Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694841353508.pdf (Malta)
PARLAMENTTA' MALTA IT-TNAX-IL LEGIZLATURA P.L.

3443 Dokument imqieghed fuq il-Mejda tal-Kamra tad-Deputati fis-Seduta Numru 191 tas-27 ta' Ottubru 2014 mill-iSpeaker, 1-0nor Ang1u Farrugia.
Raymond Scicluna Skrivan tal-Kamra PAR LAMENT TA' MALTA HEALTH CHOICES PROPOSALS OF THE PARLIAMENTARY WORKING GROUP ON DIABETES MELLITUS House of Representatives, Valletta, Malta 24th October, 2014 1 2 Members of the Parliamentary Diabetes Working Group: Frederick Azzopardi MP Simon Busuttil MP, Leader of the Opposition Claudette Buttigieg MP Deo Debattista MP Claudio Grech MP Godfrey Farrugia MP, Chairperson of the Working Group Marlene Farrugia MP Michael Gonzi MP Franco Mercieca MP Marthese Portelli MP Clyde Puli MP Secretary to the Group Kevin Mizzi # 3 ln trod u ction Diabetes is a growing problem and is a good example of whY we need new thinking about ho\\· to pro,·ide integrated sercices in our national health system to fight the incidence and prO\ ide a better life for those affected.
This chronic disease.

characterised by h:verglycemia.

resulting from defects 1!1 insulin secretion.

insulin action or both, affects 382 million people in the world.

A further 316 million are diagnosed \vith impaired glucose tolerance placing them at high risk from the disease- an alarming number that is set to reach 471 million by 2035. ln our continent we ha\ e about 60 million people with diabetes, which sees 10.3% of European male population and 9.6~ o of female population aged 25 years and o\·er.
Estimates show that in Malta there are more than 30,000 adults known to be diabetics and another 8.000 adults who are undiagnosed diabetics.

We have the second highest percentage of diabetics in the .111editerTanean smvassed only by C:rn1s.

If we take type 2 Diabetes, comparable data shows that incidence in Europe accounts to 8.2% of the population as compared to Malta's 9.5%.
These statistics should not go unheeded and as politicians w·e are duty bound to inten·ene with concrete action after haYing listened to all those concemed.

Eleven MPs from both sides of our House of Representatives placed our act together and committed ourse]\ es to tackling this challenge by acting against this 'silent killer'; which is a leading cause of blindness, amputations.

kidney failure.

hem1 attacks.

stroke and early death.


Since Ap1iL on the initiative of the Leader of the Opposition Simon Busuttil MP, together with our endeavours and under the Chainnanship of Godfrey Fanugia MP, we came a long way in putting our minds together to explore options how to improve lives of people suffering from diabetes.

As a Working Group we are not on our own.


The Go,·emment set up a steering cmmnittee made up of competent professionals in the field of diabetes to come up with a \fational Strategy for .111alta.

Our work dovetails with that of this committee.

Also, there are similar working groups like ours in other European Parliaments.
... '-' Putting Dartisan oolitics aside~ The Parliamentarv -V·/orkinQ Groun on Dlahetes focused entirely on what aYenues should be pursued for action in fa\·our of the' ictims, their families and health care professionals.

~ ... ~ ' .

Despite not being part of the executi\·e we beliew that we managed to raise the issue of diabetes on our political agenda through the help of all stakeholders involved.
A word of thanks goes to those were there consistently with us to make our exercise worthwhile in a Yery tangible way.

The document describes the recommendations put forward for the executi\·e to provide tools and resources towards coordinated action.

4 Through our proposals we seek to align levers and incentives to facilitate delivery of integrated care across provider institutional boundaries.
We want to empower patients with information to support their choices about their own health and care and support the development of IT solutions that allow sharing of information between providers and between providers and people with diabetes.
We want to look toward to the future with optimism by delivering continued improved outcomes for people with or at risk of diabetes through an effective preventive care system, sustainable procedures in addressing the incidence at an early stage and provide the necessary synergy between primary care and the patient.
It is by putting the necessary resources in place, creating the necessary teclmological framework and combating combined diseases in a coordinated manner that we can succeed in our aim to provide a better life for those in need.

This will also ensure a lesser long-term burden on our public finances and a more educated population towards a higher degree of healthy living in Malta.
5 GE:'>ER.\L I:'>FOR'\lATIO:'> A. :\!alta's fon1 ard looking policy and direction \1ost European Health Care Systems are at a cross road.

".1alta along with another seHnteen European countries is no exception and faces specific EC country recommendations.

The public perception to health care has and is changing.

A fast deYeloping industry of technological medical aids, more inno\·atiYe phannaceuticals.

widespread on line access to health infonDation and research, haYe increased demands.
\1oremer, it is the public's desire, to ha1·e a more holistic .

.

'-:ational Health Care System within a set-up of a synergistic Public-Pri,·ate Health mix, where the pillars of equitable access, quality assurance and sustainability are safe guarded to the highest standards.
:\a matter how strong any nation's economy is, this is not easy to achieYe unless gover11111ent is also backed by a sound Health Act standardized health outcomes and a cost and effectin health SYstem assisted bye-health and an ongoing process of monitoring of the OYerall health perfonnance.

Sustainable budgets haYe to be do,·etailed on to a Health Strategy.

There are no short tenD fixes.


In deed this has influenced a number of go,·emments to refonn their current management processes and introduce more e\"oh·ed best clinical practices, whilst concurrently adopting 'a whole society approach'.

The key to any success lies in empowering the health consumer through health promotion and preYention, and to deli1·er a more personalized health care which is primmily cormnunity oriented and where each individual takes care of ones wellbeing.
\Ve haYe to transfonD our present strategy from "one size fits all' to 'one size fits one' and redefine our health perfmmance outcomes from one of medical diagnosis to one that is hallmarked by wellness goals.

All four levels of heath care services have to develop in synchTony, with Primary and Community Health Care as the comerstone of any health care system.

Ultimately this is smarter spending as it im·est in the citizens' wellbeing.
To achieve and implement these health status objecti1·es we are of the finD opinion both as politicians (and as health care professional), that health should be driven away fi·om partisan politics.

We must shift to models that encourage consensus across party lines, increase health care professional collaboration, increase public ownership and team up with .

'-:GOs in Public Social Partnerships.


Pro-actiYe management of diabetes and its co-morbidiiies will in time reduce the use of more costly acute secondary health care sen·ices.

Vv'hat holds for this chronic ill health will likewise hold for other preYalent cJn·onic deceases.

B. Diabetes !\iellitus and the !\ialtese The Maltese population is an aging one, as Malta has a low mortality rate, and a poor population gwwth.

Fertility rate has declined.


The leading cause of death is cardiovascular disease and this accounts for 45% of all deaths, with diabetes playing a major role as a contributing factor to this silent killer.

The mortality rate of diabetes as a direct cause of death hits the 3.4% mark.

6 The prevalence of diabetes in Malta is I 0% and with many risk factors associated with non communicable disease (example obesity) on the rise, the present forecasts do not augur well if the projections remain unchanged.
Malta ranks seventh among 3 0 European countries.

It is common knowledge that Diabetes type 2 can be prevented and kept in check by leading an active life style and eating a healthy diet.

It is also a known fact that early diagnoses of the other types of diabetes can go a long way towards minimizing complications.

In Malta data on diabetes care and treatment outcomes are not at all well monitored and recorded.

There is room for more co-ordination that leads to quality health care.
C. Initial State of Affairs In the last Budget (October 2013) it was announced that a Diabetes Policy was to be defined in 2014.

Tilis would go hand in hand with the work in progress of a National Health Strategic System and a Complimentary Report on Community and Primary Health Care.

A lead person was identified in January 2014 with the intention that a policy be published in November 2014 on World Diabetes Day.

In May a Steering Committee was set up by the Secretariat of Health.
D. Parliamentary Working Group on Diabetes Mellitus (PWGD) In February 2014 a number of MPs from both sides of the house were invited by the Leader of the Opposition Dr. Simon Busuttil to set up a Parliamentary Working Group on Diabetes Mellitus (PWGD).

Eleven accepted the invitation.

The scope of the working group is to: - promote awareness among Members of Parliament on Diabetes and the cause of fighting diabetes.
- promote consensus building between the different working groups on Diabetes -promote and oversee a National Diabetes Plan for Malta - identifY and bring together stakeholders in the fight against Diabetes -organize I participating in Diabetes events in Malta and abroad A first informative meeting was held in early April.

This was followed by an official launch on 7th May in parliament.
This was opened by The Leader of Opposition, Hon Dr Simon Busuttil followed by an audio visual message by President of the International Diabetes Federation Mr Michael Hirst.

Hon Dr Godfrey Farrugia was unanimously chosen to chair this working group.

Since then this group has held a further four meetings all hallmarked by presentations and consultations with eminent authorities, health care professionals and diabetes support groups.

These were held on 3rd June, 14th July, 7th and 13 October.
In the latter meeting outgoing EU Health Commissioner Dr Tonia Borg and Mr Martin Seychell, Deputy Director General of SANDO addressed PWDG.

7 Apart from these scheduled parliamentarY workmg ~~·oup meetings the chainnan represented the committee: DeJi\·er\' of an opening speech in an Intemational Conference titled 'Diabetes and ~1icrm ascular Disease: :\ew Insights'.

hosted in ~1alta between I 6-1 7th ~1ay.

In July the working group was im·ited to expose its aims and workings.
in particular to the Jegislati\ e model of the Legal :\otice, to a Steering Committee on Diabetes that was set up in early May by the SecretaJiat of Health.

T\YO meetings were held with Dr !\1iguel Debono a Consultant Diabetic Physician from Sheffield CniYersity on a plausible way forward to field a research project.

Throughout the smm11er recess parliamentary members from both sides of the House made their presentation within their respectiYe parliamentary group to identify a common working pathway.
Chairperson also met with the Leader of the House, Hon Cannelo Abela.

In September the chairperson was invited by Parliamentary Secretary Hon Chris Feame to discuss the way fon,·ard and liaison in the drafting of the Legal ~otice.

It was decided that the proposed report is to be handed to the Ministry by 27th October.

before the Steering Group on Diabetes finalizes its position.

In September a consultation meeting was held with EU Health Commissioner Dr Tonia Borg at Valletta's EC office.
8 OBJECTIVES OF THE PARLIAMENTARY WORKING GROUP In this document three proposals are being forwarded by DPW A.

These will be pursued throughout their work in progress.

It is our firm opinion that these will ultimately ensure that health care providers and team behaviour are optimized, a support patient behavioural change is provided and that these will create the necessary synergy that will build the necessary impetus to change the very design of our health care system.
In addressing this speciality within the frame work of Malta's National Health Services, PWGD will contribute towards the road mapping of more concrete measures to address Malta's EU Country Specific Recommendations.

The latter are hallmarked by the strengthening of Primary and Community Health Care services, better financial sustainability and the continued monitoring of our National Health outcomes.
I) PWGD's Consultation Report Since its foundation it has always been PWGD's intention to consult, analyse and forward a document to the Ministry of Health and Energy that determines innovative pathways to prevent and diagnose diabetes~ whilst a national awareness plan and screening program be set up.

This would go a long way towards ensuring access to quality care, treatment and the prevention of complications in un/diagnosed patients.
The primary intention of this document is to position diabetes within a self-management comprehensive supportive model of healthcare which will redefine our health performance outcomes from one of medical diagnosis to one that is defined by wellness goals by motivating individuals to take care of their wellbeing.

Undoubtedly this will make this niche of health care more sustainable.
All meetings were well attended by a dedicated audience of Health Care Professionals, NGOs, patients interested in this speciality and some members of the Secretariat's Steering Committee on Diabetes.

Opinions and questions were floored after each presentation.

Seventeen consultation were held.

(For full details see Addendum I) Hon Chris Feame also addressed the working group and welcomed the initiative.
The following consultations where held with: I. Dr. Natasha Azzopardi Muscat, Consultant on Public Health; 2.

3.

4.

5.

6.

7.

8.

9.


Profs Stephen Fava, Chairperson of Internal Medicine; Ms. Christine Mifsud, Diabetic Ms Alma Zammit McKeon, President of the Maltese Diabetes Association Dr. Nadine Delicata, Chief Executive Officer, Gozo General Hospital Dr. Mario Caruana, Director ofNutrition and Dietetic Service Ms. Dolores Gauci, Directorate Students Services Ms. Phyllis Camilleri, Senior Podologist Dr. John Torpiano, Consultant Pediatric Endocrinologist 9 10.

I 1.

12.

13.

14.

15.

16.

I 7.


Catherine Azzopardi u '\1oira Gtixti.

Specialist '\urses in Diabetes '\1s.

Ruth Theuma.

Principal Phanuacist in Clinical Diabetes and Endocrinolog,· Profs Joseph Azzopardi.

Consultant Endocrinologist Profs Kevin Cassar.

Consultant Vascular Surgeon Profs Ciantar Soler, Private Family Practitioner '11r.

Franco Mercieca, Consultant Ophthalmologist Dr. Tonio Borg, EC Health and Consumer Affairs Commissioner '11r.
'11artin Seychell, Deputy Director General SA'\ CO Throughout these intet"centions the following questions \vere raised and explored within the remits of this speciality: \\ l1at quality of care are we deliveting?

Is it accessible" Are sen·ices co-ordinated" Do "·e ha,·e a system of health care delivery that is sustainable?

Which areas are lacking good diabetic health care?


How should we implement" Do we have an ideal Private-Public Health mix to support diabetic patients 0 \Vhat are the reasons of poor management" \Vhat inten•entions can we provide to help improve the outcomes from health care?

What pharmaceuticals (medicine, consumables.

medical de,·ices and aids) are being offered° Can we improve treatment on a cost benefit analysis basis?

Is nutritional advice adequate?

Are patients following it?


Are patients carrying out physical activity" How can we reduce diabetes complications?

How can we prevent diabetes?

Wnat are our screening measures" Wl1at are the monitoring techniques used by patients" Can we improve self-management by patients" Is advice constantly giYen?

\Vhat is the incidence of diabetes related admissions and how can we reduce these" Are the community sen·ices we offer adequate?

\\·nat is the role of the health care professionals?
How is their team work co-ordinated?

Once the proposed report is compiled and officially launched by PWGD, this is forwarded to the Secretariat's Stee1~ng Committee on Diabetes, through Hon Cluis fcamc in time to be reviewed prior a memo addressed for Cabinet's approval is finalized.

There after a petiod of public consultation will be launched by TI1e Ministry of Health and Energy and a final document on a diabetes policy for Malta is issued.
During this interim period a legal notice will also be drafted by the Ministry on the working group's proposed model through which PWGD will be fon,·arding its parliamentary and professional experience.

10 2) A Legal Notice Legislating a Health policy will clearly define targets and responsibilities.
It is the intention of this Parliamentary Working Group to liaison with the Steering Committee on Diabetes that had been set up by the Secretariat by submitting this consultative document and further more with the legal division of the Ministry in the preparatory drafting.

It is our firm opinion that this legislation is presented as a Legal Notice within the established frame work of the Health Act, and not as an Act by itself.
Once approved by cabinet, a Legal Notice will be presented to parliament within the regulatory frame work of a Private Members Bill, in a symbolic bipartisan approach, by all members ofPWGD.

The necessity to legislate a Health Policy is highlighted by the following differences between Law and Policy I Strategy: A policy is a document that outlines what a government is going to do and what it can achieve for society.
It outlines the methods and principles that the government will use to achieve its directive.

Legislation are actual laws that are enforceable, which means they must happen and should be followed.

Policies are like a plan of action which guide towards making sure legislation is complied with.

Legislation refers to laws which serve to legally prohibit cetiain actions and ensure others are carried out A policy has no way of compulsion.
Legislation is a law and consequently you are required to follow the law.

Once a Law is passed from Parliament it may only be amended (or repealed) by another Act of Parliament.

However for practical reasons, patiicular issues may be further developed etc with the use of Legal notices (Regulations).

A policy may be amended, changed, substituted, even disregarded or superseded by another policy without any particular formality.
A policy outlines what a government ministry hopes to achieve and the methods and principles it will use to achieve them.

It states the goals of the ministry.

A policy document is not a law but it will often identify new laws needed to achieve its goals.

Laws set out standards, procedures and principles that must be followed.

If a law is not followed, those responsible for breaking them can be prosecuted in court.
A policy document may be seen as setting the pathway to an eventual law A law is ENFORCEABLE in our Courts.

This proposed model will present a first ever coherent legal frame work that focuses on a holistic Diabetes Policy and Strategy that is dovetailed within the workings of a National Health Systems Strategy 2015-2020.

PWGD will liaison with the Secretariat in drafting the details of this legislation.

PWGD is proposing the following Model Legislation: 11 PART!

General ProYisions Title.

Commencement.


Interpretation.

Establishing the core elements To manage Diabetes 'vlellitus w·ithin the holistic concept of patient-centered care that also targets personal and social de,·elopment as well as psychological support.

PART II :\ational Diabetes Council Classification and diagnosis Establishment.

Appointment, Functions and Powers of a ;\ ational Diabetes Register, to detem1ine preYalence, record and assess outcomes and goals of diabetes care.
A commitment to support the importance of continued research in this speciality.

PART III A Strategy for Diabetes Establish Strategy by law·.

Analyze and integrate existing Health Policies including that of Active Aging.

A proactive emphasis on Corru1mniry Oriented Health Care versus Hospitals' Clinics' sen·ices.

Special Recognition of a national health system embarked on a public-private health.

Assessment of cormnon co-morbid conditions (e.g.


hearing impairment, obstructive sleep apnea, fatty liver disease, periodontal disease, cancer, fractures, cognitive impainnent, depression, infertility) and Diabetes's bi-directional relationship to other diseases.

The setup of National Active Screening programmes: e.g.

Diabetic Foot Screening, Retinopathy Screening, and Nephropathy Screening.

PART I\' Pre-Diabetes: The testing of Diabetes in undiagnosed patients.
The use of life style clinics: active and passrve screenmg.

lmpro,·e public health through healthy eating and healthy living.

A renewed nutrition and dietetic strategy.
A new approach to supporting patients' beha\'iourai change (eg \veight reduction: physical actiYity, non-use of tobacco, effectiYe coping) 12 Prevention and I or Delay of chronic ill health in specific Family Cycle settings or specific settings: - Pregnant women (gestational diabetes) - Children and adolescents -Transition from Paediatric care to adult care -Adults ~Elderly - Mental patients - The insularity of Gozo -Diabetic care in hospital PARTY A holistic Diabetic Quality Health Care delivery Prevention I Delay of Type II Diabetes.
An emphasis on follow ups and monitoring of patients by focusing on the principles of the Chronic Health Model thus minimizing the 1isk of long term complications: cardiovascular, nephropathy, retinopathy and neuropathy.

PART VI Delivery System Design A Health System that is hallmarked by a dedicated Multidisciplinary Health Care Team approach working in an enviromnent, where a patient-centered high quality experience is a priority.

Public-Social Partnerships and funding of support groups.
Improving Community resources (This may prove to be the pivotal force of this proposed Legal Notice.

There are already a number of services etc in place, but a more co-ordinated and holistic delivery system that is goal based is essential.)

PART VII Diabetes is defined as a chronic disease which may lead to certain aliments I disabilities.

(It is our opinion that it is improper to consider Diabetes Mellitus as a disability ji-om the onset of its confirmed diagnosis.
It is also a fact, that its economic impact is high in the employment sector (due absenteeism) and social welfare (benefits).

If diabetes had to be considered a disability, other legislation applicable to this scenario has to be reviewed.

This would include the Equal Opportunities Act, Employment Law, and the Constitution.)

13 PART \"III An O\ era!

I approach to Benefits and SerYices and reconunendations.

A focus on easy accessible pathways to introduce ne\\· measures and innoYati,·e treatments (e.g.
Islet cell transplantation) and · or consolidate the existing frame work for the pro,·ision of phannaceuticals.

consumables.

equipment.

aids, de,·ices and sen·ices including those noted as Out Reach sen·ices.

ReYiew of Schedule V applicability.

The establishment of prescription guidelines and protocols.
(This legislation must not duplicate the existent legislatire structure that is identified H'ithin the established schedule (Jf Chronic Disease and the parameters of cost-benefit analnis and patient charter rig/us as setH·ithin !he Health Act.)

PART IX Education.
PART IX Education.

support and trainmg (This is a pinnacle of any policy) Clinical lnformatiYe Systems including electronic medical records Diabetes Self-Management Education and SuppOii (DS:'\1E & DS:'\iS): Empower patients : parents to take charge of disease management by offering good access to continuous structured education and decision support.

The setup of National Standards.

Family Support to improYe quality of life.


De,·e]opment scheme to build a strong diabetes suppo11 sercice and a specialized caring team.

The integrated role of the Health Promotion L:nit to increase public education and awareness.

Education at schools.

(Resources have to be directed so as to excel by adopting best clinical protocols as the norms of standard demand.)

PART X Miscellaneous Powers to make regulations, penalties, and operational time frames etc.
as detennined bv the Minister/ Parliamentary Secretary.
(it is 11·ise rhm rhe operarional rime Ji'ame would be one that ewhes in a step up pall11my, srarring off with rhe re-organi::arion of the present senices leading ro neH· screening programs and the introduction (J( new sen'ices, 11·ith a continuous analnis (J( health outcomes and fine tuning of the strateg;) 14 3) Research Evidence based policies substantiated by research delves into a deeper understanding of what is feasible and what I where resources are needed.
This PWGD proposal guarantees an evolutionary process of updating our health care services focused on this speciality within a Maltese scenario.

Ground work and contacts have already been established to partner health care professionals and academics from the University of Malta and the Ministry of Health and Energy with the University of Sheffield and its hospital authorities.

Contacts have also been made with WHO's m-health scheme and the International Telecommunications Union.
It is hoped that we take the opportunities given by EU funds to apply for Horizon 2020 initiatives (which opened last June and will close in 25th April 2015).

It is envisaged that this research will focus on the prevention of diabetes in the overweight and obese.

It is suggested that a randornised, controlled, parallel, interventional studies are held in Malta and the United Kingdom in collaboration with other interested nations (e.g.
Estonia, Portugal and Finland) with Malta being the prime mover, to: investigate whether mobile technology using a pre-diabetes app that can be downloaded and used on iOS, iPad, Android, Android Tablets and Windows phones to record daily diets and physical exercise may prevent diabetes investigate whether automated "warning" messages via the pre-diabetes app and frequent e-mail advice will prompt patients to modifY daily nutrition and exercise with an aim to prevent diabetes identifY what types of food intake are associated with an increased risk for fi.Jture diabetes explore whether mobile technology using a pre-diabetes app to record daily nutrition and physical exercise impacts on prevention of cardiovascular disease establish whether modified-release formulations of hydrocortisone reduce the risk for diabetes in steroid-induced pre-diabetes explore whether mobile technology using a pre-diabetes app to record daily nutrition and physical exercise impacts on prevention of steroid-induced diabetes investigate whether lifestyle change using mobile app teclmology is cost-effective It is suggested that 600 patients are recruited who are overweight or obese and suffering from impaired glucose intolerance I impaired fasting glucose by screening patients with an increased risk for diabetes using ADA criteria.
Patients will be recruited by advertisement and by direct patient encounter at Family Practice, Health Centres and Diabetes Outpatients Clinics.

Population-based disease registries will also be used to identifY patients at risk.
One group of 300 patients will receive intensive lifestyle change monitoring and advice using a pre diabetes app ( e-Monitming) which will be available in both the English and Maltese language and which will be customised to include foods that are commonly eaten both in the 15 LK and ".1alta.

whereas the other 30() patients will receiYe com entional management.

A sub study will be carried out in patients on steroid treatment.
The studies will be carried out by clinical fellows nursing personnel specialised in diabetes care.

All data will be recorded in databases that are accessible to all national primary and secondary health care workers and international research groups: this allowing long-terrn follow up of patients on these in ten entions and establishment of patient cohorts that may be used in future studies.

family doctors From a scientific.


political and Malta's points of \·iew this research may be ground breaking and will set Malta's Health Care on a strong foot hold in this speciality.

It will further instigate citizens to responsibly take care of their wellness and update their medical records.
This research project is intended to stimulate the necessary authorities and specialists to strengthen the scope of refining our local knowledge and at the same time use innoYati Ye measures and technology for the mutual benefit of the health care professionals and patients.

Once e\·idenced based infom1ation is fmalized.

this may further sen·e to amend and update the work in progress of the then established ongoing policy, strategy and its do\'etailed legislation.

if the need arises in the years to come.


16 CONCLUSION PWGD emphasizes that it is the legislators' and policy makers' responsibility to motivate people to cherish their health and enjoy a healthy lifestyle.

Education from an early age can go a long way towards instilling an innate culture of healthy living in the upcoming generations but incessant, effective Public Health Campaigning has to reinforce this positive ambition towards achieving and retaining an optimum state of wellbeing.
PWGD highlights that it- we deliver a goal based diabetic care if we optimize provider and team behaviour, support patient behaviour change, and change the very system and design of care.

This is the much needed reform and transformation needed which will lead to a more sustainable health care system.

Finally nothing can replace prevention and patient self-determination.

This is the corner stone of a Diabetes Health Policy, strategy and its legislation.
Dr Godfrey Farrugia MD MMCFD MP Chairperson, PWGD 17 Addendum 1 Salient Points- Recommendations 1) Peo Je 1.1) Diabetes Education Cnit: • Due to the increase in the sen·ices being offered and the increase in newly diagnosed patients with Diabetes both Type 1 and Type 2 and the early initiation of insulin therapy, we need an increase in Human Resources and work space for all of our objectives 10 be implemented.

l.:!)
l.:!)

Diabetic Children: Increase quota of free blood sugar test-strips to 4 per day; • • Reduce resl!iction on insuline analogues (esp.

glargine): • lmprm·ed support for diabetic children at school: and • Regular reviews by dietician, psychologist & social worker 1.3) Ophthalmology: Health Promotion ... • Through early diagnosis but control as well: • On how diabetes harms: • On HbA 1 c y·s random; and • By addressing the misconception to some that Laser is hannful.
2 Procedure 2.1) Mental Illness: • Public Health Inten·entions • Effective Treatment- phannacological and psychological • Training of Health Care Professionals (GPs, Nurses and Specialists (Endocrinologists and Psychiatrists) • Research to improve treatment effectiveness • Co-morbidity (diabetes and its effects on de\·elopment and mental health) in children and young people • Epidemiological studies on co-morbidity of diabetes and depression 1.2) Family Doctors: • Allow specialists in family medicine to prescribe, modify and monitor treatment, and an·ange specialist care when needed; 18 • Prescriptions and Schedule V 2.3) Treatment in Gozo Expansion of service to include: • Access to diabetologist for adults on a visiting basis • Diabetes specialist nurse based at GGH • Diabetic foot clinic through ERDF-funded equipment • Multidisciplinary diabetes clinic • Care plans based on agreed protocols • Education o Cultural shift - primary care hub 2.4) Nutrition and Dietetic Services: • Further develop the profession as an expert resource across all the Maltese Islands; • Develop an effective response to government targets on nutritional issues such as obesity and diabetes; and • Develop a modem, equitable and responsive dietetic workforce.
2.5) Diabetes and Medicine: • Inclusion of new anti-diabetes drugs on the GFL is vital; • Drug & equipment protocols need to be less restrictive; and • Increased drug expenditure BUT cost-effective in the long run (less diabetes complications, less hospital admissions and improved patient quality of life) 2.6) Lower Limb amputations in Malta due to diabetes: Priorities are those to sort out current services: • OPU o Pharmacy • Community nursing 2.

7) Diabetic Foot Better psychological after care.


CPD progranillle for care providers reteaching strategies.

Unit for screening/monitoring amputees.


3) Technology 3 .I) General: • A National Diabetes Register with an agreed upon departmental policy that all patient data is computerized; • Each patient will have an electronic record; and • The system will be able to generate statistically meaningfully national data 19 ' 21 Ophthalmology: An Acti'e Screening and Treatment Prot,~~amme with includes:- • Community bases screening with fundal photos> 12years on an annual basis: • Photos to be checked.
with in doubt patient to be recalled: and • Health Centre based checks & Laser treatment.

3.3) Lower Limb amputations • A '\ational foot screening programme 3.4) Family Doctors lm estigations (through access to iSoft) • • Refernls (easy access to out-patient appointments.

fast-track urgent cases) • Patient registration with family doctor 3.5) :\Iental Illness \1ulti-condition Collaborati,·e Care Programme • • Routine screening of patients "·ith diabetes for psychopathology and vice-,·ersa.
as well as lifestyle risk factors, to infom1 practice for more effective management and pre\ ention planning.

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n Vl (f) 0 c ..., 0 (j) I (j) Ol "" ::r ~ :::J ..., (j) < iii' :;: (f) c < (j) '< N 0 0 ():J Anxiety and/or depression 19.0% - 1 (p = < o.os) 1 12.5% -- ·--=====-················ ---.. ···-- ·-.- .... · .. ,_ .. ___ • Diabetics • Non-Diabetics 2 0 ........ r························ r··· .
Males Females Source: Health Interview Survey 2008 c 0 VI VI Q) 20 ' ' 18 16 ..... 0.. Q) ""0 ..... 0 .......... _ 14 ""0 ""0 c Q) ro VI 12 > ""0 ..... ..... ro 10 - Q) ""0 - X C c ro ro +"" u VI c 0.. 0 V) ..... UJ ..s:: - u bO 8 6 4 .... j : c -+"" ..... 0 0.. Q) ..... "212- Consumption of prescrib~ed medicines 54.9% 52.2% [.

( P == < 0 05-:l) · J I Ill Diabetics Ill N o· b .

on- 1a et1cs 60 ,_ "0 w o .

.0 - ...... ,_ u a .

- 50 Vl QJ "0 QJ u QJ ,_ X a. QJ -~ "0 0 ~ ::0 40 c QJ "0 QJ c 0 ·.
;::; ~ ro - a.E N ..... c... ::l Vl Vl t; 30 ro w c a .

- Vl c 0 Vl QJ 20 u ·- ...... tl.O c c QJ ..0 0 · - ·.
;::; ...... ro rc: ·- """" g_ -~ "0 10 QJ"O QJ .... ~ E 0 Males Females Source: Health Interview Survey 2008 : 1 r~JCC~ej ;-;L;;ll:J6i~ cf diabetics in Malta 32,924 34,277 35,451 30,009 24,145 50000 - 45000 40000 35000 30000 25000 20000 15000 10000 5000 I l --- --------- 0 -- -- -·-· 2008 2020 2030 2040 2050 Source: National Statistics Office - ' Projected trend by age-group 14000 12000 10000 8000 6000 4000 2000 0 35-44 -~' .,.~ - -45 -54 -... ......_,...,_, .. , ......... ~ ....
~..._.-- / --------------- -------- -·"----- 55 - 64 - -65 -74 ---75+ 2008 2020 2030 2040 2050 Source: National Statistics Office Develupi11~ a l\iatior1ai -Siraiegy for Diabetes .. !
National Health Systems Strategy Non Communicable Disease Strategy WHq,Health 2020 Strategy I European Union: Chronic Disease Management Healthy Weight for Life Strategy International Diabetes Federation ~ ~ Steering group Experts i t l t Patients National Diabetes Strategy Objectives -To prevent diabetes -To diagnose diabetes earlier -To ensure access to innovative quaf1ity treatment -To prevent complications Ultimately to improve the quality of life for persons with diabetes DIABETES TREATMENT IN MALTA: NEED FOR NEW TREATMENT OPTIONS Professor Stephen Fava JVID, MRCP(UK), FACP, FEFL\1, FRCP(LondO, MPhil(Melit), PhD(Exeter) Consultant in Diabetes, Endocrinology & Medicine Head, Diabetes & Endocrine Centre, Mater Dei Hospital Chairperson, Department of Medicine, Mater Dei Hospital Diabetes is common condition world-wide, especially in the elderly(!).
Poor glycaemic control is known to be associated with increased risk of microvascular disease, peripheral vascular, cerebrovascular disease, coronary artery disease, heart failure and cataracts (2).

The tisk of infections also rises progressively with tising blood glucose.

Apart from these classical diabetes complications, inadequate blood glucose control is also associated with other, more recently recognized complications, including dementia (3, 4).
Blood glucose rise after meals is also associated with cardiovascular disease (5).

Unfortunately, many of the treatments currently available to treat diabetes can cause hypoglcaemia (low blood sugar).

This is associated with decreased health-related quality of life (6) and with increased risk of accidents (7).

Insulin treatment in the elderly is also associated with increased risk of falls !

8).
8).

The risk of falls increases progressively with tighter control in elderly insulin-treated diabetic subject !9).

Hence.

currently one has to choose between either anempting good control with the serious risk of h)]Joglycaemia.

or less tight control in order to aYoid hypo glycaemia but at risk of predisposing to long-tenn complications ( 10 ).

Therefore there is an urgent need to introduce neve and safe medication to treat diabetes in the '\ational Formulary.
Although there is a cost implication in introducing new medicines, this has to be balanced against their benefit in helping to achie\·e good blood glucose control and therefore reduce the risk of complications, and to do this with a low risk of hypoglycaemia.

EYen from a purely economic perspective, one has to bear in mind that most of the expense in treating diabetes is related to treatment of its complications (11-14).

Hypoglycaemia is also associated with significant health costs !151.
Therefore im·esting in the treatment of diabetes.

which improye glucose control with a low risk of h)]Joglycemia, will eventually resnlt in cost saYings (16).

Finally, one should note that some of the newer anti-diabetes have been shown to reduce mortality when compared to the older which are available in the local '\ational Fommlary (17, j Q\ l "-'}· In conclusion, there is an urgent need to introduce new ant-diabetes drug treatment in the local National Formulary.

REFERENCES 1.
REFERENCES 1.

McDonald M, Hertz RP, Unger AN, Lustik ME.

Prevalence, awareness, and management of hypertension, dyslipidemia, and diabetes among United States adults aged 65 and older.

J Gerontal A BiolSci Med Sci.

2009; 64A:256-63.

2.

Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, Hadden D, Turner RC, Holman RR.

Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study.

BMJ 2000; 321: 405-12.

3.


Mortimer JA, Borenstein AR, Ding D, Decarli C, Zhao Q, Copenhaver C, Guo Q, Chu S, Galasko D, Salmon DP, Dai Q, Wu Y, Petersen R, Hong Z.

High normal fasting blood glucose is associated with dementia in Chinese elderly.Alzheimers Dement 2010; 6:440-47.

4.

Cukierman-Yaffe T, Gerstein HC, Anderson C, Zhao F, Sleight P, Hilbrich L, Jackson SH, Yusuf S, Teo K; ONTARGET/TRANSCEND Investigators.
Glucose intolerance and diabetes as 1isk factors for cognitive impairment in people at high cardiovascular risk: results from the ONTARGET/TRANSCEND research programme.Diabetes Res ClinPract 2009; 83:387-93.

5.

Fava S: Role of postprandial hyperglycemia in cardiovascular disease.

Expert Review of Cardiovascular Therapy.

2008; 6:859-872 6.

Levy AR, Christensen TL, Johnson JA.


Utility values for symptomatic non-severe hypoglycaemia elicited from persons with and 10~thout diabetes in Canada and the United Kingdom.

Health Qual Life Outcomes 2008; 6:73 7.

Hitchen L. Doctors are failing to tell diabetic people about UK d1iving rules.

BMJ 2006; 8;332(7545):812 8.

Christensen TL, Johnson JA.

Schwartz A V. Older women with diabetes have a higher risk of falls: a prospective study.

Diabetes Care.

2002;25: 1749-54 9.

Scll\nrtz A\·.


\'iningboff E. Sell10.1eyer DE.

Feingold KR.

de Rekeneire '\.

Strotme:;er ES.

ShorT Rl.

\'inik AI.

Odden MC.

Park SW.

Faulkner~.'\.

Banis TB.

Health.

Aging.

and Body Composition Study.

Diabetes-related complications.

glycemic control.

and falls in older edults.

Diabe:es Care 2008:31:391-6 10.

FanS.

Glycaemic control: a balancing act or a different approach'.'

Curr Diabetes Re\ 2014.10:214-30 11.


Clarke P. Gray A. Legood R. Briggs A. Holman R. The impact of diabetes-related complications on healthcare costs: results from the l'nited Kingdom ProspectiYe Diabetes Study (CKPDS Study '\o.

65y.Diabet '11ed.

2003 Jun;20(6):442-50.

12.

A.nieta F. Rubio-Terres C, Rubio-Rodriguez D, Magana A, Pinera 'vl, Iglesias P. Nogales P. Calaiias A, J\oye]la B, Botella-Canetero JL Deban C. Zamarron L Mora G, Balsa JA.
Vazquez C; Study Group on Diabetes.Estimation of the economic and health impact of complications of ty}Je 2 diabetes mellitus in the autonomous community of '11adrid (Spain) .EndocrinoL'\ utr.

2014 Apr:61(4): 193-201. doi: 10.1016j.endonu.2013.11.005.

Epub 2014 Jan 17.

13.

Ward A, Al\'arez P, VoL, MartinS.

Direct medical costs of complications of diabetes in the United States: estimates for event-year and annual state costs (USD 2012).J '11ed Econ.

2014 Mar;17(3):176-83.

1.:1.


Vupputuri S, Kimes T\1.

Calloway '110.

Christian JB.

Bruhn D, '11anin .A...A., J\ichols GiL The econornic burden of progressiYe chronic kidney disease among patients with t0ve 2 diabetes..!

Diabetes Complications.

2014 Jan-Feb:28(1):10-6.

15.

Brod M. Wolden M, Clu·istensen T. Bushnell DM.

Understanding the economic burden of nonsewre nocturnal h:voglycemic events: impact on work productivity, disease management, and resource utilization.

Value Health.
Value Health.

2013 Dec: 16( 8): 1140-9.

16.

Fitch K, Pyenson BS, Iwasaki K. Medical claim cost impact of improved diabetes control for medicare and commercially insured patients with type 2 diabetes.

J Manag Care Pharm.

2013 Oct;19(8):609-20, 620a-620d.

17.

Zhang Y, Hong J, Chi J, Gu W, Ning G, Wang W. Head-to-head comparison of dipeptidyl peptidase-TV inhibitors and sulfonylureas - a meta-analysis from randomized clinical trials.

Diabetes Metab Res Rev 20 14;30(3 ):241-56.

18.


Wu D, Li L, Liu C. Efficacy and safety of dipeptidyl peptidase-4 inhibitors and metformin as initial combination therapy and as monotherapy in patients with type 2 diabetes mellitus: a meta-analysis.

Diabetes Obes Metab 2014; 16(1 ):30- 7.

Recommendations by Ms. Christine Mifsud, diabetic patient: I.

2.

I think that there should be more promoting of awareness regarding diabetes in all our communities.
These should start from a very young age in schools and going on to other education levels.

In our communities, entities should be encouraged to promote awareness regarding check-ups, monitoring and following of a healthy diet and exercise.

Persons should be tested, even if they do not show signs of diabetes, started from the overweight children and going on to older ages.
Taking random HGT tests on World Diabetes Day has proved a success and this should not happen once a year, but this should be even made available, at a low cost or free of charge even from pharmacies of your choice.

3.

24 hr help should be given to those newly diagnosed, especially children and parents.

A 24 hr helpline consisting of a nurse, doctor, and psychologist should be available in the early stages of diagnosis and when medication is started.
This will avoid anxiety and the feeling of helplessness when one is newly diagnosed and needs help even in the simplest of tasks such administration of insulin or tablets, nutrition and diet, monitoring etc.

4.

Psychological help should be offered and made obligatory to those who are newly diagnosed to help overcome the initial shock and to help accept changes this condition brings with it.
This will avoid parents, partners and family members being over protective and hindering one's adaptation to a new lifestyle.

This will also help persons accept this condition and take proper care of themselves and avoid future drastic side effects such as amputation and losing their eye sight or getting other related eye complications.

5.

Pregnant women and their child should be given priority when it comes to services, monitoring in hospital and research funds should be allocated in this sector.
Frequent follow ups must be given if needed.

Many woman get diabetes in their pregnancy, but many manage to control it and they do not become diabetic after childbirth however these women must be checked periodically after their child is born.

1).

The government must carefully plan a strategy to include all the above and the right service provided to the right person.

A patient must be allowed to choose his own consultant and feel at ease and have a good relationship with his doctor.
Outpatient visits should not take too long from one appointment to another, remember that not everyone can afford to go to a private consultant.

This long time frame between one appointment and another could lead to complications going unnoticed.

Prevention is much better than cure.

The media should be made to help in promoting awareness everyday through television educational clips and features in papers and on the internet's most visited sites.
L The Malta Diabetes Association should play a main part in decision making, as it is in close contact with persons suffering from diabetes.

It should be allocated funds to keep promoting.

1.

Persons like me too should give their experience and play a good part in decision making, because at the end of the day, it is us who go through the system in hospital, who have to take the medication provided, who know what is best for a diabetic person.
Politicians and Consultants, doctors and GPs and the general public all should work hand in hand to prevent diabetes and its complications and provide the right services for diabetics.

1 10.

\1edicauon.

especially the blood glucose sticks should be giwn for free to all.

Remember persons like me need triple the amount of strips giYen by the Go' emment.

When faced with financial difficulties and huge home loans and bills.

one has to choose what to pay for and what not.


Sometime health comes last in line.

Opportunity cost is not a good option "·hen it comes to health.

11.

The old diabetes passport should be re-introduced as it used to keep record at all times of what tests the patient had to undergo during a year.

This was of help to both doctors and patients.

12.

Pre,·ention is better than cure.


If one follows a good routine of frequent ,·isits, controls his monitoring, medication and exercise, one can pre\'ent a controlled condition turning into a disability.

This will effect persons in many drastic ways and life would ha\'e to change completely imolYing higher costs, adaptations and might lead to poYerty too.

If the government im·ests well in this strategy .


it will also ha,·e a good economic result in areas such as housing, disability pensions, inYesting in job coaching for the disabled.

redundancy.

im esting in m::>re hospital sen ices for persons effected by disability.

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_:: :: .. : -~ -- .. ...- :- --~ ~---~ :--:~ The local outlook ~ Only 304 out of 29,878 Gozitans "dared" to be tested for diabetes (Vivian Study, Phase 1) ~ "The average age of the participants was 55 years and out of the 94 tests which were taken under fasting conditions, 1 9% were above normal whilst the results taken from the 210 tests taken randomly, 1 5% vvere also above normal levels," Vivian Corp.
Phase 1 Phase 2 ~ Participation rate went up to 504 in Phase 2 ~ Throughout study,out of the 221 tests which were taken under fasting conditions, 30% were above normal whilst the results taken from the 587 tests taken randomly, 14% were also above normal levels '· '.
The Gozo Health Service ~The Gozo General Hospital ~The Rabat "Health Centre" ~ 12 peripheral clinics/bereg ~ 3 consultant physicians ~ 2 5 GPs ~ 3 community nurses Diabetes in Gozo - some figures Diabetes Clinic GGH- Activity figures (Patient Encounters) Year Male Female Diet Tablets : Insulin 2007 2008 2009 2010 2012 2013 866 707 839 589 617 693 753 570 589 437 434 531 307 220 259 91 48 66 ' 1063i 832!

870'.
870'.

714 674 805 ' 249 225 299 221 329 353 - Total - - 1619 1277 1428 1026 1051 1224 Diabetes in Gozo - some figures o·~·· ~-- .

·~···.

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• -k.;.<.,' '•"• Year 2007 2008 2009 2010 2012 2013 ,, "' ,, ' .

,-- Male 866 707 839 589 ' .... 617 693 .. .... ...... ~-- ' I % I I 53.5 55.4 58.8 57.4 58.7 56.6 ' ..... ,.

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< I Female 753 570 """~····- : '. "


589 .............. ( .,.,,,,,,,.,,,'' """'' 437 434 531 % 46.5 44.6 ... "''"'"'• - ' 41.2 42.6 41.3 43.4 ., ..

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Totals 2009 2010 2011 2012 2013 DOP ACC DOP &ACC DOP &ACC DOP &ACC DOP &ACC 32 9 96 104 92 132 1364 1483 2400 2677 2676 2831 - ·- 1396 1492 2496 2781 2768 2963 Diabetes in Gozo - some figures Glucose tests : 2011=18116 2012= 18046 2013= 1,9616 Totals of HbA 1 c test for 201 3: 2621 ' Services currently provided:: adult ~ Diabetic outpatients 3 times weekly (consultant physicians) ~ Ophthalmic referral: check for diabetic retinopathy, glaucoma, visual fields ~ Other specialist referrals as necessary ~ Podiatry ~ Tissue viability ~ Peripheral vascular assessment Services currently provided: child I adolescent ~ Paediatric Clinic every 3 months: visiting specialist plus specialist nurse ~ Teens/adolescents: visiting specialist every 3 months plus practice nurse ~ Support group Services currently provided: awareness jed ucation ~ Yearly activities linked to world diabetes day ~ Outreach awareness activities in the community: seminars, talks, monitoring of blood glucose, BP and BMI ~ Liaison with local councils, parishes and commercial centres ~ Organised by outpatients team at GGH '~~fa"y· ·.. ··f·,r::\.
tr;w .. ·a· ,,rd, ·.

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·,v~~ur: Expansio'n of service to include: ~ Access to diabetologist for adults on a visiting basis · ~ Diabetes specialist nurse based at GGH ~ Diabetic foot clinic through ERDF-funded equipment ~ Multidisciplinary diabetes clinic ~ Care plans based on agreed protocols ~ Documentation and statistics - shared register ~ Education ~ Cultural shift - primary care hub.
Dietiti.ans' role in the Prevention & · Management of Diabetes ' Considerable body of evidence that dietary advice plays an important role in the successful management of various medical conditions, including DIABETES 1.

Evidence-based nutrition guidelines for the prevention and management of diabetes (May 2011) 2.

Nutrition Recommendations and Interventions for Diabetes A position statement of the American Diabetes Association (2008) 3.
National Institute for Health and Clinical Excellence (NICE, 2013) Position Paper on the Role of the Dietitian in the Prevention and Management of Gestational and Type 2 Diabetes (EFAD, 2012) The role of nutrition and dietetics.

Dietetics focuses on the nutritional requirements of individuals and how these Inay best be n1let.

A dietitian is a person with a qualification in Nutrition & Dietetics recognized by national authority( s ).
The dietitian applies the science of nutrition to the feeding and education of groups of people and individuals in health and disease.

The dietitian is considered a ceLttral role in the diabetes team Current Dietetics Service The nutrition and dietetic service in Malta & Gozo is under developed if compared to other EU countries -73.5 FTE -7 Diabetes alone ca 0.
5 FTE Recent data from the European Federation of the Association of Dietitians shows that dietitian staffing, ratio is at an average of 15 per 100,000 population size (EFAD, 2013).

*Currently Waiting List for people with diabetes to see dietitian - > 1 year!

*No time is allocated to research or audit and data systems only record face to face contact with little or no outcome information collected.
The small number of dietitians in profession has also made difficult student training, thus affecting recruitment.

NUTRITION AND DIETETIC SERVICES STRATEGY 2010-2020 November 2009 Compiled jor H ealtb Worliforce Team (NHvVT) within the 1-Iealtbcare Services Division Strategic Objectives l.Develop a vvorkforce for the future 2.

Further develop the profession as an expert resource across all the Maltese Islands 3.
Develop an effective response to government targets on nutritional issues such as obesity and diabetes 4.
Develop a modern, equitable and responsive dietetic workforce Cost-benefit analysis of dietary treatment ""Ji-cutmenl hy the dietitiun /ws vurious sociul hen~Jits.Thc hmlth ofrhe putienl (unci hisj:uni/y) improves, such tfwt costs of' health cure cun be uvoidecl unci tlu: production c:f the putient increuses_ Fhe treatment (?fputicnts with obesity und ohesity-relotccl diseuses (e-8- Diuhetes) creutes sociul benefits c:f € 0.4 to € 1.

9 billion over u period o(flve veurs.


I ,T,_i ;; For every € 1 spend on dietary counselling ~f these patients, society gets a net € 14 to € 63 in return: € 56 in terms ofimoroved health, € 3 net sewings in total health care costs and € 4 in terms if productivity gains."

._y 1 Jlmst a dum, November 20 l 2 Commissioned hy the Dutch Association ofDietitiuns (Nederlundse Verenif!illf!
von Diiitisten) Marloes Lammers, Lucy Koh Summary & Conclusions ·' IMPLEMENTATION of the Nutrition & Dietetic Services Strategy Thank You Dr Mario Caruana, 03/06/2014 ._.

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II l_l Co-morbidity l_Jll II I .______ _____ ___, o Greatest challenge facing medicine is co-morbidity o Two thirds of all people over 55 years of age with a chronic disorder such as diabetes and Depression, hove more than one illness at the some time (WHo 201 1) o Co-morbidity of mental and physical illness is much less appreciated despite co-occurring commonly with grove consequenceS(Lawrence & Coghlan, 2002) o Prevalence of diabetes is increasing in both the general and psychiatric populations (Katon et al 2009) o Health and Economic burden of diabetes falls disproportionately on persons with mental illness particularly depression and anxiety (Atlantis et al 2012) --- ---- I __ T ___ -----~:----- - --- ------------- -- ---~ r· I ' .. ·- ---- -- --------If_ --------- . '
II 1 - • I : I Diabetes and Schizophrenia o People with schizophrenia o hove multiple risk factors for type 2 diabetes o may represent on independent high-risk group for diabetes o Interaction between Schizophrenia, antipsychotic medication and diabetes is complex o Schizophrenia itself may be on additional risk foetor for diabetes as may antipsychotic treatment (metabolic disorders) de Hert, M ., 2012 l'f-1----, 1.. .... -~·;- -;·- .•.

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Ill II I ~l: Co-morbidity in Children & Young People o Diabetes has a negative impact on virtually all aspects of child development increoseing the risk for psychiatric disorder, anxiety and depression being the most common.

o Females with type l diabetes ore twice as much at risk of developing anorexia or bulimia.

o 40% of 15-30 year olds regularly omit insulin with possible devastating consequences intake o Emerging dual diagnosis of type l diobetes ond eating disorder.
o Syndrome termed "ED-DMTl "; affecting teenage girls o Describes the intentional misuse of insulin for weight control o Devastating effects leading to mortality o There is still o Iorge unmet need to quontify and qualify the co-morbidity of these disorders in children and young people .

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I 1: 1: ----- -·----- TI- ll Diabetes and Depression: Facts o Type 2 diabetes and depression o ore common chronic illnesses (Katon, 1992; American Diabetes Association, 2012} o individually con be among the most disabling chronic disorders and when they occur comorbidly, they ore even more detrimentdl o 31-33% of persons with diabetes suffer from (Anderson & Freedland, 2000; Van Der Feltz c M, depression 2011} o In the presence of diabetes, the prevalence of depression increases to 15% to 30% depending on depression definition, population sample and study type (Stone et al .
2006; Anderson et al 2001) o Persons with depressive disorders are twice as likely as the rest of the population to also suffer from diabetes (Bjorntorp, 2001) .
: - ......... ~ I Bi-directional relationship o Diabetes and Depression exhibit a bi-directional relationship, with each disease an independent risk factor for development of the other o Prognosis of both diabetes and depression is worse for either disease when they are co morbid than it is when they occur separately (Luslman et al., 2000; Egede,2006) o Bi-directional relationship is not limited to its effects on prevalence.
When these diseases are co-morbid, they significantly amplify the cost, morbidity and mortality expected from either one alone o In the case of depression, changes in blood sugar levels hove been linked directly to moods such as anger, anxiety, sadness, frustration and g e· n era I we II being (Gander-frederick et al.. 19891 ___ -~:·-.-------r·t - ' ..

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, I ---------------------····-··.-- ----- ·r- ---- ' Bi-directional relationship o More than 70% of patents with diabetes have depressive episodes lasting longer than 2 years (Katon, et.
a\2004) o Dysthymia and double depression is more common in patients with diabetes (Katon, et a\2004) o MDD is highly recurrent in diabetic patients - 80% of depressed persons with diabetes experience a relapse of symptoms with an average relapse rate of nearly 1 episode every year (Lustman eta!, 1997) o Depression is one of the most disabling chronic conditions.
The functional impairment it causes is substantially worse when it occurs in the context of diabetes o Depression in diabetes has been associated with decreased self-care, including decreased adherence to treatment, exercise, smoking cessation and eating a healthy diet (Ciechanowski eta\, 2000) · .. ,_ ... · .. ,, .... II U~.
~--~ Bi-directional relationship & other risk factors o Depression o contributes to the pathophysiology of diabetes (Katon et al 2004) o is associated to many other adverse outcomes (de Groot et al, 200 l) o in diabetic patients is a risk factor for dementia, hospitalisation and even death o In the case of dementia, diabetes and depression ore independent risk factors for vascular and Alzheimer-type dementios, and co-morbidly they import substantially rnore risk than either one alone , -· -.
··-----r ~------------------------- :-----~'- --~------,1 :-_ --- : I .

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I i i' -·-·--- ------ ·- ··-·- .. -- ..... --··- ·--~-------------,-,------ Increased costs of diabetes care o Depression contributes to decreased quality of life and increased costs of diabetes core o Costs of the core for depressed versus non-depressed patients with diabetes was 4.5- fold higher · o Costs for severely depressed patients were 86% higher than those for patients with less severe depressive symptoms ( Ciechonowski et ol, 2000; Egec:je et ol, 2002) o The economic impact is particular high in the area of employment because of absenteeism, presenteeism and withdrawal from the labour market, as well as in the area of social welfare due to benefits (McDaid, D. 2012) I i .l ·--C-' -' ___ .LL_ I I Conclusions o Prevalence of diabetes and mental .
1ncreas1ng .
illness is o Association between type 2 diabetes and mental illness is bi-directional o The prevalence of diabetes has been found to be consistently higher for people with mental illness o There is limited awareness and knowledge of the o frequency and consequences of co-morbidity of diabetes and mental illness o developmental and psychological impact of diabetes on children and young people o Resources directed towards improving care and quality of life for persons with co-morbid diabetes and depression are insufficient ' 1 ; - - : --:.--w---- ---- ··· T ·rr-:, --- - --n ----- -------------·---·---·---·---~--- Recommendations o Multi-condition Collaborative Core Programme o Routine screening of patients with diabetes for psychopathology and vice verse, as well as lifestyle risk factors, to inform practice for more effective management and prevention planning.
(e.g PHQ-9) o Public Health Interventions o Effective Treatment - psychological pharmacological and o Training of Health Core Professionals (GPs, Nurses and Specialists (Endocrinologists and Psychiatrists) o Research \ .. : .r· I···· .. o Co-morbidity its effects on development and mental health) in children and young people (diabetes and o Epidemiological studies on co-morbidity of diabetes and·depression o Treatment effectiveness ., .. , !_ I I Acknowledgements o Profs Norman Sartorius and Mr Lorry Cirnino and the Dialogue on Diabetes and Depressiion Platform o Profs Alan M. Jacobson, M.D.
Chief Research Officer, and Director of the Diabetes, C)besity and Cardiometobolic Research Centre, Winthrop University Hospital Mineola, NY o Profs.

Bennett L. Leventhal, MD, Deportment of Child and Adolescent Psychiatry, NY University Lanqone Medical Center and the NYU Child Study Center. '

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The Diabetic Foot putting the best foot forward Phyllis Camilleri Podiatrist Diabetes Foot Care PATHWAY OF CARE FOR THE FOOT IN DIABETES STAGE CARE NEED HEALTHY FOOT SCREI;NING- early detection of complications and risk factor • > early intervention and education.· presently done in secondary and primary care but not all stake holders aware.

NATIONAL DIABETEIC FOOT SCREENING PROGRAMME IS NEEDED.
REQUIRES MORE SPECIFICALLY DEDICATED, HUMAN RESOURSES ,EQUIPMENT AND SPACE.

ONCE IN PLACE PATIENT AND HEALTH CARE PROVIDER AWARENESS CAN BE IMPROVED.

PATHWAY OF CARE FOR THE FOOT IN DIABETES STAGE CARE NEED THE 'AT RISK/ AND 'HIGH RISK' FOOT REGULAR PREVENTIVE CARE AND TIMELY OR IMMEDIATE INTERVENTION WHERE NECESSARY.

Currently available with good liaising between professionals who are aware of serv1ces.
Introduction of joint vascular clinics and vascular surgery has lead to improvement in limb salvaging.

Improvements necessary: •Appointments for further investigation.

•Budgetary and human resource limitations at OPU.

·Investment in a CAD-CAM 30 scanner will reduce timing of orthotic supply significantly.
: · 300 ~--------------------------------------~ 250 200 150 100 50 Introduction of Vascular Surgery Service 84 97 104 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 I • Major • Minor I Amp,u.tations ~ ..lit'""" ·-··-· ~ ~r-~~~~ PATHWAY OF CARE FOR THE FOOT IN DIABETES STAGE THE ULCERATED FOOT CARE NEED REGULAR PREVENTIVE CARE AND TIMELY OR IMMEDIATE INTERVENTION.

Currently available with good liaising between professionals who are aware of services.
Improvements necessary: •Provision of medications including dressings and antibiotics often fraught with red tape and too much paper work.

Not clear to practitioners what can be supplied .

...... , •.

OPU supplies are crucial at this stage. "

--..

--.--,---~----·· Problems with: timing of delivery and site location of OPU not conducive to multidisciplinary liaising.
PATHWAY OF CARE FOR THE FOOT IN DIABETES STAGE THE AMPUTATED FOOT OR LIMB CARE NEED REGULAR REVIEW TO MONITOR LIMB STATUS AND PREVENTIVE CARE FOR STUM AND COLLATERAL LIMB.

Services for good after care are currently in place and generally at this stage patients will be aware of quick access pathways to any of health care professions needed.

Improvements needed: ·Better psychological after care.

• CPO programme for care providers re teaching strategies.

•Unit for screening/monitoring amputees.


• ::J 0 > ~ c ra .c 1- Childhood Diabetes in Malta Dr John Torpiano MD, FRCP(LondL FRCPCH Consultant Paediatric Endocrinologist Mater Dei Hospital, Malta Parliamentary Working Group on Diabetes in Malta July 2014 Types of diabetes in children in Malta 1.7% _ 1 .7% 1.1% DTlDM IIIIT2DM OWolfram IIIICFRD 95.5% TlDM patients incur higher mean treatment costs than T2DM patients 1 1Garattini L 2004 .

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I .l..,l Bad News: • Cannot be cured permanently • Cannot be prevented Good news: • Improvement in health and quality of life can be achieved .... but we need help Paediatric Diabetes Service: Mater Dei Hospital Children are NOT small adults • Run by paediatric endocrinologist since 2006 • Annual case-load: - 650 outpatient appointments (2 clinics per week) - 250 day-case appointments - 25 new patients (on average) • Detailed education for each new patient (circa 20 hours over 1 week) • Printed handouts for parents (Maltese & English) • Point-of-care capillary blood HbAlc (every 2-3 months) • Outreach clinic at Gozo General Hospital Childhood diabetes statistics in Malta {2006- 2010) Circa 25 new patients (under 16 years) every year 1 new young patient every 2 weeks on average Formosa N et al 2012 ---~--~-------- --- - ·----·----- 0 --" 0 N 0 UJ 0 .j>.
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0 :2:10 Frequency of daily SMBG Levine BS et al 2001 Ziegler Ret al 2011 LIVING WITH DIABETES IS LIKE WALKING A TIGHTROPE HIGH BLOOD SUGAR May lead to complications (e.g.
blindness, kidney failure, vascular disease) LOW BLOOD SUGAR Rapid drops may lead to unconsciousness, seizures and death Blood sugar test-strips Increased expenditure = €350 per child per year (1 dialysis patient= €42,000 per year) \\ Recommendations for improved care of diabetic children 1.

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:· References • The effect of intensive treatment of diabetes on the development and progression of long-term complications'in insulin-dependent diabetes mellitus.

The Diabetes Control and Complications Trial Research Group.

N Eng!

J Med.

1993;329(14):977-86.

• Danne T, Kordonouri 0.

Current challenges in children with type 1 diabetes.

Pediatr • Diabetes.

2007;8 Suppl 6:3-5.


Formosa N, Calleja N, Torpiano J. incidence and modes of presentation of childhood type 1 diabetes mellitus in Malta between 2006 and 2010.

Pediatr Diabetes.

2012;13(6):484-8.

• Garattini l, Chiaffarino F, Cornago D, Coscelli C, Parazzini F, Diabete SGRREdCeRd.

Direct medical costs unequivocally related to diabetes in Italian specialized centers.

Eur J Health Econ.

2004;5(1):15-21.

• Hoey H, Aanstoot HJ, Chiarelli F, Daneman D, Danne T, Dorchy H, et al.
Good • metabolic control is associated with better quality of life in 2,101 adolescents with type 1 diabetes.

Diabetes Care.

2001;24(11):1923-8. levine BS, Anderson BJ, Butler DA, Antisdel JE, Brackett J, laffel LIVI.

Predictors of glycemic control and short-term adverse outcomes in youth with type 1 diabetes.

J Pediatr.

2001;139(2):197-203.

• Miller RG, Secrest AM, Sharma RK, Songer TJ, Orchard TJ.
Improvements in the life expectancy of type 1 diabetes: the Pittsburgh Epidemiology of Diabetes Complications study cohort.

Diabetes.

2012;61(11):2987-92.

• Skyler JS.

Diabetic complications.

The importance of glucose control.

Endocrinol Metab Clin North Am.

1996;25(2):243-54.

• Ziegler R, Heidtmann B, Hilgard D, Hofer S, Rosenbauer J, Holl R, E!t al.

Frequency of SMBG correlates with HbA1c and acute complications in children and adolescents with type 1 diabetes.

Pediatr piabetes.
Pediatr piabetes.

2011;12(1}:11-7.

• To alleviate symptoms • To minimise the risk of long term compliications- cardiovascular dise;ase1 nephropathy1 retinopathy and neuropathy • Secondary prevention of other dise4:tses • Tight control is essential '· \ • - r n OJ 0 n 0 c - n A ::J -· ::J - OJ r-+ .. LQ \ 0.. -· -· (1) ~ OJ lJ'l u :::r- (1)' (1) r-+ ·:J (1) n lJ'l 0 0.. 3 \ c u lO OJ OJ \ (1) \ 0.. 3 r-+ OJ 0 3 lO (1) c ::J -· r-+ 0... OJ (1) \ -.
-· -· c ::J 3 (1) lJ'l -· -· lJ'l ::J 0 r-+ :::r (1) \ MALTA GOVERNMENT FORMULARY LIST (GFL) OTHER COUNTR~ES (BNF) • Biguanide class Metformin • Sulphonylureas Glibenclamide Gliclazide • Opposite OHAs + • Alpha-glucosidase inhibitor • Metglitinides e.g.

repaglinide • Thiazolidinediones e.g.

pioglitazone • Gliptins • GLP-1.

receptor antgonists • Sodium-glucose co transporter 2 E:~.g.
dapagliflozin MALTA GOVERNMENT FORMULARY LIST (GFL) OTHER COUNTRIES (BNF) lsophane insulin • Soluble insulin • • Biphasic isophane insulin All 3 above are available in both vial & cartridge form I Insulin aspi=Jrt Insulin glargine Analogues approved for type~ diabete.s only • • • Opposite insulins + • • • • Insulin glulisine Insulin lispro Insulin detemir Insulin degludec • Biphasic insulin aspart • Biphasic insulin lispro MALTA.GOVERNMENT FORMULARY LIST (GFL) • Paracetamol • Non-steroidal anti- inflammatory drugs • Amitriptyline • Nortriptyline • Opiod analgesics OTHER COUNTRIES (BNF) • Opposite drugs+ • Duloxetine • Pregabalin • Gabapentin • Carbamazepine The last 3 drugs are on the local GFL but are not approved for painful diabetic neuropathy • Insulin syringes (:to/month for pink card holders and 30/month for yellow card holders) , • Insulin pens for use with insulin cartridges • Pen needles (1 needle per injettion) • Alcohol wipes (one per injection) • Blood glucose monitoring strips (so per month and :too per month in pregnancy) • No lancets • Not just a matter of numbers • C I i n i c a I s i g n i fica n c e • Type 2 DM is a progressive disease • Escalation of therapy is required as time goes by • Recent guidelines- tailor-made medicine ; , • Efficacy • Side-effects e.g.
hypoglycaemia & weight .
ga1n • Other co-morbidities • Patient preference • Submissions for inclusion of drugs on the GFL from clinicians and agents • Reviewed by Directorate of Pharmaceutical Affairs (DPA) • Prescribing pathways (guidelines) for diabetes treatment submitted by clinicians • Considered by the Government Forrnulary List Advisory Committee (GFLAC) • Inclusion of new anti-diabetes drugs on the GFLisvital, t ., • Drug & equipment protocols need,cto be less restrictive • Increased drug expenditure BUT cost eff~ctive in the long run (les's'''diabetes complications, less hospital admissions and improved pa.tient quality of life) (; • Pharmacists can influence the effective use of medicine • Vital link between the patient and other health care professionals • With the increasing diabetes epidemic comes an inevitable strain on the workload of doctors and nurses • Alternative models & opportunities for diabetes care will be sought • Pharmacists have the potential to use their skills and patient contact to support and manage patients with diabetes · • Adjustment & change of medications • Medication review from patient interviews • Assessment of medication adherence • Education & counselling about medications/ lifestyle and compliance • Distribution or use of education material & educational workshops • Drug related problems identification • Development of treatment plans • Recommendation & discussion with physician regarding medication changes & problems • Point of care testing e.g.
BGM 1 BP1 review of lab data • Lack of clinical pharmacists on the wards and at out-patient clinics • Lack of independent prescribing pharmacists • Lack of pharmacist-led chronic disease medication review clinics • Lack of remuneration for point of care tests and services offered by community pharmacists , , • Electronic patient health records not available on a national level " - -'· Unite forDiabetes DIABETES EDUCATION UNIT -, ' ' ) ( ' , ' ' _, ~-~' (~_) '" \ ('Ill '---L ' / ' (_) ,.

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)By Mrs Moira Grixti Practice Nurse in Diabetes· Mr-s Catherine Azzopardi Practice Nurse in Diabetes ROLE OF A DIABETES NURSE SPECIALIST o To establis4 a holistic and developmental approach to diabetes care in all patients.

o Assess, plan, support, educate, and evaluate holistic specialist diabetes nursing care in the hospital and home settings.
I I: ' I ' \ Present DUTIES CARRIED OUT AT DIABETES EDUCATION UNIT o Individual education sessions to newly diagnosed patients and relatives with type 1 diabetes, patients with type 2 diabetes started on insulin therapy.

Mothers diagnosed with gestational diabetes.

o Education is given both at clinic and ward level.

o Follow ups.

o Group education sessions for patients with type 2 diabetes either as lecture form or using conversation map tools for diabetes.
\ " ) ' / \ Present METER EXCHANGE o Blood glucose meter exchange for all hospitals, health centres, homes for the elderly, MMDl'JA, prison, school nurses and patients with Type· 1 diabetes rounded up to a 1000 patients.

o Training by following the S.O.P done by the Point of Care Testing Committee on the use of the meter, performing quality control tests and correct technique regarding the uses of the blood glucose meter was given.

o Audits carried out by the POCT regarding the quality control tests.
Present DUTIES CARRIED OUT o Performing HbAlc test as a point of car~ using the HbAlc analyser for the paedia both in Malta and Gozo.

o Staff training on the management of diabetes.

o Training for endocrine patients using the Growth Hormone pen.

o Accompanying Dr John Torpiano an,d Prof Stephen Fava to Gozo General Hospital for education purposes.

o Trouble shoo'ting.

o Organising activities.

for world Diabetes Day.

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o Performing tests using continuous glucose monitoring system.

Every patient is brought to the Diabetes Education Unit 3 times.

I i I I I: Present & ' ' .. -- DUTIES CARRIED OUT o Education materiaL o Drafting of guidelines together with the Insulin Working Group regarding Insulin and Meal Administration.

o Drafting of guidelines on Insulin injection techniques for syringes and pens.
o Recommendations on angle of injection according to needles length used.

o Guidelines on the storage of insulin.

o Nursing Clinical Guidelines.

o We help in the organisation and participate in the annual summer camp for children with Type 1 Diabetes.

( \ "\ ) Year 2007 2008 2009 2010 2011 2012 St<u-ted Full time Education.
2013 2014 till end ofjune Individual Education Lectures HbAlc CGMS Growth Hormone Pen 197 Patients 76 Patients 320 Patients 65 Patients 456 Patients 95 Patients 680 Patients 106 Patients ' 763 Patients 160 Patients 1355 Patients 120 Patients 69 Patients 90 Patients ln the following table one can s~~e the amount of patients seen by us fi:·mn the year 2007 till today.

The number of patient seen have increased and an~ still increasing.
to ~ t?J > ~ u 0 ~ 0 1-Tj trj u c;::: (1 1-1 > 1-3 0 z 3245 Patients 80 Patients 298 Patients 70 Patients 38 Patients 1776 Patients 75 Patients 230 Patients 33 Patients 5 Patients IJ)_ t!J ~ ~ (1 t?J IJ)_ Future RECOMMENDATIONS o Children: According to 'Royal College of Nursing' recommendations for nursing services for children with diabetes should be a maxim urn caseload of 70 children per Diabetes nurse specialist.
o Adults: According to ' Diabetes UK task and Finish Group Report' recommended minimum core staffing levels for an area with a population of 400 000 average of 10 per cent prevalence of diabetes, is at least 10 Diabetes Specialist Nurses.

o In total at least 15 Diabetes Nurses are needed.

( ~) Future 1.1 OBJECTIVES o Increasing awareness on diabetes not just organising free blood glucose monitoring more often but lectures targeting the general public by including local councils and media.
Awareness and management of children with Type 1 Diabetes in schools (Seminars for Teachers).

o Organising structured courses with certification for Nurses and Health Care Professionals with an interest in Diabetes Education.

PUMP THERAPY o Initiation of insulin Pump Therapy.

Drafting of guidelines and protocols on eligibility of patients to initiate Pump Therapy.
o Dedicated nurses on just insulin Pump Therapy (set up of a Pump school equipped with a kitchen, to learn proper carbohydrate counting) which will include full time nursing, full time dietician on diabetes only, consultants and psychologists.

( ,,) IMPLENIENTATION o The implementation of the guidelines prioritizing meal and insulin administration and safe practices regarding insulin injection techniques.
o The scope of the guidelines is that through optimization and standardization of meals and insulin administration times across meals, patients "With diabetes mellitus will have better control of blood glucose levels. )
I Future CONCLUSIONS o Due to the increase in the services being offered and the increase in newly diagnosed patients with Diabetes both Type 1 and Type 2 and the early initiation of insulin therapy, we need an increase in Human Resources and work space for all of our objectives to be implemented .

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( ) Diabetes in the Maltese Islands Recommendations for consideration by the Parliamentary Diabetes Working Group Professor Joseph Azzopardi October 2014 Diabetes Common, getting comm(]~ner • Raised blood glucose levels • Can cause serious problems, including early death • Serious financial burden on society The Diabetes Services in Malta The Diabetes Services • Eyes: Screening, Laser and vitreous replacement • Cardiac and peripheral vascular unit • Podology, orthotics and prosthetics service • A joint Obstetrics- Diabetes clinic • Dialysis and Transplant Service Other Services • Education - Type 1: individual education with relatives - Type 2 Diabetes: Group Education - Maltese Diabetes Association - Health Promotion Unit • Dietetics • Limited free blood glucose monitoring • service The Proposed National Dia.betes Framework should help develop further and coordinate better these existent services This Document and Presentation • Background Information on Diabetes • The Electronic Medical Record ,.
• Shared Care • Complications • Dietary, Podology, Education Services • Psychosocial Services The main focus of this presentation is on the use of Information Technology in Diabetes in Malta Digital Records • Are instantly available • Easily readable • Increase speed of information exchange • Easily available for research, audit and reports Electronic Diabetes Data in the Health Department • 1980's: WHO donated system • 1990's: In house system developed that has been updated regularly.
Last update: 2014 • As of June 2014 there were 23588 patients registered and 115161 patient visits on the database • • t"'C Q.. ~ = 0 = ~ 1-i• ~ = =- 1J).

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Pending Issues with the System • Use of System is on a voluntary basis • Manual data entry is still being used for a considerable proportion of patients • Data recording in our clinics is ~ mixture of manual and computer data entry • The System is not being used to its full potential What is needed • An agreed upon departmental policy that all patient data is computerized • It is only then that - Each patient will have an electronic record - The system will be able to generate statistically meaningfully national data May I respectfully ask that the parliamentary group include this policy in its report and recommendations Recommendations to the Parliamentary Diabetes Working Group Professor Joseph Azzopardi MD MRCP(UK) FRCP(L) FRCP(G) FRCP€ FEFIM(HOns) 7'h October 2014 I would like to thank the Parliamentary group for asking me to prepare this document with my views on Diabetes in Malta.
These recommendations are based on forty two years of experience in the field, nineteen years of which were spent at the helm of the clinical diabetes services in Malta.

Background Diabetes Mellitus is characterised by raised blood glucose levels.

About 1 in 10 of the Maltese population over the age of 18 years is known to suffer from the condition; possibly an equal number have the disease but remain undiagnosed.

There are two main types of Diabetes, Type 1 and 2.
Both result from insufficient Insulin levels.

In Type 1 diabetes there is total or near total lack of Insulin usually because of auto immune pancreatic cell destruction.

In this type of Diabetes Insulin is needed for patient survival.

Over 90% of people with diabetes in Malta have Type 2 diabetes.

In this type there is insufficient Insulin production and resistance to Insulin action.
Type 2 Diabetes is associated with obesity, increasing age and inadequate physical activity; it usually occurs over the age of 40 although the age of onset is becoming increasingly less.

This type of diabetes can be controlled with a healthy lifestyle and oral drugs; insulin treatment may also be required.

Diabetes mellitus can be complicated by heart disease and stroke, nerve damage, kidney damage, eye damage and foot damage.
These complications can lead to serious disability and even early death; they are made worse by uncontrolled blood glucose levels, duration of diabetes, hypertension, smoking, elevated lipids, obesity and a sedentary lifestyle.

Besides producing untold misery Diabetes puts a serious financial burden on society.

Some cases of type 2 diabetes can be prevented or the onset delayed.

Prevention of type 2 diabetes would contribute greatly to quality of life, besides being very cost effective.
The Diabetes Services in the Maltese Islands.

People with diabetes are entitled to free management of Diabetes and its complications.

Routine diabetes care is provided at the main Diabetes Clinic in Mater Dei and diabetes clinics in the peripheral centres.

There is both an adult and paediatric service.

The clinics have facilities lor routine care with access to investigative, cardiac, renal, peripheral vascular and neurological referral clinics as required.
Between them these centres take care of more than 95% of all with diabetes in Malta.

Inpatient care is provided as required.

There is a patient education program at present run by specialist diabetes nurses.

People with Type 1 diabetes get individual education while people with Type 2 Diabetes are invited to Group Educational sessions.

The Health Promotion Unit and the Maltese Diabetes Association also take an active role in diabetes education.
There is a dietetic service and an Orthotic and Prosthetic unit.

Patients with Type 1 Diabetes are provided with a glucose monitoring device together with a limited number of blood glucose sticks per month.

Diabetes care in Malta has been improving over the past several years.

The Proposed National Diabetes Framework will hopefully help develop further and coordinate better the services that already exist.
The Electronic Medical Record There are a number of advantages in using electronic rather than manual medical records.

1.

Digital records are instantly available.

Paper records take time to retrieve, can be lost, damaged, stolen or subject to natural disasters.

With a good backup service there is no danger of this with electronic medical records.

2.

Reduction in human errors.

With the electronic medical record one does not have to rely on illegible records or inaccurate handwriting.

3.
3.

Data is easily available analysis for research papers, audit and reports, including administrative and parliamentary questions and reports.

4.

Digitized records reduce replication of effort and increase speed of information exchange Disadvantages include: 1.

A perceived threat tq privacy because of accessibility by unauthorized parties.

While no system is 100% safe, a properly maintained password protected system allows access only to authorised personnel 2.
Some people have a fear of systems with no human management or intervention.

In fact all automated electronic medical record systems are overseen by well trained personnel who ensure that these systems function well.

Electronic Diabetes Data Records in the Health Department In the 1980's a WHO donated system was used for data collection.

This was replaced in the early 1990's by the present system that has been updated a number of times, the last time being in 2014.
Our system is a product of years of work.

The present version has been updated to satisfy user requests.

The database at present can be accessed from the .

Diabetes clinics at Mater Dei Hospital and the Diabetes Clinics at Health Centres.

As of 2.3rd June 2.014 there were 23588 patients registered and 115161 patient visits recorded on the database.

The Diabetes Management Computerised System can function as: 1.

A Complete day to day Patient Management System.


There is data on patient Diabetes History, routine parameters and medications, symptoms, general medical history, physical examination, complications list, diet and patient education.

a.

There is a facility for free text entry that helps save time by decreasing the number of keystrokes needed to insert text phrases during data entry.

b.

Patient radiological images and reports can be accessed from the system.

2.
2.

A source of data for Research, Statistics and Reports on: a. Diabetes parameters, Process measurements and management b.

Intermediate outcomes and End stage Complications of Diabetes 3.

A Basis for a National Diabetes Registry 4.

A source of data information exchange for the European Union EUBIROD.

EUBIROD can create comparative reports on data aggregated from various centres.

Reports.

Various reports can be generated from the system i.e.

1.

Data Export Report.


This generates details regarding Visit date, Patient ID, Diabetes Centre, Type of Diabetes, Sex, DOB, Date of Diagnosis, Smoking Status, Alcohol Status, Weight, Height, BMI, BP, Biochemical parameters (Hbalc, Creatinine, Microalbuminuria, Lipids), Eye Examination and status, Foot Examination and Status, End stage Complications, Hypertension and Hypertensive Medications, Diabetes Therapy, Self-Monitoring and Education.

2.

Data Export Report as per Consultant.


A patient can be linked directly a particular consultant and each consultant can now generate reports on his/her patients.

3.

Consultant Patient Report.

This report generates a list of patients as per consultant.

4.

User Audit Report lists User Name, Visit Date, Patient ID, Patient Surname, Patient Name, Created Date as per visit There are at present two pending issues with the system: 1.

2.
2.

Some data is not being completely recorded Although there is general agreement that use of IT technology is the best way to monitor and to plan forward for improved management of diabetes, manual data entry is still being used for a considerable proportion of patients.

The result is that at present data recording in our diabetes clinics is a mixture of manual and computer data entry.

The system has been recently updated to satisfy user requests.
The latest changes should pave the way for the system to be used for all patient visits.

What is now needed is an agreed upon policy decision to ensure that all patient data is computerized.

It is only then that the system will be able to fulfil meaningfully all its functions.

Shared Care To date patients with diabetes have been managed at the Mater Dei Specialist Diabetes Clinic and the peripheral diabetes clinics.

In my opinion: 1.

The Shared care programs should continue and be further developed.
2.

All people referred to government health services with a diagnosis of diabetes should initially be assessed by a fully qualified Diabetologist and given proper dietary and other educational advice.

These patients can then, as indicated, either be followed up at Mater Dei or referred to the peripheral clinics as part of the shared care program.

," 4.

!fJ 3.
," 4.

!fJ 3.

Patient care should be under a multi-disciplinary apwoach with patients, doctors, education nurses, podologists, psychologists, social w~"rkers and other specialists all involved.

The peripheral clinics form an important part of the shared care program but there should be continuous liaison between these and the specialist clinic at Mater Dei if patients are to be properly followed up.

Given enough personnel, ea<;h patient should be referred to the specialist centre for an annual review.
A peripheral diabetes clinic should be set up in Gozo.

Patients who opt not to continue the government health service should continue to see their family practitioner who should ensure periodic specialist review.

All medications which have an established role in the treatment of Diabetes should be made available on the health service.

In order to minimise waste and unnecessary expenditure the prescription of some of these should be based on consultant approval.

5.

6.

7.

8.
5.

6.

7.

8.

All patients should be given regular follow up appointments for retinopathy screening and podology review and periodic baseline measurements and laboratory assessments ensured.

Appropriates specialist appointments should be arranged where indicated.

All results should be made available to the patient's family practitioner.

9.

All patient records should be kept on the Computerised Diabetes Management System installed at Mate( Dei and the Health centres.

10.
10.

All personnel working in the diabetes clinic:; should enrol in periodic retraining programs Dietary and Nutrition Services Proper dietary education is needed both to prevent and treat Diabetes.

In my opinion the following measures should be further developed or set up: 1.

As part of a national strategy to prevent Type 2 Diabetes the Health Promotion unit should increase public education on healthy nutrition and the benefits of regular exercise.
The various media need to be used to good effect for this purpose.

2.

Patients with diagnosed diabetes should be given timely adequate dietary advice.

An adequate number of properly trained dietetic personnel will be required.

At present there are only three part time dieticians attending the Diabetes Clinic at Mater Dei.

In the circumstances these are doing their best to cope but there is an unacceptably long waiting list of patients waiting to see a dietician.
In my opinion a minimum of three full time dieticians are needed for the Mater Dei Diabetes clinic together with one full timer for each of the peripheral diabetes clinics.

These will need space and facilities to work properly.

3.

A regular budget should be provided for the provision of adequate dietary educational material.

This cari be through print or electronic media.

This can be provided in liaison with the Health promotion unit 4.
Patients should be given access to help and advice either through a phone and/or email service 5.

When enough properly trained nutritionists are available, family doctors should be encouraged to refer patients directly to these for nutritional advice.

Public and Patient Education 1.

The Health Promotion unit should increase its efforts to promote a healthy lifestyle and nutrition.

This should help prevent some cases of Type 2 Diabetes.

2.
2.

People with diabetes should be taught to self-manage their disease in as far as this is possible; for this adequate education has to be provided.

This includes education on life style, the nature of diabetes, self-monitoring, medications and the prevention and care of complications.

Diabetes education nurses are playing a key role in education.

The service these are providing should be expanded and present educational facilities increased.
Patients should be encouraged to make use of appropriate educational websites on the Internet.

3.

More people with Type 2 Diabetes should be invited for group educational programs and those invited should be chased up to ensure that as many as possible attend.

4.

People with Type 1 diabetes and those with Type 2 on Insulin should continue to be given individualised education.

5.

All patients with diabetes should be provided with free blood glucose monitoring devices.
Some may need more blood glucose testing strips than others.

Podology Services A good .Podology service is necessary for patient preventative education and conservative foot management.

Podology services are available at Mater Dei Diabetes Clinic and in the Health centres.

The Mater service is a specialised one where three podologists see people with diabetes; the service in the health centres is a general one where diabetes patients are also seen; problem cases are referred to the Mater Dei Clinic.
The peripheral health centres provide a podology consultation service St. Vincent de Paule hospital, Mtarfa home, Sir Paul Boffa hospital and Mt.

Carmel Hospital.

A shoe and artificial limb service is available.

Podologists educate patients in preventative foot care, perform routine foot examinations, and treat common foot ailments which may or may not be directly related to the diabetes .

and treat diabetes related foot lesions.


There is close collaboration between podologists, diabetologists and the hospital neurology and peripheral vascular service and patients referred.accordingly.

There is a need for: 1.

A national foot screening service to prevent, detect and treat foot lesions earlier 2.

The Orthotic and Prosthetic unit at St Luke's Hospital needs more staff and a new facility needs to be set up to provide a quicker and more efficient cost effective service.

3.
3.

More educational material to be provided to patients 4.

Regular retraining courses for podologists, including possible exchange visits with foreign Institutions Complications Eye complications With time nearly all patients with diabetes develop some degree of retinopathy.

Regular screening for retinopathy is essential as this is often initially asymptomatic.

All persons with diabetes need to be screened for retinopathy.
This is at present done at the diabetes clinic at Mater Dei (through ophthalmoscopy and retinal camera screening), in the ophthalmic Department and in two health centres.

A number of patients see specialists privately.

These services need to be better coordinated to ensure that as many patients as possible are regularly screened.

Fundus examination can be carried out by ophthalmoscopy or fundus photography.
Ophthalmoscopy, particularly direct ophthalmoscopy, is inexpensive, transportable and widely available; however it requires adequate training of the examiner.

Screening for diabetic eye disease should be carried out by eye.

specialists or a trained diabetologist.

A substantial number of patients are at present screened in the diabetes clinic by diabetologists and referred to ophthalmology as required.
All modern facilities for treating diabetic retinopathy are available at the ophthalmic department at Mater Dei.

Recommendations for managing diabetic eye disease 1.

Optimal blood glucose blood pressure and renal function control 2.

A national screening programme for diabetic retinopathy 3.

An appropriate referral system for patients needing ophthalmic management 4.

Attenda nee to the psychological and social needs of patients with visual impairment The Kidneys and Renal Support Therapy 1.
Blood pressure and blood glucose should be regularly monitored and optimally controlled to minimise the chances of renal complications.

Renal biochemical parameters should be regularly monitored.

2.

A policy of early referral to nephrologists should be adopted in order to optimally decide on the need for and timing of kidney replacement therapy 3.

Patients embarking on renal replacement therapy need special psychological support.
Peripheral Vascular Services All people with diabetes should be routinely screened for peripheral vascular disease.

Patients with vascular problems should optimise their care and be referred to the peripheral vascular service unit.

Psychosocial and Social Services 1.

People with diabetes are more prone to psychological problems and depression.

A psychological service should be set up as part of the multidisciplinary approach to diabetes.

2.
2.

Patient with diabetes should be given a pink card for free medications.

Diabetes is an expensive disease and these people should be given all the financial support worker should be available for referral for those with social Diabetes Mellitus and perip,heral arterial disease ~Diabetes mellitus is one of the major risk factors for pf3:nilf:),t:leral arterial disease (i.e.

blocked arteries in le.gs) ~ Foot.and leg.


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below the ankle) is very high in diabetics <?The risk of major amputation (i.e.

amputation of leg below the lmee or above the knee) is 1 7 times more common in diabetics [>arliamentary Working (-;roup on Diabetes Mellitus 7th Oclober 2014 \'~· Diabetic foot, P',FO:ble1rns ~Diabetic foot problems- ulceration, gangrene, diabetic foot infections are the most common cause of hospital admission in diab~etics ~The number of admissions to hospital for diabetic foot prob.Jems is increasing!
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....... " "" 92 ........ __ 82 )11'..1 ·.- Introduction of vascular service 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Parliamentary Working Group on Diabetes Mellitus 7th October 2014 Minor amputations - toe and trans metatarsal Introduction of Surgery Service 13 lis.. 9 .. 13 * 1 0 "" 1 ~~- -~ 9 .. -~.r ... 19 ... 30 ·~~ 15 .... 1 ~ ... 24 f>arliamentary Working Group on Diabetes Mellitus 7th October 2014 • ..._.

What should we do to reduce amputations?
0 Diagnose diabetes early - routine screening in community with all citizens registered with GP 0 Control diabetes in those with the condition - glucose monitoring sticks, systematic follow up 0 Routine foot care education and foot care in all diabetics 0 Risk stratification for foot ulceration 0 Preventative measures - insoles; footwear; podiatric care 0 Urgent offloading and footwear prevention for those who have already lost toes or had ulceration - OPU Parliamentary Working Group on Diabetes Mellitus 7th October 2014 What's causlng thls epide111ic 0 We don't know patient is diabetic - 14% previously undiagnosed diabetics 0 When we know, diabetes is poorly controlled- 92% HbA1c >8% 0 We don't check their feet - no national foot screening 0 Even in those who have their feet checked - no proper preventative measures -- no shoes/ no insoles 0 Even in those who have aheady had problems and lost toes - no preventative measures or significantly delayed flartiamentary Working Group on Diabetes Mellitus 7th October 2014 W·,h,at~.s <$> Patients will only present when problem already set in <$> Too late <$> Uphill and costly struggte to attempt limb salvage and often digit or foot amputation inevitable <$> Of those who lose their limb, risk of death is high 0 10-15% of major amputations dead within1 month 0 66% of above knee amputations dead within 7 months Parliamentary Working Group on Diabetes Mellitus 7th October 2014 What's real:ly hap~pening - OPU ?
• 0 OPU - department provides footwear/insoles - chronically and severely underfunded 0 Funds for 2014 used up by beginning of April- no funds 0 Patients are not being provided with footwear or provision is severely delayed - patient comes in for toe amputation will lose more toes or even a limb by the time footwear provided 0 Patients undergoing minor amputations have no temporary footwear provided - relatives need to buy them/leave hospital simply wearing bandages 0 OPU is severely understaffed l'a•liau~<·ntHry \V,>rking (;''"'!'
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:!Ill t What's really ha!ppening - pharmacy?
i> Patients with bone infection (osteomyelitis) require antibiotics 3-6 weeks i> Chronic and persistent shortage of antibiotics - out of stock items i> Bureaucracy - almost impossible for patients to receive their antibiotics i> Repeatedly turned away by pharmacists for more forms and more signatures i> Question of entitlement to antibiotics - pink form/yellow form i> Most patients unable to afford 3-6 weeks of clindamycin/ciprofloxacin combination let alone linezolid or other more expensive antibiotics i> Same applies for dressings which need to be altered frequently and new paperwork, forms need to be filled in i> Often dressings out of stock even for in patients i> False economy - cost of limb loss significantly higher Parliamentary Working Group on Diabetes Mellitus 7th October 2014 What's really happening -·· foot screening?
<$> No national foot screening programme - previous proposal turned down <$>Capital investment 50,000 euro for equipment in health centres <$>No systematic organised comprehensive footcare programme <$> Recently aggravated by industrial action by podiatrists Parliamentary Working Croup on Diabetes Mellitus 7th October 2014 W;h;at n,e,e,d.s to be done?
<$> Don't bring in new services <$> Adequately fund current services <$> Basics: 0 OPU needs proper funding to enable rapid assessment of high risk patients <3> Tmely provision of footwear of good quality that patients will use 0 Eliminate bureaucracy and ensure that patients who require antibiotics and dressings get them - without hassle and humiliation and undue suffering Parliamentary Working Group on Diabetes Mellitus 7th October 2014 If vve can ma,nage that 0 What we really need: 0 National register of all patients diagnosed with diabetes 0 A comprehensive national foot screening service where all diabetics are called for foot assessment and education 0 All patients are risk stratified 0 Based on their risk assessment appropriate preventative measures implemented 0 Timely and appropriate provision of insoles/footwear as required 0 Routine and regular follow up of all patients with call ups for non attenders Parliamentary Working Croup on Diabetes Mellitus 7th October 2014 <$> For those who still present with ulcers/gangrene <S> Adequate beds for admission to wards with trained vascular nurses - not into corridors <S> Once minor amputations performed provision of temporary offloading footwear <S> Community nurse service adequately supplied with dressings required so patient does not have to provide his/hei own dressings <S> Early assessment at OPU and rapid provision of preventative footwear Parliamentary Working Group on Diabetes Mellitus 7th October 2014 -::•.
Guarantee ' If we can do all that minor amputations will be reduced from 800/year to 1 00/year 0 Equivalent to 2800 bed days per year 0 836,000 euro per year saved in bed ocupancy alone 0 Further cost savings in dressing~, antibiotics, nursing time ' If we can do all that we will reduce major amputations by a further 20/year 0 420 bed days - acute hospital 0 50,400 euro per year in bed occupancy alone 0 200,000 euro savings in major surgery - i.e.
anaesthetics, nursing, operating time tl!amentary Working Gwup on Diabetes Mellitus 7th October 201,1 ~Limbs saved - how do you 'Cost a saved limb ~Lives saved - how do you cost saved lives ~Patients remaining in the community, continuing to work - how do you cost quality of life Parliamentary Working Group on Diabetes Mellitus 7th October 2014 Conclusion 0 How much funding has been committed?
0 Priorities: sort out current services 0 OPU 0 Pharmacy <:> Community nursing 0 Then consider <:> National Diabetes register 0 National foot screening programme Parliamentary Working Group l)n Diabetes Mellitus 7th October 20 !4 L...!

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o "For almost 40 years, there has been evidence that intensive lowering of glucose levels in patients with type 2 diabetes mellitus (OM) can lead to significant harm and has limited benefits.
In contrast tO' the effects of lowering blood glucose level, RCTs of reducing either BP or blood cholesterol levels have found major reductions in both macrovascular and microvascular disease.

/ f Havas, 5.

Arch Intern Med 2009; 169 (2): 150-4 '··· l1.'

o "Blood pressure below 130/80 mm Hg was not associated with reduced risk of all cause mortality in patients with newly diagnosed diabetes, with or without known cardiovascular disease.
Low blood pressure, particularly below 110/75 mm Hg, was associated with an increased risk for'poor outcomes."

Vamos eta/; BMJ 2012;345:e5567 Appropriate interventions?

o Diabetes management in primary care, outpatient and community settings can be improved by interventions targeting health professionals, and organisational interventions that increase continuity of care • Renders, CM, Valk, GD, Griffin, SJ, Wagner, E, van Eijk, JThM andAssendelft, WJJ.

Cochrane Collaboration; 21 January 2009.


• The review found that multifaceted professional interventions (for example combinations of postgraduate education, reminders, audit and feedback, local consensus processes, and peer review) could enhance the performance of care providers.

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1989.

A population based longitudinal study of the natural history of NIDDM and IGT in Malta.
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o Maltese Transition Project • 55,359 encounters • 12,227 patients • 2001 to 2004 • 450 episodes of care (398 [88°/o] type II, 52 [12°/o] type I), of which 100 (22.2°/o) new 121 RfE in 100 New Episodes of care of DM Code Label *60 *34 *62 *61 *64 *35 Result test/procedure Blood test Administrative procedure Result examjtestjlett oth provider Encounter/prob initiated by provider Urine test 7 U02 Urinary frequency/urgency 8 T90 Diabetes non-insulin dependent 9 T01 Excessive thirst 10 T08 Weight loss 11 *45 Observ/health educatjadvice/diet 12 A91 Abnormal result investigation NOS 13 N17 Vertigo/dizziness 14 A98 Health maint/preventive medicine 15 D10 Vomiting 16 *31 Medical examin/health eva!
partial 17 P12 Bedwettingjenuresis 18 L17 Foot/toe symptom/complaint 19 A04 Weakness/tiredness general 20 *65 Enc/prob init by other than pt/prov Total 21 18 12 10 9 8 7 5 4 4 2 2 2 2 2 1 1 1 1 1 Total 121 Likelihood of a new episode of type II OM starting with selected RfE or history elements_ Comparison of data from Malta and Dutch Transition Projects_ Dutch data on RfE alone, excluding hi~tory, and use ICPC-1 where diabetes type I and II are included in T90_ for encounter I LR+ (95% CI) Malta LR- (95% CI) Malta LR+ (95% CI) Dutch LR- (95% CI) Dutch Jniticant) (Urinary uency) 6.55 0.95 2.99 0.98 , (2.99-14.33)* (0.90-1.00) (1.96-4.57)* (0.97-0.99)* 0 (Diabetes type 797 0.95 543.58 0.86 II) TO 1 (Excessive thirst) T08 (Weight loss) ' (156.56- 4057.38)* (0.90-0.99)* C392.o9- 1 753.61)* (0.83-0.88)* 136.63 (35.87- 1 520.5)* 19.62 I (7.29-52.77)* 0.97 0.85 (0.93-:LOO) I (86.37-133.19)* I (0.83-0.88)* 107.26 I 0.96 I 11.00 I 0.97 (0.92-1.00) (7.43-16.28]1* (0.95-0.98)* A91 (Abnormal result inv.)
A04 (Weakness/ tiredness) I I 49.05 0.98 7.1:31:3 1.00 c11.22- 1 co.95-l.01) 1 (2.49-24.57)* 1 (0.99-1.00) 214.39)* 0.32 I 1.021 co.o4-2.22) I Cl.oo-l.o5) 1 1.00 I 1.00 co.74-t.3:;r) 1 (0.98-1.02) Diagn9sis of DM in FM o Patient suspects he/she has diabetes o Excessive thirst o Abnormal results of investigations o Weight loss o Urinary frequency o Soler JK, Okkes IM.

2005.

Diagnosis of diabetes mellitus in Malta.


The contribution of patients' reasons for encounter and .doctors' interventions to the final diagnosis of diabetes.

Poster presentation.

EGPRN meeting, Tartu, Estonia.

www.egprn.org Diagnosis of OM using HGll o Protocol where capillary fasting plasma glucose tested during usual care.in patients at risk o Repeat a not her day if > 6.
0 m moi/L o Test positive if second > = 7.0 or if first reading >= 7.0 and second reading > 6.0 o Positive predictive value of 82°/o o Klein Woolthius EP, de Grauw WJC, van Gerwen WHEM, et al.

2005.

Portable blood glucose meters useful in stepwise screening for Type 2 diabetes in general practice.

Poster presentation.

EGPRN meeting, Tartu, Estonia.

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w Starfield B.
w Starfield B.

Is primary care essential?

Tfle Lancet 1994, 344: 1129-33 ® The strength of a country's primary care system was negatively associated with: • all-cause mortality, • all-cause premature mortality, and • cause specific premature mortality from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease and heart disease.
® Strong primary care system and practice characteristics such as geographic regulation, longitudinality, coordination and community orientation were associated with improved population health \!)

e Macink() J., Starfield 8 and Shi L. 2003.

The contribution of primary care systems to health outcomes wittlin OECD countries, 1970- 1998.

Health Services Research 38(3): 831-865 What are the advantages and disadvantages of restructuring a health care system to be more focused on primary care services?
WHO Regional Office for Europe's Health Evidence Network (HEN) January 2004 ore elements of primary health care o Starfield: Primary contact, continuity, comprehensive~ess and coordination o Starfield B.

Is primary care essential?

The Lancet 1994, 344: 1129-33 o EURACT: primary care management, specific problem-solv_ing skills, community orientation, comprehensive approach, holistic approach, patient centeredness.

o Heyrman J, editor.

EURACT educational agenda.

EURACT;2005.
Features of a good primary health care ystem ® Patient registration • First contact • Longitudinality ® Electronic patient records • Longitudinality • Coordination ® Access to special investigations • Comprehensiveness ® Integrated national health care systems • First contact • Longitudinality • Comprehensiveness • Coordination Strengthening the role of the family doctor to achieve better<-outcomes o Allowing specialists in family medicine to prescribe, modify and monitor treatment, and arrange specialist care when needed • Investigations (access to iS oft) • Prescriptions and Schedule 'V • Referrals (easy access to out-patient appointments, fast-track urgent cases) • Patient registration with family doctor Thank you o Henk Lamberts, Inge Okkes, Sibo Oskam o John Buhagiar, Jason Bonnici, Daniel Sammut, David Samrnut, Frank P Calleja, Mario R Sarr1mut, Carmen Sammut o Antoine Schranz What's Diabetic Retinopathy N·orma:~ Backgro'LlHd iLlR Non~pro~·,iferative 0 R: Severe rN on~ POR P'IDR neo;v~E~:scul~iliriz:art~on Fi:brov.a s·c:uilar membra:nes ' _-;.,,-<-- .
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i --; ,, 0 c ... a. a D) 3 PARLIAMENTARY WORKING GROUP ON DIABETES MALTESE PARLIAMENT MALTA, THE PALACE, VALLETTA 13 OCTOBER 2014 SPEAKlNG POINTS Honourable Members of Parliament, Ladies and Gentlemen, • I am grateful for this opportunity to contribute to your discussions here in the Diabetes Working Group.

· • Let me take this opportunity to compliment the Working Group on its efforts to shape recommendations to fight,,,_.,, diabetes here in Malta.
• I would like to focus on what the EU is doing to help fight diabetes.

Strong synergies between efforts at national and European level are important to succeed in fighting this growing disease.

• Current diabetes trends are indeed worrying.

1 • In the EU alone, 32 million people are living with diabetes.

If this trend continues, this is estimated to rise to 38 million by 2035- over 8% of the European population.
• The situation is quite varied across the EU, as prevalence ranges from 5.7% in Sweden to 12.7% in Portugal.

• Here is Malta, prevalence is high- 9.5%- which translates into more than 30,000 people suffering from Type II diabetes.

• The burden on health systems is substantial.

In Malta in 2011, 11.2% of the total health expenditure was spent on diabetes care.
• We all know that 9 in every 10 cases of diabetes are Type II; Type II which is largely preventable and closely linked to over-nutrition and insufficient physical activity.

• When we look at the number of people who are overweight, obese and physically inactive in the EU, it is to put it mildly- alarming.

• Based on the latest estimates over half of Europe's adult population is overweight or obese.
• Malta is top of the league with an estimated 74% of adult men and 58% of adult women being overweight or obese.

• More worrying is that over 20% of school-aged children are also overweight or obese - over 12 million children in the EU alone.

Consequently, we are seeing more and more cases of Type II diabetes amongst children as well.

• Malta fares worse than the European average.

"e ·10 ar1d 11 year-olds m Malta are the second most ·· "· .
overweight and obese 1n the world, according to new research, surpassed only by Greece.

• These trends all point to a need for greater investment in effective and targeted prevention.

• Yet encouraging people to adopt healthy lifestyles - including balanced nutrition and sufficient physical activity -is much more easily said than done.

**********************************************·*********************** • There are a number of initiatives where the EU can help.
The EU" addresses diabetes as part of its broader approach to tackling chronic diseases and its risk factors.

3 • Addressing obesity and promoting physical activity 1s a European Union priority.

• The European Commission works closely with Member States in this regard.

Earlier this year, Member States have agreed on an Action Plan on childhood obesity - at the High Level Group on nutrition and physical activity, where Malta is represented.
• In addition, the EU Platform on Diet, Physical Activity and Health provides a Forum in which we work with stakeholders to generate initiatives to address obesity.

• I convened a Summit on chronic diseases in Brussels in April to explore what additional added value action the EU could take to help prevent and fight chronic diseases such as diabetes.

• The Summit called for a European Coalition to address these diseases to be created in partnership between Member States and stakeholders.
• I presented these developments 1n July at the United Nations in New York - where global progress on fighting chronic diseases, including diabetes, was reviewed.

4 • The European Commission already launched a Joint Action on Chronic Diseases in January this year.

• This Joint Action - with a budget of almost €1 0 million - will support EU countries to move towards more efficient prevention and management of chronic conditions.
• This Joint Action has singled out one disease - and one disease only- diabetes.

The Joint Action includes a work package dedicated to diabetes, with the aim of shaping a • , , , - .

~' set of good practice guidelines to address diabetes in a comprehensive manner.

• To get there joint work IS focusing on prevention, identification of people at high risk, early diagnosis, and comprehensive care.
• In addition, this work is supporting the development of National Diabetes Plans; and the exchange of good· practice, and cooperation among EU countries.

• Progress is encouraging: all EU countries have taken some action towards tackling diabetes and many have ' developed national plans or guidelines on treatment.

5 • The Commission is also initiating a I million euro pilot project requested by the European Parliament on the prevention of diabetes.
• Finally, the Commission supports research and innovation initiatives that aim to address the question of diet-related diseases.

• The research framework programme alone devoted 402 million Euros to diabetes research between 2007 and 2012.

• Thus the European Union is very active in supporting Member States in their fight against chronic diseases 1n general and diabetes in particular.
****************************************************************** Ladies and Gentlemen, The Diabetes Working Group has an important mission towards a national diabetes policy and strategy for Malta, addressing key 1ssues, such as prevention, early diagnosis, treatment and care.

6 • I would strongly encourage you to continue and intensify this work within the Joint Action on chronic diseases as this important project takes shape and rolls out.
• The increasing burden of diabetes in Europe calls for a sustained commitment of governments, non-governmental organisations and people suffering from Diabetes.

• It calls for a commitment to move from words into action.

·• • .We need innovative and determined approaches to win the battle against diabetes.

• I wish you well in this very important work.


End: 896 words 7 MR MARTIN SEYCHELL's ADDRESS TO THE PARLIAMENTARY WORKING GROUP ON DIABETES MALTESEPARL~ENT MALTA, PARLIAMENT HOUSE 13 OCTOBER 2014, 19:30 SPEAKING POINTS Honourable Members of Parliament, Ladies and Gentlemen, • I am grateful for this opportunity to contribute to your discussions.
• Commissioner Borg has given you in his speech an overview of strategies, policies, activities, and initiatives at the European level which are relevant to diabetes.

• Allow me now to talk about some of these activities 1n more detail from a technical point of view.

Joint action • Let me start with the "Joint Action addressing chronic diseases and promoting healthy ageing across the life cycle".
1 • Joint actions are cooperation projects funded by the EU health programme, bringing together competent authorities in EU Member States and further eligible countries.

• This particular joint action is a first outcome of the reflection process on chronic diseases to support Member States in their efforts towards more efficient prevention and management of chronic conditions.
• It involves 23 Member States and some 37 associated partners that actively work on closing the gaps and improving the network for exchange and information on approaches to chronic diseases.

• One work package of the Joint Action will be devoted to diabetes - to serve as a case study on barriers to prevention, screening and treatment of diabetes.

• Specific attention will be paid to equity, and the impact that social determinants have on people's access to care.
• At the same time it looks to improve co-ordination and co operation among EU countries.

2 • Emphasis will also be placed on supporting the development and implementation of National Diabetes Plans as well as on the exchange of good practice.

• I am pleased that the Health Ministry of Malta is taking part in the Joint Action as a Collaborating Partner.

This project is a great opportunity to link with authorities and ,.

organisations which are working in the field of diabetes across Europe.
In particular it will help to define key elements.

which hc:1ve been proven to be effective for existing national diabetes strategies.

Prevention of chronic diseases • Let me switch now to our work on prevention of chronic diseases.

We have in place a EU strategy on nutrition, overweight and obesity related health issues since 2007.

The key feature of our approach is to work in partnership.
With Member States, we coordinate our policies, actions and approaches in the High Level Group'on nutrition and physical activity.

This Group has recently adopted the Action plan on childhood obesity, which the Commissioner mentioned.

3 • In parallel, we work with stakeholders in the EU Platform on Diet, Physical Activity and Health to generate initiatives to address the obesity epidemic.
• This work is directly linked to diabetes, because it addresses the main underlying factor behind the dramatic rise in type II diabetes.

However, in view of the ongoing increase in obesity rates worldwide and in Europe, we need to identify smarter ways to educate and convince people to personally address this problem.
Financing • To support Member States in their efforts to tackle these worrying trends, the EU Health Programme gives the opportunity to finance projects in the area of chronic diseases including diabetes.

• I would like to encourage Malta to take the opportunity to participate in activities under the EU health programme.

4 • In the past, the Commission has been financing numerous projects in the field of diabetes.
Examples include "European Best Information through Regional Outcomes in Diabetes (EUROBIROID)", "Better control in paediatric and adolescent diabetes in the EU: working to create Centres of Reference (SWEET)" and "Development & Implementation of a European Guideline and training standards for Diabetes Prevention (IMAGE)".

:.
:.

• The IaUer three-year-project began in June 2007, and a multidisciplinary consortium has been created which involved healthcare professionals, behavioural and health scientists from 32 institutions and 16 countries.

'· • The main outcomes of the.

project are Guidelines 1 , which are highly relevant for future work on diabetes prevention: 1.

A "European Evidence-Based Guideline for the Prevention of Type 2 Diabetes", 2.
A "Toolkit for the Prevention of Type 2 Diabetes m Europe", 1 Hormone and Metabolic Research, 51 Volume 42, April 2010, Page 51-564 5 3.

"Quality Indicators for the Prevention of Type 2 Diabetes in Europe", and 4. more recently, a "Comprehensive curriculum for the training of diabetes prevention managers".
• I believe that these outcomes are very useful and pragmatic tools, and that they should be taken in consideration when national policies and strategies for Diabetes prevention are estabiished and implemented.

• In addition, substantial money is spent for research in the field.

The Commission supports initiatives that aim to address the question of diet-related diseases.

• These efforts will be continued in the future with the Horizon 2020 Research Programme.
It is essential to support European research that benefits patients whilst boosting competitiveness.

6 xxxxxxxxxxxxxx Ladies and Gentlemen, • To effectively address diabetes we have to work on the broader context of health promotion and tackling risk factors, and on developing innovative approaches to prevention.

One of these could be the new insights we rece)ve from behavioural science which can help u,s to define strategies which 'nudge' people towards healthier choices.
• At the same time, we cannot forget the patients suffering from chronic diseases.

This is why as part of our work with Member States towards making health systems more sustainable and effective.

We assist them to find ways of making savings without compromising universality and quality of care.

It ·is important that health and social systems adapt to be able to meet the challenge of chronic diseases.
This means for example breaking down barriers ' between services, strengthening primary and community care, and empowering patients.

7 • There is also a link to demographic change and population ageing: the European Innovation Partnership on Active and Healthy Ageing also provides important pointers towards interesting and innovative approaches across the continent.
• Let me close by also wishing you success in your endeavours in Malta, and by inviting you to take forward your work in cooperation with EU Member States and based on the good practice which has been developed in different parts of the European Union.
8 Addendum2: Meeting Minutes • Meeting 1 -9th April, 2014 • Meeting 2 -7th May, 2014 • Meeting 3-4th June, 2014 • Meeting 4 -14th July, 2014 • Meeting 5-7th October, 2014 • Meeting 6 -13th October, 2014 r Deo Debattista sahaq fuq il-bzonn ta· abar lena minn bll aspen lill-persuni bid-dijabete.

b'mod partikulari psikjatrija minhabba incidenza frel·wemi ta· dipressjoni.
Huwa gal li rridu nindirizzaw apatija kbira inkluza fil-pazjemi u wera x-xewqa li bnala pajjiz isir program.m ra· screening ghall-popolazzjoni generali.

4) Konkluzjoni Il-President tai-Grupp Godfrey Farrugia irrillgrazzja Iii kull min ippartecipa waqt ii-Jaqgha u anke lil dawk li attende•.v.
Huv.a •Nera x-xewqa li fiJ-laqg.t-w li jwiss i}:un hem.m wistiedna s Segretarju Parlamentari ghas-Sahha Chris Fearne flimkien rna· konsulenti u esperti oilra fil qasam sabiexjibda x-xogliol sabiexjitliejja rapport ta· hidrna mi!l-grupp.

Kien hemm qbil fuq is-suggeriment ta' Simon Busuttilli 1-laqgliat tal-grupp ikunu mifruhin ghal min il:un interessat janendi.
Huwa qalli bhala membn tmdu nistradaw ix-xogliol biex irJwenqu 1-istrategija taglma bil-ghan li sal-bagit li gej ibnu tressqu tlen proposti konkreti biex jigu adonati rnill-Gvem.

5) Aggornament Il-laqglia li jrniss ser issir nhar 1-Erbgha 4 ta' Gunju fis-1930hrs.

tnedija tal-\'v.G serjigu mistiedna sabiexjanendu.

Il-membri rnistiedna gliat 4 Anna Zammit McKeon sanqet fuq kemm 1-gharfien fuq il-kundizzjonijistajwassal ghal gnaqda u sapport retiproku.
Hija dahlet fuq aspetti prattiti bhall-provvista ta' 1-istrips, it-tqassim taghbom u n-necessita' u d-dipendenza ta' min ghandu 1-kundizzjoni fuqhom.

Ms. McKeon tat liarsa ukoll lejn aktar titjib fuq livell skolastiku fl-interess tat-tfal dijabetii:i u jehtiegujilqghu ghaliha wkoll fil-hinijiet ta' 1-iskola.

David Mario Fenech, dijabetiku minn Ghawdex sahaq fuq nuqqas ta' gharfien fuq il inkluz minn professjonisti fl-isptar Generali ta' kundizzjoni, partikularment fGhawdex, Gnawdex.
Bhal Christine Mifsud huwa tkellem fuq dak li ghadda minnu sal-lum li madankollu rna Z.ammux milli jaghmel success fit-taghlim;u 1-hiliet tieghu.

Huwa esprima diffikultajiet rnarbutin rnat-tehid ta' insulina tal-pen u anke vjaggar ta' kuljum ghax-xoghol bejn Malta u Ghawdex minhabba 1-kundizzjoni tieghu.
Is-Sur Fenech inkoraggixxa lill-Grupp jasal gnal proposti rnarbutin rna' aktar psikologi li jittrattaw diabetici, aktar gyms li jkunu friendly' rna' min hu dijabetiku u tkattir ta' aktar gharfien fGhawdex.
Huwa anke esprima d-disponibbilita' tieghu lijiwaqqaffergha tad-Diabetes Association gewwa Ghawdex~ ''· Gnall-mistoqsija tal-President tal-WG Godfrey Farrugia rnarbuta rna ±ieda ta' ini:idenza ta' dijabete minn eta bikrija, Dr Torpiano qalli r-rata qed ti±died u pajjizna huwa klassifikat bnala 1-hames 1-aktar pajji± bl-gholja rata ta' ini:idenza fl-UE.

Huwa qalli t-twaqqif ta' dan il-Grupp ta' 'f=lidma bi-partitiku huwa sens ta' soljev.
3) Diskussjoni Marlene Farrugia fethet id-diskussjoni billi rreferiet ghall-b±onn li nneliliu 1-partiggjanizrnu minn nofs sabiex kulliadd jigbed nabel wiehed, flirnkien rna' stakeholders, favur persuni diabetii:i. Hija qalet li dan il-kumitat lest jisrna' lil kull stakeholder li jrid iwassal il-fehma tieghu u qed joffrilu vantagg li dan huwa kumitat parlarnenti li rna jridx iservi biss ta' talking shop.
Hija qalet li hemm b±onn kura holistika ffukkata fuq dawn il-persuni sabiex ikunu aktar involuti fit-tehid tad-dei:izjonijiet.

L-Onorevoli Farrugia ai:i:entwat ir-rwol utli tal-genituri u 1- ghallierna fis-sui:i:ess ta' tfal b' din il-kundizzjoni.

Hija !men tat p:llnn nuqqas serju ta' teamwork fejn ir-ri±orsi huma provduti imma r-riZ.Ultat ahhari mhux jilhaq il-b±onnijiet mixtieqa minn dawn in-nies.
L-Onor Farrugia rrakkornandat lill-rnembri shaba sabiex jittella' pjan ta' hidma biex jigu ndirizzati problemi li sse=ew rnah;!

il-laqgha .

-;!.

... .

Claudio Grech gharnel nota ta' ringrazzjarnent lil dawk kollha li attendew u qasrnu 1-esperjenzi taghhom rnal-kumitat.

Huwa emfasizza 1-prini:ipju ta' gustizzja soi:jali filwaqt li ammetta li s sisterna li thaddem dan il-prini:ipju ma rnexxietx ghal omm bhal Christine Mifsud.
Gnaldaqstant huwa sanaq fuq bzonn ta' miZ.Uri tangibli permezz ta' miZ.Uri aktar qrib il-pazjent.

Huwa qalli dan il-kumitat ser ipoggi pressjoni fuq 1-e±ekuttiv u jrid ikun rilevanti permezz ta' azzjoni bba±ata fuq evidenzi u outcomes fattwali.

3 r·· . '

i ' I L ~ l. \\.ara intenent introduno;ju mum Simon BusuniL K.ap ta· 1-0ppozizzjoni.

il-K.um.itat ghadda sabiex jigi appuntat President.

Fuq nomina ta · Claudio Grech gie maghzul Godfrey Fwugia bha1a President b'l-:unsens u akklamazzjoni.
Fil-kelmtejn introduno;ji tieghu Godfrey Farrugia qalli flimkien rna· shabu membri ser i1:un kommess fuq hidma 1ejn 1-ekv,ita' u l-v.e/1-being ta· persuni bid-dijabete bil-ghan li titnaqqas din 1-epidemija u nassiguraw mekkanizmu effeniY ta· pre1enzjoni.
2) Preientazzjonijet F'messagg awdjoYiZil·, il-President ta' l-lmernarional Diaberes Federarion Sir ~1ichael Hirst fahhar 1-inizjaui,-a ta' Simon Busuni1 sabiex jim·aqqaf dan il-Grupp u esprima d-dispjacir tieghu li rna setax ih:un prezenti fizikament ghal t-tnedija tal-Kumitat.

Huwa gal li inizjani1·i simili huma fl-interess ta' persuni suggeni glial din il-k--undizzjoni li jirrikjedu artenzjoni partik--ulari u hidma iffukata.
Fil-prezentazzjoni taghha Dr. :\'atasha Azzopardi Muscat irreferiet ghal zieda fl-incidenza ta' Dijabete Type 2 fuq il-medda ta' tmien snin, primmjament minhabba demografija u obezita' izda wkoll zieda konsiderevoli ta' 20% fdik Type I, li norrnalment inpoggu anqas emfasi fuqha.

Hija sahqet li dieta Mediterra.TJea tnaqqas id-dijabete u qalet li dijanjozi fi stat bikri "'"assalli jigu evitati ak:tar h:umplikazzjonijiet.
Dr. A..zzopardi 'vfuscat inimarkat li kura efferti\·a fil-qasam tirrikjedi ppjanar u inwsliment, xi haga li bhalissa qed tigi studjata fil-l:untest ta' .\'ariona/ Diabeles Healrh Plan li kumbinazzjoni gie pprezentat dakinhar stess mill-GYem.

Hija qalet li hemm artenzjoni ffukata fuq (a) il-pre,·alenza tal-1.-undizzjoni kifukoll (b) il-bzonn li nnaqqsu 1- l:umplessita'.
Fil-prezentazzjoni tieghu 1-Professur Stephen Fava emfasizza b'mod partik--ulari fuq !-aspen klinik-u u medih:u fejnjidhol tranament ta' pazjenti b'mod partih:ulari f11q 1-aspett ekonomilm tal preven.Zjoni fi stadju bikri.
Christine Mifsud, omm li zviluppat 1-bmdizzjoni tad-dijabete meta kienet tarbija ta' sena u nofs tat rendikont personali ta' minn xiex kellha tghaddi sabiex taccetta 1-k-undizzjoni li giet fuqha allanieda permezz ta' Yirus u 1-fazijiet ta' maturita' li kellha tghaddi milmhom mit-tfulija, marul it-tqala u issa ar-J:e- fit-trobbija tat-tfa1 taghha stess.
Hija sahqet fuq 1-aspett ta' monitoragg matul hinijiet differenti tal-gumata u t-tranament ta' 1- insulina fhajja li kifiddeslaivitha hi stess hija 'mimlija daqs bajda'.

l\1s.

Mifsud qalet li !-pass li qed jiehdu 1-membri tal-IYorking Group huwa wiehed apprezzat fejn permezz tal-hidma tagh hom tistenna titjib il-promozzjoni u ]-awareness tal-k-undizzjoni.

Hija rreferiet ukoll goal pregudizzji li ghaddiet minnhom u ghelbithom b'deterrninazzjoni u perseYeranza.
2 Laqglia Grupp ta' Hidma Parlamentari fuq id-dijabete No.2 Data Hin Post 7 ta' Mejju, 2014 2000hrs Kamra tal-Kurnitati, Parlament Attendenza: Simon Busuttil, Godfi'ey Farrugia, Claudio Grech, Marlene Farrugia, Frederick Azzopardi, " Claudette Buttigieg, Michael Gonzi, Marthese Portelli, Deo Debattista, Clyde Puli, Franco Mercieca, David Agius, Kevin Mizzi L-Agenda kienet is-segwenti: I.
Introduction on the establishment of the informal Diabetes Working Group (D WG) in the House of Representatives- Simon Busuttil MP 2.

Election of Chairperson of the DWG.

3.

Audiovisual message by Sir Michael Hirst, President of the International Diabetes Federation.

4.

Pr .

:ntation by Dr. Natasltia Azzopardi Muscat 5.

Presentation by Professor Stephen Fava, Chair of the Diabetes & Endocrine Centre - Mater Dei Hospital (C""LINICALIMEDICAlJ 6.
Presentation by Ms. Christine Mifsud, a mother who is blind due to Diabetes Complications 7.

Presentation by Ms Anna Zammit McKeon, President of the Maltese Diabetes Association (NGO) 8.

Exchange of views.

9.

Conclusions by the Chai1person of the D WG.

1) Appuntar ta' President 1 ~· L. Bnala follow-~p.

Simon Busuttil ssuggerixxa li tigi cirkulata lil!-rnembri koliha tal-Grupp u neggeg lill-membri kollha sabiexiagh!

'J l-kontribuzzjoni taghhom taht kull i;ern.


Kien hemm qbilli fil-nidrna tal-Grupp ikun hem.

'll spirru kollettiv li kemm jista jkcm flimki en nagnru ezempju billi npoggu l-quddiem gnan wiehed.

Kien hemm qbil fuq il-prinCipju li ghandna nharsu lejn il-kundizzjoni tad-dijabete bhala stil ta · hajj au mhux marda, kifukoll illi naglimJu sforz sabiex id-disk"Ussjoni fil-grupp massal ghal abar azzjoni fanu il-pazjemi u l-professjonisti milli diskussjoni retorika.
lsserrnnew numru ta' diffikultajiet li qed j affaccj aw kemm p azj enti kif ukoll professj onisti fejn tidliol il-kl.mdizzjoni tad-dijabete, fosthom is-segwenti: • 111ajezistix registru pubbliku u ghaldaqstant.

fl-assenza tiegliu.

majistax il:un hermn screening propju tal-pazjenti.

• Hemm nuqqas ta' monitoragg fuq il-kundizzjoni b'mod generali inkluz 1-ezigeD.zi • fmamjaiji tal-pazjenti u nuqqas ta' mateijal medik'lllijkun disponibbli.
:\uqqas ta' gharfien anke fl-iskejjel fuq 1-gnoti ta' 1-insulina atcenm·at ukoll minhabba l assema ta' sapport professjoni rnedilm in place, spetjalrnent fi skejjel tal-primaija.

Proposta li giet imsemmija li fuqha ghandha ssegwi diskussjoni fil-Grupp ta' Bidma kienet 'Outreach programme' ta' screeing aniv u mlmx biss metajl:un hemm xi kumJ ... -:joni.
Simon Busuttil ghamel referenza ghai glwdda ghad-dispozizzj ani ta' dan il-Grupp ta' H'idma, li fi kliemu burna: Il-Kumitat Konsultattiv tas-S anna • • Too/l.

:iffuqpolicy glial politici magl\mul minn esperti fil-qasam.

• Kuntarti mad war id-dinja lijistghujigu mgnoddija lilna mill-International Diabetes Federation (IDF) permezz ta' IDF Malta, inkluz ta' politici.

• Esperti lokali u organizzazjonijiet Yolontaiji.


3) Il-Jaqgna li jmiss: Gie miftihem li marul il-laqgna li jwiss ilmn herrm1 tnedija forruali tal-Grupp ta' Bidma.

Kien .

hemm qbil ukoll illi 1-karigi tal-Grupp jitnabbru lill-mezzi tax-xandir dakinhar, fil-prezenza ta' ghaqdiet non-goYematti-ri D alLk:e ·Jeoding p~-cle55iana!s 'li jkt-Inu mistjedna li j attendu.

4) Aggornament: Il-laqgf1a giet aggornata gnas-7 ta' Mejju fit-2000hrs.
Laqglia Grupp ta' Hidma Parlamentari fuq id-dijabete No.1 Data Hin Post 9 !

'April, 2014 1930hrs Kamra tal-Kurnitati, Parlament Attendew: Simon Busuttil, Claudio Grech, Marlene Pullicino, Deo Debattista, Franco Mercieca, Clyde Puli, Marthese Portelli, Stephen Spiteri, Claudette Buttigieg, Frederick Azzopardi, Michael Gonzi Skuzat: Godfrey Farrugia Min uti: Kevin Mizzi !
Dettalji tal-Lagglia 1) Introduzzjoni: Simon Busuttil ini.ngrazzja lil Onorevoli Membri li gliogobhomjilqgliu 1-istedina glial pa1tei:ipazzjoni f'dan il-Grupp ta' Hidma.

Huwa spjega li 1-hsieb wara 1-proposta tieghu kien li jigi ffurmat grupp infonnali ta' membri rniz-zewg nahat tal-Kamra lijiffukaw il-hidma taghhom fuq is-suggett sensittiv tad-dijabete sabiex tinghata 1-importanza rnisthoqqa lil din il-mateija li tolqot hafua nies hawn Malta.
Apparti dan, il-Grupp ta' Ridma jista jzomm taht skrutinju 1- hidma tal-Gvem kifukolljaghti proposti ta' azzjoni bit-tama lijinstab kunsens Nazzjonali fuqhom.

Simon Busuttil qalli ikun ghaqli li majkunx hu lijippresedi fuq dan il-Grupp ta' Hidma u ppropona lil Marlene Farrugia sabiex tkun i)-President ta' dan il-Grupp.

Ma kienx hemm oggezzjonijiet mill-membri fuq in-nominata' Marlene Farrugia.

Kien hemm qbil Ji tissejjah mill-anqas laqgha walida fix-xahar.
2) Disknssjoni: Simon Busuttil ghadda kopja ta' korrispondenza li kien bghat lil Marlene Farrugia qabel il laqgha li kienet telenka numru ta' punti ghal diskussjoni matull-ewwellaqgha.

I j i ' !

I L .• L L I Fdan ir-rigward huwa inforrna lill-Grupp li 1-UE kienet varat Joint Action snin ilu ta' taghlim receiprok:u minn pajjizi membri perrnezz ta' 'good practice'.

Huwa qal li €9 miljun gew ivvutati biss fuq il-k:undizzjoni tad-dijabete.
Is-Sur Seychell sahaq li b'dan il-mod 1-UE tk:un tista taghmel progress konkret jekk 1-azzjonijiet ikunu tassew koordinati u ppjanati garadarba li lkoll nafu 1-fatturi ta' riskju li jwasslu ghal-Dijabete Type 2.

Id-deputat DG SANCO irrijafferrna 1-importanza ta' kooperazzjoni shiha bejn il-pazjent u t tabib sabiex il-k:ura tahdem, xi haga li hija riflessa fi 15 -il pjan Nazzjonali ta' membri stati fl-UE.
Huwa kompla jghid li 80% tal-piz fuq mard fl-Ewropa huwa mard kroniku u ammetta li 3% mill-budget Ewropew ghall-prevenzjoni huwa baxx hafua.

Apparti dan huwa sahaq li 1- industrija ta' l-ike!

tista taghmel aktaru esprima qbil mal-Kurnmissarju Ewropew li majistax ikun lijunkfood jibqa jkun orhos minn ike!

tajjeb ghas-sahhajekk nippretendu li 1-inizjattivi taghnajkunu ta' success.

Huwa appella ghal aktar responsabbilta mill-industrija fdan is-sens.
Martin Seychel tkellem fuq 1-importanza ta' 1-E-Network sabiex ikun hemm monitoragg kostanti fug il-pazjenti u appella ghal rieda politika ta' 'good governance' favur azzjoni fit tulli thalli effett.

Matul id-diskjussjoni tqajjmu kwistjonijiet marbuta ma' 1-efficjenza tal-E-Health, xi haga li trid tigi assigurata b'mod specjali wkoll mill-professjonisti, fejn il-Kummissarju rrefera ghal sistema tajba ferm adottata fit-Tramuntana ta' 1-irlanda.
Il-Kurnmissarju Borg ammetta li 1- mi±ur:i fiskali kienu 1-aktar mezz effettiv kontra t-tipjip.

Madakollu huwa qalli jekk tgholli 1- prezz ghal xi haga ha2:ina trid tkun akkumpanjata minn trahltis fil-prezz ghal xi haga tajba.

Huwa spjega li minkejja li 1-UE m'ghandiex Strategija Ewropew fuq id-Dijabete, gew minfuqa €400 miljun fuq Ricerka u Innovazzjoni bejn 1-2007 u 1-2013.
Bha1a konk!uzjoni 1-Kummissarju Borg kkongratu1a !-Grupp ta' Bidma tax-xogho1 u kontribut minghajr ghamad partiggjan fl-interess ta1-pazjent.

Huwa sahaq li jemmen hafna fdak 1i jghidu "We are what we eat" u appella ghall-gharfien xieraq biex il-pazjent jikkoopera mal-professjonist u 1-politiku jassigura 1i mizuri fiskali, gharfien fuq is-sahha u programmi ta' prevenzjoni jibqghu pi1astri fundamentali sabiex 1-incidenza tad-dijabete tigi ndirizzata bis-serjeta'.
Laqgha Grupp ta' Hidma Parlamentari fuq id-dijabete No.6 Data Bin Post 13 t'Ottubru, 2014 1930hrs Kamra ta1-Kumitati, Parlament Attendenza: Godfrey Fanugia, Simon Busuttil, Marthese Portelli, Frederick Azzopardi, Claudio Grech, Deo Debattista, Michael Gonzi, Claudette Buttigieg, Marlene Fanugia, Kevin Mizzi Mistiedna: L-Kummissarju Ewropew ghas-Sahlla u Konsumatur Dr. Tonio Borg Id-Deputat DG SAN CO Martin Seychell Min uti: !c.-Chairman tai-Kumitat Godfrey Farrugia ta merbha lill-Kummissarju Ewropew ghas-Sahha u 1-Konsumatur Dr.Tonio Borg u d-deputat DG SANCO is-Sur Martin Seychell u rringrazzahom ta' 1-interess Ii jindirizzaw lill-kumitat.
Dr. Fanugia qalli bil-kontribuzzjonijet li ser jinghataw matul il-laqgha il-grupp ta' hldma ser ikun sema' total ta' 17 -il kontribuzzjoni.

Dawn sam minn varji persuni, primarjament professjonisti fil-qasam tad-dijabete minn April 2014, id-data meta gie varat il-kumitat fuq inizjattiva tal-Kap ta' 1-0ppozizzjoni Dr. Simon Busuttil.
Huwa qal li din 1-informazzjoni hija ta' utilita' u wieghed li ser tigi mixtarra sew, bir rakkomandazzjonijiet li hargu ikunu riflessi r dokument li jipproponi mud ell ta' ligi ghall implimentazzjoni ta' politika Nazzjonali fuq id-Dijabete fMalta.

Dan il-mudell ser isir fforma ta' Private Members Bill imressaq mid-deputati kollha membri tal-kumitat miz-zewg nahat tal-Kamra.

Huwa habbar li 1-publikazzjoni tad-dokument ser issir lejnl-ahllar ta' dan ix-xahar.
Fil-prezentazzjonijiet tieghu, il'Kummissarju Borg emfasizza fuq is-sensittivita' tal '·problema ta' 1-inCidenza tad-dijabete Ii tolqot 382 miljun persuna fid-dinja.

Huwa qal Ii 1-medja ta' 1-incidenza Type 2 fl-Ewropa hija ta' 8.2% fi!waqt Ii dil' rMalta hija ta' 9.5%.

Il-Kummissarju sahaq fuq 1-importanza li !-problema tigi ndirizzata kmieni kemm jista jkun sabiex 1-kura tipprovdi ghajxien dicenti lill-persuna koncenata, b 'dixxiplina fuq attivita' fizika u nutrizzjoni b 'mod partikulari.
Huwa semma' li 1-UE ghad m'ghandiex strategija ghall-inCidenza tad-dijabete, b'differenza mill-marda tal-kancer.

Fi kliemu huwa kkritika wkoll 1-inCidenza qawwija ta' obezita' fl-irgiel Maltin, kundizzjoni ohra li tohloq aktar komplikazzjonijiet ta' sahlla apparti d-dijabete.

Is-Sur Martin Seychell kompla fuq dak Ii qal il-Kummissarju Borg, u rrijafferma dak Ii qal fuq kumplil,azzjonijiet ta' mard Ii jkunu kkawzati minhabba xulxin.

dmmi fl-ghajnejn mi1m 4.5% ghal 0.5%.


ghandu jkun !-onus tal-Gvem u mhux tal-pazjent.

Ghaldaqstant huwa sahaq li !-active screening Bhala konkluzjoni, c-Chairman Godfrey Farrugia 1rnngrazzja ppartecipaw u dawk kollha li attendew tal-kontribuzzjonijiet taghhom.

lill-kellima li Huwa habbar li nhar it-Tnejn 13 ta'Ottubru.

1-Kummissjaru tas-Sahha u Konsumatur Dr. Tonio Borg.

flimkien rna' d-deputat DG SAN CO urew ix·xewga li jiltagghu mal·Kumitat fil prezenza tal·media.
Dr. Farrugia informa lill-membri li 1-istedina ntlaqghat bil-qalb u l-laqgha ser !SS!r fis- 1930hrs.

Sahaq ukoll fuq !-problema ta' salarji li naghtu bhala pajjiz lil specjalisti fil-qasam li huma ppegjati rna' Gradi baxxi ferm.

Dan iwassal ghal braindrain inevitabbli u dettriment akbar ghas-settur tas-sahha fpajjizna.

lt-tlett rakkomandazzjonijiet li ghadda Profs Cassar fit-tmiem tal-prezentazzjoni tiegl:iu kienu: 1.
M'ghandhomx jigu introdutti servizzi godda, izda ghandha tittejjeb il-kwalita' tas servizzi ga ezistenti; 2.

Jigi assigurat li jingl:iataw dawn iz-zraben specjalizzati u jk:unu tajbin; u 3.

Tigi eliminata immedjatament il-burokrazija zejda.

It-tielet kelliem kien it-tabib tal-familja Jean Karl Soler, li qalli !-problema ta' pi±, ta' pressjoni u colesteral bhala problemi aktar serji li jwassalu ghad-dijabeti milli z-zokkor innifsu.
B'hekk ir-riskju ta' incidenza huwa mifi:ux fuq spettru aktar wiesa' mentri z-zokkor johloq problemi aktar ak:uta fuq 1-vizta.

Huwa saqsa b'mod retoriku hux minnu li tassew 1-inCidenza tad-dijabete tikkostitwixxi 10% tal-popolazzjoni minhabba 1-fatt li huwa jistma li din tilhaq biss is-6%.

F.i kliemu rna riedx inaqqas mis-serjeta' ta' 1-inCidenza u r-riperkussjonijiet fi.1q verji fatturi Nazzjonali.
Huwa emfasizza fuq ir-rwol sensittiv tat-tabib tal-familja u kemm jista jaghmel dijanjozi klinika effettiva abbazi ta' indikaturi u ratios li thaffefil-pressjoni minn fuq specjalisti ohrajn ghall-gid tal-pazjent innifsn.

Sahansitra certa dijanjozi tista ssir mill-pazjent stess.

Madankollu, huwa sahaq, dan jista jsir biss jekk insahhu 1-k:ura primarja u invaraw registru tal-pazjenti.

95% tal-kazi ta' dijabete, skond Dottor Fleuri Soler, jistgnujihdew ujispiccaw ghand it-tabib tal-familja.
Dr. Fleuri Soler esprima 1-fi:ustrazzjoni tieghu meta kazijiet serji intefghu xi sena jew aktar l'boghod ghax 1-awtoritajiet ta' rakkomandazzjonijiet medici.

jabbuza mis-sistema li k:ull GP jissuspettaw Hemm bzonn ukollli titwaqqaf sistema ta' electronic patient records fic-centri tas-sahha biex titl:iaffef il-kura u !-process 1i jwassal ghaliha.
Qal ukollli anqas hemm bzonn li GP jibghat pazjent 1-isptar ghal Schedule V form, xi haga li tista ssir fil-post mit-tabib tal-familja stess; izda dan isir jekk jigi fforma1izzat u organizzat ahjar ir-rwol tat-tabib tal-familja u ghaldaqstant j igi msahhah i1-k:uncett tal-' continued care'.

Fl-ahharnett tkellem il-membru tal-Grupp ta' Hidma Franco Mercieca, li huwa oftamologista di professjoni, fejn naturalment pogga 1-lenti fuq il-lisara li ssir fir-retina ta' 1-ghajn permezz ta' 1-incidenza tad-dijabete.
Beda biex jghid 1i 1-incidenza rik:urrenti hija li 1-pazjenti jigu ghall-k:ura meta jk:un tard wisq.

Huwa sahaq li din hi 1-kawza principali fost dawk i1-pazjenti bejn 16 u 64 sena; minkejja li !

laser huwa effettiv jekk 1-intervent isir fwaqtu.

Deterrent prinCipali fil-k:ura specjalizzata fl-ghajn huwa 1-assenza ta' pjan nazzjonali ta' screening fpajjizna, fejn pazjent m'ghandux gharfien fejn ghandu jirrikorri.
In oltre, active screening process itaffi 1-pressjoni finanzjarja fuq il-pajjiz u jipprovdi k:ura aktar fil-l:iin.

L ezempju li gab Dr. Mercieca kien dak ta' 1-Islanda fejn beda fl-1980 u naqqas 1-incidenza ta' tipprovidi qafas siewi ta' mmanigjar mill-professjonisti.

Madankollu mhux kull professjonist ghandu access jew juza is-sistema, lakuna principali li twassal biex rna tinghatax 1-istampa reali ta' 1-incidenza tad-dijabete fpajjizna.
Il-Profs Azzopardi sahaq li minghajr rna jkollna data aggomata angas rna nkunu nistghu nohorgu data komparattiva fug bazi regjonali fpajjizna.

Sabiex naslu ghal dan, il-Professur Azzopardi rrakkomanda li s-sistema rna tibgax wahda volontmja ghall-professjonisti, partikularment it-tobba tal-familja, izda tigi obbligatoija li tintuza b'informazzjoni specifika u diretta kif mitluba.

L-ew,Nel pass jista jkun li tinghataw rights ta' 'read-only access' ghat-tobba tal-familja.
Il-Kap ta' 1-0ppozizzoni Simon Busuttil, fisem il-Grupp ta' Bidma laqa' 1-proposta tal-Prof Azzopardi sabiex issir zjara sabiex il-membri tal-Grupp jaraw kif tiffunzjona sew is-sistema fl-isptar Mater Dei.

It-tieni preientazzjoni saret mill-Profs Kevin Cassar u ffukat b'mod partikulari fug amputazzjonijiet u hsara serja fuq ir-riglejn.

Huwa qal 1-kazijiet fejn ikollhom jingatghu riglejn mill-irkoppa minhabba kundizzjonijiet severi ghadhom gholjin, minkejja li naqsu mill-2006 sal-lum.
Huwa sahag fug bzonn ta' azzjoni immedjata, partikularment ghoti ta' antibiotici fug pazjenti b'kundizzjonijiet severi li ghadhom jithallew jistennew is-sieghat twa!

fl-emergezna.

F'dan il-kuntest huwa gal li minuti zejdajistghu ankajikkawzaw hsarat irreparabli u anke imwiet.

Huwa kkritika 1-fatt li ghad m'ghandiex sistema fejn pazjenti ikun affiljat mat-tabib tal tamilja li minn naha tieghu jkun fpozizzjoni li dan ta' 1-ahhar ikun jista jibga jaghmel monitoragg tal-kundizzjoni tal-pazjent b'mod adegwat.
B'Registru Nazzjonali tad-Dijabete, skond il-Professur Cassar, inkunu qed innaggsu 1-pazjenti fpajjizna b'70%.

Huwa esprima c-certezza tieghu minn 300 amputazzjoni li qed issir bhalissa, facilment jistghu jongsu ghal 100.

Dan iwassal ghal tnaqgis fl-ispiza pubblika, apparti socjeta aktar b'sahhita u kwalita ta' hajj a ahjar ghall-pazjenti.

Profs Cassar stieden lill-membri tal-Grupp ta' Bidma sabiex izuru 1-0PU fMater Dei, li fi kliemu huwa fi stat delapidat ghal!-ahhar.
Zied jghid li minn April l'hawn m'ghadux jiffunzjona ghax spiccaw il-fondi peress li Gvern wiehed wara l-ienor qatt rna jolloka fondi kemm ikun hemm bzonn.

Fattur iehor inkwetanti huwa li Profs Cassar sejjah sabiex rna nibggtm ngt1addu biz-zmien .
bil-pazjenti li jithallew jistennew il-konsenja taz-zraben specjalizzati li gatt ma jkunu ordnati 1nin_LlJ.abba nuqqas ta' flus ... Huwa sahag fug il-bzonn li neradikaw proceduri burokratiti li jtellfu 1-hin lill-kulhadd, inkluz lit -tobba, li qed jiggravaw 1-kundizzjonijiet tal-pazjenti.

Profs Cassar emfasizza li minghajr National Screening progranlill, lm u 1-kollega iehor li jahdem fil-gasam, ser jithallew jghazgu tl-ilma.
Huwa kkritika wkoll Azzjonijiet Industrijali kkawzaw inkonvenjenti konsiderevoli, tant li 1- amputazzjonijiet fokkazzjonijiet imsemmija kienu bi kwantita akbar minn nonnal.

Grupp ta' Hidma Parlamentari fuq id-Dijabete Laqgha no.
5, Il-Kamra tal-Kumitati, Parlament ta' Malta It-Tlieta, 7 t'Ottubru, 2014- fis- I 830hrs Attendenza: Godfrey Farrugia, Simon Busuttil, Claudio Grech, Claudette Buttigieg, Franco Meri:iei:a, Deo Debattista, Kevin Mizzi Skuzati: Marthese Portelli, Michael Gonzi, Marlene Farrugia Assenti; Frederick Azzopardi, Clyde Puli Agenda: 1.

Introduzzjoni mic-Chainnan 1-0nor Godfrey Farrugia, MP 2.

Prezentazzjoni minn Profs Joseph Azzopardi, Endoi:rinologista 3.
Prezentazzjoni minn Profs Kevin Cassar Konsulent fuq mard Vaskulari I Professur 4.

Prezentazzjoni minn ProfS Jean Karl Ciantar Soler, Tabib tal-familja 5.

Prezentazzjoni mill-Onor Franco Meri:iei:a, MP, Oftamologista 6.
Rimarki konklussivi mic-Chairman 1-0nor Godfrey Farrugia, MP Min uti: FI-Introduzzjoni tieghu ic-Chairman Godfrey Farrugia elenka 1-liidma li saret matul il gimghat tas-sajf; minkejja lima niarnmux laqgliat, fejn semma' li: Beda 1-abbozzar ta' dokument li ser jintrodui:i Iigi Ii tirregola 1-politika tad-dijabete fpajjizna; InZarnmu laqghat fosthom rna' Dr. Miguel Debono minn Sheffield Univesity fuq din il-hidma u kuntatti glial progett ko-finanzjat minn fondi Ewropej; Diskussjonijiet fuq prezentazzjoni bi-partitika ta' Avviz Legali; u Laqgha ta' koordinament mas-Segretarju Parlamentari Chris Feame.
Minnufih ic-Chairman sejjali Jill Professur Joe Azzopardi sabiex jaghmel il-prezentazzjoni lill-kumitat u 1-membri prezenti.

Fil-pre:ientazzjoni tieghu 1-Professur Azzopardi gliamel rijassunt tas-servizzi ta' sapport li huma provduti rMalta fll-qasam tad-dijabete, b'mod partikulari 1- edukazzjoni personali provduta ill dijabetici ta' Tip 1 u fi grupp fil-ka:i ta' dijabetici tat-Tip 2 u 1-applikazzjoni tat-teknologija sabiex tigbor data centarlizzata.
Huwa sejjali glial framework strutturat fdan ir-rigward u ssottometta dokument ta' rakkomandazzjonijiet.

B'mod specifiku, 1-Professur Azzopardi iddiskuta t-tema tat-teknologija lejn kura organizzata u ffukata gewwa pajjizna.
Huwa qal 1i hemm regestrati 23,588 pazjent fuq is-sistema sa Id-data ta' kull wielied u walida minnhom hija ffukata fid-dettal taghha u Gunju 2014. hawn Malta hija limitata ferm li tpoggi restrizzjonijiet fuq 1-ispizjara fuq x'jaghtu lill-pazjenti li huma suggetti ghal risk factors specifici, Hija ghamlet referenza ghal anti diabetes drugs u open drugs protocols li jridu jirrispettaw rigorozament fil-hidma taghhom 4) Catherine Azzopardi u Moira Grixti (Specialist nurses in diabetes) Ms. Azzopardi u Ms. Grixti, li huma z-zewg specialist nurses li rrefera ghalihom Dr, Torpiano qed jahdmu beyond their means.
Huma sahqu fuq 1-edukazzjoni u ppjanar ahjar fil-qasam tad dijabete, fejn isiru sessjonijiet fi g:tuppi ghal nies li jbatu minn Type 2 diabetes permezz ta' interactive maps.

Din il-hidma ssir ukoll b'limitazzjonijiet logistici uta' hin gewwa Ghawdex ukolL Huma esprimew 1-inkwiet taghhom ghal dak li qed isehh fil-wards ta' 1-isptar wara li nurnru ta' nurses jirrifjutaw li jattendu 1-korsijiet li jagntu sabiex izidulhom 1-ghar:fien fuq il-kundizzjoni tad-dijabete.
F'dan is-sens humajhossuli anke 1-pazjenti gewwa 1-isptarijiet huma 'unsafe'.

Fil-prezentazzjonijiet tagnhom huma rrimarkaw it-problema serja ta' rizorsi fejn bejniethom raw xejn anqas minn 3,245 persuna fl-2013 filwaqt li sax-xahar li ghadda kienu diga raw 1,776 persuna.

L-istatistika qed tizdied b'mod allarmanti u 1-kura qed issir ukoll kawza ta' troubleshooting minhabba li m'hemmx altamattiva ohra.
Fir-rakkomandazzjoni taghhom huma sahqu li hemm bzonn 10 - 15 specialist nurse sabiex ilahhqu max-xoghol.

Huma talbu sap port fuq Insulin Pump Therapy li in the long run 1-Gvern jiggwadanja minnha.

5) Aggornament.

Filwaqt li !-President tal-Grupp ta' liidma Godfrey Farrugia irringrazzja lill-kelliema u 1-persuni li attendew huwa sejjah gnal laqgha ohra bejn 1-ahhar ta' Lulju u 1-ewwel gimgha ta' Awwissu sabiex imbad lejn 1-ahhar ta' Settembrujittressqu 1-proposti lill-Gvem ghall-budget 2015.
11-gumata u 1-hin ghall-laqgha li jmiss ser tinghata fil-granet li gejjin.

biex il-Gvem jiffranka fuq spiza rik:urrenti qed twassal biex ikollu jonfoq aktar minbabba nuggas serju ta · regular checking li k:iek:u jelimina k:umplikazzjonijiet.

Ir-rakkomandazzjonijet fmali ta ·Dr.

Torpiano kienu: • Ak:tar stricks ghall-persuni bil-k:undizzjoni tad-dijabete, specjalment dawk ta' eta' zghira.

lnqas restrizzjonijiet fuq 1-u±u ta' 1-insulina fl-iskejjel.
• • Ak:tar nurse specialists, u • Ak:tar professional reviews.

Genitur ta' tifel bid-dijabete qasam 1-esperjenza emozzjonali tieghu uta' martu fkaz ta' meta s suggett kien rnarid b'gastric flu.

L-u±u ta' !-sticks jizdied drastikarnent, b'k:ull strip tiswa €22 (€6 il-farnilja li rninghajrhorn it-tifel rna jkarnpax.
ghola rninn kernm kienet qabel) li tpoggi piz finanzjarju eccessiv fuq 2) Dr. Chris Fearne (Segretarju Parlarnentari) Is-Segretarju Parlarnentari Chris Feame habbar li il-Gvem ser jaghti kernm hernm bzonn sticks li persuni anqas rninn 18 -il sena.

Huwa fahhar 1-inizjattiva tal-Grupp ta' J=!idrna u d deterrninazzjonali ta' kulhadd sabiex b'rnod l'fuq rnill-politika partiggjani jigu rnbuttati proposti u rakkomandazzjonijiet sabiex jghinu lill-Gvern fit-tfassil ta' Strategija Nazzjonali fuq id Dijabctc.
B'dan il-ghan huwa habbar numru ta' focus groups li ser ik:unu qed ji1taqghu fAv-·wissu u fSettembru sabiex jitlesta r-rappm1li mahsub jigi ppubblikat fl-14 ta' Setternbru 2014. ls-Segretarju Parlamentari satJaq fuq il-bzonn ta' metodi innovattivi, inizjattivi godda fuq riabilitazzjoni, assistenza akbar ta' psikjatrija, tishih tad-drittijiet ta' pazjenti bid-dijabete, gharfien an jar lejn ghajxien aktar san u azzjoni iffukata fuq gruppi vulnerabbli.
Dan kollu jrid isir fil-k:untest ta' aktar kura preventiva li tbieghed il-k:umplikazzjonijiet.

F'dan is-sens huwa sahaq fuq il-b?.onn ta' involvement akbar fil-livell ta' k:ura primarja, specjalment mit-tobba tal familja.
Huwa elenka inizjattivi godda li 1-Gvem qed jahdem fuqhom fosthom cameras godda gt1al screening ta' l-ghajnejn mix-xahar id-diehel, Lifestyle clinic fSan Gwann li ser tibda minn din il-girngha u post-Graduate diploma fuq id-dijabete- kors il jibda fSettembru 2015 fil-fak:ulta tal-Health Sciencies.

Fl-ahhar nett huwa qal ukoll li 1-Gvem qed jahdem biex iwaqqaf registru tentarlizzat tad Dijabete bhala bazi ahjar ta' ricerka.
3) Ms. Ruth Thenma (Principal Pharmacist Clinical Pharmacy) Ms. Theuma ghamlet elenku komparattiv ta' mediCini li huma disponibbli fuq il-formularju fMalta u dawk fil-forrnularju ta' pajjizi Ewropej ohrajn.
Id-differenza hija tara, fejn 1-ghazla Laqglia Grupp ta' Hidma Parlamentari fuq id-dijabete No.4 Data Hin Post 14 ta' Lulju, 2014 1900hrs Kamra tal-Kumitati, Parlament Attendenza: Godfrey FaJTugia, Marlene FaJTUgia, Franco Mercieca, Claudio Grech, Deo Debattista, Kevin Mizzi Skuzati: Simon Busuttil, Clyde Puli, Claudette Buttigieg, Marthese Portelli As senti: Michael Gonzi, Frederick Azzopardi Prezentazzj onij iet: 1) Dr. John Torpiano (Consultant Paediatric Endocrinologist) Fil-prezentazzjoni tiegliu Dr. Torpiano, li ilu jopera fil-qasam mill-2006, gliamel referenza glial rata gholja ta' incidenza tad-Dijabete Type 1 fit-tfal.
Huwa qal li 1-incidenza fil-popolazzjoni Maltija ta' talit is-16 -il sena qed tizdied b' 20% fis-sena.

Dan ipoggina fil-51-ghola post fl-UE fuq ini:idenza tad-dijabete Type 1 fit-tfal b'gliajnuna disponibbli li tkun ferm anqas minn pajjiz ohra.
Huwa spjega fid-dettal il-pressjoni fuq ir-rizorsi umani li gliaddej minnha fil-prattika tiegliu fejn irrimarka li hemrn biss zewg tobba specjalizzati fid-dijabete bit-tielet wielied qed jigi irnharreg, li fi flit kliem ifisser li sa liames snin ohra ser jibqgliu b'zewg tobba biss.

B 'referenza ghall clinical nurse specialists Dr. Torpiano qalli jezistu 2 biss glial popolazzjoni ta' 35,000.
Fi kliem Dr. Torpiano huwa fundamentali li tizdied mill-anqas nurse olira fuq dijabete biss, biex rna nsemrnux social worker u exercise specialist li sal-lum majezistux hawn Malta.

Referenza specifika giet impoggija · fuq il-provvista ta' 1-insulina fejn it-tifel jew tifla bl incidenza tad-dijabete huwa necessaJju li jeliodha rninimu ta' 4 darbiet kull jum, attivita fizika mhejjija apposta u nutrizzjon ippjanat.

Tqajjmet ukoll !-issue ta' 1-iskejjel, fejn minkejja.]
assenza ta' nurse fkull skola- li tkun 1-idejali - hemm ukoll restrizzjonijiet legali, anke minn Unions fuq kundizzjonijiet ta' igene.

L-assenza ta' medical support assistants iggieghel lill genituri jaqilgliu t-tfal mill-iskejjel ta' 1-istat u jibghatuhom fil-privat biex ikollha s-servizz disponibbli.
In-nuqqas ta' sticks li jinghataw rnill-Gvem li qed ipoggu s-sitwazzjoni medika ta' diversi persuni friskju seJju u 1-uiu tal-pumps, li huwa mezz modem li jnaqqas ir-riskji; gew diskussi fil-kuntest ta' spiza fuq il-Gvem.

Minkejja li jinvolvu investiment finanzjaJju, 1-assenza ta' dan Ms. Camilleri tat rendikont tax-xoghol li taghmel hi u shabha fejn jidhlu prevenzjoni u trattamenti sabiex persuni bid-dijabete majitilfux riglejhomjew partijiet ohra ta' gisimhom.
Ms. Camillleri ghandha espeljenza ta' 25 sena fis-settur.

Fattur rikunenti fl-ispjega taghha kien il bzorm ta' komunikazzjoni effettiva mal-GPs sabiex il-kundizzjoni ta' deteljorament fir-riglejn u swaba tinqabad u tigi trattata ma1ajr kemm jista jkun.

F'dan is-sens hija appellat ghal National Screening Programm kemm fis-settur primalju izda anke dak sekondalju tas-sahha pubblika.

Bhal ta' qabilha Ms. Camilleri appellat gha1 aktar specjalisti fil-qasam ta1-podologija.
Hija tat ezempji ta' spejjez li jridu jinganu mill-Gvem u 1-pazjenti anke fejn jidhlu zraben 1i jista jigi indirizzat jekk naslu fpunt li jizdiedu !-minor amputations flok il-major amputations.

Sfortunatament bhalissa l-prassi hija bi1-kontra minhabba nuqqas ta' rizorsi, burokrazija u nuqqas ta' komunikazzjoni fuq livell ta' prevenzjoni.

Il-problema qed tinqabad fi stadju avanzat hafna u ghaldaqstant dak rakkomandat mhux qed ikun possibbli.
Hija appellat ghal uzu ahjar tar-rizorsi limitati, partikularment b'anqas dupp1ikazzjoni ta' xoghol fejn tidhol id-dermato1ogija.

Fi kliem Ms. Camilleri, awareness akbar ta' GPs fuq kif jiddirezzjonaw i1-pazjenti tghin hafna fejn tidhol flessibilita' u u2:u ta' joint-clinic darba fil-gimgha.

Konklli:i:joni: Gie maqbulli 1-laqgha ta' Lulju tkun 1-ahhar wanda qabe1 is-Sajf, fejn ikun hemm waqfa qasira.
Gie maq\!ulli ghall-1aqgha ta' Lulju ikunu mistiednajaghtu 1-prezentazzjoni taghhom: • Dr. John Torpiano (Consultant Pediatric Endocrinologist at Mater Dei Hospital) - li talab 20 minuta u • Ms. Ruth Theuma (Clinical Pharmacist) Kien hemm qbil ukollli n-numru ta' prezentazzjonijietjitnaqqsu sabiex il-kontenut ikun analizzat u diskuss b'mod aktar cffettiv.

Aggornament Il-laqgha li jmiss ser issir fid-9 ta' Lulju, fis-1830hrs fil-Parlament.
3 L-aktar bzonnijiet urgenti li semmiet Dr. Delicata kienu support ta · professjonisti fil-qasam tad dijabete, anke jekk ikunu visiting professionals, b 'mod specj ali ta · diabetic specialist nurse.

Fil mument hemm 43 vakanza fid-dipartiment ta' 1-infermiera fGiiawdex.

Hija sejliet ukoll glial aktar support fil-psikj atrija.

Hija sahqet li minghajr dan is-sapport is-servizzi tas-Saliha ge111wa Gliawdex mhux lakemm jigu at parma' dawk ta' Malta.

Preientazzjoni no.
Preientazzjoni no.

2- Dr. Mario Caruana (Dietitian & Nutritionist, Researcher) Dr. Caruana beda 1-prezentazzjoni tieghu billi spjega r-rwol ta' dietitian fil-qasam tal prevenzjoni u anke 1-kura tal-kundizzjoni tad-dijabete.

Huwa emfasizza r-rwol centrali fis socjeta' u spjega li !-quota mitluba skond standards internazzjonali huma ta' 15 il-dietitian glial l.:ulllOO,OOO pazjent.
F'dan il-kuntest Dr. Caruana amplifika fuq in-nuqqas fdan ir-rigward billi spjega li bhalissa jezistu biss 3 fMalta kollha, li konsegwenza ta' hekk ma jl:unx possibli li jinvestu liin fricerka u audits li jkun hemm bzonn.

Dr. Caruana spjega li nvestiment fdietitian mill-Gvem jiffranka liafna flus pubblici.

F'dan il kuntest huwa qalli minhabba fhekk qed isiru sforzi sabiex jinfetali kors universitmju li jgliin fil capacity building fdan il-qasam.
Huwa qalli blialissa hemm zewg persuni li qed jitliarrgu barra minn Malta.

Huwa appella gliall-bzonn ta' talirig ta' dietricians Iii studenti flivell post-graduate, kemm fl.

Universita u anke fl-MCAST.

Dan ibn jista jgliin sabiex tittaffa !-problema ta' follow-ups li jridu jsiru li blialissa rnhux qed isim.

Preientazzjoni no.

3- Dr. Dolores Ganci Dr. Gauci gliandha espeJjenza twila fil-qasam tas-sahha mentali u meqjusa bhala esperta fil qasam taghha.
Hija spjegat kifil-problema ta' sahha mentali tkun sproporzjonata fuq persuni fil qasam tad-dijabete b'dettalji kumplessi li jistgliu anke jwass-Ju ghal skizofrenija.

B 'mod partik:ulari hija rreferiet ghal dijabetici bil-kundizzjoni taghhom Type 2 li minliabba nuqqas ta' screening rnajkunx faC!i li tigi identifikata malajr il-problema u allura ssir aktar severa.
Sabiex tigi indirizzata din il-'bi-directional relationship' li tezisti bejn dijabete u dipressjoni Dr. Gauci appellat glial aktar joint-care planning ma' GPs kifukoll fl-isptar Mater Dei.

Hija appellat ukoll ghal aktar komunikazzjoni effettiva mal-health centres fil-komunita.

Fi tmiem 1-intervent taghha, Claudio Grech esprirna 1-ammirazzjoni tieghu fisern il-grupp ta' hidma lejn ix-xoghol kbir li ghamlet u gliadha taghmel Dr. Dmis Gauti fil-qasarn tas-sahha men tali.

Preientazzjoni no.
Preientazzjoni no.

4: Ms. Phylis Camil!eri (podiatrist) 2 Laqgl\a Grupp ta' Hidma Parlamentari fuq id-dijabete No.3 Data Bin Post 4 ta' Gunju, 2014 1830hrs Kamra tal-Kumitati, Parlament Attendenza: Godfrey Fanugia, Simon Busuttil, Marlene Fmrugia, Franco MerCieca, Claudette Buttigieg, Deo Debattista, Claudio Grech, Frederick Azzopardi, Michael Gonzi, Kevin Mizzi.
Skuzat: Clyde Puli Assenti: Marthese Portelli Ic-Chairman tal-WG Godfrey Fanugia informa lill-membri li s-Segretmju Parlamentari Chris Feame kien mistiedenjattendi izda infurmah sabiexjiskuza ruhu minli.abba appuntmnent urgenti.

Huwa informa lill-membri prezenti li pparteCipa £'seminar intemazzjonali fuq id-dijabete li sar f'Malta wara li rceva stedina bhala chairperson tal-Gmpp ta' Bdima.
Qabel rna stieden lill-mistednin tal-kumitat sabiex jaghmlu 1-prezentazzjoni taghhom huwa talabhomjibghatulu synopsis ta' zewg pagni ghal uzu eventwali tal-kumitat.

Prezentazzjoni 1: Dr. Nadine Delicata (Chief Executive Officer, Gozo General Hospital) !1-prezentazzjoni ta' Dr. Delicata tat harsa dettalj ata lejn is-servizzi offruti f'Ghawdex fil-qasam tad-dijabete u 1-isforzi li qed jaghlu 1-ispetjalisti fil-qasam sabiex jilhqu lil dawk li huma affettwati mill-kundizzjoni.
Minkejja li dahlet fi statistika dettaljata hija esprimiet xetticizmu fuq kemm din 1-istess statistika taghti stamp a reali tal-kundizzjoni fil-gzira Ghawdxija.

Dr. Delicata spjegat li hemm servizzi mehtiega u essenzjali li mhux qed ikopm d-domanda partikolarment fejn jihlu adulti bil-kundizzjoni, fejn f'mod specifiku semmiet dietricians u psikologi.

Hija fahhret il-hdima ta' support group volontarju Ghawdxi li qedjaghmlu xoghol utli hafna specjalment maHfal fi sforz li jaghmlu outreach usa fil-komunita'.
Minkejja dan 1-hidma mhix koordinata bizzejjed, anke mill-lat ta' servizzi professjonali offruti in konnessjoni mas servizz ta' kura primarj a.

1 Deo Debattista sahaq fuq il-bzonn ta' aktar kura mmn l.:ull aspett lill-persuni bid-dijabete, b 'mod partikulari psikjatrija minhabba intidenza frekwenti ta · dipressjoni.

Huwa gal li rridu nindirizzaw apatija kbira inkluza fil-pazjenti u wera x-xewqa li bhala pajjiz isir programm ta' screening ghall-popolazzjoni generali.
4) Konkluzjoni 11-President tal-Grupp Godfrey Farrugia irringrazzja lil kull min ippartecipa waqt i1-1aqgha u anke 1il dawk li attendew.

Huwa wera x-xewqa 1i fi1-1aqgha 1i jrniss ikun hemm rnistiedna s Segretruju Par1amentari ghas-Sahha Chris Fearne flimkien rna' konsu1enti u esperti ohra fil qasam sabiexjibda x-xogho1 sabiexjithejja rapport ta' hidma mill-grupp.

Kien hemm qbi1 fuq is-suggeriment ta' Simon Busutti1li 1-1aqghat ta1-grupp ikunu miftuhin gha1 min ikun interessat jattendi.
Huwa qa11i bt1ala membri irridu nistradaw ix-xoghol biex inwettqu 1-istrategija taghna bi1-ghan li sal-bagit li gej ikunu tressqu tlett proposti konkreti biex jigu adottati mili-Gvern.

5) Aggornament 11-1aqgha 1i jmiss ser issir nhar 1-Erbgha 4 ta' Gunju fis-1930hrs.

11-membri rnistiedna ghat tnedija tal-WG ser jigu mistiedna sabiex jattendu.

4 Anna Zammit McKeon sahqet fuq kernrn 1-gharfien fuq il-kundizzjonijistajwassal ghal ghaqda u sapport reciproku.
Hija dahlet fuq aspetti prattiCi bhall-provvista ta' l-istrips, it-tqassim taghhorn u n-necessita' u d-dipendenza ta' min ghandu 1-kundizzjoni fuqhorn.

Ms. McKeon tat harsa ukoll lejn aktar titjib fuq livell skolastiku fl-interess tat-tfal dijabetici u jehtiegu jilqghu ghaliha wkoll fil-hinijiet ta' 1-iskola.

David Mario Fenech, dijabetiku rninn Ghawdex sahaq fuq nuqqas ta' gharfien fuq il inkluz minn professjonisti fl-isptar Generali ta' kundizzjoni, partikularrnent f'Ghawdex, Ghawdex.
Bhal Christine Mifsud huwa tkellem fuq dak li ghadda minnu sal-lurn li rnadankollu rna zarnrnux rnilli jaghrnel success fit-taghlim; u 1-hiliet tieghu.

Huwa esprima diffikultajiet marbutin rnat-tehid ta' insulina tal-pen u anke vjaggar ta' kuljurn ghax-xoghol bejn Malta u Ghawdex minhabba l-kundizzjoni tieghu.
Is-Sur Fenech inkoraggixxa lill-Grupp jasal ghal proposti marbutin ma' aktar psikologi li jittrattaw diabetici, aktar gyms li jkunu 'friendly' ma' min hu dijabetiku u tkattir ta' aktar gharfien f'Ghawdex.
Huwa anke esprima d-disponibbilita' tieghu li jiwaqqaf fergha tad-Diabetes Association gewwa Ghawdex: ·· Ghall-mistoqsija tal-President tal-WG Godfrey Farrugia rnarbuta rna zieda ta' inCidenza ta' dijabete minn eta bikrija, Dr Torpiano qalli r-rata qed tizdied u pajjizna huwa klassifikat bhala !-names 1-aktar pajjiz bl-gholja rata ta' inCidenza fl-UE.

Huwa qalli t-twaqqif ta' dan il-Grupp ta' tiidrna bi-partitiku huwa sens ta' soljev.
3) Diskussj oni Marlene Farrugia fethet id-diskussjoni billi rreferiet ghall-bzonn li nnehhu 1-partiggjanizrnu minn nofs sabiex kulhadd jigbed habel wiehed, flimkien rna' stakeholders, favur persuni diabetici.

Hija qalet li dan il-kumitat lest jisma' Iii kull stakeholder li jrid iwassal il-fehma tieghu u qed joffrilu vantagg li dan huwa kumitat parlarnenti li ma jridx iservi biss ta' talking shop.
Hija qalet li hemm bzonn kura holistika ffukkata fuq dawn il-persuni sabiex ikunu aktar involuti fit-tehid tad-de6izjonijiet.

L-Onorevoli Farrugia accentwat ir-rwol utli tal-genituri u l ghalliema tis-success ta' tfal b'din il-kundizzjoni.

Hija lmentat p1inn nuqqas seiju ta' teamwork fejn ir-rizorsi huma provduti imma r-rfwltat ahhari rnhux jilhaq il-bzonnijiet mixtieqa minn dawn in-nies.
L-Onor Farrugia rrakkornandat lill-mernbri shaba sabiex jittella' pjan ta' hidrna biex jigu ndirizzati problemi li ssemmew rnatltl il-laqgha.

Claudio Grech gharnel nota ta' ringrazzjarnent Iii dawk kollha li attendew u qasmu 1-espeijenzi taghhom rnal-kurnitat.

Huwa emfasizza 1--prinCipju ta' gustizzja socjali filwaqt li ammetta li s sistema li thaddern dan il-principju rna mexxietx glial ornm bhal Christine Mifsud.
Ghaldaqstant huwa sahaq fuq bzonn ta' rnizuri tangibli perrnezz ta' rniZ:uri aktar qrib il-pazjent.

Huwa qalli dan il-ku1nitat ser ipoggi pressjoni fuq l-ezekuttiv u jrid ikun rilevanti perrnezz ta' azzjoni bbazata fuq evidenzi u outcomes fattwali.

3 Wara inter\'ent introduttorju minn Simon BusuttiL Kap ta' 1-0ppozizzjoni, il-Kumitat gnadda sabiex jigi appuntat President.
Fuq nominata' Claudio Grech gie rnagt1tul Godfrey Farrugia bnala President b'kunsens u akklamazzjoni Fil-kelmtejn introduttorji tieghu Godfrey Farrugia qal li flimkien rna' shabu membri ser ikun kommess fuq hidma lejn 1-ek:wita' u !-well-being ta' persuni bid-dijabete bil-ghan li titnaqqas din 1-epidemija u nassiguraw mekkanizmu effettiv ta' prevenzjoni.
2) Preientazzjonij et F'messagg awdjoviziv, il-President ta' 1-Interna/ional Diabe1es Federation Sir Michael Hirst fannar 1-inizjattiva ta' Simon Busuttil sabiex jitwaqqaf dan il-Grupp u esprima d-dispjacir tieghu li rna setax ikun prezenti fizikament ghal t-tnedija tal-Kumitat.

Huwa qal li inizjattivi simili huma fl-interess ta' pcrsuni ,ug~ctti gnal din il-kundizzjoni li jirrikjedu attenzjoni partikulari u nidma iffukata.
Fil-prezentazzjoni taghha Dr. Natasha Azzopardi Muscat irreferiet ghal zieda fl-intidenza ta' Dijabete Type 2 fuq il-medda ta' trnien snin, primarjament rninhabba demografija u obezita' izda wkoll zieda konsiderevoli ta' 20% fdik Type I, li normalment inpoggu anqas emfasi fuqha.

Hija sahqet li dieta Mediterranea tnaqqas id-dijabete u qalet li dijanjozi fi stat bibi twassalli jigu evitati ak:tar kumplikazzjonijiet.
Dr. Azzopardi Muscat irrimarkat li kura effettiva fil-qasam tirrikjedi ppjanar u investiment, xi haga li bhalissa qed tigi studjata fil-kuntest ta' National Diabetes Healih Plan li kumbinazzjoni gie pprezentat dakinhar stess mill-Gvern.

Hija qalet li hemm attenzjoni ffukata fuq (a) il-prevalenza tal-kundizzjoni kifukoll (b) il-bzonn li nnaqqsu 1- kumplessita'.
Fil-prezentazzjoni tieghu 1-Professur Stephen Fava emfasizza b'mod partikulari fuq 1-aspett kliniku u mediku fejnjidnol trattament ta' pazjenti b'mod partikulari fuq 1-aspett ekonomiku tal prevenijoni fi stadju bikri.
Christine Mifsud, omm li zviluppat 1-kundizzjoni tad-dijabete meta kienet tarbija ta' sena u nofs tat rendikont personali ta' minn xiex kellha tghaddi sabiex taccetta 1-kundizzjoni li giet fuqha allarrieda perrnezz ta' virus u 1-fazijiet ta' maturita' li kellha tgnaddi minnhom mit-tfulija, matul it-tqala u issa anke fit-trobbija tat-tfal taghha stess.
Hija sat1qet fuq 1-aspett ta' monitoragg matul t1inijiet differenti tal-gumata u t-trattament ta' 1- insulina fhajja li kifiddeskrivitha hi stess hija 'mimlija daqs bajda'.

Ms. Mifsud qalet li !-pass li qedjielidu 1-membri tal-Working Group huwa wiehed apprezzat fejn permezz tal-nidma taghhom tistenna titjib il-promozzjoni u 1-mmreness tal-h.'undizzjoni.

Hija rreferiet ukoll ghal pregudizzji li ghaddiet minnhom u gnelbithom b'determinazzjoni u perseveranza.
2 Laqglia Grupp ta' Hidma Parlamentari fnq id-dijabete No.2 Data l'!in Post 7 ta' Mejju, 2014 2000hrs Kamra tal-Kumitati, Parlament Attendenza: Simon Busuttil, Godfrey Farrugia, Claudio Grech, Marlene Farrugia, Frederick Azzopardi, Claudette Buttigieg, Michael Gonzi, Marthese Portelli, Deo Debattista, Clyde Puli, Franco Mercieca, David Agius, Kevin Mizzi L-Agenda kienet is-segwenti: I.
Introduction on the establishment of the informal Diabetes Working Group (D WG) in the House of Representatives- Simon Busuttil MP 2.

Election of Chairperson of the DWG.

3.

Audiovisual message by Sir Michael Hirst, President of the International Diabetes Federation.

4.

Presentation by Dr. Natashia Azzopardi Muscat 5.

Presentation by Professor Stephen Fava, Chair of the Diabetes & Endocrine Centre - Mater Dei Hospital (CLINICAL/MEDICAL) 6.
Presentation by Ms. Christine Mifsud, a mother who is blind due to Diabetes Complications 7.

Presentation by Ms Anna Zammit McKeon, President of the Maltese Diabetes Association (NGO) 8.

Exchange of views.

9.

Conclusions by the Chairperson of the D WG.

1) Appuntar ta' President 1 Bhala follow-up, Simon Busuttil ssuggerixxa li tigi Cirk:ulata lill-membri kollha tai-Grupp u heggeg lill-membri kollha sabiexjaghtu 1-kontribuzzjoni taghhom taht k:ull item.
Kien hemm qbilli fil-hidma tai-Grupp ik:un hemm spirtu kollettiv li kemmjistajk:un flimkien naghtu ezempju billi npoggu 1-quddiem ghan wiehed.

Kien hemm qbil fuq il-prinCipju li ghandna nharsu lejn il-k:undizzjoni tad-dijabete bhala stil ta' hajj au mhux marda, kifukoll illi naghmlu sforz sabiex id-diskussjoni fil-grupp twassal ghal aktar azzjoni favur il-pazjenti u 1-professjonisti rnilli diskussjoni retorika.
Issemmew numru ta' diffikultajiet li qed jaffaccjaw kemm pazjenti kif ukoll professjonisti fejn tidhol il-kundizzjoni tad-dijabete, fosthom is-segwenti: • Majezistix registru pubblik:u u ghaldaqstant, fl-assenza tieghu, majistax ikun hemm screening propju tal-pazjemi.

• Hemm nuqqas ta' monitoragg fuq il-k:undizzjoni b'mod generali inkluz 1-ezigenzi finanzjarji tal-pazjenti u nuqqas ta' mateljal medik:u lijk:un disponibbli.
• Nuqqas ta' gharfien anke fl-iskejjel fuq 1-ghoti ta' 1-insulina accentwat ukoll minhabba 1- assenza ta' sapport professjoni medik:u in place, specjalment fi skejjel tal-primalja.

Proposta li giet imsemmija li fuqha ghandha ssegwi diskussjoni fii-Grupp ta' A:idma kienet 'Outreach programme' ta' screeing attiv u mhux biss meta jkun hemm xi k:umplikazzjoni.
Simon Busuttil ghamel referenza ghal ghodda gliad-dispozizzjoni ta' dan il-Grupp ta' A:idma, li fi kliemu huma: Il-Kurnitat Konsultattiv tas-Sahha • • Toolkiffuqpolicy ghal politici maghmul minn esperti fil-qasam.

• Kuntatti mad war id-dinj a li jistghu jigu mghoddija lilna mill-International Diabetes Federation (IDF) permezz ta' IDF Malta, inkluz ta' politici.

• Esperti lokali u organizzazjonijiet volontalji.


3) 11-laqgha li jmiss: Gie miftihem li matul il-laqgha li jmiss ikun hemm tnedija formali tai-Grupp ta' A:idma.

Kien hemm qbil ukoll illi 1-karigi tal-Grupp jithabbru lill-mezzi tax-xandir dakinhar, fil-prezenza ta' gttaqdiet non-governattivi u anke 'leading professionals' li jkunu mistiedna li jattendu.

4) Aggornament: Il-laqgha giet aggornata ghas-7 ta' Mejju fit-2000hrs.
Laqg!Ja Grupp ta' Hidma Parlamentari fuq id-dijabete No.1 Data Bin Post 9 t'April, 2014 1930hrs Kamra tal-Kumitati, Parlament Attendew: Simon Busuttil, Claudio Grech, Marlene Pullicino, Deo Debattista, Franco Mercieca, Clyde Puli, Marthese Portelli, Stephen Spiteri, Claudette Buttigieg, Frederick Azzopardi, Michael Gonzi Skuzat: Godfrey F anugia Min uti: Kevin Mizzi I Dettalji tal-Lagg!Ja 1) Introduzzjoni: Simon Busuttil irringrazzja Iii Onorevoli Membri li gnogobhomjilqghu 1-istedina gnal parteCipazzjoni fdan il-Grupp ta' Hidma.
Huwa spjega li 1-nsieb wara 1-proposta tieghu kien li jigi ffunnat grupp infonnali ta' membri rniz-zewg nan at tal-Kamra li jiffukaw il-nidma tagnhom fuq is-suggett sensittiv tad-dijabete sabiex tingnata 1-importanza mistnoqqa Iii din il-mateJja Ji tolqot nafua nies hawn Malta.

Apparti dan, il-Grupp ta' Hidmajistajzomm tant skrutinju 1- nidma tal-Gvem kifukolljaghti proposti ta' azzjoni bit-tama lijinstab kunsens Nazzjonali fuqhom.
Simon Busuttil qalli ikun gnaqli li majkunx hu li jippresedi fuq dan il-Grupp ta' Hidma u ppropona lil Marlene Fanugia sabiex tkun it-President ta' dan il-Grupp.

Ma kienx hemrn oggezzjonijiet mill-membri fuq in-nominata' Marlene Fanugia.

Kien hemrn qbilli tissejjan mill-anqas Jaqgna wanda fix-xahar.

2) Diskussj oni: Simon Busuttil gnadda kopja ta' korrispondenza li kien bgnat Iii Marlene Fanugia qabel il laqgha li kienet telenka numru ta' punti gnal diskussjoni matull-ewwellaqgna.
Addendum 2: Meeting Minutes • Meeting 1-9th April, 2014 • Meeting 2-7th May, 2014 • Meeting 3-4th June, 2014 • Meeting 4- 14th July, 2014 • Meeting 5-7th October, 2014 • Meeting 6 -13th October, 2014