Plenary, 03 Sep 2009

Meeting date: Thursday, September 3, 2009

Official Report 734KB pdf

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Insulin Pump Therapy

The final item of business is a members' business debate on motion S3M-4723, in the name of David Stewart, on insulin pump therapy. The debate will be concluded without any question being put.

Motion debated,

That the Parliament acknowledges the benefits that insulin pumps have for people with type 1 diabetes in assisting with the condition; notes that between 4% and 14% of people with type 1 diabetes meet the criteria for eligibility for insulin pump therapy under current clinical guidance; notes the variation in financial provision across NHS boards for insulin pump therapy, whereby in Fife funding has been allocated for 10 pumps per year, whereas in Highland there is no separate budget despite all NHS boards having received funding for access to insulin pumps; further notes the differences in waiting times for eligible patients whereby in Lothian the average waiting time including waiting for training and education is estimated to be around 12 months and in Grampian and Orkney the current waiting time is six months; notes with concern the low level of insulin pump usage in Highland, which, at 0.9 per cent is the second lowest in Scotland, after Ayrshire and Arran; believes that further steps are required to monitor NHS boards to avoid a postcode lottery for patients with insulin-dependent diabetes, and looks forward to renewed commitment to action on diabetes in Scotland in 2010 and beyond.

I welcome the opportunity to debate access to insulin pumps and thank members throughout the chamber who signed the motion and who have deferred travelling to their constituencies and regions to be here this evening.

I warmly welcome to the gallery members of the insulin pump awareness group and representatives of Diabetes UK. On a quick personal note, I welcome my son, Andrew, to the gallery. He is doing a PhD in neuroscience at the University of Edinburgh. This is his first time in the Parliament. I hope that he is not after my seat.

Why have another debate on diabetes? As members are aware, Scotland has the third highest incidence of diabetes in the developed world. Diabetes is the main cause of blindness in those of working age in Scotland. Also, half of all non-traumatic lower limb amputations are due to diabetic complications. According to NHS Quality Improvement Scotland, diabetic care now costs £1 billion, which is 10 per cent of the national health service budget. As members will be well aware, diabetes is a condition where the body cannot use glucose properly. If untreated, it l can led to heart disease, stroke and kidney complications.

There are, of course, two forms of diabetes: type 1, or early onset diabetes, which—as the name suggests—usually develops in younger people, and type 2 or maturity onset diabetes, which in the main affects people over 40 and which is the most prevalent form of the condition.

Many members will be aware of my campaign, and that of Diabetes UK, for a high-risk screening programme for type 2 diabetes for those who are over 45 and have a family history of diabetes or are overweight.

The purpose of the debate is to argue for the greater use of continuous subcutaneous insulin infusion or—as is perhaps easier to pronounce—insulin pump therapy for eligible type 1 diabetics. The campaigning slogan from Diabetes UK Scotland is pump up the volume—it is about ensuring that those who could benefit from the improved quality of life provided by a pump are not denied one.

In its submission to the Government's consultation on better diabetes care, Diabetes UK Scotland quoted the mother of a 13-year-old boy with type 1 diabetes, who said:

"Scotland is in the dark ages as far as access to pumps is concerned. This must be addressed. Rates of type 1 diabetes on pumps is amongst the poorest in Europe—there is a real postcode lottery."

What does an insulin pump do? The pump is an external device that continually infuses insulin into the user's body and controls glycaemic levels, which many users would otherwise struggle to do. With the pump, insulin levels can be increased simply by pressing a button on the pump instead of using a pen needle, which can be embarrassing for individuals, particularly when they inject in public. I heard earlier from the pump action group that it is greatly reassuring for parents whose children have pumps to know that they have their pump with them when they are out and about at weekends and so on—that is especially the case with teenagers.

Insulin pumps empower users to have greater control over their condition as it gives them a more flexible and reliable means of managing their glycaemic levels. Improved control over health means an improvement in the quality of life, fewer hospital visits, a more productive work life and less stress at home. Fewer hospital admissions and a reduction in primary care contacts mean that there is less strain on the national health service.

Diabetes UK Scotland has argued that more than £23,000 could be saved over two years, which would comfortably offset the initial cost of providing pump therapy. It is important to consider the big picture and to compare the cost with that of poorly controlled diabetes: a one-night stay in hospital following admission to accident and emergency for a diabetic emergency costs about £410, one course of laser treatment for retinopathy costs about £850, one procedure of dialysis treatment costs £500 and renal dialysis for one year costs more than £15,000.

The National Institute for Clinical Excellence guidelines estimate that between 10 and 15 per cent of Scotland's 27,500 type 1 population is eligible for pump therapy, yet only 1.6 per cent of type 1 diabetics—roughly 448 people—have a pump. The English figure has been estimated by one consultant to be around 5 per cent. Why is there such a disparity? Do people with type 1 diabetes in Scotland have a lesser need than patients over the border? The user group for insulin pumps tells me that more than 40 per cent of eligible type 1 patients at a paediatric clinic in Leeds are on pump therapy.

I did a little international comparison. In the United States, 40 per cent of eligible type 1 diabetics have a pump. In Israel, the figure is 20 per cent, and in Germany it is 18 per cent. As the minister will be aware, in July 2009 I asked a parliamentary question on pumps. It was a simple question about the percentage of type 1 diabetics who are users of pumps, broken down by health board area. I shall give a quick summary of the response—I am glad that I have Cathy Jamieson next to me; she has taken an interest in the issue. The figure for NHS Ayrshire and Arran was a disgraceful 0.1 per cent—a dunce's cap for that health board. In NHS Greater Glasgow and Clyde it was 1.9 per cent, in NHS Fife it was 2.4 per cent, in NHS Lothian it was a bit better at 3.2 per cent and in NHS Tayside it was 4.2 per cent. I am sure that Mary Scanlon will take an interest in the figure for my local NHS board—a pitiful 0.9 per cent. I ask the simple question: if it is good enough for Hollywood, Honolulu and Houston, why is it not good enough for Highland?

Type 1—or early onset—diabetes has a peak age diagnosis of around 10 to 14 years, so those with type 1 will have a lifetime experience of the condition. A close relative of mine was diagnosed with type 1 when he was 12. He died in 2007, aged 75, having had 63 years' first-hand experience of the condition. He told me about the regular pen needle injections and having to balance each dose.

As we all know, too little insulin can lead to hyperglycaemia, coma or death. Insulin pumps give greater control over blood glucose levels, which reduces the chance of diabetics developing complications. Pumps give precise doses, which lowers blood glucose and increases life expectancy, as was confirmed by the recent diabetes control and complication trial study.

An insulin pump is about the size of a pager—and, as someone recently said to me, it is probably less irritating. It is also the closest substitute to the body making and delivering its own insulin. I accept, of course, that the cost is initially higher than the alternative, but in the long term there will be savings through fewer hospital admissions.

The big picture is to seek an end to postcode prescribing. We need to monitor what health boards are doing more closely. I am sure that the minister will mention that in her summing up. We need to ensure that health boards implement national targets.

In its response to the "Better Diabetes Care" consultation, Diabetes UK Scotland said:

"The difficulty appears to be the result of a number of pressures to the system: local resources are inefficient, business cases are slow to be made; there are pockets of professional scepticism about the effectiveness of pump therapy that spring more from a historical basis … It appears that questions around costs and accuracy of quality of life measurement remain with the health service."

I think that I have made the benefits of pumps clear. They are simply these: a decrease in blood glucose levels; a reduction in insulin levels; a reduction in severe hypoglycaemia episodes; and a fall in the number of hospital admissions.

I ask the minister to pump up the volume, to spread the word on the effectiveness of insulin pumps and to give hope and confidence to our young people and to diabetics of all ages about being able to live their lives free of diabetic complications.

We come to the open debate. As a substantial number wish to speak, I ask members to limit their contributions to four minutes.

I congratulate David Stewart on securing this debate on an issue of great importance for many families throughout Scotland. As we have heard, type 1 diabetes is a particularly unpleasant, completely unpreventable, condition. Many sufferers are subject to symptoms such as extreme tiredness, anxiety, weight loss and persistent thirst, and life expectancy is reduced by 23 years, on average.

Although the condition is not preventable, a strict regime that includes regular planned exercise, a carefully planned diet, regular blood glucose testing and multiple daily injections of insulin can allow sufferers to lead as normal a life as possible. I imagine that everyone here agrees that that cannot, by any stretch of the imagination, really be considered to be a normal lifestyle, however. Looking around the chamber, I am well aware that the vast majority of members do not have a carefully planned diet or take part in regular planned exercise—I certainly do not—never mind devoting large portions of the day to regular blood testing and insulin injections.

Colleagues will agree that any measures that can improve the standard and expectancy of life for type 1 diabetes sufferers in Scotland should be taken. It is vital that awareness and knowledge of insulin pump therapy is increased throughout Scotland.

Jenny, aged 11, lives in Fairlie in my constituency. She is insulin-dependent type 1 and has been since the age of three. Jenny has been on a basal-bolus regime since she was seven, which involves an average of six injections a day. As members will appreciate, a child who lives with 2,000 injections a year would absolutely love to have an insulin pump, which requires only a set change every three or four days.

While she was living in England, Jenny's parents asked her consultant whether she could have a pump. He said no. Because she co-operated with respect to her care and kept excellent control, she did not meet the criteria. That is equal to someone being told that it is only if they do not give a damn about their care and let the disease spiral out of control that they will be considered for the best type of treatment.

Thankfully, Jenny has continued to co-operate on her care. She asked again this year about the possibility of a pump, at Crosshouse hospital. Again she was denied. She did not meet the criteria. That insult was compounded with the closing comment, "It's only a few injections," as if a child having six injections a day has no right to seek better alternatives.

Not everyone who suffers from type 1 diabetes is eligible for the treatment, but the benefits for those who are eligible are dramatic. Although regular insulin injections work, it is difficult to achieve a perfect blood-glucose balance, which can lead to further health problems. Insulin pumps remove the element of chance by providing precise and adjustable dosing, which in turn leads to a greater quality of life and greater life expectancy.

The number of patients who receive insulin pump therapy varies dramatically, as David Stewart pointed out. Like Cathy Jamieson, I am a member for the area that is covered by Ayrshire and Arran NHS Board which, as we have heard, provides pumps to—the figure is, frankly, embarrassing—0.1 per cent of patients. Only two people in the health board area receive insulin pump therapy. In Tayside NHS Board, the rate is 4.2 per cent.

Funding for treatment is equally varied. Ayrshire and Arran NHS Board allocates funds for a mere three new pumps per year, Lothian NHS Board has a budget of £382,000 for insulin pump therapy, and Dumfries and Galloway NHS Board and Highland NHS Board have no separate budgets for the therapy.

I have information on Ayrshire and Arran, which the member might find useful. As I understand it, a redesign of the dietetic resource is going on, to support the insulin pump service. It is expected that the service will be provided by October, so pump provision should improve. I will take a close interest in the matter, as I am sure will the member.

I am delighted to hear that. I was contacted by constituents about the issue only this week. If that redesign is taking place, I hope that people whose children need insulin pump therapy will be told about it and able to access the therapy as soon as possible.

Funding is difficult to come by, of course, and the initial cost of insulin pump therapy is greater than the cost of treatment by multiple daily injections, but David Stewart elucidated well the point that embracing the technology is an investment in the health of our nation. Insulin pump therapy is a sensible and ultimately cost-effective method of treating sufferers.

The member should conclude.

I will finish on that point, then.

I am obliged.

I welcome the opportunity to speak in the debate on insulin pump provision, which is an important issue, and I congratulate Dave Stewart on securing the debate and on his dogged determination to raise the profile of diabetes in the Parliament and to highlight the need for insulin pumps. He secured a members' business debate on increasing access to insulin pumps last year; tonight's debate gives us an opportunity to reflect on progress at Scotland and health board level on ending the postcode lottery of care and ensuring access to insulin pumps for everyone who meets the criteria, wherever they live in Scotland.

It is unfortunate that, throughout Scotland, there is still far too little access to insulin pump therapy. The Government has committed to monitoring its availability closely. I would appreciate an update from the minister on that work and on how the Government plans to ensure that Scotland achieves the rates that are proposed in the NICE guidance, according to which between 4 and 15 per cent of people who have type 1 diabetes in Scotland should benefit from insulin pump therapy. Currently, only 450 people who have been diagnosed with type 1 diabetes are using pumps. If the 15 per cent rate were achieved, more than 4,000 people would be on pumps. That would be a tenfold increase on the current provision. Substantial progress must be made if we are to achieve the rates in the NICE guidance.

Scotland's record is poor in comparison with that of other western countries. Scotland is at the bottom of the league table of western health care systems' delivery of insulin pumps. In Lanarkshire, which I represent, only 1.1 per cent of the people who have type 1 diabetes have a pump—the third lowest percentage in Scotland. Even if all health boards in Scotland achieved only the minimum, 4 per cent uptake, another 651 people in Scotland would benefit from insulin pump therapy, which would undoubtedly make a difference to their lives.

Despite the existing guidance and policies and despite the apparent commitment at national and health board level, the majority of people who could benefit from insulin pumps simply do not have access to that valuable therapy. Too many diabetics continue to fight against a health service that is reluctant to grant them access to such treatment.

Although there is no doubt that substantial costs are associated with the treatment, considerable savings to the NHS can accrue when people use insulin pumps. Diabetes UK Scotland estimates that the reduction in the need for on-going clinical intervention for problems such as recurrent hypoglycaemic episodes and hyperglycaemia could result in savings of up to £23,500 per patient over just two years. Those savings could be offset against the cost of maintaining a patient on insulin pump therapy.

A recent survey by Diabetes UK Scotland found that pumps are within the top five priorities for local service development, especially for parents of children with diabetes. However, although NICE has recommended that between 15 and 50 per cent of under-12s with diabetes would be suitable for pump therapy, the latest statistics show that we have only 57 under-15-year-olds in Scotland on pumps.

Other members have mentioned Diabetes UK's campaign to pump up the volume. I am wearing my campaign badge tonight and encourage other members to do the same.

That is a good point on which to conclude.

I, too, congratulate David Stewart on securing the debate. It is appropriate that we discuss insulin pump therapy again, given the commitment that the Cabinet Secretary for Health and Wellbeing made in the debate 15 months ago:

"I will ensure that I and the Scottish diabetes group continue to monitor closely insulin pump programme availability throughout Scotland".—[Official Report, 21 May 2008; c 8840.]

Despite that monitoring, we still have pitifully low numbers of people on the therapy in Scotland—only 1.6 per cent of those with type 1 diabetes have access to insulin pump therapy.

There are many benefits to using the treatment, which has been with us since the 1970s. The large uptake of pumps in Europe and the USA is testament to the progress that has been made. The benefits of the therapy have been stated, so I will not repeat them. My colleague Nanette Milne made a good point in the previous debate when she described it as

"a spend-to-save provision that concurrently leads to improved quality of life for successful users of the technology."—[Official Report, 21 May 2008; c 8833.]

The National Institute for Clinical Excellence's technology appraisal 151 also fully endorses the value-for-money argument.

It is recognised that not everybody is suitable for an insulin pump. As the motion states, only 4 to 15 per cent of people with type 1 diabetes meet the current criteria for the therapy. It also needs a commitment from the patient, backed up with support from the health care team. However, the benefits are evident.

As Karen Whitefield said, only 57 children in Scotland currently use pump therapy, but according to NICE's estimates, it should be at least three times that. In the Highlands, as David Stewart mentioned, the figure is embarrassing—a word that Kenneth Gibson used—to say the least and probably pitifully low. I understand that no patients under the age of 18 use insulin pump therapy in the Highlands, despite its being available in many other health board areas in Scotland.

The other health board that I will mention is the one that is covered by my colleague John Lamont, who would have liked to attend the debate but has another commitment. He has been contacted by a constituent whose 11-year-old son needs, and is appropriate for, an insulin pump, but has been told by NHS Borders that there is no money for it. I know from parliamentary answers that one person under 15 in the Borders is on the therapy. As other members have done, I ask the minister to comment on what appears to be a rationing policy, if not postcode prescribing. Given the fact that all health boards should have an insulin strategy that covers the full range of insulin use, I also ask the minister to look into the situation in NHS Highland.

I have also been made aware of patients in the west of Scotland who have been described as being "neurotic" for urging consultants to consider the insulin pump therapy option. As David Stewart said, a treatment that can end daily injections and the embarrassment that they can bring, and which can reduce worry, allow more flexible eating and improve care quality and sleep patterns for patients must be encouraged.

In my opinion, the main benefit must be the long-term improvements to health. Diabetes increases the incidence of many life-threatening conditions, but I am told that insulin pump therapy can protect the vital vascular system from that future deterioration.

The member must conclude.

I will leave it there.

As has been said, Parliament had the opportunity to discuss this important matter in May 2008. I thank Dave Stewart for securing this evening's debate and for rightly keeping the matter to the fore. He clearly outlined the cost benefit for patients and the NHS, so I will not go over that.

Members know that this time is set aside during the parliamentary week to allow members to highlight issues. No decision is taken on the debates, as the Presiding Officer always reminds us, but we listen carefully to what the final speaker—the minister—has to say. At the previous debate on the issue, the Deputy First Minister and Cabinet Secretary for Health and Wellbeing told us that the Government was

"committed to ensuring that people with type 1 diabetes who meet the criteria should have access to the insulin pumps that deliver therapy."—[Official Report, 21 May 2008; c 8838.]

I welcomed that commitment, but I am told that people who meet the criteria are still not getting quick access to that therapy. We have heard during the debate how such access varies around the country.

One of my constituents raised with me the experience and difficulties that his young relative has had in that regard. That young man, who is now 16, was diagnosed with type 1 diabetes four years ago. The diagnosis was a nightmare for him. He was and is needle phobic, so members will understand the other difficulties that he has to live with daily. Last summer, he became unwell and, while looking for ways to feel better, started chatting to other young people via the internet. Sadly, he had never met anyone of his age with type 1 diabetes because he was, on diagnosis, referred straight to adult services. I am sure that people will agree that that is a sad situation for a young person. Many of the young people whom he sought out and spoke to told him that they used insulin pump therapy, and that it had brought great benefits to them, to the quality of their lives and to that of other family members.

Over the past year, that young man and his mother have had a long and stressful battle with the NHS to get a pump. He is sure that his symptoms, his swings in blood-glucose levels and the negative impact that they have on his quality of life and ability to enjoy everyday things would be greatly improved if he had pump therapy. His family are still hopeful that he will get a pump, because they believe that he meets the criteria that have been set. However, he needs the pump now, at a time in his life when he has so much to do to complete his school education and get qualifications that will open doors on the quality of his life and his aspirations for the future. However, he still does not have the pump.

That was a short story about a young 16-year-old boy. We heard Kenny Gibson give the example of a young girl in his constituency. I am sure that the story can be replicated across the country—there are loads of people out there with similar experiences. I say to the minister that, although we welcome the commitment that was given last year, it is not good enough that people's quality of life is being wasted—we need action now. We have heard the arguments about the cost benefits, and I am sure that we all accept that they are right. People who meet the criteria should therefore have pump therapy now. I believe that the minister has the power to direct the health boards in that regard. I know that the boards should drive the issue, but I ask the minister to use the power that she has to direct boards to get on with the work and improve the quality of so many people's lives up and down the country.

I, too, congratulate David Stewart on securing the debate and on his continued interest in the matter.

I must make a declaration of interest, Presiding Officer, but it is not one that you will find in the members' register of interests. Nevertheless, it is appropriate on this occasion. I have been a type 1 diabetic for 44 years. I am very sparing in the public contributions that I make to debates on diabetes, but I regard the issue as singularly important. I therefore elected to seek to contribute to the debate, and the Presiding Officer granted me permission to do so.

I am philosophically very opposed to categorising people into great cohorts. One real difficulty that arises from the tremendous surge in the numbers of diabetics is that people suddenly find that they have become simply a type 1 or a type 2 diabetic. If we are to treat people at all, we need to treat them as individuals. That could not be more true than in the case of diabetes, given that the individual who suffers from diabetes can exhibit a wide range of different symptoms. For example, I do not have a pump—I am not entirely persuaded that my medical advisers think that I am well-balanced, but that might be more to do with my mental state than with my balance in terms of an insulin regime. Individuals are different, and they need to be treated as individuals.

One or two issues need to be raised in any debate on pumps. We cannot simply take pumps in isolation. As an individual, I am increasingly concerned about the lack of awareness on the part of those who deal, very earnestly and honestly, with people who have a diabetic condition. There is sometimes a lack of understanding and awareness of the condition and the individual nature of the treatment. Some people in the health service are excellent—do not get me wrong about that—but I find too often that people do not understand the condition and therefore fail to communicate to the patient the necessary understanding of what diabetes is and what it is about. I am astonished that, even with the introduction of the excellent DAFNE—dose adjustment for normal eating—programme, I meet people who believe that they can control their diabetes only by insulin and by nothing else. They hopelessly misunderstand other elements that are necessary. Therefore, I believe that we cannot make progress on insulin pumps against a background in which those who give advice on diabetes do not communicate an adequate understanding of the condition to those who suffer from it.

Nevertheless, I am absolutely clear that the present number of people who have access to pumps, and the way in which that access is given, is—to be honest—totally and completely unacceptable. The new National Institute for Health and Clinical Excellence guidance has been an improvement, but there are two issues with the guidance, one of which Kenny Gibson mentioned when he talked about his constituent Jenny. The guidance suggests that people should become eligible for a pump where insulin therapy has "failed". There are good medical reasons for that, but the use of such phraseology is unfortunate. Insulin pumps should not be regarded as available only for those for whom insulin therapy has failed. The adjudication should be on the basis of individual need, not on a presumption of failure. In addition, the guidance suggests that insulin pump therapy should be made available to under-12s when multiple injections are regarded as "impractical or inappropriate". That recommendation acknowledges that a degree of subjectivity is involved, yet the guidance does not permit enough people to be eligible.

The insulin pump awareness group and Diabetes UK are to be congratulated on their recent campaign. The figures are unacceptable: far too many people are suffering who should not need to suffer. I hope that we can agree that, as well as widening our understanding of what diabetes is and what is necessary to control it, there ought to be a substantial increase in the number who are eligible to access pump therapy in Scotland.

I congratulate David Stewart on continuing to bring to our attention an issue that is of great significance to far too many people throughout Scotland.

Let me welcome a number of the campaigners who are in the public gallery tonight. They include Fiona Campbell, who is from my constituency. Unfortunately, Dorothy Farquharson from my constituency, who had intended to be present, is unable to be here due to illness. The other campaigners from the west of Scotland include Martyn Cross from Barrhead—in Ken Macintosh's constituency—who is a young beneficiary of insulin pumps.

I must gently chide David Stewart on his pronunciation. In comparing where insulin pumps are available, he said that they are available in Hawaii but not in Highland, and in Houston but not in Highland. I think he meant Houston, Texas, because, as his figures showed, people who live in Houston, Renfrewshire, do not have the same access to insulin pumps, which, as Ross Finnie, Mary Scanlon, Karen Whitefield and others have said, is an absolute disgrace.

In the conversation that I had with the campaigners this afternoon, I was struck by the difference that appropriate access to insulin pumps has made to people's quality of life. Ross Finnie is right—they are not for everyone—but when they are for someone, they can make a huge difference. Fiona Campbell described to me what a huge difference having a pump has made to her—I hope that she does not mind me using her case as an example. For 20-odd years, she had to go into hospital every two to three weeks because of issues to do with her diabetes, but since she has had access to a pump she has had weeks and months when that has not been an issue.

Leaving aside the human benefit to Fiona, if the cost benefit that is associated with that relief were repeated, the benefit to the health service would be huge. It is true that an up-front investment of £2,500 to £2,700 per pump is required, but the long-term benefits to the health service are incalculable, as is the difference that use of a pump can make to the quality of life of the people concerned. The case has been made for those to whom a pump is available.

One thing about this afternoon's conversation that disturbed me is the uncertainty that still exists among clinicians. Fiona was told that it would be dangerous for her to have a pump but, now that she has used a pump on a trial basis, she has been told that it would be dangerous for her to come off it. It is clear that there is an issue for politicians and health boards to address, but that inconsistency of approach suggests that there is also an issue for clinicians.

Fundamentally, what we are looking for, as Mary Scanlon said, is a commitment to progress. The warm words of a year to 15 months ago are appreciated, but now it is time for delivery. The minister and the cabinet secretary should use their undoubted influence so that progress on the matter can be made right across Scotland.

At this stage, I would be prepared to accept a motion without notice to extend the debate by up to 10 minutes.

Motion moved,

That, under Rule 8.14.3, the debate be extended by up to 10 minutes.—[David Stewart.]

Motion agreed to.

I, too, am pleased that David Stewart has secured the debate and thank him for his efforts in doing so. My comments will be fairly brief but, given that I chaired the breakfast meeting on insulin pumps that the cross-party group in the Scottish Parliament on diabetes held before the summer recess, I thought that I should make a short contribution to this important debate.

I am sure that the members who are present who also attended that breakfast meeting will have been as impressed as I was by the enthusiastic support for their pumps that was expressed by the patients who possessed them, and by the medical presentation about the effectiveness of pumps in improving glycaemic control in suitable patients. A gentleman from the London area gave us a notable account of his experiences. His blood sugar was maintained at stable and near-normal levels, and his quality of life had improved enormously since he began to use his insulin pump.

That was in stark contrast to the frustration of those who could have, but do not yet have, insulin pumps, which was expressed forcibly by members of the insulin pump awareness group. Their pleas were quite moving because it was clear that they or their children were having a hard time controlling their diabetes and that their quality of life was less than ideal.

It is quite concerning that, across Scotland, an average of just over 1.5 per cent of type 1 diabetic patients currently use pumps, when NICE guidance indicates that up to 14 per cent of patients should be considered as suitable users of pumps. It is also concerning that there is considerable variation in health boards' provision of the service and in waiting times for pump provision.

I know that health boards are having to look carefully at their budget priorities at a time of increasing financial constraint, but the provision of insulin pumps to appropriate patients is undoubtedly a spend-to-save exercise, as the resultant improved blood sugar control and reduced incidence of complications will inevitably lead to fewer primary care contacts and fewer out-patient and in-patient hospital attendances. As David Stewart told us, according to one published study, that will mean an estimated saving of around £23,500 over two years, which surely represents good value for money.

Pumps are also popular with patients. It is notable that they are popular with parents of children and adolescents with type 1 diabetes, who will be confident that their offspring's blood glucose is easier to control effectively, with less risk of severe and incapacitating hypoglycaemic episodes. As Ross Finnie said, the NICE guidance recommends pumps for children under 12 if multiple injections of insulin are reckoned to be inappropriate or impractical.

This is not a good time to urge health boards to spend extra money. They are looking to tighten their financial belts. However, if insulin pumps are used for appropriate patients according to up-to-date NICE guidance, they will soon pay for themselves in savings for the NHS. I hope that the minister will look to health boards to make sensible investments in insulin pump therapy, to ease the postcode lottery for patients with type 1 diabetes, to help those whose condition is suitable for such therapy to lead less complicated, more enjoyable and healthier lives, and to avoid some of the complications of such a serious long-term condition.

I, too, congratulate David Stewart on securing the debate, which is the third debate on diabetes in the Parliament. As Nanette Milne said, we received a helpful briefing on the subject at a breakfast meeting. From that, I thought that it was now beyond dispute that patients' lives can be turned round and transformed by pumps, and that no one should need to be convinced of that.

As Kenny Gibson and Ross Finnie said, it is inappropriate to see pumps as being only for people whose treatment fails. They are for people who have particular problems that need to be treated. There is a catch-22 situation that needs to be considered.

I want to ask a series of questions rather than make a speech. I assure the minister that I do not expect all those questions to be answered today, but perhaps they could be answered in due course.

Sixteen months on, why is the usage figure at only 1.63 per cent? Why has only one health board met the lower level of the NICE target, which is 4 per cent? Does the minister accept the guideline figure of up to 14 per cent, or is there another Scottish benchmark? In her accountability reviews, has she raised with any boards their poor performance on this? It is 14 months since we first debated the matter. Cathy Jamieson was then promised that there would be contact with all health boards that were performing poorly. Has that been done? What was their response? Perhaps the minister could place a detailed response to that question in the Scottish Parliament information centre.

The situation in Ayrshire and Arran is appalling. For the health board there to say to David Stewart that it plans to reach 1 per cent usage in three years indicates that we are not really getting a grip of the matter. If a board thinks that it can get away with a level of 1 per cent three years on, it must be asked serious questions.

The other two areas in which there is pump usage of 1 per cent or less are Highland and Greater Glasgow and Clyde, which has not been mentioned in particular. The usage there is 1 per cent. That is one of the biggest areas. There is mass deprivation in it and serious diabetes complications. What on earth is NHS Greater Glasgow and Clyde doing?

How many and which boards have committed specific spending to pumps? How many have now produced business plans? Perhaps information on that could be placed in SPICe. How much of the change and innovation funds, which are now called health improvement funds, has the Government allocated to redressing the balance and dealing with what is becoming a national scandal? What steps will the minister take to ensure rapid progress to the minimum target?

We have found it difficult to interrogate boards on waiting times—that is also clear from answers that David Stewart has obtained. The outliers appear to be Grampian and Orkney at six months. Is there a common data set and common collection? If not, why not? Will that be part of the 18-week referral-to-treatment guarantee?

I appreciate that there are many pressures on the ministers, not least as a result of swine flu over the summer and upcoming legislation on tobacco and alcohol, and that it is not their job to micromanage the service. However, the second most important fact in considering the issue is that rapid implementation will bear fruit in efficiency savings, as members have said. Will the minister indicate a model for efficiency savings that can be placed in the boards' efficiency savings targets? That alone will encourage them to spend money in order to save.

The most important fact is that patients have a better quality of life on insulin pumps when they are suitable for pumps. The issue needs to be dealt with before it becomes the subject of a main debate for one of the parties, which will require a decision to be made.

I acknowledge David Stewart's long-standing commitment to the issue in the Parliament. As members have said, the Cabinet Secretary for Health and Wellbeing noted in her reply to the debate last year that the Parliament would want to monitor the issue closely. This afternoon's debate shows that she was correct in that prediction.

I fully understand the concern of the insulin pump awareness group and Diabetes UK Scotland that those who would benefit should have access to insulin pump therapy. We know that enabling people to achieve better control of their diabetes can promote confidence in their ability to manage their condition and that improved control reduces the devastating complications of diabetes, which members have mentioned. I am also aware that we are, in the main, talking about young people with type 1 diabetes, who have to manage their condition along with all the other things that they have to cope with, especially during adolescence. I can well sympathise with the anxieties of their parents, who naturally want to ensure that their children are getting the best possible care.

For all those reasons, it is already our national policy that each NHS board should have an insulin strategy that covers the full range of insulin usage, including insulin pump therapy. Ross Finnie made the important point that an insulin strategy must cover all the issues, including communication with patients. We expect NHS boards, in considering their approach to insulin pump therapy, to be guided by the latest evidence on clinical effectiveness. As members have mentioned, that is set out in technology appraisal guidance 151, which was published in July 2008 by NICE and has been validated for Scotland by NHS QIS. Under that technology appraisal guidance, insulin pump therapy should be considered as an option for adults and for children over 12 when multiple dose insulin therapy has failed. I take the point that some members have made about insulin pumps not being used only in response to the failure of other therapies. I will go back and have discussions on that point. Pumps are recommended as a possible treatment for children under 12 with type 1 diabetes if treatment with multiple daily injections is not practical.

Despite the concerns that have been raised, which I totally understand, access to pumps in Scotland has improved, although at a more gradual rate than many would like to see—I accept that. As members have pointed out, there are unacceptable variations between NHS boards in terms of the availability of pumps. So, although we have seen, I think, a 66 per cent rise in the use of pumps throughout Scotland since 2007, the baseline figure was unacceptably low and a lot of progress still requires to be made. I have asked the Scottish diabetes group to keep me regularly informed of progress, and I will write to NHS boards, reminding them of the need to make progress.

The Government is currently undertaking work to review the Scottish diabetes framework. I do not expect the minister to tell us what will be in the revised document, but can she give us an assurance that there will be concrete measures in the revised framework to ensure the roll-out of insulin pumps throughout Scotland?

I will come on to the framework in a minute.

Some of the credit for the progress that has been made—albeit that there is still more to do—must be given to the measures that we and the Scottish diabetes group have put in place. Chief among those is the regular reporting of the position on a board-by-board basis. Pump availability is a standing item on the agenda of the regular meetings that our lead clinician for diabetes has with the clinical leads of the diabetes managed clinical networks.

The measures also include events such as the very successful insulin pump study day, which the Scottish diabetes group organised in May. The event brought together more than 60 health care professionals to learn more about insulin pumps from patients, specialists and suppliers. I welcome the fact that other such events are likely to be held in future years. It is at such events that we can perhaps address some of the points that Hugh Henry raised about the differing views among clinicians.

We acknowledge the need to do more, though, and there are a number of opportunities to do so. The Scottish intercollegiate guidelines network is reviewing its guideline on the management of diabetes. I do not want to pre-empt SIGN's work, but the indications are that its advice is likely to be much in line with the NICE technology appraisal. The revised guideline will be accompanied by a resource impact appraisal. That should clearly establish for NHS boards the costs and benefits of further investment in insulin pump therapy over and above other insulin therapies, and encourage them to develop their insulin pump provision appropriately.

The Scottish diabetes group's short-life working group on type 1 diabetes is developing a template for insulin strategies that will help to promote consistency of approach at board level. The availability of insulin pumps within each board will be recorded in the Scottish diabetes survey from this year onwards. That will help to formalise the collection of information on insulin pump usage across Scotland, allow boards to compare their progress with progress in other boards and enable the Government to carefully monitor that progress.

That approach will be supplemented by Diabetes UK Scotland's plans for its pump up the volume campaign, through which it will ask NHS boards to ensure that those who would benefit from a pump are not denied access. The campaign will ask boards to indicate the level of resources that they will allocate to pump provision over the next five years.

The Scottish diabetes group is aware of the need to develop a standard approach to calculating the waiting times for access to insulin pump therapy, which is one of the other issues that is covered by the motion. It needs to be made clear, at the very least, whether the waiting time includes waiting for the essential education and training that are required before someone is able to manage a pump.

Insulin pump therapy and structured education are two of the key issues that are discussed in the consultation document on the revision of the 2006 diabetes action plan, which I launched in May this year. That revision gives us the chance to pull together all this work. The consultation specifically asked for thoughts on how the appropriate availability of pumps should be increased, and what support structures need to be in place to ensure that insulin pump therapy is fully effective. The word "appropriate" was included deliberately, because we need to be a little bit cautious in this area. Insulin pump therapy requires determination and commitment on the part of the person with diabetes. It does not inevitably lead to better control of blood glucose levels. Children, in particular, need continuing care, especially during the transition through adolescence and into adulthood. The choice of insulin regime should be reached by agreement between the person with type 1 diabetes and the team supporting their care—I think that that was one of the points that Ross Finnie made.

In framing the section of the revised action plan that deals with insulin pump therapy, I can give a guarantee that we will take account of those responses, as well as the points that have been made in the debate. I am happy to come back to Parliament to give members that information. Richard Simpson asked a number of questions, and I will ensure that he gets answers to them. I will make those answers available to others, too, if they would find that helpful.

Meeting closed at 17:53.