Thank you, Chairman. I thank the committee for the invitation to address it. This is the third consecutive year that the Irish Endocrine Society and the Diabetes Federation of Ireland have made a presentation to the Oireachtas Joint Committee on Health and Children. We thank the committee for its interest and for the opportunity to make this presentation.
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.
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, understaffed and under-resourced national diabetes service.
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 were included in this group and have given their time, energy, commitment and ideas to the HSE and the expert advisory group in the hope that a national diabetes strategy would be implemented. They submitted their recommendations to the HSE in September 2007. However, nine 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, 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, resource and staff in place to deal with this national crisis.
The aim of our presentation today is to push forward the agenda of a national diabetes strategy and to highlight five urgent deficits that require immediate attention. The first deficit relates to diabetic eye disease or retinopathy. 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 which requires expert ophthalmic follow up and treatment. Diabetic eye disease is preventable. The establishment of a national retinal screening programme using retinal cameras 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 area received similar funds in 2008 but is still awaiting clearance to recruit staff to run the retinal screening programme. We are asking for the committee's help with regard to the immediate expansion of the existing retinal screening programmes and in pushing for the development of a national retinal screening programme for Ireland.
Our second point relates to diabetic foot disease, particularly in respect of podiatry. Every 30 seconds, a limb is lost in the world due to diabetes. Patients with diabetes are up to 40 times more likely to have a lower limb amputation than someone who is not diabetic. 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. We do not know. Nobody in Ireland knows so we are giving the committee an estimate. We estimate that 5% of the Irish population have diabetes but this is likely to be an underestimate. The prevalence of diabetes in Europe is close to 8%, while in the US, it is approximately 10%. I do not know whether diabetes is more prevalent in Mayo or Donegal compared with Dublin. We need to know this information so that we can plan service development for the future to deal appropriately with the epidemic of diabetes. A national diabetes register would be a simple, straightforward and achievable step which would significantly improve diabetes management across the country.
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 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. Information, treatment protocols, treatment plans, education sessions, regular education and patient updates are then shared between the hospital and primary care practices to deliver the optimal level of care to the patient. This system is not operating on a national basis in Ireland, again, due to the following: a lack or absence of a specialist hospital diabetes service in parts of the country; lack of resources, support and capital investment in primary care in Ireland; and an absence of community dietitians and community diabetes nurse specialists who would play an integral part in linking the care between the hospital and community. Therefore, 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. We ask for the committee's help to ensure the recommendations of the expert advisory group are implemented and to promote the message of integrated care for patients with type 2 diabetes.
We call for the development and expansion of existing services. Unfortunately, in 2008 some hospitals do not have a consultant diabetologist or endocrinologist. The hospital diabetes multidisciplinary teams are understaffed, overstretched and frequently operate out of buildings or rooms which are completely inappropriate to their needs.
Diabetes care in the community is essentially non-existent. Paediatric diabetes care is under-resourced and must deal not only with type 1 diabetes but also with obesity and type 2 diabetes in young children. Unfortunately, there is either no or only limited access to psychological support for patients with diabetes.
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. 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.
On behalf of the Irish Endocrine Society and the Diabetes Federation of Ireland I thank the Chairman for his kind invitation to make a presentation to the committee, and for his time and his interest in diabetes. We have a blueprint for a national diabetes strategy. The diabetes community is very clear on what we need to do to improve diabetes care throughout the country. We all know times are difficult and money is tight but this excuse should not apply to diabetes care. If we invest in diabetes care now, we will save money down the line, we will save lives and limbs and we will stop people going blind. We are asking for the committee's help to have the vision and the commitment to implement a national diabetes strategy.