Insulin Pumps
The final item of business is a members' business debate on motion S3M-1888, in the name of David Stewart, on increasing access to insulin pumps. The debate will be concluded without any question being put.
Motion debated,
That the Parliament notes the considerable benefits that insulin pumps have for diabetics to help them to manage their condition; notes with concern the current restrictive criteria for eligibility for the use of insulin pumps which have contributed to insulin pump usage in Scotland being among the lowest in western Europe, with only around 0.75% of people with Type 1 diabetes using pumps in Scotland, compared with 15% to 20% in the United States of America and Germany; is concerned at the extreme regional disparity in uptake of insulin pumps across NHS boards, with only two patients receiving insulin pump therapy in NHS Ayrshire and Arran, compared with 42 in NHS Tayside in the most recent figures, despite all NHS boards having received funding for access to insulin pumps; supports the campaign of Diabetes UK to increase access to insulin pumps and welcomes the review being undertaken currently by the National Institute for Health and Clinical Excellence (NICE) of the eligibility for use of pumps in the NHS, and believes that further steps should be taken to ensure that new NICE guidance that seeks to relax access criteria is adopted swiftly in Scotland, to support all NHS boards to increase access to insulin pumps for patients with diabetes and to enable more training for health practitioners to support patients in moving to the use of pumps where it is clearly of benefit in the management of their diabetes.
I welcome the opportunity to debate increased access to insulin pumps specifically, but also the bigger picture of diabetes and its role in health care management. The motion has widespread support across the political spectrum and I thank members who supported it. As for those who have not, I always welcome sinners who repent.
First, I acknowledge the work of the cross-party group on diabetes, which Karen Whitefield convenes and of which I am a member. I warmly welcome the visitors in the public gallery, particularly the representatives of Diabetes UK Scotland.
Some may ask, why debate diabetes? I declare a personal interest, in that about 11 years ago I made a fascinating visit to Raigmore hospital in my constituency. I went to the diabetic specialist centre there, where I was encouraged by the staff to take a particular interest in the debate. I also had a family member, who is unfortunately no longer with us, who suffered from diabetes for more than 70 years, so I have first-hand experience of day-to-day family life with a diabetic. In my Westminster days, I was secretary of the all-party group on diabetes.
Members will be aware of the major causes of concern about diabetes. It is the main cause of blindness among people of working age; half of all non-traumatic lower limb amputations are due to diabetic complications; and diabetic care costs the national health service in Scotland the phenomenal sum of about £0.5 billion.
On type 2 diabetes, members will be aware that I have supported a campaign for high-risk screening for type 2, or mature onset, diabetes for people who are overweight, or who have a family history of diabetes or who are over 45. I hope to use the United Kingdom screening committee to give some support to that campaign.
What am I calling for? It is important that we have greater use of continuous subcutaneous insulin infusion—CSII—or, as it is also known, insulin pump therapy, which is slightly easier to pronounce, so I will use that term for the rest of the debate. As members will be aware, insulin pump therapy provides significant improvement in glycaemic control and quality of life for some people with type 1 diabetes—so-called early onset and insulin-dependent diabetes.
The pump is an external device that continually infuses insulin into the patient's body and thus controls their glycaemic levels, which many patients otherwise struggle to achieve. That alternative way of maintaining insulin levels can contribute to more stable wellbeing by reducing the risk of hypoglycaemia and replacing several daily injections with only two to three a week. With the pump, insulin levels can be increased by simply pressing a button on the pump instead of using a pen needle, which can be embarrassing for patients, particularly when they inject in public.
Insulin pumps empower patients to have greater control over their condition as they give them a more flexible and reliable means of managing glycaemic levels. Improved control over one's own health means improvement in the quality of life of many patients: it means fewer hospital visits, a more productive work life and less stress at home. Fewer hospital admissions and a reduction in primary care contacts also mean that there is less strain on the NHS.
Diabetes UK Scotland has argued that there is a saving of more than £23,000 over two years, which would comfortably offset the cost of pump therapy. Let us look at the big picture and compare the cost with the costs of poorly controlled diabetes: a one-night stay in hospital following admission to accident and emergency for a diabetes emergency costs £350; one course of laser treatment for retinopathy costs £850; one procedure of dialysis treatment for kidney disease costs £500; and renal dialysis for one year costs £15,000.
Despite the outlined benefits of insulin pump therapy, it is still rare in Scotland. That is particularly problematic considering Scotland's prevalence of type 1 diabetes, which is well above the European average. Less than 1 per cent of sufferers of type 1 diabetes receive insulin pump treatment. That is in stark contrast to other parts of the world, where rates of pump use are much higher. For example, in Germany and the United States 15 per cent to 20 per cent of patients enjoy the benefits of insulin pumps. What would it mean if we had the same rate as the USA and Germany? it would mean that another 4,000 to 5,000 people in Scotland would benefit. In my region—the Highlands—that would mean a jump from six users, which is very low, to 450. In the Western Isles, it would mean a jump from only one user to 33.
What is obstructing patients from accessing the treatment, which could potentially change fundamentally the lives of so many of them? Part of the explanation is that the criteria for qualification for insulin pump therapy are currently restrictive and exclude many patients who could otherwise benefit. If a patient does not fall into the set category, they have to fund the treatment themselves, which can run into thousands of pounds. Diabetes UK Scotland has criticised the criteria, which, as members are aware, are currently under review by the National Institute for Health and Clinical Excellence. It appears likely that the criteria will change and be relaxed, but that does not mean that our work is over—we must ensure that health boards have the funds to finance treatment for the additional patients.
A further concern is that only limited specialist centres in Scotland are able to deliver pump therapy, which means that some patients have to travel extensively. The answer to a recent parliamentary question from Christine Grahame showed that since February 2007 there has been an increase in the number of users of about 127. I give praise where praise is due: Lothian NHS Board and Tayside NHS Board should pat themselves on the back, because their levels of pump usage are well above those in England and the rest of Europe. I do not, however, have such a positive message to put out for Greater Glasgow and Clyde NHS Board and Ayrshire and Arran NHS Board, which are in the corner with dunce's caps for their low level of pump usage.
As with most things in life, we never really appreciate the devastating extent of a disease until we suffer it ourselves. That is why I will end my speech by telling members a story about a diabetic who can tell members first hand how life-changing the effects of insulin pump therapy can be. Her name is Dorothy, she is in the gallery today and she has had type 1 diabetes for 37 years. She has struggled to control her blood sugar level, which has affected her health and deprived her of sleep. She states:
"Within 4 weeks of starting the pump, my blood glucose levels came down to 7.5. I suddenly got my life back. My appetite returned and at last I could see the light at the end of the tunnel.
Despite feeling 100% better, I still have problems with my control and it's my belief that had I got the ‘pump' earlier, I would never have experienced these problems.
For this reason and many others, I strongly believe that continuous subcutaneous insulin infusion (CSII) should be available to everyone who would benefit from it and especially to young people who have their whole life in front of them.
It is my dearest wish that they may live their life free of all diabetic complications."
I call on the Cabinet Secretary for Health and Wellbeing to follow NICE guidelines and to encourage increased use of pump therapy, to provide a new era of hope for type 1 diabetics.
I am pleased to take part in the debate and I commend David Stewart on lodging the motion. Since I entered Parliament five years ago, my focus and that of many others has been on the frightening increase in the incidence of type 2 diabetes in our population, following what is almost an epidemic of obesity that affects younger and younger age groups. Because type 2 diabetes is such a great public health concern, it is easy to forget that the incidence of type 1 diabetes in Scotland is among the highest in the world.
As we know, diabetics depend on a successful insulin regime to keep their blood glucose under control. The better and more consistent the control is, the less likely it is that they will suffer the long-term complications of type 1 diabetes, such as retinopathy, arterial disease and renal failure. Many people adapt to their changed lifestyles after diagnosis without too many problems, but others find it hard to achieve a normal blood glucose level and fluctuate widely between hyperglycaemia and hypoglycaemia, both of which are dangerous for the patient in different ways.
There appears to be no doubt that better control of blood sugar, with fewer fluctuations and complications, can be achieved by many people who use insulin pumps, and that the quality of life of patients and their families is improved as a result. As David Stewart said, children in particular have been shown to adapt well to the use of insulin pump technology.
Clearly, any device that can improve blood-glucose control in diabetes will lead to long-term benefit, not only to the patient's health and wellbeing but also to the NHS, which will be faced with fewer complications to treat, and will experience reduced hospital admissions and less medical staff time being used in primary, secondary and tertiary health care settings.
Not every type 1 diabetic is considered suitable for, or wants, an insulin pump, but even under the fairly stringent eligibility criteria that have been recommended by NICE, which are currently under review, there are significantly fewer pump users in Scotland than in the rest of the UK, and many fewer than in the diabetic populations of the rest of the European Union and in the United States. Now that all health boards in Scotland have strategies in place for prescribing insulin pumps, their use is on the increase, but there is still significant regional disparity in the provision of pumps. Many more people could benefit from them.
The pumps do not come without cost, and their effectiveness depends on a sufficient number of health practitioners having been trained to support patients in their use. However, the long-term savings could be very significant. It is indeed a spend-to-save provision that concurrently leads to improved quality of life for successful users of the technology.
Several recent members' debates have illustrated the patchy provision of life-enhancing equipment in Scotland. There was Trish Godman's debate on wheelchair provision, mine on alternative and augmentative communication aids, Alison McInnes's on school book provision for visually impaired pupils, and now David Stewart's on the availability of insulin pumps. All those debates have concerned people for whom improved provision would make a huge difference to the quality of their lives. I am sure that there are many other long-term conditions for which treatment could be improved by technology or by more specialist nurses or other staff within the community.
Taken together, the improved quality of life for many people, and the resultant decrease in use of highly specialist secondary and tertiary NHS facilities and other public services, could only be of long-term benefit to our society, both physically and financially.
In supporting David Stewart's plea for greater provision of insulin pumps, I suggest to the cabinet secretary that a good deal of work needs to be done by, and with, the Long-term Conditions Alliance Scotland, to consider how provision could be improved across the board, with the ultimate goal of eliminating postcode lotteries in Scotland and improving the quality of life for all patients with chronic conditions who currently receive less than optimum care—including type 1 diabetics. [Interruption.]
I am sorry—I do not want to be a spoilsport, and I should have said this earlier—but applause from the public gallery is not permitted.
I welcome the opportunity to speak in this evening's debate and congratulate David Stewart on securing a members' business debate on this important topic.
Some members may recall that I, too, secured a members' business debate on diabetes a few years ago. That debate was the first time—and, I think, the last time—that the then Lord Advocate spoke in a debate in this chamber on a topic that was outwith the justice field. Colin Boyd wanted to participate to highlight the effect that diabetes had had on his life. His speech clearly demonstrated the wide-ranging impact of diabetes in our society. There cannot be a family that has not been touched by diabetes in some way.
I know only too well the difficulties and challenges that diabetes can cause within a family. Those difficulties are why it is vital that our NHS provides support, care and clinical treatment to those who suffer from the illness. Previous initiatives such as the launch of the Scottish diabetes framework and the associated action plan, as well as the ban on smoking in public places, have all been positive but, as others have said, we can still do much more to improve diabetes services in Scotland. Today's debate highlights just one way in which we can do that.
Insulin pumps will not be suitable for all diabetes sufferers. The treatment requires commitment on the part of the patient, as well as proper support from clinicians. It is also true to say that substantial costs are associated with this form of treatment. However, as the briefings from Diabetes UK and Roche Diagnostics clearly demonstrate, considerable savings to the NHS can accrue as a result of people using an insulin pump. The savings come from a reduction in the need for on-going clinical interventions for problems such as severe recurrent hypoglycaemic episodes and hyperglycaemia. Diabetes UK estimates that such a reduction could result in savings of up to £23,500 per patient over two years. That can be offset against the cost of maintaining a patient on an insulin pump.
Not only are we not delivering on that potential saving and improved service, we are not even achieving the number of people that NICE estimates should be accessing the service in Scotland. That point has already been made, and I am sure that it will be made again.
Unfortunately, Lanarkshire, where I live and part of which I represent as an MSP, has some of the worst health statistics in Scotland. That is certainly true with regard to type 1 diabetes; the number of people in Lanarkshire who suffer from the condition is 18 per cent above the Scottish average. However, the percentage of those people with an insulin pump is only a quarter of the figure for the rest of Scotland and a tenth of the UK figure. In short, Lanarkshire has one of the worst problems with diabetes and one of the poorest records in supplying insulin pumps. That situation must be addressed and I urge the Cabinet Secretary for Health and Wellbeing to work in partnership with NHS Lanarkshire to ensure that the people of Lanarkshire are not disadvantaged in comparison with other parts of Scotland or the UK.
I very much welcome the steps to improve the prevention, diagnosis and treatment of diabetes in Scotland, but in the provision of insulin pumps we are clearly lagging behind the rest of the UK and are far behind many other parts of the world. It is important that the cabinet secretary listens to Diabetes UK's concerns and provides funding and resources to ensure that the Scottish people get the very best possible care and treatment for their diabetes.
I, too, congratulate David Stewart on securing this debate. I am slightly disappointed that there are not more members in the chamber—indeed, one party is not represented at all—because diabetes is very serious and important health issue, the complications of which, as Nanette Milne has made clear, have massive consequences for not only individual suffering but the cost to society.
Over the past 20 or 30 years, diabetic care has improved substantially, and the shift to primary care has been fundamental in ensuring a much more proactive and individualised approach. The creation of care plans, for example, has been important, but we are still some way from the establishment of key workers, which I think is also fundamental to the delivery of good care.
In the early 1990s, during the time of fund holding, I was among those who were invited to carry out a study on how fund holding and commissioning could be used to drive forward a retinal screening programme in my locality. In two years, the subsequent programme increased the level of screening from 60 per cent to 92 per cent. What levers are available nowadays to deliver on these matters? The information that we have received makes clear the extreme range of provision. For example, the figure for those with diabetes who have insulin pumps is 0.1 per cent in Ayrshire and Arran, but 2.7 per cent in Tayside. I am glad to say that two out of the three health boards in my region of Mid Scotland and Fife—NHS Tayside and NHS Fife—are doing quite well in that respect.
I should also point out that Tayside has the most highly developed diabetic programme in Scotland. In identifying diabetics and ensuring more integration of care, the diabetes audit and research in Tayside Scotland study, which involved the Tayside medicines monitoring unit, has helped to drive up care levels in that area in a way that perhaps has not happened elsewhere in Scotland. It is therefore no surprise to me that the figure in Tayside for those with insulin pumps is 2.7 per cent, a full 1 percentage point above any other area.
I suggest that the benchmark for Scotland should be in the region of 2.5 per cent and that we invite the Cabinet Secretary for Health and Wellbeing to use every available means to hold health boards, particularly the outliers, to account and to ask them to explain these massive discrepancies between one area and another—to her, to the Government and to the Parliament.
Pumps are not suitable for everyone, but for people for whom they are suitable, particularly those who are unstable and require a background delivery of insulin, savings can undoubtedly be delivered.
One of the problems for the health service is the demand that we place on it to achieve efficiency savings. That demand is entirely appropriate, but it is far too often recognised only in the short term. We need a system that allows health boards to invest the savings that they make and encourages them to invest for future savings. We need to raise people's sights and horizons to savings that could be made down the line, which will involve thinking beyond the spending cycle that, to a large extent, governs our actions. In the 1980s, I made proposals to eliminate a nine-month waiting list for vasectomy that I said would have a one-off cost that would be paid for in six years. The health board's response was that it did not think that far ahead. We need to think that far ahead.
I welcome the opportunity to take part in this evening's debate on the provision of insulin pumps and congratulate David Stewart on bringing the issue to the Parliament. As other members have said, the subject is important, as it affects not just the treatment of type 1 diabetes but the whole NHS.
As Nanette Milne said, type 1 diabetes is an extremely serious issue in Scotland, given the high incidence of the condition here—the third highest in the world. We have about 197,000 sufferers of diabetes, more than 26,000, or 15 per cent, of whom have type 1 diabetes. That is an extremely large number.
As other members have said, the condition has a significant impact on young people, 35 per 100,000 of whom are affected by it. That has an impact not only on their lives, but on those of their families and on the support that the NHS provides through treatment of continuing illnesses.
It is clear that the use of insulin pumps can make the treatment of type 1 diabetes more effective, in that it can help people to manage their condition, make them more disciplined and contribute to an improved quality of life. The disparity between the use of insulin pumps in Scotland and in the rest of the UK and internationally is a concern. About 1 per cent of people in Scotland who have type 1 diabetes use insulin pumps, whereas the figure for the UK as a whole is 2 per cent. The disparity is even starker if we compare the situation in Scotland with that in other EU countries, where the figure ranges between 10 and 20 per cent. In the United States, too, the figure approaches the 20 per cent mark.
As other members have said, there are wide variances between the rates in different health board areas. There are more than 5,000 sufferers of type 1 diabetes in the Greater Glasgow and Clyde NHS Board area, but only 31 of them use insulin pumps, which equates to a rate of 0.6 per cent. The rate in Lanarkshire, too, where only 21 out of more than 3,000 sufferers use insulin pumps, is only 0.6 per cent, which is well below the Scottish average and even further below the UK average. It is clear that urgent action is required. It is important that we raise the standard. I endorse Richard Simpson's suggestion that we should try to raise the level of insulin pump usage to 2.5 per cent across Scotland.
The provision of an insulin pump costs about £1,600 a year, whereas injections cost about £500 a year, but as Karen Whitefield and David Stewart said, the use of pumps can result in the NHS recouping £23,000 over two years because type 1 diabetes sufferers can go on to suffer from heart disease, stroke, kidney problems and blindness, which has an impact throughout the service. The use of insulin pumps to tackle type 1 diabetes has two main advantages: it improves people's health and it reduces the long-term strain on the NHS.
I congratulate David Stewart on raising this issue. He has helped to raise its profile, which I hope will help diabetes sufferers and have long-term benefits for the nation's health.
I thank David Stewart for bringing the issue to the chamber, and I thank those in the public gallery who have attended to hear the debate. Like other members, I pay tribute to the work of Diabetes UK Scotland.
Other members have highlighted effectively the scale of the diabetes challenge. More than 200,000 people in Scotland have a diagnosis of diabetes. Every one of them needs access to high-quality services and appropriate educational programmes to optimise self-management. People with type 1 diabetes, who need insulin to survive, make up about 13 per cent of the total. That means that more than 27,000 people need access to structured care, timely advice and local education programmes.
As we have heard in the debate, between 1 and 2 per cent of people with type 1 diabetes use an insulin pump to deliver insulin continuously. There is no doubt that, for suitable people with type 1 diabetes, getting access to continuous subcutaneous insulin infusion—I will refer to that as insulin pump therapy from now on—can be a life-changing event. We have heard examples of that during the debate. I assure David Stewart and others that the Government is committed to ensuring that people with type 1 diabetes who meet the criteria should have access to the insulin pumps that deliver therapy.
We heard during the debate of the poor figures for Ayrshire and Arran. Given that, does the cabinet secretary feel it appropriate to get in touch specifically with Ayrshire and Arran NHS Board to ascertain what it intends to do to progress matters?
I am always happy to follow up issues individually with health boards, and I will return to the issue of variability across boards in a minute.
As members are aware, our national policy is set out in the diabetes action plan. Each NHS board area should have an insulin strategy covering the full range of insulin use, including, where appropriate, the use of pumps. Local implementation of that insulin strategy is the responsibility of each NHS board, working closely with its diabetes managed clinical network to ensure that it complements the other services for people with diabetes. That approach allows the diabetes MCNs to monitor regularly the availability of pumps, and to report their findings to the Scottish diabetes group. The group arranged for advice on the subject to go to all the diabetes MCNs in spring of last year. It also organised a national meeting of MCN representatives to share best practice around insulin pump therapy. A working group then produced a national educational curriculum, which is available to all NHS boards. The diabetes lead clinician intends to ensure that progress is a standard item on the agenda for the regular meetings that he has with the networks' clinical leads.
There has been a growth in the use of pumps across Scotland. We should acknowledge that progress, but we must recognise that there are two main concerns about current performance, the first of which is the variation in provision across NHS boards. The motion, quite rightly, draws attention to the disparity in uptake of pumps across NHS boards. A number of members have touched on that in relation to specific boards: NHS Ayrshire and Arran, and NHS Lanarkshire. I assure members that I will continue to press boards on that issue.
Another concern that has been highlighted in the debate is that, on current criteria, as set out by NICE, our use of pumps is at the lower end of the spectrum. There are 263 people on an insulin pump, whereas applying the NICE criteria suggests that the number should be somewhere in the range of 260 to 530. As we have heard, NICE is reviewing its technology assessment, which might mean that around 15 per cent of people with type 1 diabetes could be considered eligible for an insulin pump.
I want to introduce an important factor that is not mentioned in the motion but which was touched on by, I think, Richard Simpson. For people with type 1 diabetes, it is a case of determining the insulin regime that is best suited to each person's circumstances. We also need to take into account the type of regime that commands the confidence of the team that provides diabetes services. As members know, the main options are insulin injections, which might need to be administered between two and four times a day, and insulin pumps, which are now technically much more reliable than they used to be. The choice of insulin regime should be agreed between the person who has type 1 diabetes and the team that supports their diabetes care.
The benefits to patients of insulin pumps were well described by David Stewart and other members, but it is important to put on record that insulin pump therapy is not always an easy option and requires determination and commitment on the part of the patient, coupled with a structured education course. Insulin pump therapy improves patient satisfaction in some cases, but it does not inevitably lead to better control of blood glucose levels. Children who are on insulin pump therapy need continuing care, especially during the transition to adolescence and adulthood. However, as many members said, insulin pump therapy can offer people with diabetes increased freedom and flexibility and a better quality of life. We would not want to reduce such an issue to a crude cost benefit analysis, but points about cost savings were well made by members.
We will encourage boards to continue to increase the number of people who use insulin pumps, but we need to acknowledge that that must be a managed process, in part because a key factor is the availability of staff to deliver the education programmes that are needed before pump therapy commences, to ensure that the regime is used optimally. Structured education is very important in maintaining and improving blood glucose control in all 27,000 people with type 1 diabetes and is an important adjunct to insulin pump therapy.
I repeat my thanks to everyone who took part in the debate. I acknowledge the importance of the issue and I support the thrust of the motion. I will ensure that I and the Scottish diabetes group continue to monitor closely insulin pump programme availability throughout Scotland and on a board-by-board basis, particularly when the new NICE criteria are available. I have no doubt that the Parliament will also want to monitor the issue closely.
Meeting closed at 17:42.