Seán Power (Kildare South, Fianna Fail)

I thank Members for the opportunity to address the House on the important issue of diabetes. It is a chronic, progressive metabolic disease that impacts on almost every aspect of a person's life. Its prevalence is progressively higher in older ages groups, however, it can affect infants, children, young people and adults of all ages. There is a great deal of concern because diabetes is becoming more common throughout the developed world.

There are two different types of diabetes. Type 1 diabetes affects mainly young people and has a sudden, and sometimes life threatening, onset. It requires lifelong insulin. Type 2 diabetes is much more common and usually has its onset in middle age. It is associated with lifestyle factors and usually treated by a combination of behaviour changes and medication.

In the course of my presentation I wish to give an outline of the nature, prevalence and impact of diabetes; to describe the initiatives currently under way in regard to prevention; to outline the nature of diabetes care; and to inform Members of the national working group on diabetes and the model of care which will inform future diabetes services. Diabetes is a chronic, progressive metabolic disease. Type 1, or insulin dependent diabetes, accounts for approximately 10% of cases. This affects mainly young people and requires lifelong treatment with insulin.

Type 2 diabetes accounts for the remaining 90% of all cases and affects mainly middle aged or older people. The prevalence of type 2 diabetes is increasing due to a number of factors, including the ageing population and lifestyle issues such as obesity. It is estimated that there are approximately 140,000 people with diabetes in Ireland. Diabetes has a profound impact on lifestyle, work, well-being and life expectancy. Life expectancy is reduced by approximately 20 years in people with type 1 diabetes and up to ten years in people with type 2 diabetes. There are approximately 2,000 deaths annually from diabetes.

Diabetes also causes significant morbidity. Studies have estimated that type 2 diabetes is present for an average of seven years prior to the diagnosis, and up to half of people at this stage may have evidence of complications of diabetes. These complications include eye, kidney and nerve damage. Diabetes also causes vascular complications resulting in coronary heart disease, stroke and peripheral vascular disease, which are the main causes of premature death for people with diabetes.

Diabetes is the most common cause of blindness and amputations in the working population. Foot problems are the most common cause of diabetic admissions to hospital. Diabetes also confers additional risks in pregnancy, where there is an increased chance of losing the baby or of having a congenital abnormality. The increase in frequency of diabetes has led to an increase in hospital admissions. In the past three years, hospital admissions have increased by 32%, with almost 40,000 admissions annually.

There is consensus on the importance of early detection, diagnosis and treatment for people with diabetes. The complications of diabetes are preventable, but to do so diagnosis must be made as early as possible. The provision of services for people with diabetes is complex and care is provided by a wide range of professionals in a wide range of settings. These include general practitioners and their staff, community health staff and hospital specialist diabetes teams, as well as patients themselves and their carers. The achievement of good outcomes for people with diabetes is dependent on the provision of well-organised and integrated diabetes care.

The majority of patients, particularly those with type 2 diabetes, receive their care in the primary care setting. In this setting, there are obvious benefits of convenience, continuity of care and immediate access. Other patients, particularly type 1 diabetics, receive their care primarily in the hospital setting, usually from a physician with a specialist interest in diabetes or from an endocrinologist specialising in the treatment of diabetes. These consultants form part of a specialist team that includes, among others, the clinical nurse specialist in diabetes. A way of integrating this care is through the provision of shared care between the hospital specialist team and primary care. In shared care, roles and responsibilities are clearly understood, and it is supported by agreed protocols. This type of care has been shown to be particularly effective for the management of type 2 diabetes.

In late 2003, the Minister for Health and Children asked the chief medical officer of the Department of Health and Children to chair a working group consisting of the Department, service providers and the Diabetes Federation of Ireland. The membership of the group reflected the multidisciplinary nature of diabetes care and included representatives from the Irish College of General Practitioners, diabetes nurse specialists, the Diabetes Federation of Ireland, health boards and the Department of Health and Children.

As the terms of reference were drafted prior to the establishment of the HSE, the group determined that there should be two phases to the process, namely, a policy aspect which outlines a model of diabetes care and what services diabetes patients should receive, and an implementation phase which would be the responsibility of the Health Service Executive.

The strategy was intended as a high level policy document to set out a model for diabetes care together with a range of preventive and therapeutic services that diabetes patients should expect to receive. To achieve this, the report recommended the following: the development of population and high-risk approaches to prevent diabetes; the development of podiatry services as a priority issue to prevent foot care complications; the introduction of a diabetic retinopathy screening programme to prevent eye disease; the development of a diabetes register; the setting out of a model of high-quality care which describes what children and adults with diabetes shall expect to receive throughout their lifetime; that diabetes services should be prioritised and reflected in the national service plan of the Health Service Executive; and the development of "shared care" which described a model of care that is developed jointly between primary care and specialist services, and which has been shown to be most effective in diabetes prevention and the management of complications.

It also called for a planning and service delivery framework, involving diabetes service development groups with management responsibilities for planning and delivering services and clinical activities in service networks and the application of protocols to support better quality care. The policy guidance has been published on the Department of Health and Children website and the report forwarded to the HSE for implementation.

Diabetes has been acknowledged as a priority issue and the 2006 HSE service plan has identified that current policy guidelines will be translated into specific action plans with the initial focus on the development of a national diabetes service framework. The chief executive of the HSE has identified the establishment of expert advisory groups as a major step in the reform programme. The purpose of these groups is to facilitate key stakeholders, including the clinical and health community, patients, clients and service users in having an influential role in service development. One of the first expert advisory groups to be established will deal with diabetes.

Following the publication of the report, the recommendations have been considered by the management team of the primary, community and continuing care directorate. The management team has identified the following priorities for primary, community and continuing care services: to audit and assess current provision in the local health areas and the administrative areas; to identify best practice; the development of local registers; the identification of high-risk patients; the development of the working arrangements between the HSE and the voluntary sector; and the further roll-out of the screening programme for diabetic retinopathy.

Funding has been approved by the strategic planning and implementation unit of the HSE to develop a self-care and management network for patients with diabetes in each of the four administrative areas. This was one of the key recommendations of the report. Work is advanced in conjunction with the Disability Federation of Ireland in agreeing the allocation of the funding and the service level agreements for the development of the networks. Funding has also been prioritised in 2006 for the development of multidisciplinary community intervention teams for diabetes and work on the roll-out of these proposals is in progress.

The Department of Health and Children is currently implementing a number of strategies, the health promotion aspect of which is of direct benefit to diabetics. These strategies include the cardiovascular health strategy, the health promotion strategy and more recently the obesity strategy.

The cardiovascular health strategy makes 211 recommendations, of which approximately 50 relate to prevention of all cardiovascular diseases, including diabetes. The strategy does not deal with the identification or treatment of diabetes. However, the implementation of the health promotion aspect of Building Healthier Hearts is of direct benefit to diabetics. Some €60 million has been allocated to the strategy, employing approximately 800 professionals to date. Of this, €5 million has been allocated to health promotion employing almost 150 additional health promotion officers. Under the cardiovascular health strategy, a number of agencies and initiatives have been funded, and these include the Diabetes Federation of Ireland. Since 2002, the health promotion unit has provided an annual grant of €63,000 to the Diabetes Federation of Ireland to help fund its health promotion activities.

The national programme in general practice for the secondary prevention of cardiovascular disease, Heartwatch, commenced on 1 October 2002 and is being implemented by the HSE in partnership with the Irish College of General Practitioners and the Irish Heart Foundation. Heartwatch concentrates on secondary prevention of cardiovascular disease. In addition, 1,000 people with diabetes, who are at high risk of developing heart disease, living in the former Midland Health Board area are being included as part of the programme at a cost of approximately €200,000.

Building Healthier Hearts, published in July 1999, identified that secondary prevention for most patients with cardiovascular disease should be provided in the general practice setting. This service model is also relevant to patients with diabetes. The future of the programme will be informed by an independent evaluation currently being considered by the Department and the HSE.

Overweight and obese individuals are at an increased risk of type 2 non-insulin dependent diabetes. As much as 58% of type 2 diabetes is attributable to excess body fat. The report of the national task force on obesity, Obesity: The Policy Challenges, was presented to the Taoiseach in May 2005. The report contains 93 recommendations aimed at tackling overweight and obesity. Revenue funding of €3 million has been allocated to the Health Service Executive to progress the implementation of relevant recommendations of this report.

Intervention to prevent overweight and obesity improves quality of life and life expectancy and will also lead to a reduction in type 2 diabetes, some cancers, obesity-related psychological problems, hypertension and other cardiovascular risk factors. The following projects have been approved by the Health Service Executive to take place during 2006: the expansion of the healthy food made easy programme; the recruitment of four physical activity officers to target obesity in all settings; the provision of four specialist community dietician posts for obesity and weight management to support all initiatives; the purchasing of equipment for growth monitoring; and further progressing work with the food service sector on healthy food provision.

The HSE has allocated €400,000 to develop the service in St. Colmcille's Hospital in 2006. This will allow for the appointment of additional relevant staff and improvements to the physical infrastructure. The HSE also plans to consolidate the one existing obesity service that operates from St. Colmcille's Hospital, Loughlinstown, to support the development of additional centres based in Cork, Galway and north Dublin and to commence the development of a service for children based at Our Lady's Hospital for Sick Children, Crumlin.