James Reilly (Dublin North, Fine Gael)

I thank the Minister of State for giving me the opportunity to discuss this matter, even if it is only in the context of statements to the House.

A few months ago, the Irish Endocrine Society and Diabetes Federation of Ireland made a presentation to the Joint Committee on Health and Children. Dr. Diarmuid Smith was present and that meeting, and I would like to quote extensively what he said, because I could not put it any better myself.

We would like to be able to say that over the past three years the care of diabetes patients in Ireland has improved but, unfortunately, it has not. The title of our presentation is "Diabetes in Ireland: Are We Coping?" The stark reality is we are not coping, which significantly affects the quality of care we can deliver to patients with diabetes in this country. The greatest health challenge the world and Ireland face this century is the epidemic of diabetes. The prevalence of both type 1 and type 2 diabetes is increasing each decade. In the case of type 2 diabetes, we expect to see an increase in its prevalence of approximately 37% over the next ten years.

We know that if diabetes is not treated appropriately, life expectancy is shortened. We know that diabetes is the commonest cause of blindness in working age adults. We know that diabetes is the commonest cause of renal failure and we also know of the need for dialysis in Ireland. Diabetes is associated with a 40-fold increased risk of lower limb amputation and an increased risk of heart disease and stroke. Diabetes care consumes between at least 6% and 8% of the annual health care budget and 60% of that budget is spent on the management of diabetes-related complications. Several diabetes complications are preventable, so if we invest appropriately in diabetes care, we can stop limbs being amputated and people going blind and save the health service money. [The Minister of State has acknowledged this.]

In 1989, the Department of Health and Children signed up to the St. Vincent declaration. With this declaration, the Irish Government made a commitment to reduce new blindness cases due to diabetes by one-third or more, reduce numbers entering end-stage diabetic renal failure by at least one third, reduce by at least 50% the rate of limb amputations for diabetic foot disease and reduce morbidity and the mortality rate from cardiovascular disease. Unfortunately, successive Irish Governments have failed to deliver on these commitments.

In 2002, the diabetes community submitted a document entitled "Diabetes Care: Securing the Future" to the then Minister for Health and Children. This report outlined very precisely what Ireland needed in terms of staff numbers and infrastructure and provided precise costings on how to establish an internationally accepted national diabetes service for this country. The recommendations of this report have not been implemented and so today, we are still providing a sub-optimal, under-staffed and under-resourced national diabetes service. [This has obvious consequences for our patients.] In 2006, the HSE established an expert advisory group to look at the development and implementation of a national diabetes strategy. Several people here on our panel [i.e at that committee] were included in this group...They submitted their recommendations to the HSE in September 2007. However, nine months later [it is now 18 months later], none of the recommendations of the expert advisory group has been implemented.

In Ireland, the diabetes community is very clear about what we need to do, how we need to go about delivering a world-class diabetes service for the people of Ireland and how much this will cost the country. The only blockage appears to be a lack of political will in the past, possibly a lack of knowledge in regard to the seriousness of diabetes and, unfortunately, a lack of resources. We are asking for the committee's help to have the vision and political willpower to realise that Ireland is facing an epidemic of diabetes. We need to put structures, resources and staff in place to deal with this national crisis....

Diabetes is the commonest cause of blindness in working-age adults. Up to 5% to 10% of people with diabetes have sight-threatening eye disease [acknowledged by the Minister of State] which requires expert ophthalmic follow up and treatment. Diabetic eye disease is preventable. The establishment of a national retinal screening programme using retinal cameras [as outlined by the Minister of State] and pictures would help us to identify diabetic eye disease early, allow appropriate therapy to be initiated early, reduce the number of new cases of diabetes related blindness and improve our patients' quality of life. It would also be cost-effective as it would pay for itself within a few short years. The cost of screening a patient with a retinal picture or camera is approximately €65, while the cost of treating someone with sight-threatening diabetic eye disease is more than €1,700.

A national retinal screening programme is the international best practice and has been effective in other countries of similar size to Ireland in reducing diabetes related blindness. However, this programme is only available in small pockets of Ireland like the north west, where it runs very successfully. In 2007, the HSE west was promised a capital expenditure of €750,000 to expand the retinopathy screening programme within the area. The money in 2007 never materialised. [The money in 2008 never materialised either, and we are now in 2009.] The area received similar funds in 2008 but is still awaiting clearance to recruit staff to run the retinal screening programme. . . [Does that sound familiar? Did somebody mention recruiting staff?]

Our second point relates to diabetic foot disease, particularly in respect of podiatry...Diabetic foot disease is preventable. Ireland has the lowest manpower in podiatry for diabetes. There are only two full-time hospital posts in the whole country. The country needs between 90 and 100 full-time podiatrists for diabetes foot care, based both in the community and the hospital. The podiatrists need to be appropriately trained, equipped and resourced if they are to have a positive impact on reducing the risk of diabetic foot disease. Investing in podiatry care will help us save limbs and improve the quality of life of our patients and would be cost-effective.

The third issue relates to a national diabetes register. I cannot say exactly how many people in Ireland have diabetes. [Generally, for every case we know about, there is another case we do not know about. By the time such people present, they have complications which might have been avoided had they been diagnosed earlier.] We do not know...I do not know whether diabetes is more prevalent in Mayo or Donegal compared with Dublin...[We do not know how we compare with the US or anywhere else. We need a register, which would not cost much money.]

The fourth issue relates to integrated care. Integrated care refers to the care of patients predominantly with type 2 diabetes. It refers to the integration and sharing of care of all patients with type 2 diabetes between the hospital diabetes specialist team and the primary care physician [i.e. the GP] who has an interest in diabetes. The system essentially is structured on an annual visit or a visit every 18 months to the hospital diabetes specialist team, and three monthly in-between visits to the primary care physician...[A small programme was run on this basis in conjunction with Heartwatch, which proved to be very successful in the midlands.] Patients with type 2 diabetes are often only seen once a year for their diabetes or not at all and if they are seen more frequently, it is often in an unstructured fashion with little access to, or support from, the diabetes multidisciplinary team...

The diabetes community wants to develop a system of integrated care between the hospitals and primary care providers.

This all occurred last year. Dr. Smith went on to talk further about the development and the expansion of existing services, and we know none of that happened. He went to give a stark example:

A few weeks ago, in a kidney clinic I run with my colleague, Professor Peter Conlon, in Beaumont Hospital, I met a man from the country who had type 1 diabetes for 39 years.

During those 39 years he had never met a diabetes or endocrine consultant. [Not once.] I was the first consultant diabetologist he had met. Unfortunately, at this stage he was almost blind, had laser therapy to both his eyes, had renal failure and was beginning the process for renal transplantation and had lost the sensation in his lower limbs. I could not believe this could still happen in the Ireland of the 21st century but I am afraid this story is not uncommon.

That is an absolutely shocking story of a health service that has lost its way. That can still happen today. He went on to say that we have a blueprint for a national diabetes strategy, but I will not go into that.

Dr. Colm Costigan's main quote was, "if the Committee could do one thing for us today it would be to add political pressure to implementing the report; we do not need new reports or fudging of the issues". Dr. Tony O'Sullivan, a GP who has diabetes, attended the meeting. He said he noticed a 10% incidence of depression among people with diabetes, yet there is no counselling or psychological support for them. Dr. Obada Yousif pointed out that diabetes has been recognised by the United Nations as being the only non-communicable, non-infectious disease that poses serious threats to countries and communities alike.

In 2002, the estimated capital cost of a diabetes retinopathy screening unit was €1.984 million, with an ongoing annual cost of €2.5 million, which one can weigh against the annual cost of looking after 100 registered blind people of €2.4 million. That is the cost for just 100 people; we have 14,000 people at risk of losing their eyesight from diabetes alone. Doing this would cost a fraction of the cost of care for those people.

The presentation to the committee stated:

The recommendation of the group present is to provide a retinal screening unit in each HSE region, either a mobile or stationary unit, depending on the public-rural mix and geographical profile of the area. Each regional diabetes centre should also be adequately resourced and funded, with a retinal screening unit. There should be a centralised screening mechanism, whereby images from rural areas would be streamlined into a central station where they could be placed in the different grades of retinopathy and dealt with according to a pre-agreed priority strategy. We also recommend an increase in the number of retinal surgeons from ten to 15 to deal with the work generated by the expected level of detection.

There is a major issue here that is, unfortunately, symptomatic of where we have been going in this country. We commission a report, get experts to join in and get the best of minds applied to the issue, and they produce an excellent report. In this case the report's strategy is very cost-effective, but for want of €750,000 it does not happen. There is a general realisation in the medical and broader communities that the diabetes epidemic in this country is closely correlated to the obesity epidemic. Some 15 years ago, type 2 diabetes was always associated with people in their middle years who were obese or seriously overweight. We now see type 2 diabetes in children, which we did not see 15 or 20 years ago, and that is directly related to obesity in children. Again, this Government had the best of minds brought together from a broad range of people and put together an obesity taskforce which came up with 128 recommendations. At the Oireachtas committee meeting to which I referred I asked the witnesses if they could tell me how many of those recommendations have been implemented. Not one could be pointed out to me and I believe that is the case. I would be happy to be contradicted but I do not believe I will be. We must ask what happened to the €750,000 for the roll-out in 2007 and 2008.

The moneys were put aside for the roll-out of the diabetic retinopathy screening programme which would save people's eyes and prevent many from going blind. It is essential that this money be made available. It is penny wise and pound foolish not to do so, not to mention the human suffering that occurs because of a late diagnosis of diabetes. We are all aware of the cutbacks that must be implemented, but no matter how hard times are and how bad the economy is, such programmes give results very quickly and will save money, as had been pointed out.

It is very difficult not to be confrontational about this. I would like to take a different line, but yet again promises are made that are broken and plans for action are seen as a substitute for real action. The Minister of State mentioned advertising and I read the report. They were recruiting in 2008, are still recruiting in 2009 and hope to advertise soon. We all know that from the point of advertisement, to having interviews, to appointing people — particularly consultants — can take from 12 to 18 months. How many more people will go blind during that time due to our failure? I ask the Minister of State for that small amount of money and to fight hard for the people with diabetes. It is only small beer but means so much to so many people.

See this speech in context