We will now have a discussion with the Diabetes Federation of Ireland regarding the rise in type 2 diabetes in Ireland. I welcome the following representatives: Dr. Tony O'Sullivan, chairperson of the Diabetes Federation of Ireland; Dr. Richard Firth, chairperson, diabetes section of the Irish Endocrine Society; Ms Maria Carr, chairperson of the Irish Diabetes Nurse Specialists Association; Dr. Fidelma Dunne, diabetes section of the Irish Endocrine Society; and Ms Sinead Powell, diabetes section of the Irish Nutrition and Dietetics Institute. I ask Dr. O'Sullivan to commence his presentation. Members may then ask questions. I remind them of our agreement reached prior to Christmas that we will try to confine questions to between 20 and 30 minutes in total. I also remind them of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable.
Diabetes Federation of Ireland: Presentation.
Dr. Tony O’Sullivan
On behalf of the Diabetes Federation of Ireland and the Endocrine Society, I thank members for inviting us to come before the committee to discuss type 2 diabetes. I will take approximately 15 minutes to highlight some of the main issues and present what is a united front between the professionals and people with diabetes in terms of our priorities for the next year or possibly two. We have a broad representation of professional groups which reflects the fact that diabetes is a multi-professional, multidisciplinary issue. This is the clearest show of unity among the different groups since we all got together to publish a strategy for diabetes, Preserving the Future, in 2002. The Vice Chairman introduced the various members of the group and I will not repeat what he said.
I wish to give the committee some simple background information. For a long period type 2 diabetes has been put forward as a future threat. Unfortunately, those of us working in the field are now aware that it is no longer a future threat; it is very much a current crisis. There is a visible increase in numbers, as is evident from the fact that many clinics, even major diabetes centres in Dublin, now find that they have as many patients with diabetes attending as they have clinic appointments in the year. This means that routine reviews which we expect should be three or four times a year are impossible and nobody can expect to be seen more than once a year in such a centre. That is the way the numbers are rising.
In addition, there has been a noticeable fall in the age of onset. Type 2 diabetes which we called the mature onset form used to be an issue for people over 50 years, often in their 60s and 70s, but there are now huge numbers contracting diabetes in their 30s and 40s, quite a few do so in their 20s. Some children are also contracting it. That raises a new problem because this form of diabetes will lead to the people concerned developing complications during their lifetime.
The actual prevalence of diabetes is not known. However, from our assessment of hospital attendances, we estimate that there are approximately 250,000 people in Ireland with diabetes, approximately 90% of whom have type 2. There are probably another 100,000 who have abnormal blood glucose levels or undiagnosed diabetes. We have estimates from, for example, a diabetes detection study carried out through general practice which showed that for every four people who already had diabetes, we found another one. Another 25% have diabetes that has not yet been detected. There are other signs of this. In the UK PDS study, for example, it was estimated that people with type 2 who were presenting for the first time probably had diabetes for up to seven years and were developing microvascular complications, including eye disease, during that time.
The modern management of diabetes is complex and requires adjustment of blood glucose levels and many other cardiovascular risk factors. This involves both medical intervention and a major behaviour change sustained over the person's lifetime. This is a lifetime illness. The aim of treatment is to manage symptoms, in the first instance, and to prevent the long-term complications. These include cardiovascular disease, which includes stroke, and peripheral vascular disease or limb problems, kidney disease, eye disease and foot problems. Those are the main complications but there are others. This is clearly much more difficult with younger people developing type 2 diabetes and facing a long lifetime with the condition.
There are other problems with diabetes. The evidence shows that type 2 diabetes is very insidious, with progress taking place towards complications often without any symptoms. A person can feel fine but his or her blood glucose levels may be too high and they may be rapidly moving towards complications. The other problem is that the condition is very progressive over time. We see this from the many clinical trials to examine the disease. Unfortunately, when we think we have things under control, if we do not go back and review a person in a short time, certainly within six months, the symptoms will almost always have moved off the scale. This is the reason we believe type 2 diabetes must be the priority chronic illness during the next three years.
The experience of individuals with diabetes in Ireland varies significantly according to where they live. Problems include access to medical care. Type 2 diabetes care in general practice is widespread but is largely unstructured. Many areas also have no diabetes specialists and no viable day centres. Access to the educational expertise of dietetics and diabetes nursing is highly variable and there is a general lack of team care outside the city centres.
Diabetes and its complications can remain undetected over very long periods and preventable complications such as cardiovascular disease and foot amputation remain far too common. Cardiovascular disease affects 50% of people with diabetes, whereas in the general population it affects only 30%. Diabetes is the most common cause of adult blindness, renal failure and amputation. There is nothing mild about type 2 diabetes.
Diabetes is expensive. In 2001, it consumed, we estimate, 10% of the overall health budget. This amounted to approximately IR£350 million per annum at the time. We also worked out that 60% was being spent on dealing with complications. A person with complications uses approximately four times the health care resources of somebody who does not have them. In fact, at the time only 18% of the overall spend was expended on the daily management of diabetes. It appeared we were putting too much of the money into the wrong end of the condition. Unfortunately, even though the health budget is much greater, there has been relatively little co-ordinated investment in diabetes and the expenditure on complications has probably risen to about 70% of the overall diabetes budget.
The interventions we are proposing are very affordable. They are not high expenditure interventions but have demonstrated proven cost effectiveness. They will actually reduce overall costs in the medium term.
The Diabetes Federation of Ireland and the Irish Endocrine Society have jointly worked out a number of urgent priorities which I hope to explain to the committee. There are just five and could certainly be the focus of our lobbying. I hope they will prompt action from this committee, as well as from the Minister and the Health Service Executive.
The first is a national retinopathy screening programme. Everyone with diabetes needs an annual eye examination to allow the early detection and treatment of sight-threatening eye disease. A long delay in diagnosis contributes to early problems in type 2 diabetes. For example, as I mentioned, 50% of those joining a new type 2 diabetes study already had some eye disease at diagnosis. Currently, eye screening in Ireland is extraordinarily haphazard. We are not the envy of the British Isles, that is for sure.
Some regions are taking steps. The north-western regional mobile eye screening service is particularly noticeable because it has taken the excellent models that are being used in the United Kingdom and has put them into practice. Specifically, it has developed a regional diabetes register from which it invites people. The service uses a mobile screening van which means it can access people within their own community, which improves the uptake of the screening service. Digital imaging technology is used which means it takes fewer costly staff to run the system. The service also has the back-up of ophthalmology where needed. This is genuinely cost effective and has been shown to reduce costs in the short term. There are excellent models for us to review across the United Kingdom. The adjustments in case load for those working in the eye field is completely predictable.
The second of our proposals is an implementation of a structured shared care type service for type 2 diabetes, using the resources of both primary and secondary care. The right care in the right place is a familiar phrase that members of the committee might remember from the health strategy. It is a very accepted model and one that we have put into practice in a range of locations in Ireland. As it happens, general practitioner care of type 2 diabetes is already widespread. Some 95% of GPs state they provide diabetes care for their patients. Approximately 60% of patients with type 2 diabetes are being managed largely in general practice. This is particularly so in rural areas where there are very few options. Only 13% of GPs take part in the existing structured schemes. There are four schemes in operation but, unfortunately, lack of investment in the schemes is killing them off. One of them shut down last year.
I would like to define two points. What do we mean by structured care? It means maintaining a register of patients with diabetes using recall and regular review along with a planned approach to detection. By shared care we mean the planned joint care of diabetes between primary and secondary care with added communication also.
There is a lack of co-ordinated joint investment in primary and secondary care here. Our agreed model involves ensuring equivalent standards of care and equal targets in both settings. The main issues for GPs would be a remuneration system that funds the kind of structured and quite complex care that is needed within general practice to look after people with diabetes. This should be population-based because a patient who leaves a hospital clinic to attend general practice will inevitably have to pay, and that seems slightly off-key.
The third arm is the health promotion, education, awareness and support that is provided by the Diabetes Federation of Ireland. We await approval by the HSE to expand our excellent network of regional officers. We have two regional officers, one working in the north west and the other in the south. We have found that model, in addition to our volunteer branch network, is an excellent way to provide a more professional service in an equitable fashion for people with diabetes. There are many different arms of the kind of activities we provide, including structured education programmes for type 2 diabetes and education for psychologists and carers.
The fourth model is foot services. We have a major problem with foot services and podiatry. Podiatry not only means nail care and treatment of calluses but also the important debriding of foot ulcers and making orthotics to divert pressure from areas at risk. This is how we intervene to ensure that where people have an at-risk foot, it does not lead straight to an amputation. Too many are going that road without the intermediate interventions. There have been two problems: first, an embargo on employment, while the Department of Health and Children deliberated on which was the correct qualification for a podiatrist and, second, the employment ceiling in the HSE. As a result, most parts of the country are bereft of foot care services. We have a lack of secondary care services such as vascular surgery and orthopaedics. We need a multidisciplinary approach to the at-risk foot and that needs to be done in our diabetes centres.
The fifth and most important arm is that to make real progress in all these areas we need national co-ordination. We need a HSE forum on diabetes, which we have heard discussed. It is an urgent need and it should be implemented immediately. It should involve people with diabetes and professional disciplines working in the field along with senior HSE personnel and decision makers. Additional expertise can be drafted in as appropriate. Wider consultation is something else we should use.
Essentially, lack of co-ordination in developing diabetes services is our biggest problem. Direct input from forward-looking groups will certainly facilitate development at a much faster rate than is taking place. The Diabetes Federation of Ireland has already proved very effective at doing this in the midlands, the eastern region and in the north west, and service development groups such as the liaison group in the east coast area share care scheme are very effective.
We do not want another long-term strategy document which gathers dust and which is never really prioritised and implemented. We want a living, continuous process of targeted investment in order that people's experience of the condition will be the same wherever they live. The key components of that are the joint involvement of management with the people with diabetes and those who look after them. Perhaps we should focus on both the immediate blackspots, of which there are many, along with longer-term aims. We have a budget for fact finding and needs assessment as required.
Obviously, the main aspect is implementation. That is our key request. We ask the committee to help us achieve it as a matter of urgency. The committee can assist us through a range of means but, essentially, by applying pressure on the Minister for Health and Children and the HSE. We believe this shopping list is very affordable and very novel for a major disease interest group. It is also limited. There are other priorities, including the psychological impact of diabetes, diabetes screening and prevention programmes with interventions targeted at those with impaired glucose tolerance, for example, following perhaps the Finnish model which has been implemented there with great success. We need to deal with the problem of discrimination and invest in diabetes research at a time of rapidly increasing knowledge.
Before I invite members to ask Dr. O'Sullivan questions, he can rest assured that this committee will do everything possible to help him achieve his objectives. How many consultant endocrinologists are there in the country? I am talking about endocrinologists who have a specific interest in diabetes rather than physicians who do a little work in the area? How many does Dr. O'Sullivan believe the country needs?
I thank Dr. O'Sullivan for his presentation and compliment him on presenting an integrated approach, even within the various disciplines. The idea of health professionals and people who suffer from conditions working together is an important one.
I get the impression that there is a high incidence of diabetes in Ireland compared with other countries but I am not sure if I am correct in that regard. Would Dr. O'Sullivan comment on this? If there are such a large number of undiagnosed sufferers of diabetes, what happens if we establish a really good diagnostic system? Would we be in danger of having a system which is unable to cope?
Dr. O'Sullivan did not mention prevention. Are there ways of preventing diabetes and how important are those efforts as opposed to dealing with the condition itself?
I am not absolutely clear about this. I understand the concept of shared care and structured care, but Dr. O'Sullivan mentioned that in some parts of the country going through the general practitioner was the only option and that the care is provided there. Is Dr. O'Sullivan stating that such care is not necessarily the best? To put it more simply, what is the best form of care? Is it that it should be centred with the general practitioner with occasional visits to a specialist or does it depend purely on the condition? If it is centred on the general practitioner, how will we prevent an overload in general practice? There is much feedback from general practitioners to the effect that they cannot do any more work and that there are parts of the country and parts of our cities, particularly areas of deprivation, where the scarcity of general practitioners is a matter of real concern?
I welcome the representatives of the Diabetes Federation of Ireland. The title of the federation's handout, Type 2 Diabetes in Ireland: How Do We Cope?, says it all. Obviously, we are not coping well. Dr. O'Sullivan listed the statistics. There are 250,000 people with diabetes, 90% of whom are type 2 sufferers. The federation reckons there is another 25% who are undiagnosed. Those are frightening statistics.
In his presentation Dr. O'Sullivan made some excellent suggestions. Would he agree that to date the services available are reactive rather than proactive? Would he agree this is where we must start? Dr. O'Sullivan has made suggestions but this is worth highlighting. Would he agree that the federation should consider taking this message to the country at large, including using rural seminars? This is one of the greatest health problems facing this country. It has serious implications for the health services. The services available are, to a large extent, reactive rather than proactive.
Would Dr. O'Sullivan agree that in terms of cost the question is not whether we can afford to do it but, more importantly, whether we can afford not to do it? Dr. O'Sullivan has laid out the federation's views which I welcome.
Dr. O'Sullivan mentioned that for the first time type 2 diabetes is being diagnosed in children and we will hear in a later presentation about the relevance of obesity to type 2 diabetes. We had an excellent in-house seminar just before Christmas from a Ms Clarke. One worrying statistic in terms of children was that a few years ago one in 1,200 was diagnosed with type 2 diabetes, whereas now one in 500 is being so diagnosed. Those are frightening statistics by any standards. This situation is out of control. Is there an increased incidence or are there better diagnostic procedures than heretofore? The shake of the doctor's head infers the incidence of diabetes is on the increase.
Dr. O'Sullivan referred to clinics. I served on the Midlands Health Board for a long time and spoke to a number of general practitioners and physicians who said their clinics were snowed under with diabetics, despite the availability of an endocrinologist in the midlands. In addition, the Irish Diabetic Association is active in Mullingar and the surrounding area. I strongly support everything Dr. O'Sullivan said. People must get the message because diabetes has serious implications for public health. The national director of population health agrees this is the most serious issue facing society. Therefore, the public must get this message. If the federation's members have to travel around the State to deliver the message, then by all means they should do so.
I thank Dr. O'Sullivan for his presentation. Based on his figures, the provision of a world class system would have involved an expenditure of €100 million per annum in 2001 which would probably equate to €150 million today. Is that a fair reflection of the cost involved?
According to the figures, the staffing deficit is approximately 400 across a range of disciplines. If the Government stated it would provide €150 million to address this issue, is the expertise available or would a long-term plan need to be implemented to ensure such expertise was available to the HSE? In other words, are sufficient staff in place? If not, what plans can be put in place to provide enough staff to address the issue? How long would it take to provide a world class service, providing the Government had the will to do so?
Dr. O’Sullivan
The Chairman asked about the number of endocrinologists in place and how many are needed. I will ask Dr. Firth to address that question and how other disciplines are used to ensure better services are achieved at a low cost. Deputy McManus asked whether the system would be overwhelmed if the numerous people who have not been diagnosed are detected. Ms Carr will address that question. She also asked what can be done about prevention. Dr. Dunne will address that question.
The Deputy asked about general practitioners. I will address that question. Dr. Firth will address the question of whether services are reactionary, not proactive. As for how much is needed to produce a world class service, I will think about it while Dr. Firth responds.
Dr. Richard Firth
I am a diabetes endocrinologist specialist. The common theme in the contributions is the need for properly structured and planned care. I know all the consultants because Ireland is not a big country but that should work in our favour because we should be able to implement a co-ordinated plan. There are approximately 14 consultants in the State. There has been a lack of planning and unification but this can be achieved following the establishment of the HSE. It is a good model because there were approximately seven health boards previously with the result that the South Eastern Health Board area has four endocrinologists and the Midland Health Board area has none, even though there is a diabetes clinic. The North Western Health Board and North Eastern Health areas have none.
What about the South Eastern Health Board?
Dr. Firth
The South Eastern Health Board area has four. Presumably, it is a locally-driven issue for various reasons. There is one in Kilkenny, one in Waterford, one in Wexford and one in Clonmel. There is inequity not just between Dublin and the country, but between different parts of the country. There is retinopathy screening in the North Western Health Board area but not in many other places.
The model for care which will link into what I am about to say about using other disciplines is that it will be shared care, which is important. It will not be primary care, GP care or hospital care. It will involve the "hub and spoke" model of a secondary centre which will have the basic team required, as do GPs, which is a consultant endocrinologist who is trained, a dietitian whose diabetic nurse is a podiatrist. The local GPs would feed into the secondary centre which would be the first referral from the GP. For more complex procedures such as vitreoretinal surgeryor vascular surgery, there would be a further series of "hub and spokes" of the secondary care feeding into major diabetes centres where specialist work is needed. The HSE gives us an opportunity to plan this in order that there is not an iniquitous, ad hoc, heterogenous series of appointments which do not add up. We would all like to see a consultant endocrinologist in every district general hospital and in every county hospital. It may not be possible to appoint one to each hospital, but there are models of people with sessions in Cavan and Monaghan or whatever being able to service this, with the GPs feeding into it. I do not think this will need a huge investment. This is planned investment.
The second question related to the interaction of other services. To echo what Dr. O'Sullivan implied, diabetes occurs because of various lifestyle issues. The obesity task force is present. There is the prevention side of things, for instance, to consider obesity before people develop diabetes. This is an issue for Government that relates to education and health promotion. Inevitably there will be a slide into impaired glucose tolerance. This is pre-diabetes and is equally dangerous. These patients will still die almost at the same rate from heart disease as people with diabetes.
There is diabetes which is uncomplicated which requires secondary prevention. This is where we operate in hospitals with the nurse and dietitians, eye screening, kidney screening and foot screening to prevent having to use tertiary prevention which is where complications arise. We want to try to prevent these complications causing disability and death. The extreme of this is cardiac bypass and laser eye procedures. We want to put these guys out of business because we want to prevent this happening.
This is an incredibly complex issue. We cannot just pluck retinopathy or something out of it. We must prevent diabetes. We must intervene with lipids, cholesterol and blood pressure checking to try to prevent heart disease because bypasses and amputations are very expensive. This disease is the most common cause of death from heart disease, which is what most diabetics die from. It is the most common cause of kidney failure, more than the next two causes requiring dialysis together. It is the most common cause of blindness in adults. It is the most common cause of amputations. It costs €45,000 to amputate a foot and it costs €20,000 or less to save it.
These aspects must be planned in order that we are not working on an ad hoc basis. We all need each other.
I echo what Dr. O'Sullivan said that the HSE must set up — I would like this committee to recommend this — a multidisciplinary planning committee that can plan and co-ordinate all these areas in a proper way. People will continue to need preventive care and treatment. The multidisciplinary approach works and is the ultimate model of preventative care. Undiagnosed diabetes is detectable and can be treated when detected. It has been proven that intervention works and this approach has everything going for it. I see people returning at 75 and 80 years of age with diabetes, something I did not see ten years ago. This is because statins and uncontrolled blood pressure are picked up in checks. I hope these comments give the committee some flavour of the situation.
Ms Maria Carr
I am a diabetes nurse specialist and have been asked to deal with the question of screening and discovering people who are undiagnosed. As Dr. O'Sullivan said, a large percentage of the population are undiagnosed diabetics. Screening is very important, particularly in high risk groups, because early detection can prevent complications. With regard to whether we can cope with this under the current system, the answer is no, but if shared care was rolled out throughout the country in an equitable manner with ease of access, we would be able to deal with the situation. If we could prevent complications rather than treating them when they have already happened, this would have a long-term cost saving.
Dr. Fidelma Dunne
I represent the western region of the diabetes sub-group of the Irish Endocrine Society and can be seen as representing what happens outside the Pale. I have been asked to talk about prevention. As Dr. Firth pointed out, there are different areas of prevention, for example, primary prevention, as of the current disease, and prevention of the complications before they arise.
We could talk all morning about this, but I will just give the committee a little flavour of secondary prevention of the complications. Let us take, for example, the complication of eye disease in type 2 diabetic patients. By the time patients get to see us, approximately 50% of them will already have developed a complication of their disease, one complication being eye disease. Once patients get eye disease they are at high risk of becoming blind. The statistics in my part of the country show that approximately 50% of people with diabetes type 2 attending their first eye appointment in an eye department already have sight threatening retinopathy. This compares with approximately 4% to 5% in countries such as the United Kingdom or Finland that have proper screening in place to pick up eye disease.
The cost of looking after 100 patients with diabetes who are registered blind is approximately €2.5 million per year. That is the same cost as developing and running a service per year for retinopathy screening. I rest my case. I leave it to the committee to go back to the Department of Health and Children and wherever else it has influence and ask whether it is best to spend €2.5 million per year on 100 patients registered blind or on developing a proper screening programme. Not alone will the 100 blind people cost the State for services, they will not contribute economically to the country because generally they do not have a job. We could use the same model for any other complication of type 2 diabetes.
Another complication of diabetes is heart disease. People forget that as shown by research here, in the United Kingdom and America, approximately 66% of people who have any evidence of heart disease have underlying diabetes, either diagnosed or undiagnosed. It is all very well to plough money into heart care, but if we do not address the underlying basic problem, we get nowhere. People who develop heart disease and who have diabetes, have much higher mortality than patients who do not have diabetes. If we do a plumbing job on the coronary arteries and do not address the diabetes, the patients will be back again in five years with their coronary arteries all clogged up. We must address the underlying problem which, in the majority of cases, is diabetes. We try and explain to our patients that diabetes is not just a sugar problem. It is like a shamrock and has three aspects. It comes with a sugar, a blood pressure and a lipid problem and we must tackle all aspects.
Heart disease is just another flavour of the complications of diabetes. We can do something about it and intervene. That is the beauty of looking after somebody with type 2 diabetes. It is a disease for which we have a proper screening tool. The disease can be picked up and we can do something about it. More importantly, we can reduce the mortality related to the disease with a proper programme.
The problem is that we do not have a programme and have no structure. One side of the country does one thing while the other does something else. There is no overall plan because we have not sat down and put an overall structure together. This is what we now propose to this committee. We have all sat down and put together our plan. We have costed the plan and given the committee the evidence that if money is put into this programme we can make real changes. There is no point in spending another five or ten years sitting around discussing the same problem. The disease is preventable. We know we can prevent it and that we can make life better for patients with diabetes by preventing the complications.
I urge the committee to go to whichever Department it represents and try to get this programme up and running. The current situation is a crisis for the Department of Health and Children and the country if we do not deal with it.
Dr. O’Sullivan
I will deal with the question of general practitioners. I am a general practitioner living with type 1 diabetes and have been working with the ICGP for a number of years to help develop general practitioner services for people with diabetes. A recent survey showed that 95% of general practitioners provide a considerable amount of general practitioner care for diabetes patients, but this is unstructured and therefore inadequate. When the care is structured it is adequate. Within the shared care scheme in which I work, when my patients attend my practice for their twice yearly visit, they see a doctor, a nurse and a dietician. They also go for an annual review in hospital where eye and kidney screening takes place. This seems to be the right balance of care. Patients enjoy the convenience of care in their general practice along with the security of knowing they have some specialist supervision.
As I see things evolving, in a properly structured situation nationally, everybody would have access to the right expertise in the right location which means we would not have an overwhelmed specialist service. We have 2,000 general practitioners in the country and this is sufficient numbers to participate in diabetes care.
How are we to move from one position to the other? Essentially, we need a remuneration system that pays for any patient who joins a shared care scheme in general practice and we need to continue to develop the current models. A particularly valuable feature of the east coast area scheme is the liaison group that includes primary and secondary care personnel and administrators from the HSE. As a result, we have produced an excellent model into which we have all bought and which is running well. We have audit and I have recently completed an audit of all the care for all of the patients during 2004.
The standard of care is excellent. We also have education. We had an initial education programme and there is a distance learning programme available through the Irish College of General Practitioners. Other programmes are available in the United Kingdom. We also have ongoing education. We have put together all the models necessary with some support from the HSE. However, to keep the programme alive we need real co-ordinated investment from the HSE.
The committee also asked whether €150 million would be enough to give us a world class diabetes service. It is certainly one estimate of many but I doubt it. The problem is we know that we will not be given €150 million to spend. We want to ensure there will not be the inequity evident at present. We do not have a world class diabetes care service. However, if we decided to improve dietetic services, for example, we would make sure these services were available in every part of the country, not just in a few special centres or in areas where the health board has taken a special interest in diabetes. Up to now, it is the central administration rather than local health administrators which has had a problem. I suggest rather than thinking about how much it would cost to build the perfect model we should focus on dietetics and consider what kind of investment in which areas of the country would make an immediate difference.
Ms Sinead Powell
I thank the committee for inviting the Irish Nutrition and Dietetics Institute to speak at this meeting. In answer to Senator Glynn's question about the reactional service, I have worked in tertiary care in a diabetes centre, in both a Mid-Western Health Board acute and primary care setting, and understand how, depending on resources, different levels of patient care are provided. It is a reactional service which is being provided. From the point of view of a dietician, patients are dealt with depending on complications and waiting lists. Faced with a huge waiting list, patients with possible renal disease, blood pressure and a lipid profile will go to the top of the list. If the system allowed for many more dieticians working within a team in primary care, patients newly diagnosed with diabetes could be seen. The evidence shows that such patients will progress and do much better if they are provided with intervention within a month of diagnosis, which is what they are asking for. When I was working in the mid-west area, it was the case that a patient did not see a dietician before seeing a consultant which could mean a waiting time of six to nine months on the waiting list. If a dietician was working in primary care, which was better resourced, a patient could be seen within a month of diagnosis.
There is a discrepancy in the type of service available to patients and there are black spots around the country. The committee will also hear a submission from the task force on obesity and there are many recommendations to be considered. We are dealing with secondary prevention but people will do better if they are seen early in their diagnosis or even pre-diagnosis, for instance, those groups at risk of diabetes and even including preschool children. More resources are needed for health promotion.
I echo what other speakers have recommended, that a diabetes strategy should be put in place to include all the relevant stakeholders and it should be implemented on a phased basis. In answer to the question of whether the professionals are available if the funding was to be provided, there is a sufficient number of professionals to start the ball rolling but there needs to be more investment in research and in the planning of courses for the different health professionals. We are a long way from being there but a start should be made by putting the relevant people in place.
I thank the delegation for attending the meeting and sympathise with its members. I agree with Ms Powell that we should get the ball rolling as so little help is being given.
The report on obesity makes very depressing reading. Dr. O'Sullivan also made reference to the fact that Ireland is leading Europe in the matter of obesity and that this should not be the case. Ms Powell was the first speaker to refer to preschool children. Is there sufficient consideration being given to the babies? The report recommends that women be given encouragement to breast-feed. I have seen babies of nine months of age who seem to be the weight of a two-year old. Is the intervention taking place at an early enough age? Public health nurses have a heavy workload but they seem to be the professionals who are supposed to moderate this situation. Is enough being done in the antenatal and postnatal periods and when children are brought for vaccination? It is not desirable to have a child who looks like the Michelin man. I suggest action should be taken much earlier.
The psycho-social effects of obesity as documented in this report make for depressing reading. It is very difficult to persuade people to lose weight. Would the delegation regard more help from psychologists as being useful in this regard? It is all very well to tell people what they should and should not eat but it does not produce results.
I have read many articles on the benefits of walking or cycling for those who are overweight as such exercise will at least help keep down blood sugar levels. There is no evidence that either the Department of the Environment, Heritage or Local Government, or the Department of Transport, are taking any notice of this fact. There is an amount of one-off housing around towns but the lack of footpaths is abysmal and I do not see many extra cycle paths being provided. Would it be helpful if this committee were to nag these Departments to do more in this regard?
The situation regarding podiatry is appalling when 20% of diabetic admissions are due to foot problems because ulcers on the feet cannot go untreated. Hospital admission is a very costly way of dealing with this problem. The podiatry list has been closed for years and I wonder whether anyone in the Department of Health and Children is taking any notice. I raise the issue regularly in the Seanad. This list has been closed for years as a result of a dispute and Dr. O'Sullivan may be able to inform the committee of the length of time it has been closed. There are vacancies for podiatrists and patients cannot have their feet examined. Reference was made in the delegation's report to joined-up writing and thinking. How can the Department be made aware that people cannot go around with ulcers on their feet resulting in significant expenditure for the health service?
I thank the delegates for their presentation. The word "crisis" has been used frequently. One would imagine that a crisis would result in a targeted response but I have no sense of this. Awareness of type 2 diabetes has somewhat increased. This is a preventable and treatable disease when the proper screening is in place and this should be given serious consideration. The signs and symptoms of the disease can be difficult to detect and only a visit to a doctor will detect them. I presume there are some physical signals of which people could be aware such as lack of energy. It is frightening that such a disease can absorb 10% of the health budget which is €350 million. The figures should be examined and the sums done in order to find a solution.
The onset of the disease is happening at a younger age with people in their 20s being diagnosed with type 2 diabetes. How long does it take to develop before it is identified as a disease? Could it be due to a lifestyle pattern that may have existed for the previous five or ten years? How long would a lifestyle need to be in existence before the disease developed? The lifestyles of children and young adults now include watching television and playing computer games and there is a pattern of eating convenience foods, often late at night, rather than natural, home cooking. Such patterns may be the cause of illness and this message should be emphasised regularly.
We appear to be following the US trend in that our population is getting fatter.
I wonder if Irish levels of type 2 diabetes are starting to meet US levels? Are the problems found in this country also found in the United States? Is there any evidence that the United States has tried to deal with this matter in any way? It used to be the case that one in 12 people in Irish society was obese, but it has been determined that one in five people is now obese, which is a frightening statistic. In 2002, 2,700 people were newly diagnosed as having diabetes, which represented an increase of 255 on the previous two years. I wonder whether that trend has continued since 2002. Is there any way of transmitting the message that diabetes is a very serious disease? Not only should we try to prevent its spread, but we should also put in place consistent national screening programmes.
I apologise for my late arrival. I thank the representatives of the Diabetes Federation of Ireland for their presentation. I am sorry that I missed it, but I have read the documents which have been supplied to the committee and listened to the questions asked. It seems it was a very interesting presentation.
Dr. Dunne said diabetes was a preventable disease. I agree with Deputy Connolly who said we should be doing more about it, given that it is preventable. At what stage do we need to take action if we are to prevent the onset of diabetes, rather than treat it? I did not hear much about diabetes until the last four or five years. Before then, I would have thought, rightly or wrongly, that diabetes was a disease associated with older men, rather than young men. Like Deputy Connolly, I would like to know whether the increase in diabetes is caused by factors such as lifestyle changes, environmental issues, diet, work and stress.
As someone who lives in the north west, where there are no endocrinologists — that is also the case in the north east — I think it is grossly unfair that there are four endocrinologists in the south east. Can Dr. Firth confirm that more endocrinologists are needed in the south east because there is a greater proportion of diabetes sufferers there? Can he compare the incidence of diabetes in the south east with that in the north west? Can he explain why there are four endocrinologists in one region, and none in another region? It seems to me that having endocrinologists in each of Kilkenny, Waterford and Wexford constitutes a doubling up of resources. The distance between such places is not as large as the distance between west or south Sligo and the north of the Inishowen peninsula in County Donegal. It seems very unfair.
Dr. Firth spoke about the establishment of multidisciplinary teams to prevent and-or treat diabetes. Is the manpower available for such teams? We need to be realistic. Is the necessary professional personnel available? Dr. Dunne mentioned that the €2.5 million spent on treating 100 patients with blindness could be used to develop a diabetes screening programme. Is diabetes more common in men than in women? Is it most likely to develop at any particular age? Does the Diabetes Federation of Ireland have figures to confirm the number who die as a result of diabetes? The issue of age is particularly relevant in the context of the development of a screening programme. Women over the age of 50 are encouraged to have mammograms. Does the federation envisage that similar provisions will be put in place in respect of diabetes, or is it likely that a younger age will be provided for?
I would like to ask two brief questions. Senator Henry and I attended a debate in Trinity College last year at which a doctor from St. James's Hospital spoke about diabetes. He made the interesting point that many young people are getting diabetes, a phenomenon that has never been encountered before. He also said the average age of a diabetes sufferer had decreased. He mentioned that various forms of prevention such as exercise had been used. There is a reduced incidence of diabetes among older people who take exercise. I was surprised to hear that the same success rate was not noted in the cases of younger people who took exercise. That is worrying because it means that if someone develops type 2 diabetes at 13 or 14 years of age, it cannot be treated by getting the person to play more sports. It is a longer term problem. Do the members of the delegation agree with the findings I have mentioned? If so, how can we address the problems faced by younger people? How can we help young people who develop type 2 diabetes to overcome it?
An article in a recent Saturday edition of The Irish Times which mentioned that Mr. Ian Dempsey had publicly stated that he had diabetes, also pointed out that some 200,000 people in this country were unaware that they had diabetes. How was that newspaper able to arrive at that figure? How can one estimate the number of undiagnosed diabetes sufferers? Could the number of sufferers be even higher? How has the figure in question been determined? I do not want to be political, but I would like to mention that Fine Gael recently announced that it favours a policy of putting in place a national screening programme.
The Senator is never political.
Having listened to the various speakers, it seems Fine Gael's proposal has some merit. It makes sense that people of all ages should be screened for diabetes every year. Given that young babies can have diabetes, as Senator Henry mentioned, it is clear that we should be constantly screening for diabetes to prevent its development, rather than chasing after it at a later stage.
Dr. O’Sullivan
I will comment on a key issue that has arisen, before asking my colleagues to respond to some of the other questions asked. Many members of the committee are concerned about the extent to which diabetes, especially type 2 diabetes, is preventable. We should bear in mind that not so long ago we were more concerned about undernutrition among the general population. There was a significant degree of incidence of type 2 diabetes in the days when we were concerned about whether people had enough to eat. The coin has flipped since then, however, with the result that over-nutrition is a key concern for many.
The number with diabetes has increased dramatically. The International Diabetes Federation estimates that approximately 50% of cases of type 2 diabetes can be attributed to weight gain, obesity and overweight. Approximately 50% of cases are preventable, therefore, but we cannot prevent every case. It is important that the Diabetes Federation of Ireland does not give the members of the committee the impression that all cases can be prevented simply by dealing with issues of obesity, such as a lack of exercise. There is research evidence to demonstrate that not all cases can be prevented. I refer to two major studies of people with impaired glucose levels, for example. When significant weight loss and increased participation in exercise were imposed on people who had abnormal glucose levels but did not quite have diabetes, the extent to which such people progressed to diabetes decreased by 60%. It is certain that the onset of diabetes in such circumstances can be reduced, but not every case can be stopped.
I will refer the question about preschool children to Ms Powell. Questions were also asked about psychology. It is tragic that there is almost no psychologocial support in dealing with diabetes in this country. Perhaps I will ask Ms Carr who is a diabetes nurse to speak about that issue. As most people with diabetes get support from diabetes nurses, as well as from the Diabetes Federation of Ireland, perhaps such nurses are the next best thing to psychological support. Ms Carr will also speak about whether exercise offers any hope in this regard. I ask Dr. Firth to speak about podiatry issues in this respect, as well as the question of when we should be screening and who we should be screening.
Dr. Dunne will speak about the need for figures and consider how we should deal with not knowing how many people have type 2 diabetes. He will assess whether a standard of data collection is needed, for example.
Ms Powell
I do not have all the answers to the obesity problem. The incidence of obesity among preschool children is increasing. I can remember my school days, as I am sure can the members of the committee. In those days, there would not have been more than one or two overweight children in each class. A study done in Cork indicated that 20% of Irish children were overweight. We need to target children and families. A significant proportion of this problem is caused by lifestyle. As Dr. O'Sullivan said, it is probably possible to reduce the incidence of obesity by just 50%. If we are to tackle 50% of the people in question, we need to focus on health promotion awareness campaigns.
People are quite aware of how one gets diabetes and what healthy eating is. Most of the advice I give is to watch portion sizes and consider exercise. The typical family now has two if not three cars and less emphasis is put on walking to the shops or otherwise taking exercise. Children do not exercise in the playground anymore. As members will be aware, television and computer games are increasingly popular and we rely more often for our calories on fast food outlets and convenience foods. We must return to health promotion. The obesity task force report contains many recommendations which we must address and whose implementation we must fund.
Our approach must be co-ordinated. While health promotion has been ongoing in Ireland for ten years, it should be noted that when I was studying in England ten years ago, there were five community dieticians whereas there are now between 50 and 60. There are projects to consider and measures are being implemented, but we must share information to move forward. We must examine the studies which have been carried out throughout Europe, especially in the Scandinavian countries which seem to be quite good at prevention. It is a question of taking the information which is available and using it to inform the establishment of strategies and working groups capable of tackling the problem at the early stage.
Ms Carr
Referral to psychologists is very useful in my practice as people must make behavioural changes which we all know are very difficult. People are required to change the habits of a lifetime and develop new ways of dealing with stress which do not involve eating. They must develop more healthy strategies. The treatment of type 2 diabetes involves helping people to develop new behaviours and ways of doing things, in which respect a psychologist's report is an invaluable aid. While, as Dr. O'Sullivan has said, a great deal of the work of diabetic nurses involves education, we are also involved to a great extent in helping people to make behavioural changes. People have issues with the acceptance of their condition and hope that if they ignore it long enough, it will go away. A psychologist would also be of help to the people concerned.
Exercise is essential and I encourage it as part of my daily work. Exercise is very useful in primary prevention of the condition itself and in secondary prevention by helping to control blood sugar levels. As part of my practice, we prescribe exercise and develop programmes for people to help them bring their exercise levels from zero to a more acceptable level at which they not only control their blood sugar but also their weight and sense of well-being. Exercise is a cornerstone of the advice I give to those at risk of developing diabetes as well as to those who already have the condition.
Dr. Firth
I will address podiatry and screening. As Senator Henry said, podiatry is part of the jigsaw. To clarify the position, the registration of podiatrists stopped because someone who wanted to tighten up the qualification requirements took a lawsuit against the Department of Health and Children accusing it of destroying her livelihood and won. The Department established two committees, one to deal with credentials and the other, which I was on and which sat fairly regularly, to apply those credentials to each chiropodist in the country. It was necessary to take this approach as there were five or six different qualifications in use, including one obtained via a correspondence course. A correspondence course is not ideal when it involves instructing people to remove calluses and debriding down to bleeding tissue. Practical experience is necessary. A system is up and running and its practices will be implemented.
There is a glaring gap in podiatry but it is a vital part of the jigsaw. Cutting nails and corns is not the answer to problems as corns are a normal response to poor footwear which leads to ulcers and, not to put too fine a point on it, amputations. All the delegates are involved in avoiding amputations through screening, diabetes prevention and control of diabetes to avoid numbness in the feet which leads to ulceration. Nurses constantly tell patients they must put on their shoes, never walk barefoot or use a hot water bottle and shake out their shoes, all of which prevents a significant number of amputations.
On the symptoms of diabetes, 50% of cases in the USA are undiagnosed because one needs very high levels of blood sugar to get tiredness symptoms but similarly high levels are not required to get damage. Screening is important, but we must not take a headless chicken approach to it. Structured methods must be applied and the resulting fallout addressed. One can become asymptomatic and present with a foot ulcer, which is awful. A foot problem can take over a person's life as he or she must attend a podiatrist every day for two years to have dressings and debridement, and may experience the salami effect of ending up with an above-knee amputation. This can destroy a person's life and is hugely resource consuming. It takes more than 10% of the budget.
We did a study in the Mater Hospital of people who had had a glucose tolerance test, were not known diabetics and who ended up with coronaries, of whom 50% were abnormal. The extent of diabetes is hidden and people are getting coronaries because they have it.
Most facilities now have a foot service which requires an orthopaedic and vascular surgeon, foot nurses and a footwear specialist to make shoes and attend the hospital once a month. In the four years over which it has been operational, the service has kept 50% of patients out of hospital who would otherwise have attended accident and emergency units and required a bed. The Tánaiste and Minister for Health and Children, Deputy Harney, will be delighted to hear we are doing our bit to keep people out of casualty. Outpatient care, screening and our efforts to maximise the efficiency of the service in a structured way pay for themselves as Dr. Dunne said.
Dr. Dunne
I will address the prevention of type 2 diabetes and its potential complications. One gets type 2 diabetes either because one inherits genes from one's parents, about which there is not a great deal one can do, or owing to environmental factors. A great deal of research is being carried out and the genetic issue should be manipulable in the future. The three environmental factors are obesity, exercise and what goes into one's mouth. While one can talk about calories, one must also consider the fat one consumes. In terms of what goes into one's mouth, the main factor is not protein or carbohydrates but fat because it makes one's insulin work less. Fat reduces insulin in people who are in a pre-diabetes state or susceptible to diabetes. It is important, therefore, to try to make the insulin work better, which will not occur in somebody who eats a great deal of fat.
There are, therefore, only three take home messages. Action needs to be taken on obesity, the content of food and exercise, all of which are major public health issues. One works on the genes through research. Unfortunately, however, as well as putting together a programme of clinical care, one must also invest in research.
Is it possible to identify those one seeks to prevent getting diabetes? To prevent a disease one must screen for it and the screening procedure for diabetes is cheap and easy to administer. One has a choice of two policies. One can decide to screen everybody in the country using an approach known as universal screening which, while more costly than the alternative, picks up everybody and provides a true estimate or knowledge of the number of diabetics and pre-diabetics in one's country. Alternatively, one may decide to invest a specific amount of money in a programme and adopt selective screening for those at high risk. How would one choose this group? We know that about one in eight people over the age of 40 years has diabetes. One could, therefore, take the age of 40 as a cut-off point and screen everyone above this age for diabetes. If one wanted to narrow the goalposts, one could decide to screen the over 70 year age group as one in four in this group will have diabetes. Depending on how much money one wishes to spend on a screening programme, one could opt to screen the whole population and obtain a true idea of the position or introduce selective screening.
Another area in which one can prevent the disease involves a specialised group of women, namely, those who develop diabetes in pregnancy. As people become more obese, gestational diabetes, that is, diabetes within pregnancy, increases. This disease tends to go away for a period, at least after the pregnancy. We now know that diabetes begets diabetes, which means the infant offspring of a pregnant woman who has diabetes will start to develop the problem in utero.
To answer the question as to where one starts to look for high-risk preventable groups, these women and their offspring are the group one needs to target. One must see these babies, about whom we are doing nothing, early. Currently, we deliver them, thank God they were born alive, and send them home. We already know from literature and research that by the time they get to 12 years, they are fatter and already have a higher instance of pre-diabetes. Therefore, if one is trying to prevent diabetes, this is the area in which to tackle it. This returns us to the question asked earlier about how one prevents diabetes. One must apply the idea of exercise, obesity and fat.
Dr. O’Sullivan
If one examines the history of the Diabetes Federation of Ireland which is almost 40 years old, one can see how our activities have changed to meet changing needs. The federation started off as a simple peer support group with local branches which held meetings at which people shared the fact that they had the condition. The organisation has since become much more professional and added to the peer support a large amount of direct structured education because there is a significant need for it. It has recognised that it is not only the stress caused by the horrible fear which comes with being given a diagnosis of diabetes, but also the long-term war of attrition, if one likes, required to make the necessary behaviour changes and make them stick. The federation provides a large number of awareness and screening programmes and does a great deal to raise public awareness of the symptoms of diabetes, those who should attend for testing and so forth.
The five steps we seek are not unreasonable. One does not need to look far for a comparison to arouse envy. If one examines the position in Northern Ireland, it has province-wide, mobile retinopathy screening, excellent, properly-qualified podiatry services and a shared care contract in general practice which works. The reason these services were introduced is that an integrated committee called CREST was established in Northern Ireland about three years ago. It brought together health professionals and officials from the department of health which produced excellent plans at four or five sittings during a period of about a year. These plans have since been implemented in order that it can be done without costing the earth. We want the five priority areas we have raised addressed quickly because they are urgent.
May we have figures for fatalities?
We might be able to get them later.
Dr. O’Sullivan
One of the problems in this regard is that no clear data recording takes place. While various public health record systems such as hospital records on admissions and discharges are in place, clear records are not available. In addition, we cannot produce a rate of death for diabetes because we do not know the total number of people with the disease.
Dr. Firth
Most diabetics die from premature coronary heart disease. Diabetics are 3.3 times more likely to die from this disease than those who are not diabetic. Those with diabetes are as likely to have a coronary as someone who is not diabetic and has already had a coronary. If one gets a coronary one is more likely not to survive it and less likely to leave hospital alive or have successful intervention, for example, angioplasty or a bypass. It used to be said that if one got type 2 diabetes at 40 years of age, one would lose five to ten years of one's life expectancy. The position is changing, however. Statins are fantastic drugs which are easy to administer. Successive Governments deserve plaudits in this respect because Ireland is a good country for diabetics in terms of treatment and free care. For example, one receives free statins, anti-hypertension drugs, aspirin, insulin, testing strips and so forth. The problem, however, is that people are getting the disease earlier. The number of children with type 2 diabetes is not particularly significant. However, to some extent it is pointing out the direction in which we are headed and the issue that needs to be addressed. If one gets diabetes at 30 years of age, one will probably lose ten or 20 years of one's life expectancy. In addition, diabetes is not a clean killer but involves a slow process.
I am conscious that a second group has been waiting for the past hour and a half. On behalf of the joint committee, I thank the delegation for attending this meeting and providing members with a comprehensive presentation which I found very informative. I speak on behalf of the joint committee in undertaking to take up the issues raised with the Health Service Executive. We will be in touch with the delegates.