certain comments which could be taken to refer to only one person, my hon. Friend the Member for Belfast, East (Mr. Robinson). I should like you to read the Hansard and give a ruling on the matter.

Mr. Deputy Speaker

The matter will be looked into. Let us return to the Adjournment debate.

Mr. Sanders

Currently, more than 140 million people around the world are known to have diabetes. That figure is projected to rise to 300 million by 2025. In the UK, the figure is currently 1.4 million, and it rises every week.

Diabetes is the biggest single cause of blindness among adults of working age in the UK. The risk of hospital admission owing to heart disease is increased fourfold among those with diabetes. Diabetes is one of the most common causes of kidney failure. Half of all lower limb amputations other than those carried out following trauma are a consequence of the disease. Diabetes consumes more than 5 per cent. of health care spending in this country, which is £2.5 billion each year or £70 a second.

The Government's response has been to launch the national service framework on diabetes. It is imperative—[Interruption.]

Mr. Deputy Speaker

Order. The best thing would be for the owner of that device to leave the Chamber.

Mr. Sanders

It is imperative that people with diabetes have access to top-quality diabetes care. I hope that the national service framework will achieve that, when it is published in 2001. The Government recently announced the co-chairs of the NSF expert reference group, and are currently assembling the core members of the group. I hope that people with diabetes are properly represented on the core group and topic sub-groups, because they are the end-users; they, like me, live with the condition every day. People with diabetes are the real experts and the Government should make full use of their input.

The scope of the NSF has yet to be announced, but I believe it to be imminent. Vital to the success of a comprehensive NSF is that it covers the entire diabetes life cycle, from cradle to grave. That means from diagnosis to treatment, and from childhood to old age.

At the beginning of this month, the British Diabetic Association launched its report on diabetes care in nursing and care homes. Research reveals numerous deficiencies in the care elderly people receive in care homes: lack of care planning, inadequate nutritional guidance, lack of specialist health expertise input, and inadequate and unstructured medical follow-up. With about one in 10 people in care homes having diabetes, that issue must be examined. I should like all to receive equal, high-quality care, and the BDA report makes a number of suggestions, based on the active involvement of individual residents, to rectify the shortcomings I have described. The Secretary of State has been sent a copy of the report, and I hope that he will respond positively and take action.

The Government announced in the Queen's Speech their proposals for a care standards Bill to improve care across social services in private and voluntary health care and in child care. I hope that such a Bill will have the desired effect. Meanwhile, the on-going "Fit For the Future?" consultation document on improving standards of residential care for older people is a further opportunity for progress.

It is important that better standards of care are introduced, and we need to end discrimination against people with diabetes. The recent implementation of the second European Community directive on driving licences effectively bans insulin-dependent diabetics from driving large vans and minibuses.

Mr. Desmond Browne (Kilmarnock and Loudoun)

I first became aware of the absurd state of the law in relation to insulin-dependent drivers in the United Kingdom when one of my constituents, James Murray, who was a light goods vehicle driver, became insulin dependent and found himself almost overnight not entitled to an LGV licence or to retain the licence that he had previously held, which allowed him to drive vehicles between 3.5 and 7.5 tonnes and some minibuses.

The hon. Gentleman will be aware that the roots of the legislation lie in the directive to which he referred, but it is one that allows some flexibility to the member countries of the European Union. Does he agree that the James Murrays of this world will find it inexplicable that while our Government have applied the directive stringently, other European countries have protected existing drivers who have occupational licences by using the exceptional circumstances provisions of the directive?

Mr. Sanders

The hon. Gentleman is absolutely correct. There are different interpretations and it is bizarre that a Dutch diabetic can come to the UK and drive a vehicle on our roads while a UK driving licence holder cannot drive the same vehicle if they are both insulin-dependent diabetics.

Since 1991, diabetics have been banned from driving heavy goods vehicles under the first EC directive on those matters. I would argue that the Department of the Environment, Transport and the Regions has interpreted the second directive in an unnecessarily harsh way. I would reiterate the points that the hon. Member for Kilmarnock and Loudoun (Mr. Browne) made.

Since 1998, more than 1,000 people with diabetes who applied to renew their C1 licence, which allows them to drive a van or vehicle weighing between 3.5 and 7.5 tonnes, have had their application refused. My attention was recently drawn to the case of a man who ran a haulage firm in Kent for 26 years. Running the company meant moving lorries around in the depot. He lost his licence as a result of changing on to insulin. He was a diabetic before that happened. As he could not afford to hire an extra employee, he was forced out of business.

I have examples of people in my constituency who have had their earnings reduced—at worst they have lost their jobs—as a result of the restrictions. There are hundreds more cases of that sort, yet the Department's suspicion that people with a medical condition, such as diabetes, are less fit to drive than others is not substantiated by any medical or scientific evidence. Instead of a blanket ban, I believe that a system of individual assessment should be adopted by the Driver and Vehicle Licensing Agency.

The EC directive under which the regulations were adopted allows for a certain amount of flexibility, and as I have mentioned, other EU member states take a more lenient approach. I am not advocating a lapse in road safety—far from it. Stringent annual health checks by a diabetes specialist should be used as a basis for individual risk assessment. Only those who show good blood glucose control and have no further complications would be allowed to drive larger vehicles or passenger carrying vehicles.

Blanket bans are always unfair and I am sure that many hon. Members will be aware from their postbags and surgeries that this discriminatory policy is causing distress to many people throughout the country. With the possibility of a third EC directive on driving in the pipeline, it is time that the Government reviewed their approach. Meanwhile, the Select Committee on Science and Technology is investigating the issue, and I hope that the Government take note of evidence to the Committee calling for a fresh look at the regulations.

Health care should be accessible, and that includes accessibility in terms of cost. Yet in many parts of the country people who use pen needles to inject insulin currently have to pay for their needles. I and a number of hon. Members on both sides of the House have been engaged in a long battle to make those needles available on prescription. I pay tribute to the hon. Member for West Lancashire (Mr. Pickthall) for the work that he has done on the issue over the years.

When the current Secretary of State for Health was first at the Department, before his spell at the Treasury, he initiated a consultation process, but the matter has still not been resolved almost a year on. I see no justifiable reason why the decision should be delayed further. The Government have given an assurance that they agree with the principle that pen needles should be free on prescription. They say that they are still consulting, but surely the situation should not be allowed to drag on any longer.

Meanwhile, the Department of Health has yet to rule out the blacklisting of disposables as a cost-saving measure. Disposable pen needles are essential for people who have visual impairment or lack manual dexterity and find it difficult to fill reusable pens. These simple devices are a vital part of many people's diabetes control. I ask the Government not to delay any further, as the current situation discriminates against poorer people with diabetes.

Good health care should be a right in this day and age, and should not be based on ability to pay. I urge the Government to consider seriously the various points that I have raised tonight, and to ensure that people with diabetes are treated with equity, fairness and dignity.

12.6 am

The Minister of State, Department of Health (Mr. John Denham)

I congratulate the hon. Member for Torbay (Mr. Sanders) on raising this important subject and making his points clearly and concisely. I am aware of his close interest in the subject, as the chair of the all-party group on diabetes and, as he told the House, because he himself has diabetes.

I hope to respond to all the issues that the hon. Gentleman raised. I begin by assuring the House of the seriousness with which the Government take diabetes. It is, as the House has heard, an important health issue in terms of both morbidity and mortality. More than 1 million people in the United Kingdom have diabetes, and that number is forecast to increase significantly over the next decade.

Diabetes has a significant impact on the national health service. Our estimate is rather higher than the hon. Gentleman's—diabetes and its complications account for at least 9 per cent. of health care costs in the UK. If it is not properly managed, diabetes can result in a range of long-term complications which the hon. Gentleman listed—blindness, renal failure, lower limb amputation and cardiovascular disease.

I acknowledge that there is some evidence of considerable variations around the country in the organisation and quality of diabetes services. For that reason among others, my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson), the former Secretary of State, announced in January that the next national service framework would cover diabetes. I shall return to the national service framework later and respond to other specific issues, but first I shall touch briefly on the wider context of Government policies for tackling diabetes.

The previous Administration signed up to, and we endorse, the St. Vincent declaration, which recommended action in key areas and set outcome targets. The principles and targets of the St. Vincent declaration have been at the core of what successive Governments have done on diabetes, in partnership with health service providers, the British Diabetic Association and others.

The St. Vincent joint task force for diabetes set up by the Department and the BDA made recommendations in 1995 about good clinical and management practice in 11 agreed priority areas. That was followed in November 1997 by service guidance for the NHS entitled "Key features of a good diabetes service", which was developed by a sub-group of the Department's clinical outcomes group. The key features guidance made suggestions about how health authorities, working in partnership with primary care and all those involved in the planning and delivery of local diabetes services, including people with the condition, should work together to agree a structured programme of diabetes care.

A raft of other work feeds into the new quality agenda. The Government are supporting a range of current activities to improve knowledge-based decision making in diabetes care. The Department has commissioned new national clinical guidelines for type 2 diabetes, and other clinical effectiveness materials.

The hon. Gentleman rightly stressed the importance of the user's perspective and needs and of ensuring that the NHS provides effective services to meet them. We attach great importance to involving patients, carers and the wider public in decisions about health service delivery, and we also want individual patients to play a greater role in determining the care that the NHS gives them. An NHS that works effectively with patients will deliver better results for individual patients and better health for the whole population.

An example of that is the Bradford health action zone programme, which is developing models for delivering accredited diabetes care within primary care. The Bradford HAZ has set up a network of local diabetes satellite clinics in general practitioners' surgeries and, instead of visiting hospital, patients can receive specialist care locally. That is an example of how our determination to modernise the NHS and tackle inequalities is already improving services.

The BDA is also participating in the expert patients task force, headed by the chief medical officer, which was announced in the White Paper "Saving Lives: Our Healthier Nation" and met for the first time last week. The task force will design a programme to help people with a chronic disease or disability such as diabetes to take the lead in managing their condition, with appropriate support from the health service.

The Government are making a major contribution to diabetes research through the Medical Research Council and NHS support for research and development. The MRC, which is the main agency through which we support medical and clinical research, spends about £3.5 million a year on diabetes. In addition to commissioning specific projects, the Department supports research funded by charities such as the BDA and the MRC, which takes place in the NHS. More than £4 million a year of that funding supports endocrinology and diabetes research.

I shall deal briefly with issues surrounding diabetes screening. The UK national screening committee is considering the case for introducing a screening programme targeted at people at high risk of contracting type 2 diabetes. We expect to receive its advice later next year, and it will also be linking type 2 diabetes with other risk factors in its consideration of screening for vascular disease. It also recently commissioned a working group to develop proposals for a national screening programme for diabetic retinopathy. The proposals being developed would ensure national coverage to national quality standards.

I deal now with some of the specific issues raised by the hon. Gentleman. On driving and diabetes, I am afraid that there is little more that I can say this evening. The way in which the driving licences of people with diabetes treated by insulin are considered is of course a matter for my right hon. Friend the Secretary of State for the Environment, Transport and the Regions. Briefly, as the hon. Gentleman said, the current position is based on European legislation—the second driving licence directive. That directive provides for licensing restrictions on those with insulin-treated diabetes—in particular in respect of driving heavier vehicles—based on risks associated with insulin treatment. I understand that the advisory panel on diabetes and driving, which advises my right hon. Friend, has, over a long period, consistently advised against the granting of licences to drive the largest vehicles, such as lorries and buses, to people with insulin-treated diabetes, based on its knowledge of the risk of a hypoglycaemic attack occurring without warning and the associated road safety risk.

That bar was extended to small lorries and minibuses on implementation of the second driving licence directive which, for people with insulin-treated diabetes, came into effect at the beginning of 1998. However, on the advice of the panel, the Government felt able to relax the law in September last year to allow drivers of small lorries to renew entitlement obtained before 1 January 1997, provided that they can satisfy specified conditions. I shall of course draw the attention of the relevant Minister to the debate. I am also aware, as is the hon. Gentleman, that the Science and Technology Committee is currently considering diabetes and driving licences.

Mr. Browne

I am grateful to my hon. Friend for giving way. I realise that the issue that exercises me is the responsibility of another Department, but when he draws the debate to the attention of the relevant Minister, will he stress that the arguments are fundamentally underpinned by a desire for the Department to treat people with this disability as individuals, not a coherent group? We are arguing for an approach that recognises people's individuality and that would reflect the stance that other European countries appear to be adopting.

Mr. Denham

I repeat my undertaking to draw the appropriate Minister's attention to the points that have been made in this debate. However, it is not for me to intrude on the responsibilities of another Department.

The hon. Member for Torbay expressed concern about the inadequate diabetes care suffered by some elderly people in residential care homes. That issue was highlighted recently in a report by the BDA. Among the deficiencies identified by the BDA were a lack of diabetes care planning, inadequate dietary advice, a lack of specialist health professional input, high ratios of staff with no experience of diabetes and a lack of diabetes training for care home staff. The report raised serious issues and made important recommendations, which we shall consider further. In particular, I confirm that this aspect will fall within the scope of the national service framework for diabetes. The BDA report will help to inform its development.

As the hon. Gentleman rightly said, the care standards Bill announced in the Queen's Speech is relevant because it is designed to drive up standards in care services, with a new independent regulatory system to inspect care homes and other services against national standards. Also relevant is the consultation document "Fit for the Future?", which includes proposed standards for older people in residential and nursing homes.

The hon. Gentleman also raised the issue of the availability of insulin injection pens and needles on GP prescription. We consulted between February and April this year on a proposal that was designed to open the way for insulin pen needles and reusable insulin injection pens to be available on GP prescription on the NHS. Reusable pens and needles would be free to people with diabetes who need treatment with insulin and who produce the necessary prescription charge exemption certificate.

The proposal on which we consulted was to prevent GP prescribing of pre-filled, disposable, insulin injection pens because it was significantly more expensive to administer insulin using those pens than using reusable pens, and they seemed to offer no clinical benefits or benefits of patient convenience or comfort to justify the extra cost.

Most of the organisations consulted responded, including the companies that market insulin pens and needles, which have proposed to equalise the costs of pre-filled and reusable pen-based insulin regimes by adjusting their pricing. We thought that this proposal, which would have avoided the need for the proposed blacklisting of pre-filled pens, was well worth exploring with the companies. It was clear from the consultation that some people felt there was a need for pre-filled pens because they are less fiddly to use. Some people with diabetes who could not use the reusable pen may be able to use the pre-filled pen. The companies' proposal offered one way of responding to this need, although not the only way.

We are currently in negotiation with the companies. A central point is agreeing a price for the reusable pens that is fair and affordable to the NHS. We wrote to the companies about a month ago, setting out prices that we believed were fair. We asked for their reactions, and the ball is now in their court. If they agree to our pricing proposals, we can quickly make reusable pens and needles available through GPs on the NHS. If not, we will have to consider what alternative options might be open to us. That may well include making pen needles available on GP prescription while postponing a decision on making some or all reusable pens similarly available. It would not, however, be sensible for us to postpone a decision on pre-filled pens.

Allowing pen needles to be prescribed could make use of the pre-filled pen more attractive than at present, because people would no longer have to buy the needles for them. To forestall growth in this relatively expensive way of administering insulin, we may need to return to the original proposal of blacklisting pre-filled pens, or at least restricting their availability to those who really need them. I share the hon. Gentleman's impatience to see this matter resolved, and I assure him that we are endeavouring to make progress as quickly as possible.

I referred earlier to various initiatives to improve services for people with diabetes. They are valuable, but they will have their greatest impact if they have to take place in a clear structure that holds those who deliver services to account.

Shortly after taking office, we set out in the White Paper "The New NHS—Modern, Dependable" and the policy document "A First Class Service—Quality in the New NHS" a range of measures to raise quality and standards and to decrease unacceptable variations in service. We said that standards would be set by the National Institute for Clinical Excellence and by national service frameworks. For the first time in the history of the NHS, we are setting clear national standards to guarantee fair treatment wherever patients live.

The national service framework for diabetes will be published in 2001, for implementation in the NHS from spring 2002. The national service framework will set national standards, define service models, introduce strategies to support implementation and delivery, and establish performance measures against which progress within an agreed time scale will be measured and monitored.

We have started work in earnest on the diabetes NSF. We have been putting together a team of officials at the Department to co-ordinate its development, and working out a project plan. As the hon. Gentleman said, last month we announced the appointment of the co-chairs of the expert reference group for the diabetes NSF. We shall soon announce the scope of the NSF and also the terms of reference and membership of the expert reference group. It will bring together representatives of the main interested parties, including diabetologists and other health care professionals and managers, service users and carers and partner agencies.

Mr. Sanders

And patients?

Mr. Denham

Service users will certainly include patients—those who have diabetes. The group hopes to meet in the near future, once we have announced its membership.

Each member of the expert reference group will be expected to play an active role and to take responsibility for advice on specific topic areas within the scope of the diabetes NSF. That scope will be broadly drawn, covering prevention, identification and management of diabetes and its major complications. As well as including people with diabetes on the expert reference group, we shall be looking at other ways to involve them in the development of the NSF, and as part of that the NSF will focus specifically on the needs of minority ethnic groups.

I hope that I have been able to respond as fully as possible to all the points raised by the hon. Gentleman in what was, even at this late hour, an important debate on a subject that interests many people.

Question put and agreed to.

Adjourned accordingly at twenty-two minutes past Twelve midnight.