I welcome Dr. Richard Firth, consultant physician endocrinologist; Dr. Diarmuid Smith, consultant endocrinologist; Ms Margaret Donoghue, dietitian; and Ms Deirdre Moyna, nurse. Before the delegates commence their presentation, I draw their attention to the fact that members have absolute privilege but this same privilege does not apply to witnesses appearing before the committee. Members are reminded of the long-standing parliamentary practice to the effect they should not comment on, criticise or make charges against a person outside the Houses. I ask Dr. Firth to commence the presentation.
Shared Care for Diabetes Patients: Presentation by Irish Endocrine Society.
Dr. Richard Firth
I do not have one.
That is all right.
Dr. Firth
When we appeared before the joint committee approximately one year ago, we made a formal presentation. We envisaged that this would be an information session for the committee. I will introduce the issues we have at present.
The areas on which we were asked to focus have not changed. For years diabetes patients were looked after by hospital doctors in an ad hoc opportunistic way without much of a structure. It was based on models of disease management. People got sick, came to hospital, were given an antibiotic and went home. As people live longer, we see more chronic diseases, particularly diabetes and heart disease. People live longer but require focused, proactive chronic disease management. This care differs from that for single episode sickness. Moves are afoot to structure diabetes care and it pans out in different ways.
The Government, similar to many others throughout the world, is moving towards a model of primary care whereby there will be a certain number of visits per year. Our brief is to ensure primary and secondary care services progress together and that resources are allocated to both. In other words, care of the patient is shared and he or she does not belong to one group. This will be set against the background of the introduction of the new GP contract if it comes into force. Various models have been proposed throughout the country, ranging from complete primary care to the shared care we hope to see. This would mean a seamless transition, whereby day-to-day patients seen by their doctors, namely, type 2 patients who are not on insulin and do not have special needs or require special expertise, would register with their local hospitals. It would also mean resources for both would be provided for equally.
Intervention in respect of diabetes can take place at many levels, including population screening, education about obesity in children to prevent them from developing diabetes later in life and controls to prevent complications. Where complications subsequently arise, vascular or bypass surgery, or laser surgery to the eyes, can be carried out. It is a structured disease in that it is progressive and predictable in its effects, so the response to chronic disease has to be equally structured if people are to be properly treated. An approach that seeks to avoid complications rather than allowing them to grow to the point where they cause disability or death has been proven worthwhile economically.
I hate to describe the ongoing debate over who should look after diabetes as a battle. However, I make the committee aware that we consider it important to avoid the route taken in the UK, where primary care has become all-powerful. Assets have been stripped from centres of excellence because of the power of GP trusts, with the result that there are no facilities in hospitals, nobody wants to specialise in diabetes and endocrinology anymore and GPs have no one with whom to share care. Several associated problems have also arisen. For example, consultants feel they are firefighting because they only see patients in crisis where complications have already taken hold. We cannot look after the exploding numbers of type 2 patients in this or any other country and while GPs have to look after them, we want to ensure that resources at the level of tertiary care are not neglected in favour of complete primary care. That is our worry at present and we would like to believe services will be of benefit to patients in the long term.
On more specific matters, the priorities we discussed at our last meeting with the joint committee included screening for retinopathy. Laser treatment can prevent blindness in 80% of people with diabetic retinopathy but screening is obviously needed to diagnose the disease before it can be treated. Retinopathy is the most common cause of blindness among adults of working age, so screening would be worthwhile. Models including mobile screening are currently being proposed by the HSE and we hope that in urban centres, where cameras in vans could end up on the M50 for half the day, a different model will be introduced comprising cameras in hospitals to which GPs have access. Rather than sit in our ivory towers, we want to open up care to GPs and the community in general.
We have already discussed the shared care programme. At present, podiatry is terribly under resourced throughout the country, even though diabetes is the commonest cause of non-traumatic amputations. Amputation has profound effects on the quality of life of sufferers and consumes significantly more resources than addressing issues at an early stage through sensible footwear, foot education and proper care of foot ulcers.
People recoil in horror at the amount of work involved in preparing a register but we are of the view that general practitioners and local centres should form joint registers. Various hospitals have already discussed the possibility of linking them. This is a way to establish the database. Other actions could also be taken to facilitate the process. There are many sources of information, including GP records, hospital records, HIPE data, long-term illness data and pharmacy data. If they could be harnessed, an IT database with a recall facility would make a big difference in the treatment of diabetes.
We are happy that Mullingar Hospital has advertised for a consultant, as has Sligo General Hospital, as to date there has been no consultant in the former Midland Health Board area. The north west and north east have also seen a major problem. I apologise for mentioning the war, but Cavan-Monaghan Hospital should make a joint appointment. While one does not necessarily require acute medical intervention for diabetics in Monaghan, the area is another black hole. The main priorities are shared care, retinopathy screening, an IT database and podiatry.
I am sorry if my presentation was a little disjointed.
It was fine.
Mr. Diarmuid Smith
On the reference to a black hole in respect of diabetes care, Letterkenny General Hospital has no diabetes specialist. It has one nephrologist and is about to appoint a second. We all know that diabetes is the most common cause of renal failure in the western world, not just in Ireland. It is unusual that a centre in the north west will have two kidney specialists, yet we will not have a consultant diabetologist who might prevent diabetes patients reaching end-stage renal failure and having to undergo dialysis.
The plan for diabetes care takes a long-term view. It is cost effective because by preventing complications through the provision of appropriate early treatment we can avoid the consequent huge drain on the health budget.
I thank the delegates for attending. It is very useful to learn about the issues and how they can be progressed.
Letterkenny General Hospital is extremely busy. Has an application been made for the appointment of a diabetes consultant? Who determines that such a post is required? What happens to patients with diabetes in the north west?
To save time, I will ask all my questions now. What happens if, after screening for retinopathy, it is discovered that many need treatment? Is there capacity to provide treatment? Are there differences between public and private provision of care for diabetes patients or is there equal treatment?
On podiatry services, I am horrified at the way elderly people in nursing homes or their own homes cannot access chiropody services to which they are perfectly entitled because of the complete breakdown in the system. They can access care if they pay to visit a chiropodist privately but the service is in disarray and a source of great concern, particularly for elderly people, many of whom I imagine are diabetic.
I would not have thought it was too difficult to creat a database as the information required must be in the possession of general practitioners and hospitals. It seems to be only a question of linking up. Perhaps I am being a bit innocent in that regard. The cancer register has been established, so perhaps the witness could indicate the reason it would be difficult to do something similar. How could we help to resolve the issue?
I also welcome the group, to which we listened very carefully the last time it was before the committee. Will the witnesses evaluate for us how the situation has developed since their last presentation to the joint committee? How has the interaction with the HSE panned out and how does it compare to the old health board system? How responsive is the current operation of the HSE to the group's objectives of delivering the service?
The witnesses are concerned about primary care development and the lack of prioritisation for secondary care but is there evidence this is happening? There is clearly a reason for raising this issue and perhaps some of the background could be provided as to why we should be concerned. We take on board the events in Britain. For the uninitiated, the witnesses might briefly outline the benefits of a database and how this could improve the delivery of service.
I welcome the delegation. I have an interest in the issue of diabetes and I have spent two years trying to initiate a debate on it in the Seanad. I eventually succeeded and we debated the matter for an hour and a quarter, which could speak volumes.
Everything we are doing thus far is reactionary, which the witnesses have themselves intimated. Chronic disease management and the structure of diabetic care has been mentioned, but I firmly believe that when people progress to type 1 diabetes, we have lost the battle anyway. I may be repeating myself but it bears repeating. It makes much sense to have a register in the local hospital. Any physician will indicate that his or her clinic is exploding in numbers of people with type 2 diabetes. Some Members of the Oireachtas have diabetes, and some of these I would never have guessed had it. Some people I am friendly with in Mullingar are also type 2 diabetics.
Judging from Dr. Firth's comments, it appears we are not winning the battle and we are merely trying to maintain a scenario. We are limping along. Dr. Firth has put forward suggestions and the compilation of the register would be very important. It should also be borne in mind that people primarily have responsibility for their own health. For example, I am an adult with power of decision in matters pertaining to myself and I should be able to have regular checks. I am very disappointed there is a debate over who should be caring for diabetics. Is this the introduction of the old adage that doctors differ while patients pass to another level? I hope this is not the case.
The centres of excellence have not been stripped of their resources because of the GP trust, and the witnesses might further explain this. Statistics relating to laser treatment of diabetic sufferers indicate it can prevent 80% of blindness from diabetes, a phenomenal figure. We have had the obesity report and taken in its findings and it is interesting to note that the rise in the incidence in type 2 diabetes has been in tandem with the increase in fast food outlets. This is a statistic that will stand up to scrutiny. Lifestyle is also a factor in contributing to the growth in type 2 diabetes along with fizzy drinks and food components such as salt.
Has the situation improved since Dr. Firth's last visit to this committee? If it has not then we must go back to the drawing board because almost everything we have done thus far on the treatment of diabetes has been reactionary. The obesity report was a very important step but the enactment and enforcement of reports is quite distinct from their being published. Indeed, the word "enforce" is regrettable because it implies people are not taking responsibility for their health. I believe that primary care provided by general practitioners along with the co-operation of society as a whole, can provide the answer to this issue.
Dr. Firth
Deputy McManus raised the issue of Letterkenny hospital. There is a type of diabetic clinic there run by Dr. Liam Bannon who was registrar to my predecessor, Dr. Drury, for a couple of years. His main interest is cardiology and he would be the first to say he should not replace a trained accredited specialist. Specialists in diabetes have chosen to spend their lives looking after people with that condition and will be the driving force behind the structures needed to treat it. This is the most complete model of preventative medicine one can find because it has well known symptoms. It is common, it is easy to detect if one has the will to do so, there are treatments available and they have proven useful. Every box in structured care is ticked so care must be structured. This is why we want retinopathy screening, information technology databases and so on.
This is what happens in Letterkenny and probably explains why a parallel eye screening programme has grown in the north west under the tutelage of an ophthalmologist; there has been no diabetologist there. This has been done very well but the ophthalmologist in question will not seek pediatrists, dieticians or nurses and this is why these deep, dark holes must be filled. Many come to Dublin from Donegal, though this is less the case in the rest of the country because things are moving along, appointments are being made and structures are being put in place.
At present retinopathy screening is important because diabetes is so preventable. Screening is simple because only a camera is needed to take photographs which can go to a grader, who need not be a doctor, and can then be fed up the system if there are problems. Diabetes is the most common cause of blindness in working life adults and, according to a recent report in the British Journal of Ophthalmology, it is increasing.
In terms of detecting people, does the capacity exist to provide the laser treatment?
Dr. Firth
There are ophthalmologists. If they were freed of the burden of screening, they could carry out the necessary laser therapy.
Dr. Smith
I work in Beaumont Hospital and while we do not currently have a retinopathy screening programme, we are trying to put one in place. Our patients have raised the money to buy the camera but we have not bought it as yet because we have nowhere to put it, we do not have funding to operate it, and we do not have funding for anyone to report on the pictures taken by it. We have spoken to our colleagues in the Mater Hospital, which is the eye centre for north Dublin, and they told us that if they could be freed from screening these pictures they would have the capacity to carry out the laser therapy. Screening through using retinal photography in Britain costs approximately £13, while the cost for using laser is £1,300.
Dr. Firth
The cost of an amputation is €45,000, but to save a leg with an ulcer would cost between €10,000 and €12,000. Preventing these problems and treating them is quids in from every perspective.
Dr. Smith
Deputy McManus raised the question of podiatry. Podiatry is in a bit of a mess across the country. When I was younger I worked as a registrar in St. James's Hospital. We carried out an audit examining the number of foot ulcer admissions to the hospital in 2002 taking account of bed stays and the procedures involved. This cost €750,000 in 2002, although that figure excluded antibiotics, blood tests, dressings, outpatient follow-ups, etc. If those were added, it would probably have amounted to €1 million. St. James's did not have a podiatrist at that time. The annual salary for a podiatrist would probably come to €60,000 in the health service.
There is good evidence to show that if podiatry is included in a multidisciplinary foot clinic it will reduce amputations significantly. We established a multidisciplinary foot clinic in Beaumont and reduced amputations from 21 patients annually to three or four. We had a good podiatrist in Beaumont and met with our finance committee seeking to have her appointed full-time. However, the committee only sanctioned her position as a 0.5 whole-time equivalent. She is not able to have the impact that she could have in saving the health service money.
Ms Deirdre Moyna
I work in the north east and even though medical card patients are entitled to podiatry, the HSE does not employ any podiatrists in the region. Regardless of what their medical cover is, the patients must pay for their podiatry.
Dr. Firth
We have a multidisciplinary foot clinic in the Mater Hospital — we are blessed in very many ways. We have shown that we can reduce accident and emergency admissions by well over 50% by employing two trained nurses, two consultant delivered clinics per week and two podiatrists, albeit the podiatrists amount to less than one whole-time equivalent. The clinics are delivered by a vascular surgeon and an orthopaedic surgeon through the public sector. It takes a great deal of patient time because they must come in for dressings, etc., but at least patients do not end up in casualty and take up a bed for six weeks with an infected foot.
It beggars belief that these are not being funded. We do not expect everything at once. There are no quantum leaps required to institute these things. We cannot institute a register and solve the podiatry needs of the country with a snap of the fingers. I have been involved in this area for a long time and have played a part in European initiatives. It must start from the bottom. Local needs must be met and then link them up, rather than trying to impose a top-down solution because it probably will not work.
The question of the health boards versus the HSE was raised. The establishment of the HSE provides a great opportunity to homogenise and introduce joined-up thinking. As an illustration, the old South Eastern Health Board area has four diabetes doctors, which is enlightenment gone mad, whereas the midlands area does not have one and the same is true in various other parts of the country. As we have a population of only 4.5 million we need central thinking and planning and this is where a register will help. The biggest impact on the care of diabetics is when GPs and hospitals have access to a database with recall facilities so that patients who default or should return in a specific period are brought back in that time. It is all a question of structure.
Are there any other questions?
Dr. Firth
Perhaps we could also talk about the primary and secondary care aspects. We agree that GPs have a significant role to play in dealing with diabetes. Nobody wants to prevent that. At the moment we are at a big hiatus. All our shared care initiatives have been shared. Beaumont Hospital had one and we had a fledgling one. St. Vincent's and Loughlinstown had them as well. They have been shelved pending a GP contract. This has been shelved because the GPs do not know the nature of their role.
Have they been reduced or deferred?
Dr. Firth
They have been deferred completely. I mean stopped or closed down.
Dr. Smith
The Beaumont Hospital shared care programme was very successful and it worked with 20 GP practices in the north side of Dublin and north County Dublin. It was the kind of model we seek for the management of patients with type 2 diabetes. The GPs liked the regular link with the hospital. They got regular education about the management of patients with type 2 diabetes. There was agreed goal and target setting for the patients with type 2 diabetes. We were all singing from the same hymn sheet to a certain extent. Patients were seen each year for their annual review to ensure that things were going smoothly. They were also seen every three months by the GPs to check their blood pressure, cholesterol, etc. As GPs were in tune with diabetes, they were well aware of the treatments and blood pressure agents to use, and what targets patients should achieve in the management of their diabetes.
The system worked very well and we hope there will be an investment in both primary care and in our organisation so that together we can provide the best service of care for our patients. Unfortunately it was established as a research project with funding from the Health Research Board. When that funding ran out efforts were made to try to sustain it. However, there was no funding to provide the diabetes nurse specialists to go to the GP practices. Unfortunately the GPs felt they were unable to take it on because they were not being funded.
As Dr. Firth said there is a programme in Loughlinstown, the east coast area diabetes shared care programme, in which I was involved when I worked in St. Vincent's Hospital. It has approximately 11 GP practices. The GPs like it and certainly the hospital likes it because we now know that all of our patients are being looked after more appropriately and the GPs are very interested in diabetes. It is unfair to expect a solo GP to manage diabetes on his own when he must also manage asthma, lung disease, heart disease, stroke, psychiatric conditions and mental illness. It is unfair to expect GPs to be experts in the field of diabetes, which is why we need investment in both of our services so that patients are linked into the two areas.
Does the society agree that the consumption of fast food is linked to the increase in type 2 diabetes?
Ms Margaret Donoghue
I should come in at this point as I speak on behalf of the Irish Nutrition and Dietetic Institute. From our perspective, we would like to tackle it from ground level. A major issue is that we do not have people in the community giving nutrition education and tackling the matter at the baseline, to help in the prevention of diabetes and also in the appropriate management and self-management of diabetes. We need to return to the diabetic. Part of our role as dieticians is to empower the person to manage his or her diabetes to the greatest extent. We need to have education programmes at this level to target this patient group. We hope, if this filters down to education, they will require fewer hospital visits which can impact significantly on their health and improve their quality of life.
I am based at the Adelaide Hospital in Tallaght and work in a specialist unit. We must also consider the type 1 diabetic. As a dietician, I note that there is very specialist therapy and nutrition education for this patient group to improve their management of their condition, reduce hospital admissions and improve their quality of life. I am limited in my ability to provide such education due to a lack of support in the community. Not many GPs have access to a dietician. In the past five years, dietetics has tapped into primary care, but the penetration is nowhere near the level that should obtain.
Dr. Smith
Approximately 20% of the adult Irish population are obese while 40% are overweight. That means 60% of the population have a weight problem. Among children, approximately 8% are obese while up to 20% are overweight. According to US epidemiological data, obesity in a male with a body mass index of 30 to 34, which is class 1 obesity, will increase the risk of developing type 2 diabetes tenfold. For females, the statistics are worse with an obese female having a ten to 20-fold increased risk of developing type 2 diabetes. The average age for diagnosis of type 2 diabetes two decades ago might have been the seventh decade of life, whereas we are now seeing it in the fourth or fifth decade and, on occasion, in adolescents. The obesity and diabetes epidemics are going hand in hand, which is obviously related to what we are eating and the tendency to take less exercise. According to a statistic in the obesity task force document from Cork, one in three children under ten years has a television in his or her bedroom. There is no question that our society has changed completely, the effect of which on the population has been an explosion of diabetes in association with the explosion in obesity and excess weight.
If Ms Donoghue were giving dietary advice to a patient, would she place fast food in the do or do not category?
Ms Donoghue
That is a hard one. I would definitely put it on the do not list.
Why am I not surprised?
Dr. Firth
A very interesting experiment was carried out by a chap called Barker in Windsor which has been repeated ten or 15 times around the world. He examined the birth weights of children during the war when rationing was in place. The babies were small. He examined the same people 50 years later in the 1990s, by which time the smallest babies had heart disease, diabetes, high cholesterol and blood pressure. The experiment mirrored what has happened in human development over the millennia. For many years, we ran after deer with spears and would probably catch one every six weeks. After that, we grew rice in paddy fields. We were the same as the in utero malnourished babies from the experiment and are genetically and in utero primed to store as much energy as possible. Having emerged from the uterus, we eat fast food which we store as much as possible. For 900 generations, we have stored energy in the absence of food, but for the last two we have taken no exercise while storing in circumstances of unlimited food. It is a very significant problem. While it is bad enough here, the Middle East, Far East, Australasia, Africa, South America and Central America have a significant bedrock and genetic pool of diabetes. In other words, the whole world, apart from the European population, will have a prevalence of diabetes in the population of 30% to 40%. Heart disease is replacing AIDS as this century’s problem. The same is happening here. The Senator is right. Approximately 40% or 50% of glucose tolerance tests done in the coronary care unit in the Mater Hospital and every other hospital are abnormal. Those people are either diabetic or are half way to diabetes.
This is a multi-layered problem that goes all the way from lasering eyes, which is shutting the stable door well after the horse has gone, to educating children. We are talking about looking after diabetes carefully, which involves teaching patients how to control their blood sugars. We must find them, screen them, review them regularly and refer them on if all else has failed.
We would not be in medicine if we were to say that people should look after their own health. That would not be fair because people less intellectually endowed than ourselves are bombarded by advertising, which works. The availability of fast food is also an issue. If we were to say that people should look after their own health, smokers, for example, would be prevented from having lung surgery, bypasses, etc. We cannot have a completely uncaring society where we would expect people to be responsible for their own health.
I did not suggest that, Dr. Firth, but I stress that primarily we are gifted with free choice and we should look after our own health. I acknowledge that is complemented by people like Dr. Firth.
Dr. Firth made an interesting point about education. I had a heart attack eight years ago and I remember discussing it with my family, including the issue of smoking and dieting. Incidentally, the dietician in Tallaght Hospital was very good to me and told me that if I was telling her the truth, she was happy with my progress. My point is that when we talk to young people about experiences like that they say, "That is your generation". I have often said that despite all the progress mentioned and all the work that has been done, young people still think such problems are in the future for them or that it is nothing to do with them. It is important to stress that and I am glad Dr. Firth raised it.
Dr. Firth
It is difficult. There is nothing nice about diabetes. It is all "lose, lose". Diabetics cannot eat what everyone else eats. They must keep their weight down, exercise, test their blood sugar by pricking the finger four times a day and give themselves four injections of insulin a day. For what? I might as well sell life insurance. There is nothing good about it. I am giving them bad news and then telling them they must do this, that and the other in the vague promise that all will be well but when one is 21, one feels immortal.
Dr. Smith
The good news about diabetes is that if we are aggressive in the treatment and achieve good blood sugar and good blood pressure control, etc., we can make a difference. We can make a difference to our patients' lives if they are looked after properly and if this area is resourced properly.
I thank the witnesses for their presentation. I wish this committee could do something about increased funding or additional personnel but we cannot.
We can recommend it.
The Minister for Health and Children, Deputy Harney, and Professor Drumm will appear before the committee on 15 February. We will review the submission and forward it to the Department and to Professor Drumm in advance of their attendance at the committee in the hope we can prioritise the issue. That is all we can say to you. I wish we could do better than that because it is clear that some of the cases highlighted require additional funding, particularly in regard to the figures for Beaumont Hospital. At a time of plenty, one would have thought we could at least do that. That is our commitment to you from this meeting and that is as far as we can go.
Dr. Firth
We very much appreciate the committee's time. The more people we can talk to the more good will be done. We expect things will go along smoothly. We appreciate the members' time.
Dr. Smith
I second that. It makes a difference to those of us working at the coalface to know that people here are interested. We appreciate the members' time.
Sitting suspended at 2.59 p.m. and resumed at 3.01 p.m.