Dáil Éireann debate -
Thursday, 26 Feb 2009

Vol. 676 No. 3

Diabetic Retinopathy Screening Programme: Statements.

Minister of State at the Department of Health and Children (Deputy Mary Wallace)

I welcome the opportunity to speak on the HSE document, Framework for the Development of a Diabetic Retinopathy Screening Programme for Ireland, which was published in November 2008.

Diabetes is a chronic and progressive metabolic disease. There are two types of diabetes. Type 1 diabetes, or insulin dependent diabetes, accounts for approximately 10% of all cases of diabetes. It affects mainly children, adolescents and young adults and requires lifelong treatment with insulin. Type 2 diabetes, or non-insulin dependent diabetes, accounts for 90% of all cases diagnosed in Ireland. It affects mainly middle aged and older people. Its prevalence is increasing rapidly due to a number of factors, including the ageing of the population and lifestyle factors such as obesity. Diabetes is a common condition. An Institute of Public Health report, Making Diabetes Count — What Does the Future Hold?, provides the best available estimate of the prevalence of diagnosed and undiagnosed diabetes in the Ireland. Just over 140,000 adults in this jurisdiction are estimated to have type 1 or type 2 diabetes. The report predicts that this figure will increase by approximately 37% — to at least 194,000 people, or 5.6% of the population — by 2015. It estimates that this will largely result from an increase in the incidence of type 2 diabetes, as a consequence of the increase in childhood and adolescent obesity.

The diabetes policy of the Department of Health and Children, Diabetes: Prevention & Model for Patient Care, was published in 2006. It sets out a model of care, based on shared care between primary care and acute services, which will deliver quality diabetes care at an appropriate level. It identifies retinopathy screening for eye disease, patient education and empowerment and the development of podiatry services as key areas for further development. The Health Service Executive has established an expert advisory group under Dr. Colm Costigan to develop and implement the various policy recommendations. The group's report, which was published on 14 November 2008, represents a blueprint for the development of services for patients with diabetes over the coming years. It is practical and focuses on the patient. It places a strong emphasis on prevention, service integration and community based management supported by specialist services.

The expert advisory group emphasises that real savings in health care costs can be achieved if complications of diabetes, such as eye disease, or retinopathy, kidney disease and cardiovascular disease can be prevented. Retinopathy has been identified as one of the most common serious complications of diabetes. Diabetic retinopathy, which is a disease of the small blood vessels of the retina, is a common cause of blindness in people between the ages of 60 and 65. Approximately 5% or 10% of people with diabetes have sight-threatening retinopathy that requires ophthalmic follow-up and treatment. Of the estimated 140,000 people with diabetes in Ireland, between 14,000 and 16,000 will develop sight-threatening retinopathy. Screening for, and subsequent treatment of, retinopathy is effective in preventing blindness. International evidence shows that 6% of those who screened and treated for retinopathy are prevented from going blind within a year. This figure increases to 34% within ten years. The expert advisory group has recommended the introduction of a diabetic retinopathy screening programme to prevent eye disease. A subgroup of the group, the diabetic retinopathy screening sub-committee, was established to develop a framework for the development, implementation and monitoring of the national diabetic retinopathy screening programme. The sub-committee's report, which was published in November of last year, is being discussed in the House today.

In December 2007, before the expert advisory group published its report, it delivered its interim recommendations to the HSE leadership team for the development of diabetic services. The group decided to prioritise the roll-out of the national diabetic retinopathy screening programme. The targets recommended by the group at that time were that funding for the development of a national diabetic retinopathy screening programme be prioritised; that funding be made available incrementally over the next four years to implement the programme in each of the four Health Service Executive areas, with the programme being commenced in a new area each year; that the HSE immediately prioritise funding and commence procurement for an eye-specific information technology system to support a national diabetic retinopathy screening programme; that the HSE set up a formal governance structure for a national diabetic retinopathy screening programme; that 95% of registered people with diabetes be invited for screening within five years of full national implementation of the programme; and that 70% of registered people with diabetes attend such screening within five years.

In November 2008, the diabetic retinopathy screening sub-committee produced the document we are debating today, Framework for the Development of a Diabetic Retinopathy Screening Programme for Ireland. The framework sets out the aims and principles that should underpin the development of a screening programme. The aims of the national diabetic retinopathy screening programme are to detect diabetic retinopathy that is threatening sight but is treatable, to detect any diabetic retinopathy that may be detected with digital retinal photography, to provide screening on a call and recall basis according to best practice guidelines and to refer patients in a timely way for ophthalmic assessment and treatment, as required.

I will list the principles of the national diabetic retinopathy screening programme that have been adopted by the HSE's diabetes expert advisory group. A population-based call and recall programme should be delivered on an annual basis. Eligible patients should include all those with diagnosed diabetes aged 12 years and over who are medically fit to attend. It should be accessible to all eligible patients. It should be free, wheelchair accessible and delivered locally. Provision should be made for the screening of prisoners and people in nursing or residential homes who are fit to receive treatment. Screening should be carried out using digital retinal photography. Screening should be delivered in four area programmes, based on a population of approximately 1 million in each area, and in a geographic area corresponding to each HSE area. A register of people with diagnosed diabetes should be established for each area and collated nationally. A grading service should be developed on the basis of the population of each HSE area. These centres should grade images taken by all photographers in the programme for that area. The screening model should be mixed — it should feature a combination of fixed and mobile clinics, and possibly photography by optometrists, depending on the geographical distribution of the population, public transport links and economies of scale.

HSE areas should propose their preferred service model to the national screening committee and national executive office for approval. Screening should be carried out in co-operation with general practitioners, hospital diabetes service staff, optometrists, ophthalmic physicians and surgeons. There should be timely referral, assessment and treatment of any abnormalities discovered. There should be timely feedback to the screening programme of the result of screening events and of referrals. There should be a robust system of clinical governance and quality assurance.

It was decided to continue the roll-out of the programme across the HSE west, as a population-based screening programme had previously been established in the former North-Western Health Board. The funding was made available to the HSE west primary community and continuing care budget. This would allow for screening services to be offered to all people with diabetes — approximately 30,000 people over the age of 12 years — registered with the programme between west Limerick and north Donegal. Due to resource constraints, the diabetic retinopathy screening programme did not commence in 2008. The HSE is moving into the implementation phase for the roll-out of the screening programme to the rest of the western region, based on the national framework document. Funding of €750,000 is available in 2009 for this purpose.

One of the key parts of the implementation phase is the development of the governance and committee structures, and this process is under way. Job descriptions and recruitment forms for the eight agreed staff is with the relevant local health office, and it is expected that these posts will be advertised shortly. The formal procurement process for the ICT requirements of the programme is to begin in the coming months.

Deputy James Reilly

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.

Deputy Jan O’Sullivan

I would like to share my time with Deputy O'Shea. I hope this debate will do what the Irish Endocrine Society and the Diabetes Federation of Ireland hoped, namely put pressure on the Government and HSE to ensure the programme for diabetic retinopathy is rolled out in the recommended timeframe and the various recommendations of the expert advisory group are implemented. It is a disgrace that these recommendations have not been implemented in any way.

Like Deputy Reilly I was at the meeting of the health committee and he has quoted extensively from the presentation. Everybody on the committee was very struck by the urgency of this issue and the cost-effectiveness of the recommendations. Approximately 15% of acute beds are diabetes related and 10% of the budget is in some way related to diabetes. As Deputy Reilly said, the roll-out of the diabetic retinopathy programme would be cost-effective if one sets the cost of the screening programme and the treatment that would arise against the cost of people who have become blind as a direct result of diabetes. In the medium term money would be saved.

I would like to focus on the Minister of State's reply and what she might tell us in it. I found her initial contribution very disappointing because most of it was spent in describing the problem and only the last half page or so was on what is going to be done about it. I welcome that it is intended that this €750,000 that was meant to be spent last year will be spent this year and I hope the Minister of State will give us a categorical guarantee that it will happen this year and the roll-out in the north west will go ahead. As Deputy Reilly said, it is relatively small money. The health service is in financial crisis and there will be cutbacks everywhere, and we will debate that next week. However I urge the Minister of State that this relatively small amount of money, which has the potential to save money in the long term, be ring-fenced for this purpose. I refer not only to this year's money for the north west but the money required to roll out the programme for the rest of the country over four years.

We all have experience of money being set aside for such programmes as A Vision for Change and the hospice movement in the development area of the health services, and that money has gone into black holes and been spent in other areas. I would like a guarantee from the Minister of State that there is a commitment from Government that this money will be ring-fenced. Representatives of the HSE at the health committee told us that while they did not ring-fence funding for mental health and other areas up to last year, they had found a mechanism for ring-fencing it in the future. If they can do that in other areas they can do it for this programme also. I urge the Minister of State to give us that commitment in her reply.

There is a real concern among those who represent the diabetes community and those who care for people diabetes that the north-west service will be put in place this year but somehow or other the rest of this roll-out will be left behind. These programmes are vital for people who have diabetes or who may develop diabetes because they literally prevent blindness. It is a relatively simple procedure, as Deputy Reilly and the Minister of State, Deputy Wallace, outlined.

This programme dates back to the St. Vincent's declaration 20 years ago, and the diabetes service development group set up in April 2001 where the health care professionals came together because there was no Government action. Following on that, there was a Department of Health and Children working group and there was the expert advisory report published in November 2008. Then there was the commitment to spend the money, yet we still have not seen any action. It is vital that we make progress on this element of the prevention of complications of diabetes which is doable.

I want to refer briefly to the issue of podiatry and chiropody because that is also a serious problem for people who suffer from diabetes. Somebody who came to my clinic recently is a diabetic — who has a medical card and is on disability benefit — had been getting chiropody treatment on a monthly basis. He has had a toe amputation and needs this chiropody service but he was told that because he is not over 65 that service will discontinue. I tabled a parliamentary question to find out if this is the case throughout the country. Apparently, priority in the community chiropody service is given to the over 65s and people under 65 may get it at the discretion of the service if the funding is available, but it looks as if in these difficult times that funding is being cut as well. I want to make that case while I have the opportunity. These are clearly people who for medical reasons need this service and who do not have the ability to pay for it. It is an example of many of the cutbacks impacting on people. Individuals know it is happening to them but they, and at times we, do not know that it is happening throughout the country. I would urge that this matter be examined and that people who genuinely need these services are given them as they need them.

It is clear that the retinopathy screening programme involves a saving. According to the figures, as Deputy Reilly stated and as given to us at the committee, diabetes is the commonest cause of blindness in working age adults. Approximately 5% to 10% of people with diabetes have sight-threatening retinopathy which requires expert ophthalmic follow-up treatment. Using this figure it is anticipated that 14,000 to 16,000 people will develop sight-threatening retinopathy by 2010. This is a sizeable section of the population.

I again urge that today's debate be a positive measure in moving forward to ensure this programme is put in place and that it is rolled out over the next four years to the entire country.

Deputy Brian O’Shea

Gabhaim buíochas le mo chomhghleacaí, an Teachta O'Sullivan, urlabhraí Pháirtí an Lucht Oibre ar chúrsaí sláinte as ucht a cuid ama a roinnt liom. Tá suim ar leith agam san ábhar atá os comhair na Dála faoi láthair. I have a particular interest in this subject because I have diabetes. In my case there were complications but these related not to sight, but to my nervous system. I developed a peripheral problem in my legs — both legs were damaged and I had to spend quite some time on crutches. I have made a worthwhile recovery since then.

I was diagnosed with diabetes in late 2003 when the problem started to show in my legs. I had a test in 1999 which showed that I was okay and some time in between the condition developed.

Deputy Reilly dealt with some of the issues I meant to raise and I will not go back over those. The issue of children as young as 11 years developing type two diabetes because of obesity is a horrific aspect of our time. It has been put to me that all of those over 40 and over weight should be tested at least once a year to diagnose the pre-diabetes stage. If one catches the pre-diabetes stage one can do a great deal to delay the on-set of the condition.

I am struck by how incomplete and incomprehensive are the figures on the prevalence of diabetes. Frankly, because I have diabetes and people with diabetes talk to one another, it seems there are many more people with diabetes in the country than the figures would indicate. For instance, the Institute of Public Health estimated that at least 141,063 adults in the Republic of Ireland had diabetes, that is, 4.7% of the population. In my view the figure is much higher. One of the members of the diabetes expert group, Dr. Graham Roberts, an endocrinologist at Waterford Regional Hospital, stated that 15% of acute beds could be freed up by preventing the complications with diabetes. It is a significant factor in the health system.

On the issue of diabetic retinopathy with which we are dealing today, I understand that between 3% and 5% of those with diabetes develop sight-threatening retinopathy each year. That is an astounding figure when set against a background, for instance, of the Diabetes Federation of Ireland stating that in Ireland there are 200,000 diabetics, 100,000 people in the pre-diabetic condition and approximately 50,000 undiagnosed diabetics. This is a real problem.

Getting back to the point made by Dr. Roberts, if we can prevent the range of complications, whether cardiovascular, kidney disease related or retinopathy, in the long run the small amount of money needed to roll out this programme would bring a large dividend.

I do not want to delve too deeply into the entire question of diabetes today, but one cannot discuss the retinopathy issue without looking at the range of complications that arise from diabetes. A national diabetes or pre-diabetes screening programme, which would be greatly cheaper than the retinopathy programme, although it would obviously involve testing a much wider population and in that sense would be probably more expensive, would be an investment that would keep many people out of acute hospital beds. This is one of the best ways of reducing health spending by dealing with those who would need acute treatment in hospitals.

Today's statement by the Minister of State, Deputy Wallace, is heartening in as much as it indicates that the funding is available in 2009 to go ahead with the first phase of the retinopathy screening programme. This programme has encountered difficulty previously because of a recruiting embargo. Is there not a recruiting embargo this year? I question whether this scheme will go ahead against the background of the €1.1 billion additional cutbacks in the HSE budget that has been announced. I hope this is not the case because it needs to be done; it is to be rolled out over four years. Like Deputy O'Sullivan, I ask the Minister of State to tell us in unequivocal terms if this is definitely going ahead or will it be one of the cutbacks that are about to be announced as a result of the €1.1 billion in cuts? Will there be an embargo to prevent the recruitment to fill the eight positions that are to be advertised shortly? Will the procurement process for the ICT elements of the programme fall foul of these cutbacks?

The Minister of State's speech was heartening but I have great doubts that it will be delivered on.

Deputy Charlie O’Connor

I welcome the opportunity to make a brief contribution to this important debate. To an extent, this is an unreal day in Leinster House because of the situation outside the gates. I was uncomfortable in passing pickets because it is not something I like doing, and I cannot remember ever doing it before. I said to those who asked me why I was coming in that I was coming in to do my job and represent my community. Some colleagues might have differing views but it is important that we go about our business. It is an important issue, and I acknowledge the interest of my colleagues across the floor in health matters.

Notice taken that 20 Members were not present; House counted and 20 Members being present,

Deputy Charlie O’Connor

I have never had such a crowd gather to hear me speak. It was not me who called the quorum either.

I will not repeat my preamble.

An Leas-Cheann Comhairle

I am glad to hear it because it was not relevant to the debate.

Deputy Charlie O’Connor

It was noted, however, that I have not mentioned Tallaght yet, so I will do that. I psyched myself up for this debate by visiting Tallaght Hospital to see a friend this morning. Going in there, I passed the only plaque that survives from all the openings of Tallaght Hospital under various Ministers, and that is the one stating the building was opened by Brendan Howlin, TD, Minister for Health, a very good Minister for Health.

I have been interested in health issues throughout my career, including the challenges I have faced myself. Thank God I have never had diabetes but I have had a heart problem which thankfully has passed. Diabetes affects one in 20 people in this country and we are told that by 2025, the prevalence could be close to 8% of the population under current obesity trends. Approximately 10% of health care spending is diabetes related, and this will increase by up to 25% in the next 20 years. During my time on the Eastern Regional Health Authority from 1994, we were told that 7% of all health care spending in the region was diabetes related. The Minister of State, Deputy Mary Wallace, is aware of those statistics.

During my career as a community worker, I was appointed by a Fianna Fáil Minister to the Health Promotion Unit and such promotion work is important. My colleagues on the other side of the House talk about expenditure and cutbacks but health promotion should not lose out in the difficulties with health spending. Tallaght Hospital, like every other hospital, is not just about the accident and emergency ward but also deals with health promotion and this debate on diabetes highlights its importance.

People with diabetes are five times more likely to need hospital admission. If they are admitted, they are ten times more likely to suffer major medical complications compared to non-diabetics. 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. I am told there are approximately 2,000 deaths annually from diabetes which also causes significant morbidity. Studies have estimated that type 2 diabetes is present for an average of seven years prior to diagnosis and at this stage up to half of the people concerned may have evidence of complications linked to diabetes.

In Tallaght village this morning I was asked if I was on a day off because of the pickets, but I said it was a normal day in the Dáil, raising issues and looking after constituents' interests. I asked someone what diabetes meant to him and he replied, "Isn't that where people can unfortunately have strokes, heart disease and be subject to blindness?" I am not being flippant about it, but that is the image people have.

It is important to grasp the nettle, as Opposition colleagues, including Deputy Jan O'Sullivan, have said. Deputy Brian O'Shea highlighted the HSE cutbacks and I did so from these benches the other night when the Ceann Comhairle's office was kind enough to give me a few minutes on the Adjournment debate. I raised hospital care issues then and I feel strongly about the cutbacks the HSE is contemplating. It is important for all of us to tell the HSE, the Government and the Minister of State present, that patient care must be always preserved. There will be difficult challenges but the bottom line is that if people are sick they should be looked after at the local hospital. In that Adjournment debate I concentrated on the challenges facing Tallaght hospital and the services currently being provided there.

Some people may say that diabetes is not as important as dealing with accidents or heart attacks. However, diabetes is a major health problem in this country and internationally, which uses up a huge amount of resources. The Minister of State should understand that this debate is important to many people. In the context of all the challenges the health service is currently facing, let us not forget health promotion. Let us not forget either that diabetes, as with other health disciplines, requires that kind of attention.

Deputy Jimmy Deenihan

I am glad to have an opportunity to contribute to this debate on diabetes, given its increasing prevalence. Approximately 250,000 people are affected by this illness and, as previous speakers have said, we should have a national diabetes strategy. Primary, secondary and tertiary care remain generally unsupported in this country. Deputy Reilly, who has experience in this area, pointed out that patients do not have timely access to consultant diabetologists. In addition, diabetes multi-disciplinary teams are understaffed and under-resourced. Other services are unavailable, including a diabetic retinopathy screening programme, while primary care for diabetes is generally unsupported.

The report of the diabetes expert advisory group was completed and submitted to the HSE in September 2007. It is crucial that this report's recommendations should be published and implemented as a priority. We also need to develop a national diabetes patient register. The mobile diabetic retinopathy screening service in the north-west was not expanded, despite the fact that funding was set aside for such an expansion in both 2007 and 2008. This highlights the lack of support for, and possibly indifference to, the issue of diabetes. Deputy Reilly asked where this funding went. There is a need to consider the roll-out of a national diabetic retinopathy screening programme.

I wish to refer to the connection between diabetes and obesity. Given my background as a physical education teacher, for a number of years I have been highlighting the link between obesity and other illnesses, including cardiovascular illnesses. There has been an alarming increase in the prevalence of type 2 diabetes, which is now manifesting itself in our children. That is directly related to increasing levels of obesity. It is obvious that people are getting fatter and while efforts are being made to combat obesity, unfortunately they are not good enough.

Deputy Reilly referred to the report of the obesity task force, which made some 126 recommendations. Interestingly, some people without direct responsibility for Departments, put in place a number of these measures. They have lived up to their expectations, but the Government has failed dismally. I have put a number of questions to various Departments about implementing the recommendations of the obesity task force report, but there has been no commitment whatsoever. There was a commitment in that report that the Department of the Taoiseach would be responsible for co-ordinating the implementation of the recommendations. I asked the Taoiseach about this at question time but he knew nothing about it. This is regrettable because we could have become leaders in this field. We could still become leaders in fighting obesity, but unfortunately the will is not there.

We are going through an unprecedented economic challenge, but combating obesity would cost very little, while saving us a lot of money in the future. As things stand, we are storing up health problems for the future. We are sitting on a medical time-bomb if we do not address the problem of obesity and its connection to diabetes. There seems to be little or no understanding, commitment or general policy on the Government's part to tackle this matter.

According to the statistics, approximately 39% of the population are overweight — that breaks down as 46% of men and 33% of women. One in five, or 18% of the adult population, is obese. This is an alarming statistic. More men are affected by obesity than women. Ireland has the fourth highest prevalence of excess weight and obesity in men in the European Union, and the seventh highest prevalence in women. Those statistics are stark.

Research shows that childhood obesity is associated with a higher chance of premature death and disability in adulthood. Globally, in 2005, 20 million children under the age of five were overweight. On the island of Ireland, one in ten children aged between five and 12 is overweight while a further one in ten is obese. In total, 22% of seven to 12 year olds is overweight or obese. The taskforce report stated up to 300,000 children could be obese in the near future as numbers increase by 10,000 per annum. It is a crisis and must be tackled.

The UK Government recently launched a major campaign against obesity. There is a direct link between obesity and diabetes. A study from the Health and Social Care Information Centre shows that an obese woman is almost 13 times more likely to develop type 2 diabetes than a woman who is not obese. Another finding was that the prevalence of doctor diagnosed diabetes was related to increases in body mass index and raised waist circumference. Men and women who are overweight are more likely to report doctor diagnosed diabetes, 5% of men and 3% of women, than men and women of normal weight, both 2%, while obese men and women were most likely to have doctor diagnosed diabetes, 10% and 9% respectively. Both men and women with a raised waist circumference were more than four times as likely to have doctor diagnosed diabetes as those without a raised weight circumference. These are the most up-to-date findings.

Some years ago I did a survey on the lack of physical education in schools. Some schools are making a real effort to combat obesity through physical education but it is not the case in all. Tralee CBS has made great progress in this area and it should be used as a pilot project for the rest of the country's schools.

There is an emerging obesity epidemic among young people. Statistics from the UK show that by the 2050, 60% of men, 40% of women and a quarter of children under 16 could be obese. We are looking for a cross-party consensus to address this. It is one problem which all politicians can tackle together. I am willing to join with the Minister of State, Deputy Wallace, in addressing this issue for the good of future generations because of my background in physical education and keeping up my interest in it since I left teaching.

In recessions, people tend to eat less healthy foods. More young people, because they will not have access to healthy foods, will eat fattening and energy-dense foods which will lead to obesity problems. In bad economic times, people tend to be more down and eat more comfort foods. Obesity will be on the increase and linked to that will be an increase in type 2 diabetes.

Deputy John Perry

I am pleased to have the opportunity to speak on diabetic retinopathy screening programme.

Deputy Deenihan's last point is very valid. In the last economic recession, Cadburys sales doubled as people ate more high-fat content and unnecessary foods. The diabetic retinopathy screening programme is an important national initiative based on pioneering work carried out in the north west. Diabetes is the single most common cause of blindness in Ireland. It is essential the Health Service Executive takes all available measures, based on international best practice, to prevent blindness occurring in patients with diabetes. It is also essential the programme is rolled out nationally as soon as possible.

Of the €15 billion spent annually on the HSE budget, very little is spent on preventive medicine. As Deputy Reilly stated earlier, for every €1,700 spent on an illness, €65 could have been spent on preventing it. If we are examining ways of getting value for taxpayers' money, then more should be spent on public health awareness campaigns to advise people how to safeguard their health. Only a fraction of the current budget is spent on such campaigns. Those campaigns against diabetes and obesity run in the UK needed to be implemented here. In schools, sporting and outdoor activities should be encouraged more. It is disappointing when sports capital grants are curtailed. Too many children these days spend too much time watching DVDs. Sport gives good value and encourages young people to get involved and away from the television. Alcohol abuse is another factor contributing to the rise of diabetes. Tackling diabetes is about encouraging people to take responsibility for their health by adopting a healthy lifestyle and diet.

The national diabetic retinopathy screening initiative is important in increasing awareness among people about diabetes. However, it must be rolled out as soon as possible. BreastCheck, for example, is only now being rolled out in south Sligo when it has been a standard screening service in Northern Ireland for the past 25 years. Screening is money well spent for the health services.

Increasing awareness of the screening programme and encouraging people to avail of it can be done through many means. Local radio is an inexpensive way, particularly in these straitened times, to raise awareness of diabetes and preventive medicine. It is outrageous that diabetes is the single common cause of blindness in Ireland. It is important a national diabetes register is established, as a matter of priority, to ensure all patients can benefit from the service. It is equally important that the national screening programme be rolled out.

In the context of the HSE's budget going forward and the five-year envelope of funding for the Department, I am of the view that the best way to spend money is to create awareness. When one considers the development of gyms throughout the country, one realises that people are extremely conscious of their health. In the interest of expanding public health awareness, a poster campaign should be carried out in supermarkets, shopping malls, etc., in order to highlight the steps people should take to protect their health and to make known to them the initial symptoms of diabetes. If diabetes is detected early, it will reduce the cost to the State and improve people's quality of life and their life expectancy.

Diabetes has a major impact on people's lives, particularly in the context that they are obliged to inject with insulin or take other prescription drugs. The position in America with regard to obesity is appalling. A regulation was recently introduced in New York whereby restaurant menus must carry information relating to the fat content of each dish. Ireland followed New York's lead when it came to introducing a ban on smoking. It should do so again in the context of listing the fat content of dishes listed on restaurant menus. This would increase people's awareness with regard to what they are eating.

We engaged in a campaign in our schools to promote the consumption of fruit and vegetables. In current circumstances, people are seeking value for money when they shop. However, I am aware from experience that customers, particularly those on lower incomes, tend to purchase many foods that are not good for their health.

I reiterate that diabetes is the most common cause of blindness. In that context, it is important to establish a national register of diabetics. It is also vital that the HSE adopt all the necessary measures, based on international best practice, to prevent blindness in those with diabetes. Furthermore, we must focus attention on public health awareness and the problem of obesity. The health budget amounts to some €15 billion. How little of this money is spent promoting public health awareness or the importance of preventative medicine?

There should be a major radio campaign in respect of diabetes and the problem of obesity. In addition, we should launch a campaign in schools in order to promote healthy eating practices among children. We should oblige people to take on board the message in respect of health awareness issues. If, as already stated, we follow the example of New York in respect of stipulating that the fat content of each dish on a restaurant menu be listed, it would be of major assistance.

General practitioners are on the front line with regard to the provision of health services. It would be a welcome development if they were provided with a user-friendly document listing the warning signs relating to diabetes for distribution to their patients.

I again welcome the opportunity to contribute to the debate on this matter because the introduction of a screening programme for diabetic retinopathy is essential and such a programme should be rolled out nationally. I reiterate to the Minister of State that a national register of diabetics should also be established.

Deputy Niall Blaney

I welcome the opportunity to contribute to the debate on the retinopathy screening programme for Ireland. Approximately one out of every 20 people in Ireland is affected by diabetes. Of these, some 140,000 are adults. The report to which the Minister of State referred earlier predicts that this figure is predicted to increase by a further 60,000 — or 5.6% of the population — by 2015. By 2025, the level of prevalence may have risen to 8%. This gives rise to major concerns on the part of many of those involved in dealing with what might be termed a crisis. The report also estimates that approximately 10% of health care spending is diabetes-related. This figure could increased by 25% in the next 20 years.

People with diabetes are five times more likely to require hospitalisation. If admitted to hospital, they are ten times more likely to be at risk of major medical complications than are non-diabetic patients. Diabetes has a profound impact on lifestyle, work, well-being and life expectancy. The life expectancy of those with type 1 diabetes usually decreases by 20 years, while for those with type 2 it is reduced by ten years.

Diabetes also causes significant morbidity. Studies estimate that type 2 diabetes is present for an average of seven years prior to diagnosis. Up to half the population may be showing evidence of the complications of diabetes at this stage. Diabetes gives rise to many such complications including blindness, kidney and nerve damage, the vascular complications that result from coronary heart disease, stroke and peripheral vascular disease, which is the main cause of premature death for those with diabetes.

As previous speakers indicated, diabetes is the most common cause of blindness and amputations in Ireland. Foot problems are also common among diabetic admissions to hospitals. A number of risks exist with regard to pregnancy and the chances of losing a baby or of an infant having a congenital abnormality are increased among those with diabetes.

The majority of patients, particularly those with type 2 diabetes, are used to being dealt with in a primary care setting. The developments in this regard show that if the proper environment was in place, those with type 1 diabetes could also be dealt with in such a setting and by hospital care teams.

I am pleased that work on the framework is to proceed, particularly in light of current predictions and forecasts relating to diabetes. For reasons relating to finance and the well-being of patients, the traditional model used to deal with diabetes cannot be maintained. I am glad, therefore, that a new model is being devised by the Minister and Minister of State and their Department. The delivery of integrated, responsive, long-term patient care will be provided in a multidisciplinary environment in partnership with patients. In practical terms, this will require self-management support for patients, decision support and clinical guidelines for health care professionals and changes in the way services are provided generally.

Many patients with chronic conditions such as diabetes do not require hospital admission. Such conditions can be managed in primary and community care settings. If the appropriate support is available and agreed protocols and pathways are followed, the majority of patients can be catered for. The central message is that we need to increase awareness about the risk that lifestyle and behaviours have on health. This is of particular relevance given the lifestyle choices of many people here which is adding significantly to the increase in the diagnosis of diabetes.

People are inclined to demand more services and funding when they learn about increased diagnosis of various conditions. Perhaps we should take a step back and consider the causes of the problem. The Minister has taken the correct approach to this issue. We need to be proactive and ensure members of the public are aware of the causes of diabetes, how the condition can be prevented and, in the event that it is too late, appropriate ways of dealing with it.

Diabetic retinopathy screening is not the only screening programme being rolled out by the Minister. I was pleased to learn recently that breast cancer and cervical cancer screening programmes are also to be rolled out. I am particularly pleased that the Minister is extending the diabetic retinopathy screening programme to the west. Those living in the west have been correctly critical that the region has been the last to benefit from previous programmes. I am pleased to note that funding of €750,000 has been allocated to implementing the first phase of the screening service which will be offered to all those who have diabetes. Approximately 30,000 people over the age of 12 years are registered with the programme in west Limerick and County Donegal, which includes my constituency.

The Health Service Executive is moving into the implementation phase of the roll-out of the diabetic retinopathy screening programme to the remainder of the west region based on a national framework document published in November 2008. One of the key features of the implementation phase is the development of governance and committee structures. I have been informed that this process is under way.

It has been decided recently that the primary, community and continuing care area of the HSE will assume responsibility for the governance of the implementation phase of the programme, now that the expert advisory group has completed the planning phase. The current status of the recruitment process is that job descriptions and recruitment forms for the eight agreed staff are with the relevant local health office. It is expected that these posts will be advertised shortly. This is welcome news.

While I understand no funding has been expended on equipment, I am pleased to learn funding continues to be available in 2009. The formal procurement process for the ICT requirements of the programme will, I understand, commence in the coming months. There does not appear to be alternative means of using existing resources to extend the programme. The HSE has made some progress in commencing and writing specifications for the ICT system but final decisions are awaited on the details of the implementation and governance structure before a procurement team can be formally established.

I welcome the efforts of the HSE and relevant Ministers in the diabetic retinopathy screening programme. The proactive approach taken on this issue will be welcomed by patients across the country.

Minister of State at the Department of Health and Children (Deputy Mary Wallace)

I welcome Deputies' valuable contributions to the debate on the development of a retinopathy screening programme. I concur with the point made by many Deputies that the development of a screening programme is an important preventative measure in dealing with one of the most distressing complications arising from diabetes, namely diabetic retinopathy, which can result in blindness.

I assure Deputy Reilly that the Health Service Executive is in the process of implementing the programme. The publication by the HSE of a report on this issue in November 2008 was an important step. Deputies O'Shea and Jan O'Sullivan asked whether the programme will definitely proceed. Local structures are being established for the implementation of the programme and the HSE has given a commitment on what will be done in 2009. This includes a recruitment process for eight posts and the roll-out of the programme to the west. The Department has also asked the HSE to examine extending the programme.

Deputy O'Connor is correct that the publication of the framework document marks an important step in establishing a high standard, quality assured programme for diabetic retinopathy screening. The document presents a vision of a national population based programme of retinopathy screening, offered to all those with diabetes aged 12 years and over who are registered with the programme. The programme will be delivered locally and provided to the highest internationally comparable standards. It promises to be reliable, comprehensive and secure in compliance with data protection legislation.

Deputy O'Shea referred to hospital retinopathy services. While retinopathy screening is also provided in hospitals across the country, this service is different from the population based call and recall programme which will be established in the north west and west areas. The Deputy also outlined his personal experience and asked whether it was necessary to test the general population. The expert advice available to the Department is that systematic testing for diabetes in the general population should not be carried out. However, the Department and HSE continue to evaluate this policy.

Deputy James Reilly

That is bad advice. A simple urine test is sufficient.

Deputy Mary Wallace

Funding of €750,000 has been allocated for 2009 and a recruitment process is in train. Several speakers referred to podiatry, while others, including Deputy Perry, raised the issue of a diabetic register. This matter is under consideration in the HSE which is working on details. The issue of consultant diabetic posts was also raised. The number of posts has been increased and figures show it has increased from 24 in 2003 to 38 in 2007. While I do not have figures for 2008, a number of additional appointments have been made in the meantime.

Deputy Reilly made an important point about lifestyle, including the prevalence of overweight and obesity. As Minister of State with special responsibility for health promotion, I am committed to the development and implementation of various initiatives aimed at addressing the lifestyle conditions which can lead to the development of certain chronic diseases such as type 2 diabetes. I am aware that Deputies are concerned about this form of the condition as it accounts for 90% of cases in Ireland. It is considered that one of the factors leading to the increased prevalence of type 2 diabetes is the rise in overweight and obesity in our population, an issue to which several Deputies alluded.

Deputy James Reilly

What about the obesity task force?

Deputy Mary Wallace

Deputy Reilly indicated the obesity task force report featured 128 recommendations. The report made 93 recommendations, most of which have been acted upon by the Department of Health and Children or Health Service Executive. For example, we established an action plan for implementation across various Departments and agencies, including the Irish Heart Foundation.

Deputy Reilly is concerned about the number of obese children. In January this year, I established an intersectoral group comprising representatives of all stakeholders, including experts from Departments and agencies, the food industry and relevant NGOs to oversee the implementation of the recommendations of the task force on obesity and to address general lifestyle issues impacting on chronic diseases. The group has met monthly since its establishment and a third meeting will be held in March. I expect it to issue its first progress report by Easter, which is a short timeframe. In recent weeks, we have already found that a substantial number of the recommendations have been implemented. Once the first progress report has been produced, we will consider the idea of a road map. If, following the implementation of many of the recommendations, the problem of obesity persists, we will have to look beyond the task force report.

First, however, we need to establish where we are with the 93 recommendations, and we hope to have that done by Easter. Deputy Deenihan raised the related and important issue of physical activity. The national physical activity guidelines are nearly completed and we expect to launch them shortly. If we look in detail at the 93 recommendations, it is interesting to see there is a great deal happening across Government Departments. Members mentioned earlier some other areas such as the food industry. There is no doubt, as has been said in the debate today, that the impact of overweight and obesity on diabetes and other issues is obvious to all. Therefore, we need to know exactly where we are with the task force report — which we will know by Easter — and where we are going with regard to making a real difference in this important area.

I support the various comments of Members, including Deputy Jan O'Sullivan, who said that this debate will be a positive measure in moving forward on the important issue of diabetes and the underlying issues of overweight and obesity. I know Deputy O'Sullivan welcomed the 2009 funding for the programme. I also emphasise, as did Deputy O'Shea, the whole issue of prevention and the concerns we have in that area.

Given the current financial constraints, I must acknowledge that there will be difficulties with the continued roll-out of the programme. However, I welcome the HSE commitment to the screening programme, and I know it is endeavouring to identify what can be done to extend the programme within the existing resources. Deputy Niall Blaney mentioned that he was pleased about developments in his part of the country. It was decided to continue the roll-out of the national diabetic retinopathy screening service in the HSE west area because a population-based screening programme had already been established in the former North Western Health Board. This will provide a template for the extension of the service to the whole country, which is a positive step.