Diabetes mellitus, DM, is a condition characterised by high blood glucose concentrations. The hormone insulin, which is produced by the pancreas, helps the body to take energy from food and use it as fuel for the body. The raised glucose level occurs because the body is not producing sufficient insulin or the cells are resistant to the action of the insulin. There are two main types of DM. Type 1, or insulin dependent DM, accounts for approximately 10% of cases. It affects mainly young people and requires lifelong treatment with insulin. Type 2, or non-insulin dependent DM, accounts for 90% of all cases. It affects mainly middle-aged or elderly people and is associated with lifestyle factors. Tackling modifiable factors may be the most effective method of reducing the incidence of type 2 DM.
Studies estimate that type 2 DM is present for on average seven years prior to diagnosis and up to half of those diagnosed may have evidence of complications at diagnosis. Micro vascular — small blood vessel — complications include those associated with eye, kidney or nerve damage. Macro vascular — large blood vessel — complications result in coronary heart disease, stroke and peripheral vascular disease, which are the main cause of premature death in diabetes mellitus. A total of 2,747 patients with a diagnosis of type 2 DM were discharged from hospital in 2002, an increase of 26% in the preceding two years. The corresponding figure for type 1 DM is 8,279, an increase of 9%. Approximately 400 people die each year where DM is listed as the primary cause of death. Diabetes results in a high cost to the health service mainly associated with treatment of preventable complications. Interventions aimed at preventing or delaying onset of complications are cost effective. International evidence indicates that detection and control of diabetes and its complications will lead to lower health care costs in the long term.
A range of services for persons with diabetes is provided by the health services generally and many initiatives have significant benefits for persons with diabetes and in the prevention of the disease. A particular case in point is the cardiovascular health strategy, which made a number of recommendations on the prevention of heart disease and these will help to reduce the occurrence of cardiovascular disease in persons with diabetes.
People with diabetes mellitus should be targeted by GPs to tackle cardiovascular risk factors. The strategy recommends that diabetics should be treated in the same manner as those non-diabetics who have had a myocardial infarct. The 47% increase in the frequency of prescriptions for cardiovascular disease for people covered by the General Medical Services Payments Board, reflects the increase in the numbers now being detected and treated with chronic heart failure. People with diabetes have a worse prognosis after myocardial infarct and should be treated intensively. The first phase of the Heartwatch programme being carried out under the cardiovascular strategy with the Irish College of General Practitioners and the Irish Heart Foundation includes up to 1,000 people with diabetes in the Midland Health Board. The third area of prevention under the cardiovascular health strategy refers to the implementation of the health promotion aspect of building healthier hearts. This, coupled with the implementation of the national health promotion strategy 2000-2005, is of direct benefit to diabetics.
The population approach being adopted through the implementation of these strategies addressing healthy eating and increasing exercise in the population, especially among children should, in the long term, reduce the numbers developing diabetes. Also in recent years, part of the €54 million funding for the implementation of the cardiovascular health strategy is providing for the appointment of 17 additional consultant cardiologists and 300 other hospital-based professional staff, resulting in the substantial increase in cardiology diagnostic and treatment services and providing more accessible, equitable and better quality care for patients with cardiac conditions.
Another major complication of diabetes is end stage renal disease requiring dialysis and possible transplantation. The evidence suggests that diabetes is the leading cause of this condition in western countries and some estimates indicate that between 30% and 50% of all patients beginning kidney dialysis are diabetics. A pilot Irish renal register compiled a number of years ago, indicated that diabetes caused end stage renal disease in 14% of patients beginning dialysis. The incidence of this condition and, therefore, the numbers requiring kidney dialysis in the future are expected to rise significantly as a result of the growing prevalence of diabetes and the ageing of the population in future years. In anticipation of this and other requirements for dialysis, significant investment of the order of €20 million has been made over the last number of years to develop renal services in response to this increased demand. This investment is supportive of the development of services on a regional basis so that patients do not have to travel long distances for dialysis and has facilitated the approval of five additional consultant nephrologists with the commissioning of a number of new dialysis units around the country. Furthermore, I have established a group to undertake a national review of renal services. This group will be charged with formulating a national framework for the future development and delivery of services in this area with a consequent improvement in services for the large number of diabetics who require this treatment.
Another area of frequent complication is that of retinal — eye — disease leading to blindness. The evidence of the value of screening for this condition is strong and currently my Department is supporting a pilot screening project in the North Western Health Board which has set the criteria of annual examination for those with diabetes, quality assurance written into the service and a programme integrated into the care plan for each patient. A total of €340,000 has been provided by the Department for this project. It is anticipated that the first patients will be screened in April 2004.
In the development of health promotion activities and materials, the Department works in partnership with the Diabetes Federation of Ireland. These developments include a national media campaign, Ireland Needs a Change of Heart, which includes an all-island physical activity campaign, Get a Life, Get Active, and the recent physical activity campaign, Let it Go. They also include the national healthy eating initiatives. At regional level, a broad range of service developments and initiatives occurred in the areas of smoking cessation, nutrition, physical activity and dissemination of good practice. These services work in co-operation with the Diabetes Federation of Ireland. The Department supports the employment of a diabetic nurse specialist by the Diabetes Federation of Ireland which has enhanced national awareness of diabetes, development of detailed direction for early detection and prevention of diabetes and many health promotion initiatives.
The primary care strategy, Primary Care: A New Direction, is intended to develop a model of care that will provide an appropriate structure to enable the shift in care from secondary specialist care to primary generalist care and deliver the full range of health, personal and social services appropriate to this setting. A primary care project that was established in the Southern Health Board as part of the implementation of the primary care strategy and which illustrates this point is located on the Dingle Peninsula in County Kerry. The team has selected shared care of diabetes as one of its key initial priorities. It covers the entire population of the Dingle Peninsula and has been developed in co-operation between the GPs, the local health board and Tralee General Hospital. The main features of the programme include the establishment of a register, the use of opportunistic screening in domiciliary and practice settings for diabetes, a quality assurance and audit mechanism and participation in the diabetes quality of life study being led by UCC. It is an example of how structured shared care in primary care can be developed in a manner which works for both hospitals and primary care and most importantly, of how, especially in such a remote region, dependence on acute hospital care for people with diabetes can be appropriately reduced. Through further roll-out of the primary care strategy, further development of such programmes can be expected.
The national steering committee of the primary care strategy recently produced a framework for quality assurance in primary care. These guidelines have recommended that diabetes be chosen as the specific initial focus for the development of quality indicators in primary care. I recognise that more work needs to be done. After detailed consideration of issues relating to the treatment of diabetes and having had a series of meetings with the Diabetes Federation of Ireland to consider its strategy document, Diabetes Care: Securing the Future, I asked the chief medical officer to chair a working group consisting of officials of the Department of Health and Children, service providers and the Diabetes Federation of Ireland. The first meeting of the group took place on 30 January. The group hopes to report to me by the summer.
The working group will examine the current and predicted epidemiology of diabetes, health promotion and preventive initiatives including screening, current service provision including the need to achieve better integration of care using current resources and facilities and the expansion of shared care programmes and future needs in terms of service provision and staffing.