Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694840182258.pdf (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 Introduction Diabetes is a growing problem and is a good example of why we need new thinking about how to provide integrated services in our national health system to fight the incidence and provide a better life for those affected.
This chronic disease, characterised by hyperglycemia, resulting from defects in insulin secretion, insulin action or both, affects 382 million people in the world.

A further 316 million are diagnosed with impaired glucose tolerance placing them at high risk from the disease – an alarming number that is set to reach 471 million by 2035.

In our continent we have about 60 million people with diabetes, which sees 10.3% of European male population and 9.6% of female population aged 25 years and over.
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 Mediterranean surpassed only by Cyprus.

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 we are duty bound to intervene with concrete action after having listened to all those concerned.

Eleven MPs from both sides of our House of Representatives placed our act together and committed ourselves to tackling this challenge by acting against this „silent killer‟; which is a leading cause of blindness, amputations, kidney failure, heart attacks, stroke and early death.
Since April, on the initiative of the Leader of the Opposition Simon Busuttil MP, together with our endeavours and under the Chairmanship of Godfrey Farrugia 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 Government set up a steering committee made up of competent professionals in the field of diabetes to come up with a National Strategy for Malta.
Our work dovetails with that of this committee.

Also, there are similar working groups like ours in other European Parliaments.

Putting partisan politics aside, The Parliamentary Working Group on Diabetes focused entirely on what avenues should be pursued for action in favour of the victims, their families and healthcare professionals.

Despite not being part of the executive we believe 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 very tangible way.

The document describes the recommendations put forward for the executive 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 technological 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 GENERAL INFORMATION A. Malta's forward looking policy and direction Most European Health Care Systems are at a cross road.
Malta along with another seventeen European countries is no exception and faces specific EU country recommendations.

The public perception to health care has and is changing.

A fast developing industry of technological medical aids, more innovative pharmaceuticals, widespread on line access to health information and research, have increased demands.
Moreover, it is the public's desire, to have a more holistic, National Health Care System within a set-up of a synergistic Public-Private Health mix, where the pillars of equitable access, quality assurance and sustainability are safe guarded to the highest standards.
No matter how strong any nation's economy is, this is not easy to achieve unless government is also backed by a sound Health Act, standardized health outcomes and a cost and effective health system assisted by e-health and an ongoing process of monitoring of the overall health performance.

Sustainable budgets have to be dovetailed on to a Health Strategy.

There are no short term fixes.


In deed this has influenced a number of governments to reform their current management processes and introduce more evolved 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 prevention, and to deliver a more personalized health care which is primarily community oriented and where each individual takes care of ones wellbeing.
We have to transform our present strategy from 'one size fits all' to 'one size fits one' and redefine our health performance 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 synchrony, with Primary and Community Health Care as the cornerstone of any health care system.

Ultimately this is smarter spending as it invest in the citizens' wellbeing.
To achieve and implement these health status objectives we are of the firm opinion both as politicians (and as health care professional), that health should be driven away from 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 NGOs in Public- Social Partnerships.
Pro-active management of diabetes and its co-morbidities will in time reduce the use of more costly acute secondary health care services.

What holds for this chronic ill health will likewise hold for other prevalent chronic deceases.

B. Diabetes Mellitus and the Maltese The Maltese population is an aging one, as Malta has a low mortality rate, and a poor population growth.

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 10% 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 30 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.

This 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 / 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 Tonio Borg and Mr Martin Seychell, Deputy Director General of SANDO addressed PWDG.

7 Apart from these scheduled parliamentary working group meetings the chairman represented the committee: - Delivery of an opening speech in an International Conference titled 'Diabetes and Microvascular Disease: New Insights', hosted in Malta between 16-17th May.
- In July the working group was invited to expose its aims and workings, in particular to the legislative model of the Legal Notice, to a Steering Committee on Diabetes that was set up in early May by the Secretariat of Health.

- Two meetings were held with Dr Miguel Debono a Consultant Diabetic Physician from Sheffield University on a plausible way forward to field a research project.
- Throughout the summer recess parliamentary members from both sides of the House made their presentation within their respective parliamentary group to identify a common working pathway.

- Chairperson also met with the Leader of the House, Hon Carmelo Abela.

- - In September the chairperson was invited by Parliamentary Secretary Hon Chris Fearne to discuss the way forward and liaison in the drafting of the Legal Notice.
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 Tonio Borg at Valletta's EU office.

8 OBJECTIVES OF THE PARLIAMENTARY WORKING GROUP In this document three proposals are being forwarded by DPWA.

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.
1) 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 Fearne also addressed the working group and welcomed the initiative.

The following consultations where held with: 1.


Dr. Natasha Azzopardi Muscat, Consultant on Public Health; 2.

Profs Stephen Fava, Chairperson of Internal Medicine; 3.

Ms. Christine Mifsud, Diabetic 4.

Ms Anna Zammit McKeon, President of the Maltese Diabetes Association 5.

Dr. Nadine Delicata, Chief Executive Officer, Gozo General Hospital 6.

Dr. Mario Caruana, Director of Nutrition and Dietetic Service 7.

Ms. Dolores Gauci, Directorate Students Services 8.

Ms. Phyllis Camilleri, Senior Podologist 9.


Dr. John Torpiano, Consultant Pediatric Endocrinologist 9 10.

Catherine Azzopardi u Moira Grixti, Specialist Nurses in Diabetes 11.

Ms. Ruth Theuma, Principal Pharmacist in Clinical Diabetes and Endocrinology 12.

Profs Joseph Azzopardi, Consultant Endocrinologist 13.

Profs Kevin Cassar, Consultant Vascular Surgeon 14.

Profs Ciantar Soler, Private Family Practitioner 15.

Mr. Franco Mercieca, Consultant Ophthalmologist 16.
Dr. Tonio Borg, EU Health and Consumer Affairs Commissioner 17.

Mr. Martin Seychell, Deputy Director General SANCO Throughout these interventions the following questions were raised and explored within the remits of this speciality: - What quality of care are we delivering?

Is it accessible?

Are services co-ordinated?

- Do we have 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?

- What are the reasons of poor management?

- What interventions can we provide to help improve the outcomes from health care?

- What pharmaceuticals (medicine, consumables, medical devices 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?

What are our screening measures?

- What are the monitoring techniques used by patients?

- Can we improve self-management by patients?

Is advice constantly given?

- What is the incidence of diabetes related admissions and how can we reduce these?

- Are the community services we offer adequate?

- What 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 Steering Committee on Diabetes, through Hon Chris Fearne in time to be reviewed prior a memo addressed for Cabinet's approval is finalized.

There after a period of public consultation will be launched by The 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 forwarding 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 of PWGD.

The necessity to legislate a Health Policy is highlighted by the following differences between Law and Policy / 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 certain 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, particular 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 I General Provisions Title, Commencement, Interpretation.

Establishing the core elements To manage Diabetes Mellitus within the holistic concept of patient-centered care that also targets personal and social development as well as psychological support.
PART II National Diabetes Council Classification and diagnosis Establishment, Appointment, Functions and Powers of a National Diabetes Register, to determine prevalence, 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 Community Oriented Health Care versus Hospitals' / Special Clinics' services.

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

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

hearing impairment, obstructive sleep apnea, fatty liver disease, periodontal disease, cancer, fractures, cognitive impairment, 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 IV Pre-Diabetes: The testing of Diabetes in undiagnosed patients.

The use of life style clinics: active and passive screening.

Improve public health through healthy eating and healthy living.

A renewed nutrition and dietetic strategy.
A new approach to supporting patients' behavioural change (eg weight reduction, physical activity, non-use of tobacco, effective coping) 12 Prevention and / 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 PART V A holistic Diabetic Quality Health Care delivery Prevention / 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 risk 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 environment, 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 / disabilities.

(It is our opinion that it is improper to consider Diabetes Mellitus as a disability from 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 VIII An overall approach to Benefits and Services and recommendations.

A focus on easy accessible pathways to introduce new measures and innovative treatments (e.g.
Islet cell transplantation) and / or consolidate the existing frame work for the provision of pharmaceuticals, consumables, equipment, aids, devices and services including those noted as Out Reach services.

Review of Schedule V applicability.

The establishment of prescription guidelines and protocols.
(This legislation must not duplicate the existent legislative structure that is identified within the established schedule of Chronic Disease and the parameters of cost-benefit analysis and patient charter rights as set within the Health Act.)
PART IX Education, support and training (This is a pinnacle of any policy) Clinical Informative Systems including electronic medical records Diabetes Self-Management Education and Support (DSME & DSMS): 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 improve quality of life.


Development scheme to build a strong diabetes support service and a specialized caring team.

The integrated role of the Health Promotion Unit 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 determined by the Minister / Parliamentary Secretary.
(It is wise that the operational time frame would be one that evolves in a step up pathway, starting off with the re-organization of the present services leading to new screening programs and the introduction of new services, with a continuous analysis of health outcomes and fine tuning of the strategy) 14 3) Research Evidence based policies substantiated by research delves into a deeper understanding of what is feasible and what / 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 randomised, 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 future 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 technology is cost-effective It is suggested that 600 patients are recruited who are overweight or obese and suffering from impaired glucose intolerance / 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-Monitoring) 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 UK and Malta, whereas the other 300 patients will receive conventional management.

A sub- study will be carried out in patients on steroid treatment.
The studies will be carried out by clinical fellows / family doctors / 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-term follow up of patients on these interventions and establishment of patient cohorts that may be used in future studies.
From a scientific, political and Malta's points of view 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 innovative measures and technology for the mutual benefit of the health care professionals and patients.

Once evidenced based information is finalized, this may further serve to amend and update the work in progress of the then established ongoing policy, strategy and its dovetailed 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) People 1.1) Diabetes Education Unit:  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.
1.2) Diabetic Children: Increase quota of free blood sugar test-strips to 4 per day;   Reduce restriction on insuline analogues (esp.

glargine) ;  Improved 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 HbA1c vs random; and  By addressing the misconception to some that Laser is harmful.
2) Procedure 2.1) Mental Illness:  Public Health Interventions  Effective Treatment – pharmacological 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 development and mental health) in children and young people  Epidemiological studies on co-morbidity of diabetes and depression 2.2) Family Doctors:  Allow specialists in family medicine to prescribe, modify and monitor treatment, and arrange 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  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 modern, 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  Pharmacy  Community nursing 2.7) Diabetic Foot • Better psychological after care.
• CPD programme for care providers re teaching strategies.

• Unit for screening/monitoring amputees.
3) Technology 3.1) 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 3.2) Ophthalmology: An Active Screening and Treatment Programme 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 National foot screening programme 3.4) Family Doctors Investigations (through access to iSoft)   Referrals (easy access to out-patient appointments, fast-track urgent cases)  Patient registration with family doctor 3.5) Mental Illness  Multi-condition Collaborative Care Programme  Routine screening of patients with diabetes for psychopathology and vice-versa, as well as lifestyle risk factors, to inform practice for more effective management and prevention planning.
(e.g PHQ-9) 20