The following amendments have been selected: amendments 1 and 2 in the name of Rhun ap Iorwerth.

We now move on to item 6 on the agenda, which is the debate on diabetic services in Wales. I call on the Cabinet Secretary for Health, Well-being and Sport to move the motion. Vaughan Gething.

Motion NDM6292 Jane Hutt

To propose that the National Assembly for Wales:

Notes the publication of the updated Diabetes Delivery Plan and the priority areas outlined in the recent annual report to:

a) improve the standard of diabetes care across the health system and reduce variation in care practices;

b) support primary care in the management of diabetes and completion of key care processes;

c) enable people with diabetes to better manage their condition and reduce their risk of complications; and

d) use informatics to drive better integration of services for people with diabetes.

Thank you, Deputy Presiding Officer. I’m happy to move the motion on the paper and to have the opportunity to have this debate on a significant public health challenge for Wales, and to set out our progress in improving the quality of care, as well as to restate our expectation and ambition for further improvement.

I’ll briefly speak to the amendments. Unfortunately, I won’t be able to support amendment 1 tabled by Plaid Cymru, as we don’t think that it’s correct to state that children and young people are unable to access structured education. We know these services are available. But, I understand there is a very real concern about the recorded take-up of structured education and the figures that we get from our audit. All of our paediatric diabetes units offer self-management education to newly diagnosed children and young people. We want to improve what the audit counts to improve the accuracy of it, but patients aren’t referred to another setting to receive diabetes education: it is provided within the unit. We can say, though, that we’ve recently introduced a new all-Wales structured education programme for children and young people called SEREN. This programme is the first of its kind in the UK. So, we do expect to see the recording of participation in self-management education improving in future years, as well as, of course, wanting to drive up the numbers of people who do take part. So, there’s really an issue about wording, rather than our ambition and recognising we need to do more.

On amendment 2, I’m happy to welcome and to accept the amendment drawing attention to the importance of tackling obesity, and I’ll talk about that particular issue later in my contribution. But, at the outset, I want to recognise, of course, as people in this place will know, that there’s a difference between type 1 and type 2 diabetes. In type 1 diabetes, a much smaller group of people where there are no lifestyle factors linked to its development, whereas in type 2 we know that there certainly are. Much of our discussion on the growth of diabetes centres on the rise in type 2 diabetes across our country. But, diabetes in all of its forms, with all of its complications, is estimated to cost roughly 10 per cent of health spend here in Wales. And, without change, within the next 20 years we estimate that will rise to about 17 per cent of health spend. GP registers currently show that 7.3 per cent of the population aged over the age of 17 have diabetes and that numbers continue to rise. That’s nearly 189,000 of our friends, family members, colleagues and neighbours living with this disease, and others yet to be diagnosed.

So, in terms of demand, cost and direct suffering, diabetes already has a profound impact on our society and our health and care system. Numbers have increased over 17 per cent in just five years, and we estimate that more than 300,000 people will be affected by 2025. It’s important to recognise that, whilst we want to improve the care and treatment, there’s no magic pill to treat our way out of this diabetes epidemic. This is one of the great public health challenges facing Wales. It requires a significant shift in attitude and behaviour within each of the communities that we represent.

Our national approach here in Wales was updated in December last year and will take us through to 2020. On 21 April this year, we published a statement of progress and intent, and that statement draws attention to what we have achieved, as well as what we have yet to do. It sets out clearly the direction, leadership arrangements and areas of our national focus.

In addition to reducing the number of new cases of diabetes, we recognise the need for a continued focus on improvement in how we treat and support people to manage their diabetes. Many people affected by diabetes need intensive and wide-ranging support to manage their condition and to reduce the risk of blindness, foot disease, renal failure and heart disease. For the vast majority, this will be delivered in primary and community care, but others will need access to hospital and very specialist teams. That reinforces the need to work as a genuinely joined-up system. That’s why a key national priority is using informatics to deliver a unified diabetes record across different healthcare settings, and that unified diabetes record should help to deliver integrated, accurate and timely diabetes care wherever that patient accesses their healthcare. Put simply, it should help us to deliver better care for the citizen.

We’re working with primary care physicians, specialist nurses and allied health professionals to develop a new model of diabetes care fit for the twenty-first century. We’re not afraid to learn best practice both within and outside of Wales to do that. That will undoubtedly mean a further shift into primary care and reinforce the need to address local practice that is not good practice and does not properly prioritise patient outcomes.

All patients, though, with diabetes should be receiving their NICE-recommended key care processes, working towards individualised treatment targets. For all the progress we’ve made, we know we haven’t done that as consistently as we wished to do so. So, our primary care providers are already working on national audit data to tackle variation in care and improve standards. That’s proper reflection from professionals themselves about the need to further improvements.

We know from the audit that we can make progress on recent reports, which have shown six years of continual improvement in population level outcomes. We also have important work in train to support people with complex needs and those staying in hospital, as one in five in-patients have diabetes. That, again, highlights the importance of hospital service improvement programmes like Think Glucose and Think, Check, Act. Our in-patient diabetes audit confirms that hospitals are providing more personalised diabetes care, high levels of patient experience, and fewer people experiencing hypoglycemia whilst in hospital. Again, I accept there is more for us to do to seek and deliver further improvement. We have, though, to help deliver that, created a small group of national leaders to support health boards to implement the plan and tackle that variation in care that we recognise. So, using part of the annual £1 million allocation, we have a national clinical lead for diabetes, and a number of other leadership posts covering insulin pump therapy, foot care, and the transition to adult services and structured education. That national clinical lead has been widely welcomed, not just within the service, but across the campaigning third sector as well. So, the national implementation group that includes third sector colleagues will continue to set the strategic direction for diabetes and work to support health boards to continuously improve diabetes services.

Turning back to the nature of the challenge we face, we do think there is a role, for example, for more mandatory action, whether that be a sugar levy, advertising, and the availability of unhealthy food, drink and tobacco—particularly in reducing the level of type 2 diabetes and complications that go with diabetes. However, that Government intervention or compulsion will not resolve the national challenge that we face on its own. As I’ve said, we have a societal-wide problem. As a nation we do not exercise enough, we do not eat well enough, and we do not do anything like enough to minimise our chances of developing cardiovascular diseases and type 2 diabetes. We’ve known this for a very long time. We recognise the need for significant large-scale behaviour change, but we have not been successful enough at delivering that change with our communities. We won’t be successful, though, by simply lecturing people or making some of those behaviours more difficult or more expensive. That, in itself, isn’t going to be the answer that we need. We continue to need to make healthier choices easier choices to make, to understand, and to act upon. We need that societal shift in attitude and behaviour, and it goes without saying that isn’t easy. There’s no western society that has got this right, but we all face, broadly, a similar problem.

That does, though, mean a greater level of personal ownership, empowerment and accountability. Success will mean greater take-up of active travel, healthier behaviours, and providing healthy learning, working and living environments. But, of course, diagnosing the challenge and what we need to achieve is so much easier than how to do so. That’s why a key piece of joint-funded work between the diabetes, cardiac and stroke implementation groups is the national roll-out of the cardiovascular disease risk programme. It identifies those at the highest risk of cardiovascular disease and diabetes and invites those people proactively in to take part in local activities to help reduce their risk. And, crucially, it doesn’t take place all in a medicalised setting. There’s something here about behaviour change and how best to try and deliver and achieve that. This really is an innovative, multi-disease, national approach. And it’s a product not of a single politician, but it’s a product of our staff across our health and care service, making this a more social challenge, and, as I say, not simply confining it to a medical setting.

The programme is at the heart of how we’ll prevent future demand, alongside our broader approach to healthier lifestyles, and I look forward to learning from that approach as we go on. I won’t pretend to you today, or in summing up this debate, that we have all the answers in Government, because we certainly don’t. We need to understand what works in each community and how we successfully roll that out into different parts of our country, because, if we don’t, the cost isn’t just the financial terms that I set out at the start of this debate. There’s a much higher price to pay for individuals and their communities, and not just the social well-being of our country, but the economic well-being of our country, if we can’t see a significant shift in attitude and behaviour and do something more than just move the quality of care for the number of people who will acquire diabetes during their life and need not do so. I’m happy to move the motion.

Thank you very much, and I’ve selected the two amendments to the motion, and I call on Rhun ap Iorwerth to move amendments 1 and 2, tabled in his name.

Amendment 1—Rhun ap Iorwerth

Add as new point at end of motion:

Notes the importance of structured education programmes to help people manage diabetes, and regrets that more than 50 per cent of eligible children and young people are unable to participate in these programmes at the present time.

Amendment 2—Rhun ap Iorwerth

Add as new point at end of motion:

Recognises the importance of tackling obesity in preventing type 2 diabetes.

Amendments 1 and 2 moved.

Thank you, Deputy Presiding Officer. At present, 177,000 people in Wales live with diabetes. It’s possible that around 70,000 additional people suffer from it but they’re not aware of it or haven’t received a confirmed diagnosis, and by 2030 it’s expected that that number will be around 300,000 people. So, while having diabetes is a major issue for the person who is suffering from it, it’s a major problem for the health service more widely, and around 10 per cent of the budget, as we’ve heard several times here, goes towards dealing with diabetes, and a majority of that goes towards treating complications. One out of every five beds in hospitals in Wales is used by a patient who has diabetes, and those complications linked to that do create that deep impact on well-being and health and the use of healthcare services. That also means, of course, that introducing better management and more appropriate and effective management offers an excellent opportunity not just to improve the health of people in Wales, but also to save money for our public services.

I’ll come to our first amendment here: the importance of providing and holding structured education programmes for those who have just received a diagnosis of diabetes. Now, last year Diabetes UK showed that the lack of use of these courses has reached a shocking level. Only 2 per cent of those who had received a diagnosis of diabetes type 1 recently across England and Wales, and only 6 per cent of those who’d received a diagnosis of diabetes type 2, again across England and Wales, had attended a course. Now, the figures for Wales only are even worse. Only 1 per cent of those with type 1 diabetes and 0.9 per cent of those with type 2 diabetes had registered that they had attended a structured education programme. The figures also show that only 24 per cent of patients in Wales with type 1 diabetes were even offered the opportunity to attend a course. Clearly, therefore, those types of figures—and I know that the Cabinet Secretary is aware of them—should have piqued the interest of the Government.

There are now two references to education in the annual statement on progress. One refers to digital provision for adults. A platform was launched last year, and that is of course a development to be welcomed. But we would encourage the Government to consider how they will be reaching those that have been disenfranchised digitally, or those that would benefit more from a face-to-face process.

Now, the second reference notes that, even though there has been some improvement in the number of people who take advantage of structured education amongst children and young people, more than 50 per cent of children and young people don’t use the programme, with work continuing to identify the barriers to that. I think that that response is too slow. Now, the financial benefits, and, of course, the health benefits, of ensuring structured education more widely are too obvious to be left to a process that will go on organically in seeking an answer. We need an urgent response by the Government to ensure that many more people have access to structured education.

I also want to draw attention to the failure to ensure that all patients receive the full set of health audits and access to the care processes. The progress report notes that the percentage of patients that receive all eight processes has decreased over the previous years. In the long term, this could have a serious impact on general health, and the national health service in Wales needs to ensure that more is done to improve this performance. There is a great deal more that the Government could be doing.

In terms of the Minister’s intention not to support amendment 1 because he feels that it doesn’t reflect the situation fairly, well, the figures, I’m afraid, do show that there is a major problem in terms of access to structured education specifically. I’ll come very briefly to the second amendment, which of course refers to obesity, and I’m pleased to have the Government’s support on this. It’s clearly a major problem—the major public health problem facing us. I look forward to collaborating with the Government, hopefully, to have a strategy to tackle obesity on the face of the Public Health (Wales) Bill. So, please do let us acknowledge the seriousness of that problem and deal with it. But, considering the evidence that type 2 diabetes can be reversed through a healthy diet for some people, it appears to me that this is still being undervalued to some extent and there is a great deal more that needs to be done.

I’m delighted to be able to speak today in the debate. I’d first of all like to actually thank very much Allison Williams, the chair of the diabetes implementation group, and all of the partners within it, because, reading both the 2016 delivery plan and the 2017 annual statement, I do see real progress. There are some very good ways forward. There have been some very strong and structured and above all—and fairly unusual—measureable systems of seeing that there have been some really good wins. I think that’s to be welcomed, and I pay all credit to the team who are behind this.

I’m happy to support both of the amendments tabled by Plaid Cymru. Minister, I thought that when you made your opening statement you gave us all a very stark warning about the dangers of diabetes on a personal level, what happens to the individual—whether they have type 1 or type 2; if you’re a child and you have type 1, the effect it has on your health for the rest of your life; the fact that, as a type 2 diabetic, you might be able to move some of the effects that it has on you by changing your lifestyle. I thought that you laid a very stark warning out as to the effect it has on the public finance, the long-term effect it will have on the NHS, the growth in diabetes, and, when, in particular, we’re looking at type 2, the enormous costs and huge intellectual effort that’s been put into place to deal with something that, actually, we need not suffer from—that, in a great many instances, we need not have.

So, having read both the update and the delivery plan and listened to what you said, and listened to what Rhun said, actually I’ve just decided I just want to make one comment: why oh why are we not looking at how we do physical education in schools? Because, Minister, I’m going to just quote your words here. You said we’re not successful in delivering these changes. We don’t exercise enough. We do not eat well enough. You’re looking at mandatory actions such as sugar tax—you’re talking about do we need to do that. You know, these are stark warnings. I have a group of people in my constituency who are all amputees, and every single one of them is an amputee because of diabetes. They tend to be middle-aged and older people, and in fact it’s a pretty rotten way to end the rest of your life, struggling—and they do struggle, and, because they’re diabetic, and because they’ve already lost one limb, they actually often go on to lose a second limb, because their circulation is so shot.

But the one thing that this Government could do today is change how we introduce exercise into schools. If we gave our kids more time for PE, and if we made PE far more fun, and we really engaged these young people so that when they left school and they went from primary to secondary and secondary into colleges and colleges into adults they’ve actually got that partly in their DNA—that exercise does not actually have to be running round and round and round a rugby, hockey or football pitch, but that exercise can be dancing, can be riding a horse, can be jogging up and down, can be doing aerobics, can be doing circuit training, can be playing rugby, whatever it might be, whatever flicks their switches.

I have looked across other UK nations and I have looked across other European nations, because one of the things I hear from Government is the crowded curriculum: we cannot possibly squash in another hour of PE for kids in the schools. That’s simply not so. Let’s be really clear: we have some of the more depressing results in our education system, and yet you look at other schools and other countries and they will give two or three hours a week to PE, physical education, to healthy exercise, to teaching people about a positive lifestyle that can go forward.

So, here we are, spending all this time, money, and effort trying to solve a problem that, actually, if we started right back at the very beginning, we need not even have that problem. So, my plea to you, Cabinet Secretary, is for all of this great work—keep on doing it, but, actually, get hold of the education Secretary, talk to your colleagues, and let’s make a fundamental change, because we may not be able to save people who are in their 30s, 40s and 50s today, but my goodness me, if we can help the eight, nine and 10-year-olds and the teenagers and the young 20-year-olds today, we might actually avert this terrible problem that you yourself have laid out so very clearly is a time bomb waiting to go off in our NHS.

I wanted to concentrate my remarks today on type 1 diabetes, which accounts for only 10 per cent of all people with diabetes, but accounts for 96 per cent of all children and young people who have diabetes. I know the Minister, in his introduction, did make very clearly the point that type 1 diabetes is not associated with any of the lifestyle issues that we have discussed here already today. That fact, I think, does sometimes get lost in the drive to encourage children and adults to take up healthier eating and exercise habits to avoid getting type 2 diabetes, which I think is absolutely essential, but I think that the issue of type 1 diabetes is sometimes lost in that debate.

I want to draw attention today to a constituent of mine, Beth Baldwin, who tragically lost her son Peter in 2015 when he was only 13 because of undiagnosed type 1 diabetes. This, of course, is a terrible tragedy for Peter’s family and friends and it’s even more awful when you think a simple finger-prick test that would have cost pennies could have diagnosed his diabetes.

Beth has thrown herself into campaigning to raise awareness of this silent disease that strikes so suddenly in our young people. The symptoms can be masked by flu-like symptoms, as was the case with Peter. She is working with Diabetes Cymru UK to urge health practitioners and the general public to be more aware of the symptoms, which can be easily remembered as the four Ts—about being thirsty, needing the toilet, being more tired and being thinner.

Around 25 per cent of young people diagnosed late with type 1 diabetes end up in intensive care and tragically, as in Peter’s case, for some of them, this is too late. The test kit that can diagnose the diabetes is often given to GP practices free by pharmaceutical companies, but there is no culture of routine testing as there is for blood pressure, for example.

The diabetes delivery plan takes into account type 1 diabetes and says:

‘Type 1 diabetes requires prompt diagnosis and treatment to reduce the harm associated with diabetic ketoacidosis. This is imperative for children with possible type 1 diabetes; any child who is unwell and has any features of diabetes should have an urgent capillary blood glucose check and should be referred urgently (to be seen the same day) to specialist services if diabetes is suspected.’

What my constituent would like to know from the Cabinet Secretary is: what practical measures are put in place to reinforce this message? Because I think the important issue about type 1 diabetes is education and awareness so that action can be taken swiftly. Simple things like posters, reminders, training events and maybe social media campaigns could perhaps be undertaken, and maybe are undertaken by Public Health Wales, so that the symptoms can be promoted and so that people at the primary care level are aware of what the symptoms are that can lead to such tragic results.

Is it possible to outline in what way this is being measured or evaluated to ensure that the process for diagnosing type 1 diabetes outlined in the diabetes delivery plan is being followed? What commitment have health boards made to ensure that staff are being given the knowledge and equipment they need to recognise and test children with suspected type 1 diabetes quickly to avoid the serious complications of the late diagnosis?

With the support of the Baldwin family, Diabetes UK Cymru will be launching a campaign to raise awareness of the symptoms of type 1 diabetes to the general public and healthcare professions, and I was wondering whether any support could be provided to aid this public campaign. I think, talking about type 1, it is essential that we do get this message across—that there are specific symptoms that can be recognised. We want to ensure that healthcare professionals are well aware of that and are able to act swiftly to do what they can to help prevent tragedies such as what happened to the family in my constituency.

I’d just like to end by paying tribute to the Baldwin family and the way that the tragic death has led them to campaign to try to ensure that more recognition is given to the symptoms of type 1 diabetes.

Diabetes is one of the major health challenges facing our nation. As many as one sixth of the population of Wales are at high risk of developing the disease, which is blighting increasing numbers of people around the world. As the Welsh Government’s own annual statement of progress points out, there is still a lot to do to address the wider lifestyle risks for diabetes and to tackle inequalities in access to diabetes services.

The sad truth is that the population of Wales is becoming increasingly overweight or obese and, therefore, more susceptible to developing type 2 diabetes. As the ‘Together for Health’ report highlights, the most deprived in our society are one and a half times more likely to develop diabetes. Unfortunately, the majority of the general public are unaware of the risks of developing type two diabetes, and of the other health risks it brings.

People are unaware that a person with diabetes is at more risk from a stroke or a heart attack than a non-diabetic. People are unaware that a person with diabetes is more likely to have a limb amputated than a non-diabetic. And people are also unaware that a person with diabetes is more likely to die prematurely.

We have to educate the public about the risk that an unhealthy lifestyle could lead to them developing diabetes and the wider health implications that diabetes brings. Thankfully, the standards of diabetic care have improved massively in recent years, so it is now time that we start to focus on education. We have to educate the public of the risks associated with diabetes and educate them about how to properly manage the condition properly.

Diabetes UK have launched a ‘taking control’ campaign, which aims to get everyone diagnosed with diabetes to attend a diabetes education course, which will teach them how to take control of their diabetes and live a full healthy life. The Welsh Government must ensure that everyone diagnosed with the condition in Wales can attend a course within a few months of being diagnosed. Investment in this area may save the NHS a lot of money in the long run by reducing the complications associated with the disease.

However, I believe we must go a lot further. We have to ensure that every child in Wales is taught the importance of a healthy diet and the risks that come with being overweight or obese. As a former PE teacher, I endorse everything Angela Burns has said about the need to increase physical activity in the curriculum. I also believe that every child growing up should have a garden so that they develop emotionally and physically, and learn that play is important, because I think that social media has had a profound impact on children’s activity. At Christmastime, we don’t see as many children on bikes now as we used to see; they’re more involved in the internet.

So, it is a matter of national shame that nearly two thirds of Welsh adults and a third of Welsh children are overweight or obese. We have to ensure that we are better educated about the food that we eat. Part of the new national curriculum should focus on teaching our young how to eat healthy and how to live healthy. We have to teach our young children about the risks associated with an unhealthy diet, the risks of developing diabetes, the risks of dying early as a result of the complications of diabetes, and we have to teach our young people how they can avoid those risks and live long and productive lives, unblighted by type 2 diabetes. Diolch yn fawr.

About five years ago, I was diagnosed with diabetes myself, and it came as a huge shock. I didn’t meet any of the criteria that people normally would. It was type 2, but I had never smoked in my life, never drank and wasn’t particularly overweight either. Diabetes can happen to just about anybody and for various reasons. For myself, it was because of an illness that attacked my pancreas. As soon as I was diagnosed, I did as most people do, and I went straight to the internet and started to look at ways to cure myself, or heal myself, of this terrible blight. I came across quite a few things that all talked about the same areas—about losing weight.

I’m not sure, Cabinet Secretary, if you’ve ever heard of the Newcastle study on the 600-calorie diet. This is something that you mentioned there was no magic pill for, but Newcastle University did some research that was funded by Diabetes UK, and they followed 11 people. They put them on a 600-calorie diet for eight weeks, and they had an additional 200 calories from eating vegetables. At the end of the study, seven of those 11 people were no longer diabetic. That is unbelievable. That is, if you have this terrible illness and you can suddenly be in a position where you are no longer diabetic, it’s phenomenal. I myself self-diagnosed this and did this myself. I lost six stone—some of you out there might be thinking ‘Holy cow!’ I actually weighed less than my wife. She doesn’t like it when I point that out, but it’s true—I weighed less than my wife. I managed to keep myself from going onto insulin for about two years as a result of this. My doctor just couldn’t believe how my blood sugar absolutely plummeted to the normal level. But it was unsustainable for me, and because my pancreas had been attacked, that’s why it didn’t have a long-term effect on me. But for people who are pre-diabetic or people who are type 2 diabetic because of a large amount of fat around the pancreas or other organs, I would exalt you, Cabinet Secretary, to look into this. It’s not one of those crazy things from the internet; the University of Newcastle, GPs and Diabetes UK all looked into this and followed this study.

Now, 7 per cent of the population has diabetes. It accounts for 10 per cent of the NHS spend, which in Wales is £500 million a year. Over half of the population in Wales is overweight. What a lot of people aren’t aware of is that if you’re female and your waist is over 31.5 inches, and if you’re male and your waist is over 37 inches you have just increased your risk of type 2 diabetes significantly.

When I first was receiving the symptoms of diabetes—when I was what’s classed as pre-diabetic—I think if I had followed this diet, I could have pushed things back even further with it developing to the state that it did. I myself will not die from diabetes. I will die from heart disease, I will run the risk of becoming blind, of having my limbs amputated, of having a stroke. Because people don’t die from diabetes—you die from the knock-on effects of it. Before I was diagnosed, I never went to the doctor’s. I just never went—I didn’t need to. Why waste my time and waste his time in going? Since then, I’m a regular and have many other illnesses that pop up from time to time that are directly related to the diabetes. If I was pre-diabetic, believe you me, knowing what I know now, I would do everything under the sun to stop this illness from developing to the state that it is in now—everything—because it is an absolute scourge and a curse. I hope, Cabinet Secretary, that you can take a look at this study and maybe trial it. I know from speaking to GPs that most of them are not aware of this, and certainly have no idea about how to push it out to people who would be able to do it. Let’s face it—to have only 800 calories a day for eight weeks, that’s quite a big ask. You need to be motivated to do that, but there will be people out there who will benefit from this. It’s not a magic bullet, but it can help some lives. Thank you.

I call on the Cabinet Secretary for Health, Well-being and Sport to reply to the debate—Vaughan Gething.

Thank you, Deputy Presiding Officer. I want to thank all Members who took part in today’s debate. I will just run through some of the comments that have been made, in particular, and quite understandably, Rhun ap Iorwerth’s contribution. I want to deal with some of the points about structured education, because I do recognise the need for improvement—the need to have a proper audit trail to allow us to properly understand the level of take-up and what we can do to further improve the take-up that exists. It is a key part of managing the condition. It doesn’t get into, perhaps, the prevention that we’ve also discussed in a variety of contributions, but I recognise there’s something there for us to resolve. So, I do expect to be able to report in the future on the take-up of the Seren programme and that that’s had the desired impact in terms of the take-up of that structured education, in particular for type 1 diabetics, but also to see further progress made in NICE tests, because, actually, much of the fall-off has actually come down to one test where there’s been a significant fall-off and that’s the urine albumin test fall-off.

So, actually, when I talked about taking forward the audit findings and tackling the variation in care with our colleagues in primary and secondary care, that’s a really important part of understanding why there is that variation, for the testing, the care provided and the outcome. There’s real self-reflection within the profession about the fact that they are part of helping us to be able to do that. It isn’t just about trying to shift and saying this is all about the citizen taking all of the responsibility and all of the control. Actually, we’ve still got a responsibility in Government and within the service to do the right thing in terms of the care processes being there, as well as being properly accountable for what does and does not take place.

Again, in terms of Angela Burns’s contribution, which, again, I broadly welcome, what I would say about your focus on physical activity for young people—again, I recognise that it is really important, not just in this area, but a whole range of others. And it is important to see that tied in as part of the curriculum review for the future about how PE is taught. But, actually, we’re already taking steps to increase physical activity take-up in our schools—the daily mile being the most obvious example. There’s something here about not perceiving physical activity as playing sport. I, myself, love sports. I always enjoyed playing sport as a young person until I got injured out from playing sport competitively; I’m now competitive from the sidelines. But the challenge is about how we normalise physical activity and make it easy for people to do, and simple. Because I think there is a challenge about not just saying that physical activity equals sport. It is about that broader sense of how we renormalise activity in its broader sense so that people expect that and actually enjoy it.

I don’t dispute that observation at all. The reality is that PE lessons have reduced by one minute and thirty seconds over the last decade, so they’re certainly not on the increase. I do think we should try and normalise activity. It’s very difficult to do, though, when schools are being shut down more and more in terms of play facilities, outdoor facilities et cetera. That’s why I made the point about making it fun, so that those kids enjoy it. It doesn’t have to be running around a football pitch, it could be dancing at lunch time—anything like that would go well, and they’re not doing it.

Well, I reckon lots of those things do take place, particularly in primary schools, but also in secondary schools, too. There’s a challenge again about how we normalise it and also that normalisation not just being something that is confined to a school. It isn’t solely the responsibility of education professionals to get children and young people to be physically active and physically literate. That’s part of the challenge that we have, actually. It’s about the engagement of the parent and the carer group and our community examples as well. If we can’t get that part right, actually, we’re fighting an uphill struggle. So, I don’t think we have a significant disagreement. It’s really about how we get from the diagnosis and what we want to do to actually delivering that in practice.

I recognise what you say about saving people in the future, but I do think part of our reckoning is that we can save people in their 30s, 40s and 50s, either through the prevention of type 2 diabetes, or in the better management of it, and, actually, there are lots of evidence that I’m going to refer to later of the fact that physical activity has real benefits in either the prevention or actually in the better management of this and a range of other conditions.

I also recognise the points Julie Morgan raised on type 1 diabetes. I think with you I’ve met Beth Baldwin and had a discussion with her son, Peter. And as you rightly pointed out, the delivery plan recognises the need to improve type 1 detection and symptom awareness. And there are measures we’re looking to undertake with community pharmacies for the role they have to play in opportunistic testing. I’d be very grateful if you could write to me with details of the campaign awareness launch event that you referred to.

I’m thinking about the contribution made by Caroline, from UKIP, of course, and I’m pleased with the recognition of improvement that was in her contribution and also the need for more. But I would again say, gently but clearly, that learning about a healthy diet is in each one of our schools. There’s a very, very clear message, particularly in primary schools, that any of us who visit a primary school would recognise about healthy eating. It goes back to this point that there are different measures that take place outside the school gates and set the pattern for what people think and consider to be normal in terms of healthy eating and learning.

Thinking about Nathan Gill’s very interesting contribution, I am aware of the study you referred to. What I would say is that, as well as awareness of that, we already have the most significant evidence of the impact of healthier behaviour in Wales, and that exists from Wales, and it’s the Caerphilly study. That cohort of people—it’s an amazing wealth of information about the importance of managing diet, exercise, alcohol and smoking, and if we’re not able to tackle hose four big behaviour challenges—not just in this area, but in many others—we’ll have a less healthy population, it’ll be more expensive to keep unhealthy for longer, more pain and discomfort for those people, and more economic challenges as well. This is one of those areas where we see that being played out and made real.

So, I’m happy to continue to say that we need to deliver that behaviour change with our citizens—it’s not about lecturing or attempting to shame people, but working alongside them to encourage and actually to deliver some of that change, and all the measures for the compulsion and requirement, as well as that encouragement and empowerment of the citizen as well, and their own responsibility. So, I’m happy to commit to the continued improvement in the way in which we tackle the treatment and care of people with diabetes and prevention, as well as the transparency in our progress. This is not a party-political issue in so many ways, as the debate today recognises, but it really is a national issue of national importance for all of us.

Thank you very much. The proposal is to agree amendment 1. Does any Member object? [Objection.] Therefore we defer voting under this item until voting time.

Voting deferred until voting time.

Unless three Members wish for the bell to be ring, I will proceed directly to voting time.