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Lord Avebury: There is an absolute discretion in the Secretary of State's hands to decide that a particular jurisdiction—for example, Iraq and Zimbabwe—do not give people a fair trial. Does not that put too much on to the shoulders of the Secretary of State to decide in which particular foreign jurisdictions he will disregard such convictions?

Lord Filkin: First, we do not believe that he will be challenged by the volume of cases—not many cases of this type will come before him. Secondly, I do not believe that the provision is too big a burden. I believe that properly advised on the facts that he should bear in mind, he will be able to make such a judgment and will be well advised about our knowledge of the criminal law system in those countries. Were he thought to be wrong, clearly there is the possibility of an adjudicator or an IAT overturning his decision in such cases.

I want to reflect on some of the points made. We stand firm to the importance of seeking, with the protections that the clause allows, to remove people who have committed serious offences, but we will reflect on the points made in the debate.

7.45 p.m.

The Countess of Mar: Once again, I declare my interest as a member of an immigration appeals tribunal. I have listened most carefully to what the Minister and other noble Lords have said but know that we on the tribunal are already dealing with such cases reasonably satisfactorily. We are not given details of what is a serious crime and how long a sentence to consider, but we are asked to use our judgment as citizens of the United Kingdom. I have not yet been responsible for a case that has gone to judicial review.

I wonder why the Government believe it necessary to draft the clause in these terms. Perhaps the Minister could explain that.

Lord Filkin: I shall seek to be brief. The Government believe that there is no adequate definition in statute of what are serious crimes and that it is beneficial to provide one. In order to be part of the process of marking the seriousness of the matter, we expect people who have the protection of this country to behave responsibly and to make it clear that there are circumstances in which we would act to remove. We believe that it is necessary to do so.

Lord Kingsland: I thank the Minister for his response. He accepts, as do I, that there are

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imperfections in the solutions offered by the Bill and by my amendments. There are advantages and disadvantages in both. I have not undertaken a systematic analysis of the number of offences showing how, as regards a particular offence, each of the two systems would impinge.

The Minister accepted that for England and Wales the best solution would be specific listing in the Bill. He made no criticism of that, except to say that there would be difficulties in Scotland.

Lord Filkin: The noble Lord is accurate in his recollection of what I said, but he would be wrong to infer that I thought the listing was automatically perfect. I gave an undertaking to consider the pros and cons of the listing and the alternatives.

Lord Kingsland: I hear what the Minister says. If he can find no criticism, when on his feet giving a reply on behalf of the Government to the solution of listing, in contrast to the criticisms he made of the other two systems before him, there must be a presumption—and I allocate no degree of strength—that that is the best solution of the three. Accordingly, the Government, unless they have good arguments to the contrary, ought to adopt it. Of course I accept that that might mean a separate approach in Scotland from England and Wales, but that is not beyond the scope of the Bill.

Lord Filkin: It might be that uncharacteristically and unusually the noble Lord is trying to take advantage of my attempt to be brief and my genuine commitment to examine the issues. I repeat for the third time that we will examine the matter without a presumption either way.

Lord Kingsland: I am aware that we are long past the accorded time for the evening adjournment. I shall not therefore press further what I regard as an extremely strong argument on my behalf.

I thank the Minister for agreeing to consider it. We have two-and-a-half months between now and our return in October. I hope that the degree of serious consideration by the Minister will be proportionate to the length of the break. In that spirit, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 182 to 184 not moved.]

Lord Bassam of Brighton: I beg to move that the House do now resume. In moving the Motion, I suggest that we return to this business not before ten minutes to nine.

Moved accordingly, and, on Question, Motion agreed to.

House resumed.

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Diabetes

7.50 p.m.

Lord Clement-Jones rose to ask Her Majesty's Government what progress they are making on drawing up the Diabetes National Service Framework; and whether specific funding will be allocated to implement it.

The noble Lord said: My Lords, I have two key reasons for initiating the debate tonight. First, I seek to raise the question of the timing of the implementation of the Diabetes National Service Framework; and, secondly, to ask whether adequate funding will be allocated to ensure that the NSF itself will be properly implemented.

In speaking today I wish to pay tribute to bodies such as Diabetes UK and the all-party group chaired by my honourable friend Adrian Sanders. They have campaigned tirelessly for recognition of the seriousness of diabetes and improvement in diabetes care nationwide.

First, I shall set out a few facts. Around 1.4 million people in the UK are diagnosed with diabetes, with an estimated further 1 million people with undiagnosed diabetes; that is, they are unaware that they have it. Those figures already represent the largest chronic disease group in the country and diabetes is one of the fastest increasing conditions. It is estimated that about 3 million people will have diabetes in the UK by 2010.

Estimates of the costs of diabetes vary. The Kings Fund TARDIS report, published in 2000, put annual NHS expenditure at £1,738 per capita for patients with type 2 diabetes, or around £2 billion per annum, to which should be added the higher costs of 250,000 type 1 diabetes patients. Diabetes UK considers that diabetes accounts for as much as 9 per cent of the annual NHS budget. That represents a total of approximately £5.2 billion per year. Yet the potential for making savings by addressing the management of diabetes could be considerable. In his recent report, Professor Rhys Williams of Leeds University stated that £1.38 could be saved from the treatment of complications for every pound spent.

Diagnosis takes place on average nine to 12 years after the onset of the disease. As a result, up to 50 per cent of patients already show signs of complications at the point of diagnosis. These include heart disease, stroke, renal failure; retinopathy often leading to blindness; and neuropathy often leading to amputation caused by persistently raised levels of blood glucose damaging the nerves and the large and small blood vessels. The complications account for 80 per cent of diabetes-related costs. In Testing Times, the Audit Commission reported that hospital costs for people with diabetes are six times greater than for those without the disease.

People with diabetes can have a fivefold increased risk of developing cardiovascular disease. All in all, diabetes can shorten life expectancy by as much as 30 per cent. It is the fourth leading cause of death in the UK.

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Growing levels of obesity in the population mean that, horrifyingly, we are seeing for the first time ever teenage children developing type 2 diabetes. The trend is set to continue, with almost one in 10 of under-11 year-olds categorised as obese. Girls are particularly at risk. In a recent Plymouth study, one-third of five year-olds were found to be overweight. With one in five of the adult population classified as obese, that means an inexorable and exponential growth in type 2 diabetes.

In the light of those alarming facts, it is extraordinary that diabetes is not formally included in the Government's top priorities in the NHS Plan, alongside heart disease, cancer and mental illness.

Secondly, I turn to a brief history. In January 1999, the then Secretary of State for Health, Frank Dobson, announced the establishment of the Diabetes National Service Framework. Although it was intended that the national service framework should be implemented from April 2002, a 12-month delay was announced in October 2001 by the Minister responsible at the time. The first published stage of the NSF was the launch last December of a standards document, itself delayed by over a year. The standards document has been welcomed by diabetes organisations as the first step towards the prioritisation of diabetes and meeting the needs of people with the condition.

Those standards have the potential to provide a platform for massive improvements across standards of prevention, management and care, in particular early and effective treatment and good clinical care that will lead to the prevention of complications. However, it is extremely disappointing that the standards have been published without the necessary delivery strategy, resources or milestones to support implementation. It is unacceptable that the needs of people with diabetes have been put on hold and implementation delayed until April 2003.

It is essential to ensure that no further delays hamper the implementation of the NSF and that the delivery strategy will be published this summer. Can the Minister give the House that assurance today?

However, there may be something of a silver lining. Type 2 diabetes has been described as,


    "first and foremost, a primary care condition".

Primary care trusts will play a vital role. Yet it is clear that many GPs have little interest in diabetes and inadequate skills in its management. Despite the delay, or perhaps because of it, there is now an opportunity for PCTs, with their new responsibilities under Shifting the Balance of Power and the National Health Service Reform and Health Care Professions Act 2002, to ensure that they prepare fully for implementation and undertake local assessments of the diabetes services that they provide.

I hope that the delivery strategy will address fully all the issues that must be considered with regard to implementation. I shall list only a few of them: the key need for partnership in service planning, involving people with diabetes; the major problems with staffing levels, since a recent Diabetes UK survey revealed that only one in five health authorities had the recommended number of consultants, and there is a

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huge shortage of specialist diabetes nurses; the need for commonly accepted blood glucose control targets; and the need to ensure the early identification of diabetes. What is the department doing to evaluate some of the diagnostic tests and screening techniques that have been developed to detect diabetes early? Surely it cannot be right that the UK National Screening Committee is due to report to the department on this only in 2005.

I come to the issue of funding. Increased resources are key to this matter. This year the Chancellor's Budget released a great deal of extra money for the NHS. Diabetes must get its fair share. Those charged with implementation on the NHS frontline must be supported with new money and given incentives to meet agreed diabetes standards. At the same time it must be recognised that spending on the prevention and management of diabetes now will save money as well as lives over the long term, as the complications of diabetes can be delayed or avoided.

As yet, the Department of Health has refused to make any commitments on additional resources to fund the NSF. With the Comprehensive Spending Review behind us, can the Minister give the House some answers today? The adequacy of funding is a real issue. The interim Wanless report used a 3 per cent per annum increase in the prevalence of diabetes as the basis for its calculations. The final Wanless report suggests that the NSF will cost an extra £600 million per annum to implement by 2010, but attributes the majority of that cost to improved care programmes and only a modest increase in prevalence.

In fact, however, in a Written Answer dated 8th May 2002 to a Parliamentary Question put by David Stewart MP, the Minister, Jacqui Smith, stated that the estimates submitted by the Department of Health to Wanless anticipated an increase in the number of diabetes patients from 1.3 million in 2002 to 1.8 million in 2011, representing an increase just short of 40 per cent. That is hardly modest.

In addition, one must take into account the undiagnosed population. If one increased the numbers with only half of the undiagnosed group, together with those already referred to, then the number of diabetes patients would rise by up to 900,000. Based on the average cost of treatment set out in the Wanless report, that could increase NHS costs by the best part of £1 billion. In that light, a £600 million increase looks seriously inadequate.

All this bears out the magnitude of the problem and suggests that the funding proposed in Wanless is far short of what is required. One need only to compare the estimated growth of resources devoted to diabetes in the period to 2010 of 5.3 per cent with the increases anticipated for coronary heart disease at 8.3 per cent, 8.8 per cent for mental health and 6.2 per cent for cancer to see the problem. The Department of Health needs to revisit its assumptions as a matter of urgency.

We face a formidable implementation agenda. If we do not address the issues that I have raised today then, as Professor Rhys Williams said in his report, the NHS risks being overwhelmed by diabetes. I look forward to the Minister's reply.

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8 p.m.

Lord Harrison: My Lords, diabetes is not a lot of fun. As an insulin-dependent diabetic, when you first get the disease under control you are like one of those aliens in early sci-fi films who is sent to earth as a sleeper to infiltrate the general population. Everything on the surface is normal. Only the tell-tale signs—a packet of dextrose to counter a hypoglaecemia; an insulin pen, colourfully disguised but which is just too big to be a fountain pen bulging in your pocket; the abrupt spitting out of a cup of tea that has been wrongly laced with sugar—reveal you to others in the know as one of the brethren.

Later, if complications set in, you feel like a latter day Errol Flynn, parrying the various epee thrusts of eye disease, renal problems or foot ulcer, each of which can administer the fatal stiletto hit. Swashbuckling is for the movies, not for diabetics who are daily trying to balance lives, work, personal relationships and, of course, their daily shots of insulin.

In Banting, Best and Dorothy Hodgkin, discoverers and developers of insulin, we diabetics do, of course, have our medical heroes, along with our local GPs, diabetic nurses, hospital consultants and the long list of carers made up of friends and family who, in turn, become adept at recognising the onset of a hypoglaecemic reaction and who thus spot the right occasion when, "Yes, he does take sugar".

We have our heroes who are sufferers. Back in time to novelist H.G. Wells; "Goon", but not forgotten, comedian Harry Secombe; former Tottenham Hotspur football captain, Gary Mabbut; and finally, of course, Olympic rowing champion, Sir Steve Redgrave, in whom, if he will forgive the pun, we all stand in awe.

I thank the noble Lord, Lord Clement-Jones, for initiating this vital and opportune debate. I, too, associate with his praise of Diabetes UK.

The Government displayed their willingness to take on diabetes and defeat it by publishing the standards for the National Service Framework for Diabetes in December last year. The parlous state into which funding the fight against this disease had fallen is cogently set out by the Secretary of State, Alan Milburn, in his preface to that document. He declares:


    "Compared with other European countries, Britain has a poor record of blood glucose control and blood pressure control. We have",

he continues,


    "higher rates of heart attacks and strokes, foot ulcers, renal failure and nerve damage",

than the rest of the EU.

The central question is whether the Government will provide the money and resources to ensure that the ambitions of the NSF can indeed be fulfilled. It has been a major disappointment among the diabetic community that the publication of the NSF delivery strategy has been delayed until summer 2002, and that the implementation of the framework has been delayed until April 2003. Summer has arrived. Can my noble friend the Minister, whom I welcome here today, tell us where the strategy paper is? Secondly, can she

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give us an assurance that its implementation will not be further delayed and, when it is implemented, that it will have the wherewithal to make it happen?

Will my noble friend further ensure that, at the implementation stage, local health authorities are clear that this must be one of government's funding priorities and that diabetes care must feature in all future local health improvement programmes? Will she also ensure that GP practices will be helped in meeting agreed diabetes standards by receiving additional central funds? I also wonder whether the Government will be sympathetic to appointing a diabetes czar to help the 300 primary care trusts deliver the strategy.

There will be a significant pay-back for the Government if this money is applied in a timely fashion. Diabetes care consumes almost 10 per cent of the national health budget. The more that is done to diagnose diabetics early before complications set in—and there are some 1 million diabetics undiagnosed whose condition is typically not discovered a decade after the onset of the disease—the more likely it is that diabetics can lead productive and fulfilling lives longer and thus be less of a burden on the state. After all, some one-twelfth of the Government's total health budget is spent on picking up the pieces of the complications that arise from diabetes—an arresting statistic.

In the light of this and the fact that diabetes is a major killer that tracks closely the socio-economic deprivation in the general population, and that it affects some 2.5 million people in the UK, perhaps I may register my surprise that diabetes has not been cited as a clinical priority in the public service agreement targets published early this week in the otherwise very welcome comprehensive spending review. Can my noble friend solve this mystery? Can, indeed, my noble friend say on what basis her department determines national clinical priorities? Is it the prevalence of a disease? Is it the financial cost borne by the NHS? Is it health inequality? Or are the criteria the levels of morbidity and mortality? It would help to know.

By acting now on the near pandemic of diabetes, the Government will achieve some of their other major health objectives in relation to children, older folk and heart disease. One pound in every five spent on heart disease, for instance, is diabetes related.

But money is not the whole story. Both inside and outside the doctor's surgery, spreading secure knowledge of the facts and characteristics of diabetes can pay enormous dividends. I give but one example from the 12 areas of concern set out in the standards document where we could do better by increasing professional and public understanding of the disease. I refer to the care of diabetics during their stay in hospital. Despite the good intentions of all involved, I have experienced at first hand the lamentable state of knowledge of some hospital staff with respect to, say, the timing and administering of insulin injections, and the very poor understanding of the complementary therapy of giving a diabetic patient an appropriate

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diet. A diabetic diet is a normal, healthy diet, not one clogged up with compulsory sponge puddings and chips with everything, as I have been offered in hospital.

Indeed, will the Minister take note of the report published today which highlights the startling imbalance of advertising budgets for a good, healthy diet of fresh fruit and vegetables and those for poorer diets of fatty foods and sugar-added preparations which are clearly features in the rise in incidence of diabetes among children.

I opened by declaring that being a diabetic is no fun—and it is not—and that much can be done through implementing the NSF to improve the lives of sufferers and help the sterling ranks of those who care for diabetics. But let me conclude with perhaps the best bit of fun that I have had related to my condition as an insulin-dependent diabetic for the past 34 years. Some 10 years ago, as an MEP with some expertise in the application of regional funds, I was summoned to the royal palace in Monaco to participate in a small conference concerned with the pollution of the Mediterranean, a subject dear to the heart of Prince Rainier, who hosted this exclusive EU initiative. Following a productive morning of eˇchanges de vues, the speakers were invited to a relaxing lunch, at which, I might add, there was not a chip nor a sponge pudding in sight.

Before sitting down with the Prince, I had to find a bathroom to perform my pre-prandial insulin shot in privacy. Imagine how privileged I felt to be shown to the royal loo itself, a privilege entirely denied to my non-diabetic colleagues. On rejoining the royal company, I rejoiced in the fact that my condition had enabled me to penetrate one of the finest royal loos of Europe. I tucked into my fresh fish with a feeling of immense pleasure. I thought that at the conclusion of our debate on diabetes I would bring this cloacal story to your Lordships, here in the Chamber in what is, after all, appropriately called the House of Lords.

8.10 p.m.

Lord Dixon: My Lords, I, too, congratulate the noble Lord, Lord Clement-Jones, on introducing this important debate. I begin by declaring an interest as a member of the Parliamentary All-Party Diabetes Group. I am also one of the 1.4 million persons in this country to whom the noble Lord, Lord Clement-Jones, referred who are diagnosed as diabetic. I have type 2 diabetes.

From my personal experience, I believe that advice is vitally important in tackling this common and dangerous disease. Here, I should like to pay tribute to Diabetes UK, which is the country's largest patient organisation, with over 200,000 members, and to the many local diabetes groups up and down the country run by volunteers, especially the one in South Tyneside, which I know offers valuable advice and comfort to many sufferers.

A million or so people are said to suffer from diabetes and do not know that they have the disease. It is estimated that, on average, diagnosis does not take

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place for up to nine to 12 years after the onset of the disease. The longer people go undiagnosed, the more likely they are to develop life-threatening conditions such as heart disease, strokes, kidney failure, blindness and lower limb amputations.

I did not know that I had diabetes. I found out only when I went in to the Freeman Hospital in Newcastle to be treated for pneumonia in 1997 and was diagnosed as a diabetic. When I was told some of the symptoms of diabetes, I was rather surprised. I had been totally ignorant of the symptoms of the disease. One symptom, I was informed, was that a person becomes irritable and short-tempered. I can assure your Lordships that there are many Members in the other place who will tell you that I showed that symptom from the time that I entered the Whips Office in 1984. In fact, some Members next door will tell you that I am the only person who can wish 30 people a merry Christmas and upset 29 of them.

I believe from my own personal experience that there should be plenty of advice and an adequate screening service, together with a screening programme that targets people who are subject to a high risk of developing diabetes. To my knowledge, only about half of GPs' surgeries have a policy on screening, and almost 90 per cent of hospitals do not have the recommended number of consultants—although I am informed that the situation is improving. If it is accepted that 1 million people suffer from diabetes without realising it, then I have no doubt that the cost of additional screening is a lot cheaper than having to deal with the problems caused by late diagnosis.

It was the Audit Commission's report, Testing Times, which highlighted the unacceptable variations in the standard of the diabetes service in this country. It prompted the Government to announce, early in 1999, the development of a national service framework for diabetes in this country.

Treatment for diabetes is an urgent issue, and the implementation of the Government's national service framework is vitally important. In the Department of Health circular 1999/0744, issued on 8th December 1999, headed:


    "Key milestone in the setting of national standards for the care of people with diabetes",

my noble friend Lord Hunt of Kings Heath—who has taken a great interest in the treatment of diabetes; and I have no doubt that my noble friend on the Front Bench will follow in his footsteps—speaking at the first meeting of the Diabetes National Service Framework Expert Reference Group in December 1999, said:


    "The Diabetes National Service Framework will ensure that top quality standards of care and treatment for diabetes are available in all primary care, local hospitals and specialist centres".

I wholeheartedly agree with those words.

Diabetes is the biggest single cause of blindness among adults of working age in the United Kingdom. The risk of hospital admission owing to heart disease is said to increase fourfold among those with diabetes. Almost half of all lower limb amputations other than that following trauma are a consequence of the disease.

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In replying to a Commons debate in Westminster Hall on 13th March, my honourable friend Yvette Cooper—who was then Parliamentary Under-Secretary of State for Health—said:


    "Diabetes is a serious condition but the future need not be bleak because evidence shows that the onset of type 2 diabetes can be delayed or even prevented and effective management of the disease can increase life expectancy and reduce the risk of complications. The diabetes national service framework builds on the foundations".—[Official Report, Commons, 13/3/02; col. 307WH.]

Like the noble Lord, Lord Clement-Jones, I sincerely hope that there will be no further delays in the Government's diabetes national service framework and that the resources will be made available for it to be implemented.

The Wanless report calculated that an additional £600 million a year would be required to implement the diabetes NSF—and that is a tight figure. It is estimated that diabetes accounts for as much as 9 per cent of the annual National Health Service budget. Like the noble Lord, I believe that spending money on preventing and managing diabetes now will save lives, as well as money, in the long run.

I sincerely hope that my noble friend will take these points on board—as I have no doubt he will. I am not one who criticises the Government in relation to the National Health Service. It was only early in the Government's term in office that I began to be treated in hospital. I had to be treated for pneumonia in 1997, then diabetes, then cancer; and I have received first-class treatment. I am the last one to criticise the National Health Service. It is a good service. We should build on it. We should never be satisfied, but I hope that when the terms of the diabetes national service framework are published, the Government will not only implement them but make sure that the resources are available for them to be carried through.

8.17 p.m.

Lord Turnberg: My Lords, diabetes is clearly on the march. There is a lot of it about. Perhaps I may give a few statistics, some of which your Lordships may have heard previously. Diabetes affects 2 per cent of the population, and the incidence is increasing year by year, so that in the next decade type 2 diabetes will have increased by some 30 per cent.

The disease is selective in those whom it affects. The prevalence in South Asians is as high as 15 to 20 per cent—a frightening figure. There is a similar level in Afro-Caribbeans, and the figure is rising. Diabetes is increasing silently. About a million people do not know that they have the disease or are about to get it, yet they are all susceptible to complications which are either life-threatening—especially heart attacks and strokes—or health-threatening: blindness, infections, foot ulcers and the like. Much of it is preventable, if only we can intervene early enough.

It is against that background that I commend the Government for embarking on the diabetes national service framework, which is absolutely essential. But it is no easy task. There are so many aspects of

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diabetes—from prevention through to management of the complications—that it is vital that we get the priorities right and investments are made where real differences can be made, not only now but in the inevitably long period of time over which the disease evolves. We are in for the long haul.

I believe that it is clear where investment is needed. First, the cause of the diabetic epidemic is largely due to lifestyle, with diet, lack of exercise and obesity heading the list. For the population at large, changing their lifestyle is something of an uphill struggle. Few, if any, are willing to change what they do, even when threatened with ill health in 10 or 20 years' time.

Targeting those with early signs of diabetes, a family history or predisposing factors to be obese would be worth considerable effort. How do we get to such people? We need to invest much more in those who can engage directly with the communities at risk. In pole position are the diabetic nurse specialists, who do much more than provide lifestyle advice. They have key roles in early detection, in monitoring for complications and in continuing care and advice. My first request to the Minister is for a reassurance that efforts are being made to increase the number of diabetic nurse specialists across the country. Where they exist now at primary care trust level they have been shown to have enormous benefits, but many parts of the country have none or too few. Can she encourage primary care trusts to take their public health role seriously enough to appoint these invaluable nurses who can be shown clearly to have an impact on the health of their populations?

My second question is about how we might begin to fill the gap in consultant diabetologist numbers. The president of the Royal College of Physicians, Sir George Alberti, has calculated that we need to double the number of consultant physicians who specialise in diabetes to cope with the rising tide of patients who are currently overwhelming their ability to cope.

Clearly, that gap will take some time to fill, even if we start now. Meanwhile, we could try to encourage those physicians who are inclined to retire early from the NHS for a variety of reasons to stay on. The current average age of retirement for physicians is around 60. They could provide another five years of high-quality service if they stayed until the normal retiring age. Much more could be made of flexible employment arrangements for doctors who wish to slow down a little in the last two to five years. Such flexibility could enable a doctor to provide clinical service sessions, perhaps part time, without the need to carry out other roles such as administration or committee responsibilities, which many abhor. The Government are keen to encourage flexible working, but too often the incentives for trust chief executives to allow consultants to work in that way in their last few years are limited. They are often unwilling to embrace the possibility with any enthusiasm.

While we are waiting for investment in more consultants and for them to come off the training production line, will my noble friend the Minister offer

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some encouragement that efforts will be made to retain those valuable experts already in the system towards the end of their working lives? Will she encourage trusts to take up the challenge—which I know is part of her department's policy—with more enthusiasm than they have shown so far?

Many aspects of a national service framework for diabetes have to be put in place. We must move ahead as quickly as possible, but we should not underestimate the enormous amount of work to be done to make sure that we get it right. There is inevitably a need for greater investment, but there are some things that we could do now. Having more diabetic nurse specialists and retaining doctors in the service are two important areas that we could focus on. I hope my noble friend the Minister agrees.

8.23 p.m.

Lord Astor of Hever: My Lords, I congratulate the noble Lord, Lord Clement-Jones, on introducing the debate. Unfortunately, nine minutes is not long enough to do justice to such an important subject. All speakers tonight have rightly pointed out that diabetes is a major killer. The House will be particularly grateful to the noble Lords, Lord Harrison and Lord Dixon, for telling us their personal experiences of diabetes.

The delayed national service framework was finally published in December 2001, but without an implementation strategy. An implementation group was set up at the beginning of this year and the Department of Health promised that a delivery strategy would be published in the summer of 2002. However, as the noble Lord, Lord Harrison, said, summer has arrived—at last—but Ministers are now saying that it will be published later this year. Can the Minister confirm that a delivery strategy will be published, as promised, this summer and that those with diabetes and the medical professionals involved in the provision of diabetes services will not have to wait until the end of the year before the plans for implementation are made known?

I was also concerned to read an article written by the Health Minister previously in charge of diabetes, Jacqui Smith, who said:


    "the delivery strategy will set out only the first stages in a 10-year programme".

I hope that the Minister will be able to allay my concerns and those of the many organisations bringing together the users and providers of diabetic services in confirming that the Government's delivery strategy will be comprehensive and effective and will be able to start making a difference now, not in 10 years.

The department has not yet published detailed funding plans for the NSF. However, an indication of what might be expected was published in the Wanless final report, Securing our Future Health: Taking a Long-Term View. Derek Wanless estimated that the current cost to the NHS was £1.3 billion per annum and, as the noble Lord, Lord Dixon, said, a further £600 million would be required to implement the NSF.

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Concern has been raised about the calculations in the Wanless report, which it appears may fall far short of what is required. We on these Benches have two specific areas of concern.

First, the Government may have underestimated the future increase in the incidence of diabetes. Jacqui Smith recently said:


    "the rapid increase in the incidence of diabetes is not inevitable".

We are concerned that that may not be the case. Many experts in the field also take a different view from the Government.

John Murray, a public consultant, points out:


    "the prevalence of diabetes in the coming decade, and more, is largely pre-ordained. In particular, the effects of the threefold increase in obesity over the last 20 years, to one in five of the population, cannot be swiftly reversed".

Stephanie Amiel, professor of diabetic medicine at King's College Hospital, said:


    "What can be delivered is a reduction in the rate of hospital admissions per patient, but not in the overall numbers—they will continue to increase as the numbers of people with diabetes rise, and so will the costs. Ministers and their advisers must hear this message. It is absolutely essential that the NSF for diabetes is based on informed fact and not wishful thinking".

Secondly, there is the question of unhealthy lifestyles, which undoubtedly lead to an increase in diabetes. Obesity statistics in England make grim reading. Two thirds of men and half of women are overweight. Nearly six in 10 adults—some 20 million people—need a change in lifestyle, said the National Audit Office last year. Furthermore, doctors have recently seen the first cases of overweight white children in Britain with a type of diabetes normally confined to the over-40s. Obesity has trebled in England in the past two decades.

The causes of the increase in incidence of diabetes are widespread. For example, the inactivity of children could be attributed to any number of factors: watching too much television; playing video games; the preference of parents for taking their children to school by car rather than on foot; the reduction in the amount of PE at school; and the availability of high-fat foods and fizzy drinks. In the short term, it is unlikely that any significant changes in lifestyle will be achieved; all signs point to the contrary, as the noble Lord, Lord Turnberg, wisely said.

In a recent article, Jacqui Smith wrote:


    "investment in health services includes looking more closely at prevention by reducing obesity, increasing physical activity and promoting a healthier lifestyle".

Few could argue with the need to tackle these key causes of diabetes.

What steps, therefore, is the Minister's department taking to ensure a cross-departmental effort in tackling the problems of obesity and inactivity? What role does her department see the National Health Service having in promoting a healthier lifestyle? Does she envisage a stretched NHS, and in particular overworked primary caretrusts taking on an educational role? If so, additional resources, particularly in terms of staff, will be required.

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The problem that the Government have already encountered with regard to recruiting additional GPs is of grave concern. It is crucial that the Government work across all departments and do not just rely on the NHS. What discussions has the Minister and her colleagues had with their counterparts in the Department for Education and Skills and with the DCMS with regard to the diabetes NSF?

With regard to staffing, the Government have indicated the need for more staff and stated:


    "By 2008 there will be 60 per cent more nurses qualifying each year than there are today".

How many of these will be involved in providing specialist diabetes services in primary care? What plans does the Minister's department have in place to ensure that rates of GP recruitment improve? What training do the latest intake of medical students receive with regard to the delivery of diabetes services?

8.32 p.m.

Baroness Andrews: My Lords, I join noble Lords in congratulating the noble Lord, Lord Clement-Jones, on his choice of debate. After hearing the statistics produced on all sides of the House, and the very personal and moving stories from noble Lords who suffer from the disease, I am sure that noble Lords will agree that this very powerful and balanced debate has enabled us to move most productively from the general to the specific. I am most grateful to all noble Lords who have spoken.

I also join all who have praised the inestimable work of Diabetes UK and the extraordinary job it has done over the years to inform and support people with diabetes. I acknowledge too the work of the all-party group to which my noble friend Lord Dixon referred. I assure my noble friend that we have never thought his temperament, either in the other place or your Lordships' House, as anything but most sweet. I hope that he will not worry about that too much.

I shall not reiterate the statistics that have been cited. I simply say that it is the scale and the scope of diabetes that make it such a challenge. Diabetes presents a range of complications, from CHD to renal failure, to amputation, to blindness, and an extraordinary challenge in terms of prevention. As the noble Lord, Lord Astor of Hever, said, the need to change lifestyles is but one challenging aspect of prevention.

Consequently, we have to approach the problem on a national basis. We have to tackle it with national funding and a national strategy. The scale of the problem arises partly from the fact that, until testing became possible, we had no concept of the variability of treatments or the extent to which treatment would be effective. I therefore share the anxiety expressed by all noble Lords that there must be rapid action. Like many noble Lords, I also recognise that we are facing a formidable national challenge.

I was very pleased that my noble friend Lord Dixon paid such tribute to the NHS. All of its resources will have to be employed in order to ensure a better deal for

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diabetes patients in the next 10 years. The disease is almost unique in the way it crosses so many health boundaries.

As for funding, although there have been calls for action to the contrary, we believe that ring-fenced funding for the diabetes strategy would not be the most effective response. We are planning a coherent spread of well-funded strategies for prevention and treatment which will reduce the risk of complications and the disabilities that literally threaten life and limb. I therefore make no excuse for drawing to your Lordships' attention the fact that the health service as a whole is now better funded and more effectively organised. That can only help in ensuring prevention and better treatment.

Noble Lords surely must welcome the fact that we are currently increasing public spending on health faster than any other major country in Europe. That increased funding will be devolved to where it can do most good on the front line of the service. Decisions on the allocation of the funding will be made later this year. We shall ensure that noble Lords are fully aware of the implications for the spread of complications and so on.

We should, however, also remind ourselves that the challenge of diabetes is not purely financial. We have heard not least from the noble Lord, Lord Harrison, of the patchy—sometimes, as in the example he gave, disgraceful—service on offer. I do not dispute that assessment. It is for precisely that reason that we give such great priority to the national service framework. However, in addition to investing, we have to do things differently. The national service framework seeks to ensure that that happens by focusing on principles such as improved working practices, devolving resources to the front line and more choice for patients. Those principles are alive in the way in which we have prioritised better services for patients in the first set of national standards.

I was pleased recently to see that a leading academic—a specialist clinician—welcomed those standards as,


    "a totally appropriate and admirable set of standards".

As noble Lords on all sides have said, however, it is delivery that counts. I should like to reassure the noble Lord, Lord Clement-Jones, that, in the past seven months, an implementation group led by Mike Pringle, professor of primary care at Nottingham University, has been helping the Government and working extremely hard to develop the delivery strategy for the diabetes NSF—to ensure that, in operation, the NSF will be manageable, robust, sensibly paced and, above all, fully delivered in 10 years.

I take the point made by my noble friend Lord Turnberg on the scale of the problem and why it will take 10 years to deliver. It will not be 10 years before we do anything, but it will take 10 years to put in place a properly timetabled framework. We can do some things faster than others, such as improving and more effectively offering information. It should not take too long to do that. However, the delivery strategy will be

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published later this year for implementation over 10 years, from April 2003. It will set out the timetables, the benchmarks and the framework and arrangements for supporting and ensuring the delivery that noble Lords want to see.

What issues does the framework have to address? Some of them have been outlined in this debate, such as the fact that the onset of Type 2 diabetes can be delayed or even prevented; that effective management increases life expectancy; and that self-management is the cornerstone of effective diabetes care. Those are precisely the challenges that we must systematically meet if we are to reduce the incidence of diabetes particularly among the high risk groups.

There is no doubt, as the evidence presented today shows, that the challenges are increasing. We have a more obese and sedentary population. Our children are more obese and sedentary and are less active. All of that will make for a very poor prognosis unless we address the big issue of prevention—which is the first standard set by the framework itself.

I say to the noble Lord, Lord Astor of Hever, that there is a raft of work going on between the Department of Health and the Department for Education and Skills to tackle the issue of better diet, increased healthy activity and sport in schools. I am tempted to read out the list of activities which occupies four pages of my brief. However, I prefer to write to noble Lords, particularly to the noble Lord, Lord Clement-Jones, on the preventive strategies ranging from increased support for breastfeeding to food to rolling out the national school fruit scheme, the food in schools programme. It would make more sense to write to noble Lords to give them a thorough account of that. I refer also to appropriate programmes for adults.

The diabetes framework must sit firmly alongside other frameworks which can help it to be more effective. I refer to the chronic heart disease programme and to the national service framework for older people. The programmes must overlap like maps to make sure that they deliver the optimum effect. Standard 3 of the diabetes framework is concerned with putting people with diabetes in control of their condition. That constitutes effective management of the patient.

Diabetes has been described as,


    "the easiest of the chronic diseases for which to introduce a person centred service".

We want to bring an end to the spectre of the dependent and depressed patient trailing around from the dietician to the ophthalmologist to the chiropodist. Those services should be provided in one place along with the GP's practice where the patient knows that he is supported by people who are working together on his or her behalf. That is the central plank of the NSF and constitutes a new approach to care and treatment. It will enable a person with diabetes to agree their care plan in partnership with health professionals. That may involve enabling them to keep a record of blood glucose levels, altering medication, improving their diet or taking more exercise. We are looking for

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"expert patients" to manage themselves as far as they can. Some may not want or be able to do that and they must be given the right support. However, we can do much more not just in terms of giving them information but also the confidence to manage the condition and to prevent the complications which cause so much distress. That issue is less about resources and more about roles—those of patients and professionals.

What we want to see—this would enable us better to manage pressures at the primary care trust level—is the sort of coherent and comprehensive service that is evident in the North London family healthcare centre where the full range of services are available in one place or in areas such as Basildon where GPs, nurses, podiatrists, dieticians and other providers have been involved in the entire consultation process setting up diabetes services. I refer also to the district wide services in North Tyneside where people are researching ways of developing expert patients. If one makes that kind of best practice a reality, one meet the shortages which noble Lords have identified. It involves making fundamental changes to workforce planning and development linked to service needs rather than traditional roles.

We estimate that by 2010 there will be another 766 diabetes specialists. That is an increase of 50 per cent. However, in the interim, we must lay the foundations for more flexible and effective working through the continuous professional development of diabetes specialists, whether GPs or nurses. That will have an impact on service delivery. The long-term conditions care group workforce team will identify innovative ways in which the skills and competencies needed in the workforce can be delivered. We aim to make it possible for nurses to acquire specialist knowledge of how to treat diabetes. We seek to bring together professionals and patients to develop new ways of working.

Work is being done with the Sector Skills Council for Health to produce a competence framework for diabetes in the next year. I say to the noble Lord, Lord Turnberg, that there is much interesting and exciting work being carried out in the field of specialist nursing. For example, the Royal College of Nursing Diabetes Forum in collaboration with Diabetes UK is taking forward a project to map the knowledge, skills and competencies as a career framework required to deliver diabetes nursing services. A draft framework will be available for wider consultation later this year, and will provide a system of accreditation for the spectrum of nurses involved in diabetes care including healthcare assistants, practice nurses, diabetes specialist nurses and consultant nurses. And our changing workforce programme is running pilots in two diabetes services to test and implement new ways of working to improve patient services and tackle staff shortages.

There will be new opportunities—


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