Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694840187327.pdf (Malta)
IT-TNAX-IL LEĠIŻLATURA P.L.

5064 Dokument imqiegħed fuq il-Mejda tal-Kamra tad-Deputati fis-Seduta Numru 269 tas-27 ta’ Mejju 2015 mill-iSpeaker, l-Onor Anġlu Farrugia.

_______________________________ Raymond Scicluna Skrivan tal-Kamra Contribution by the Parliamentary Working Group on Diabetes towards the National Strategy on Diabetes Prevention and Healthy Living with Diabetes - fighting a growing disease.

21st May, 2015 1.
21st May, 2015 1.

General information: In October 2014 the Parliamentary Working Group on Diabetes (PWGD) issued a document by the name 'Health Choices'.

This comprehensive consultative report was presented to the Ministry of Health and Energy who is piloting a National Health Policy and Strategy for Diabetes Mellitus.

Since then, this Working Group has further consulted the public and experts in this speciality.
Sir Michael Hirst, President of The International Diabetes Association, and Dr Anne-Marie Felton, President of European Nurses in Diabetes, were among the distinguished guests who addressed these meetings.

Representatives of PWGD also met a representative of the European Regional Director of World Health Organization.

This executive brief, 'Prevention and Healthy Living with Diabetes', is an addendum to that document.
It maps out further suggestions that are being presented prior to the publication of this National Policy which is to draw to a close by 22nd May.

It has always been the firm opinion of PWGD that diabetes mellitus deserves a selective policy and strategy that singles it out from the rest of non-communicable chronic diseases.
Once the National Policy is published, PWGD in close collaboration with the Secretariat of Health will dovetail this strategy within a proposed legal notice which is to be presented as a Private Members Bill by all PWGD members to Parliament.

In this regard PWGD has served as a unique platform where through a process of consultation with all stakeholders, parliamentarians have been involved from the outset in policy development and this bi- partisan approach in health is ensuring better outcomes.
The synergy between PWGD's efforts and the Secretariat of Health is also yielding results.

Success will ultimately depend on a driving force that timely implements the operative detail of the National Diabetes Policy as part of an over-arching National Health Systems Strategy (NHSS).

2.

PWGD 's Objective: Prevention, high quality personal care and comprehensive management of Maltese diabetic patients are the key issues of successful health outcomes.
This primarily entails: - The need to optimize provider and team initiatives, including ownership - provide holistic patients' support - reform an evolving health care delivery system guided by best practices.

1 3.

Facts: It is a fast growing worldwide life threat and in Europe it has become an urgent health challenge.
United Nations resolution 61/225 states: 'Diabetes is a chronic, debilitating and costly disease associated with severe complications, which poses severe risks to families, Member States and the entire world, and serious challenges the achievement of the internationally agreed development goals including the Millennium Development Goals'.

Malta has an alarming rate of overweight, obese and an inactive population.

(Adult male: 74%, adult female 58%, the second most overweight 10-11year old in Europe).
Close to 10% of Malta's population suffers of diabetes.

These trends all point for a greater investment in targeting PREVENTION effectively by identification of people at risk, establishing an early diagnosis and providing a comprehensive health care service.

4.

Prevention: a) Primary Prevention: - The prevention of DM (pre-diabetes).

- 80% of Type II of diabetes may be delayed or prevented.

- Type I is not preventable.


Recent research however indicates that identified specific markers may lead to register progress.

This primary prevention is undertaken by embarking on a consolidated program of screening that include all those people who are at risk.

All those who have a family history, are overweight, lead a sedentary life style or eat the wrong foods are ideal targets.

The age group 30-50 years is the most likely group to be at risk.
These risks may be eliminated by encouraging lifestyle alterations through proactive CITIZEN -CENTRIC HEALTH PROMOTION and education at Primary Health Care level and through proactive screening like work place and students' screening.

The need to reverse the present negative health status trends that have plagued our society is an urgent must.

It is paramount that Maltese maintain a healthy weight and a whole population intervention, especially in school age children, is recommended.
Malta needs to identify smarter ways to educate and convince people to personally address these problems through 'health choices' b) Secondary Prevention: - The prevention of the complications of DM.

2 Once diabetes mellitus has been diagnosed, management must include aggressive lifestyle alterations, supported by appropriate medication, the management of other co-morbidities and the elimination of other associated risk factors to prevent the onset of serious health complications.
These complications may include retinopathy, nephropathy, neuropathy and cardiovascular decease (ischemic heart decease, strokes, peripheral insufficiency) and associated hypertension and widespread infections.

Having the right care is essential for the wellbeing of all diabetics as this reduces the risk, severity and costs of complications.

This has to be undertaken by patient support and education, self-monitoring and life time diabetic follow-ups and consultations.
The paediatric diabetes health services must be at the forefront of this secondary prevention's health agenda.

DIABETES SELF MANAGEMENT EDUCATION AND SUPPORT leads to the desired positive outcomes.

Patients become more empowered to take care of their own personal health care and are more likely to follow best practice recommendations.

In this regard Malta has to set its guidelines and gold standards.
These health care recommendations may be developed by making use of NICE guidelines and adapting them to our needs.

These should hold true not only for age specific variations but also geographical variants, as Gozo hails for a more patient friendly public health outreach in this speciality.

Primary and community oriented health care services are mainstay management.

They are the gate keepers.

This level of health care will lead to a lower use of outpatient and acute inpatient hospital services.
PWGD notes with satisfaction that better quality health care is being offered by a number of Health Centers' Diabetes Clinic and these outreach specialist services should be given more adequate support.

The proper support of a multi-disciplinary team of health care professionals that serve people with diabetes more effectively is imperative.
Better accessible pathways ( time and place) to the present range of outpatient services of secondary public health care is an added value and new services that matter must also be introduced including regular dental consultations and psychotherapy clinics.

It is high time that all round integrated pathway of communication between public and private health care is embarked, especially since statics confirm that 80% of all primary health care contacts are 'out of pocket' consultations.
Benefits: - An ongoing update of ' benefits' through a cost and effective analysis as defined by the present Health Act should be adopted.

This would include:  Services: to audit care processes and management targets  Pharmaceuticals (medicines, consumables and medical appliances) to update the armamentarium.

Relentless research on new classes of anti-diabetic medicine and new ways to intervene in the management of diabetes and its complications has been achieved and more is awaiting.
This is an ever evolving topic which in years to come will hopefully lead to an ultimate total cure.

3 In the last decade break through advances have been registered.

Most medicines, consumables and appliances are determined by availability and affordability and most are not part of the Government Schedule V formulary.
The need for a continuous review of the diabetic range of pharmaceuticals is a necessarily and more effort should be undertaken to approve non-formulary diabetic medication when a patients is allergic or is refractory to the conventional ones.

PWGD notes that innovative ant-diabetic medicines should be part of formulary items.

Type II Diabetic patients are mostly effected.


In the European Market, the quality of insulin has improved tremendously and insulin analogues are easily available but alternative routes of administration have lagged behind.

Under intense research are the open loop and closed loop insulin delivery systems with continuous Glucose Monitoring System (CGMS).

Better quality of life is conducted through better glycaemia control.
It is unfortunate that these medical appliances are not being given due importance.

Exciting alternatives are pancreatic transplants and islet cell tissue transplants that may be derived from embryonic stem cell cultures.

Emerging deliverables include insulin gene therapy and anti-diabetic vaccines for type I diabetes.

This armamentarium will hopefully eradicate this silent killer.
...In this regard Malta has to upgrade its legislation so as to have a more robust Organ, Tissue and Cell Donation Legislation.

c) Tertiary Prevention: - The prevention of the further worsening of diagnosed complications.

This is undertaken by prompt management and a hospital-centric specialized health care that has to liaisons with a robust out reach community health care service.
Pathways of adequate care and follow up so as not to lose sight of effective patients must be designed and more joint specialized clinics must also be established.

The present unaddressed health system's inefficiencies have resulted in premature morbidity and mortality.
Malta has a high rate of mortality as a consequence of associated Cardiovascular Disease, an alarming high rate of morbidity as a result of lower limb amputations and a high percentage of elderly diabetics who cannot cope at their home and end up in residential care.

We have to prevent from having people dying before death.

5.

A National Diabetes Policy and Strategy:  People with diabetes have a right to be fully engaged members of the society, treated with respect, dignity and social justice.
(Example, an insurance policy does not discrimantion against diabetic first time buyers) They must be supported through an  'All Government Approach' to be an integral part of society.

 No health system is sustainable unless it is continuously reformed.

Such reforms may have high upfront costs but when properly governed they will pay off on all counts.

4  The present Health Care System and service provision desire a better integrated and holistic approach.
The Maltese health scenario of a Public-Private Health Mix is an asset.

Breaking barriers between these services will strengthen management especially at primary health care and will lead to better health outcomes.

 Processes that are hallmarked by best practice protocols and backed by a multi- disciplinary team are to be ensured.

 To deliver such a Health Care System it has to be consolidated by an ICT network (E- health) and hallmarked by a patients' charter rights.
 Prevention is the top most priority of this Policy and results in better health outcomes, lesser costs, and an overall stable health sustainability.

 The prime focus of a National Diabetes Policy must be on patients' self-education and self-management, and a well-developed primary and community health care service level.

 To roll out such a strategy the National Diabetes Policy must identify immediate actions, and intermediate and long term projections.
These must be spread over a period of time and have to be secured by adequate finance mechanisms and budget forecasts that take into account our aging population, human capacity building, processes and logistics, and innovative technology.

Simplification (better regulation strategy) by seeking the benefit of hind sight, to make a process simpler and more appropriate to the patients' requirement is recommended.
Good governance, adequate information inflow and sound risk adjustment methods are key assets that enable a focused health system to adapt to an ever changing environment.

 PWGD recommends that first and foremost we must consolidate our present diabetes services so that any disparities between the various levels of health care are eliminated.

 New projects are to be introduced in a step by step direction.

A wider choice of pharmaceutical formulary is beneficiary and an immediate necessity.
 A comprehensive diabetic health reform will undoubtedly lower future annual health costs and make public health care services more sustainable.
 Having said all this, it is simpler to state that a national diabetic policy and strategy will succeed with every potential patient that is prevented from becoming one, it succeeds with every single patient who gets timely treatment for an ailment, it succeeds with every healthcare professional who harbours 'ownership' of the system, and can realise his/her full potential in the profession, and it succeeds when cost of treatments given, locally reflect realistic costs, and achieve expected results.

6.
6.

Final Remarks: PWGD is of the firm opinion that we need a sustained commitment to move into action.

An 'All Society Approach' will surely aid to seek an innovative approach to diabetes in Malta.

5 PWGD is grateful to all those who have contributed to a serious of interactive parliamentary working group meetings.
We have taken note of all patients' and health care professionals' perspectives and PWGD recognizes the role and efforts of the present health care professionals who have delivered their optimum, within the constraints of the present health care service.

Special thanks goes to the Speaker of the House and Malta Diabetic Association.

Godfrey Farrugia MD, MMCFD, MP Parliamentary Working Group on Diabetes Chairperson 6