We shall see how long that will last.
I would like to outline the nature and prevalence and health impacts of diabetes in our community. I will also describe in a very general way the services available for diabetics in the area of prevention and health promotion and in the various elements of the service provision, to indicate in a general sense the effects we hope will flow from the reform programme on care of diabetics and also to inform the committee specifically that the Minister has recently established a working group on diabetes and has asked me to chair this group, whose first meeting will be held on 30 January.
We have begun to consider diabetes as an entity because in recent years, rather than develop generic services for dealing with the entire range of illnesses, some thought has been given to identifying illnesses of a significant public health importance, with high mortality and morbidity rates, whose natural history is reasonably well understood, and for which there is good evidence for interventions. Cardiovascular disease and cancer have been targeted in this way. The cancer strategy which has been operating since 1996, and the cardio-vascular strategy since 1999, have shown the merit of dealing with these important disease entities in this co-ordinated and integrated way.
I will not elaborate on the technical details of diabetes. Possibly many members of the committee know a relative or acquaintance with diabetes and are aware of its general effects. It is an endocrine disease in which hormones are imbalanced, leading to a range of complications. There are two types: type 1 is insulin-dependent and requires lifelong treatment with insulin - it usually occurs initially in young people; type 2, or non-insulin dependent diabetes, accounts for 90% of all cases. It affects mainly middle-aged or elderly people and is growing in significance and prevalence because of the ageing of the population. It is a chronic disease from which it is estimated that 6% to 7% of the population may suffer, that is 250,000 people or more in the community who may either be already diagnosed or not yet diagnosed. It is a significant and growing public health problem. There are approximately 55,000 diabetics on the long-term illness scheme which provides their drugs free of charge.
The prevalence of diabetes type 2 in particular is on the increase due to a number of factors including the ageing of the population. There are many complications, due particularly to blood vessel problems associated with eyes, kidneys, nerve damage, coronary artery disease and a whole range of other ailments. I will mention those again later.
Diabetes in pregnancy is also of particular concern in that it is associated with higher incidences of perinatal deaths and illness. For approximately 400 people each year diabetes is the primary cause of death. It obviously results in high costs for the health services mainly associated with such complications.
As regards the service provision for diabetes, most patients would be provided for in a primary care setting. The cornerstone of this is the general practitioner supplemented by practice or public health nurses, where available, or a variety of other practitioners, many of whom are in short supply. The benefits of this type of care are the convenience and continuity of access. I will come back to that later as well.
Many other patients, particularly those with type 1 diabetes, are treated within the hospital system by general physicians with an interest in the disease or in rarer situations by an endocrinologist who specialises in the treatment of diabetes. These consultants are part of a specialist team which includes, among others, clinical nurse specialists. These are interesting and fairly new appointments within the health system and give a particularly independent and important role to nurses in the treatment of diabetics. A third approach is through shared care between the hospital specialist team and the general practitioner. Again, I will come back to that.
I mentioned the high rate of complications that attend on people with diabetes. There is a high incidence of cardiovascular disease, coronary artery disease in particular. Over a number of years the additional staffing and facilities capacity within the cardiology system has hopefully picked up many of these cases.
Another complication, end stage renal disease, requires dialysis and then moves on to transplantation. This is an increasing problem. A significant number of people who develop this complication requiring dialysis and transplantation are diabetics. Some information on that was garnered a number of years ago on a pilot register. It suggested that 14% of patients being dialysed were diabetics. That is probably a significant underestimate. The number of people requiring dialysis will increase, unfortunately, as the years go on with the increase in the incidence of diabetes. In response to this there have been some investments in the whole area of dialysis. They are identified and outlined in the paper and I will not go into them.
The other area that is a frequent problem is retinal disease. This leads to blindness in many cases. The evidence for screening is convincing as an effective tool for preventing this complication. In that context the Department of Health and Children is supporting a pilot screening project in the North Western Health Board, which revolves around the annual examination of patients with diabetes who have eye complications. It is part of the integrated care strategy for people with diabetes.
As regards prevention, there are a number of initiatives, both under the cardiovascular and the general health promotional strategies. I have outlined those in the paper. They revolve around a number of approaches. First, there is the general population approach of health information, healthier living and eating and attention to matters such as obesity. For people who have diabetes there is the need to manage the particular risk factors they have in a more progressive and proactive way. When they do get things like cardiovascular complications such as myocardial infarction or heart attacks they must be treated aggressively and effectively and there are a number of initiatives on this at present, particularly in the Midland Health Board.
In terms of prevention the Department works closely with the Diabetes Federation of Ireland on the development of information and educational materials. That is referred to within the paper. As to how it is hoped the effects of the reform programme will impact on diabetes, I have identified a number of areas within the organisational reform strategy. For instance, as regards the development of the health services executive, we hope the unitary system of management of the entire system which is implicit in the new structure will result in a greater uniformity and consistency in the development of services around the country and in their quality and delivery. The Health Information and Quality Authority, which is another part of the reform programme, will have an important role in establishing standards and guidance for the care of a whole range of conditions including diabetes.
I would like to concentrate for a moment on the issue of strengthening primary care. Part of the strategy in the reform programme is to push forward the boundaries of primary care, under the new direction document. This is about developing a model of care that will provide an appropriate structure within the community to allow the shifting of care from secondary specialist to primary generalist care and to deliver the full range of health and personal and social services that are appropriate.
In the context of diabetes one of the pilot projects is in the Southern Health Board area, which the Chairman will be aware of. In Dingle, County Kerry the pilot project team has selected shared care of diabetes as one of its priorities. It is developing a pattern of shared care between the GPs, the health board and Tralee General Hospital, which covers the entire Dingle peninsula. It is an example of how structured shared care within the community setting can work, both for hospitals and primary care and importantly how in a sparse and remote region dependence on acute hospital care can be reduced.
I chaired a committee recently which set up a quality assurance framework for primary care. We have decided that diabetes will be chosen as the initial focus for the development of quality indicators in primary care. Within the acute hospital system reform there is provision for a range of both staffing and bed capacity improvements. We acknowledge there is a requirement for additional manpower, particularly in the area of diabetes. Hopefully, within the acute hospital programme that will be addressed because of the increasing need for diabetes services.
One of the problems being grappled with is the lack of comprehensive information, not only regarding the identification of people who either have or are at risk from diabetes, but also with regard to documenting the process and outcomes of the care that is given. That is an important part of assessing need, quality and outcome. We think the development of the health information strategy will provide both the strategic framework within which that information can be developed and also improve the operational capability to do it on the ground.
I have mentioned a number of other areas in the document as regards, for instance, the development of human resources. As services are being developed the strategic development of the personnel to deal with those services runs hand in hand. I mentioned specifically the developing of capacity within the public health nursing stream. The public health nurse has access to the populace at large and in particular to children as part of the school programme. The whole issue of health promotion and developing healthy lifestyles for children is important.
Finally, the whole area of developing chronic disease management protocols is important, particularly the inclusion of patients and their families in the development of those protocols. Ultimately in illnesses such as diabetes, which is a lifelong condition, it is far better if the patient and his or her family are the ultimate managers of the condition with the assistance of the professionals. That is a particularly important area.
I will summarise what I have said and emphasise what the issues are as contained in the paper: the problems with diabetes; the service provision that is there; some of the particular plans to improve services; and the role of the working group set up by the Minister for Health and Children, Deputy Martin. He recognises that more work needs to be done on this. Nobody looking at this problem could reach any other conclusion. Having considered the matter and after a serious meeting with the Diabetes Federation of Ireland to consider its recent strategy document, the Minister has asked me to chair this working group. The first meeting will be held next week.
We hope to examine a number of issues which I have identified in the paper. These include the current and predicted epidemiology of diabetes, though there is no doubt that the prevalence of diabetes will increase. We will look at the preventive initiatives, including new ones such as screening for retinal disease, and will examine the current provision, including the need to better integrate and co-ordinate the existing services. We will also look at the need for further service provision and staffing. We hope to have our analysis and recommendations ready for consideration by the Minister by the summer, as it is important to have such a timeframe ahead of the Estimates campaign for next autumn.
I thank the Chairman and the committee for their attention. My colleagues and I will try to answer any questions and provide any clarifications. If we have not got the information to hand, we will try to get it as soon as possible.
