THE STATE WE ARE IN THE STATE POLICY PUZZLE DIABETES IN EUROPE DIABETES IN DIABETES IN EUROPE – POLICY PUZZLE – THE STATE WE ARE IN COVER_PolicyPuzzle_COVER_PolicyPuzzle_IDF 26/11/14 12:06 Page 1 © European Coalition for Diabetes, 2014 No part of this publication may be reproduced, translated, or transmitted in any form or by any means without the prior written permission of the European Coalition for Diabetes. First published, 2005 Second edition, 2008 Third edition, 2011 Fourth edition, 2014 2 ACKNOWLEDGEMENTS POLICY PUZZLE STEERING COMMITTEE • Anne-Marie Felton – Co-Chair of the Policy Puzzle Steering Committee, President of FEND • Michael Hall – Co-Chair of the Policy Puzzle Steering Committee; Medical Doctor, Honorary consultant to the Board of IDF Europe • Clifford Bailey – EURADIA DIAMAP Committee Member, Professor of Clinical Sciences, Aston University, UK • Angus Forbes – FEND, Professor of Clinical Diabetes Nursing at King’s College London, UK • Sarah Hills – Executive Director of EURADIA • Luc Martinez – Liaison Officer of Primary Care Diabetes Europe (PCDE); Professor of General Practice, Pierre et Marie Curie University; Vice-President of the French Society of General Medicine • Tim Nolan – Consultant, Editor of the Policy Puzzle • Michael Skjødt Sørensen – Board Member of IDF Europe; Medical Doctor, Vice-President of the Danish Diabetes Association SENIOR PROJECT RESEARCH STAFF • Elodie Besnier • Mayur Mandalia WE ACKNOWLEDGE THE CONTRIBUTION OF • Gaël Bassetto – Communication Officer, IDF Europe • Leonor Guariguata – Consultant • Tijana Milanovic – Diabetes Association of Serbia • Lala Rabemananjara – Regional Executive, IDF Europe • Lexitech – Translating • Fastlane – Design and layout • Rosseels – Printing REPORT FUNDING This publication was funded by FEND, IDF Europe, and PCDE, EURADIA provided a donation in kind. Generous educational grants were received from: • Lilly Diabetes • Novartis • Novo Nordisk • Sanofi Diabetes This project has been carried out with full transparency and independently from its funding sources. 1 CONTENTS 2 FOREWORD 4 PREFACE 6 EXECUTIVE SUMMARY 8 WHAT IS DIABETES? 14 INTRODUCTION 16 EUROPEAN ANALYSIS 24 EPIDEMIOLOGY AND INFO SYSTEMS 24 POLICY 29 CARE PROVISION 33 COUNTRY PROFILES ALBANIA 44 GERMANY 76 PORTUGAL 108 ARMENIA 46 GREECE 78 REPUBLIC AUSTRIA 48 HUNGARY 80 OF MOLDOVA 110 AZERBAIJAN 50 ICELAND 82 ROMANIA 112 BELARUS 52 IRELAND 84 RUSSIAN FEDERATION 114 BELGIUM 54 ISRAEL 86 SERBIA 116 BULGARIA 56 ITALY 88 SLOVAKIA 118 CROATIA 58 KAZAKHSTAN 90 SLOVENIA 120 CYPRUS 60 KYRGYZSTAN 92 SPAIN 122 CZECH REPUBLIC 62 LATVIA 94 SWEDEN 124 DENMARK 64 LITHUANIA 96 SWITZERLAND 126 ESTONIA 66 LUXEMBOURG 98 TFYR MACEDONIA 128 FAROE ISLANDS 68 MALTA 100 TURKEY 130 FINLAND 70 NETHERLANDS 102 UKRAINE 132 FRANCE 72 NORWAY 104 UNITED KINGDOM 134 GEORGIA 74 POLAND 106 UZBEKISTAN 136 CONCLUSION SUMMARY 138 THE WAY FORWARD 144 ANNEX EURADIA (DIAMAP) 146 LIST OF CONTRIBUTING STAKEHOLDERS 148 REFERENCES 152 FURTHER RESOURCES 158 3 FOREWORD The discovery of insulin in the early part of the 20th century was a major landmark in diabetes medical research. The world changed forever for those diagnosed with this life-threatening condition. Over subsequent decades, the management of diabetes has improved greatly and people with the condition who have access to professional care and education and self-management skills can expect realistically to live a long, healthy life. This reasonable expectation requires health systems to implement evidence-based diabetes care into daily practice. It is clear from this survey that this goal has not yet been realised fully in European healthcare systems. More than 20 years ago, European governments meeting under the aegis of the World Health Organization (WHO) unanimously approved the St Vincent declaration - a series of recommendations to tackle the burgeoning diabetes epidemic. The evidence that the disease had reached epidemic proportions was strong; today it is overwhelming. Diabetes is extending into particularly vulnerable populations of children, migrants and a growing ageing population. Against this background, in 2006, both the European Parliament and the Council of Ministers called for a coherent pan-European strategy to take up urgently the disease as a European public health priority. Regrettably, little positive action has been taken to accomplish this and the strategy remains fragmented throughout Europe. The International Diabetes Federation-European Region (IDF Europe) and the Foundation of European Nurses in Diabetes (FEND), together with Primary Care Diabetes Europe (PCDE) and the European Alliance for Research in Diabetes (EURADIA), have collaborated to produce a whole-of-Europe audit in order to document further the epidemic and the disparate national policies and practices that currently exist. We applaud this important work. The basis for action to tackle diabetes effectively lies in an objective and factual assessment of the situation. This audit provides just that. Europe, through the scientific research community, has an increasing knowledge and understanding of some of the causes of diabetes. However, continued investment in basic, clinical and environmental research must be continued and sustained. We are also learning to share information on what constitutes best practice in the prevention and treatment of this disease. Regrettably, this audit reveals the ongoing gap between evidence-based practice and the healthcare that our citizens receive in most European countries. 4 The 2013 IDF Diabetes Atlas 6th edition estimates that in Europe there are 56.3 million adults living with diabetes and this is projected to reach nearly 70 million by 2035 – more than 10% of the total population of the wider European region. Significant efforts have been made to raise awareness of diabetes, both at the international level, with the UN Resolution on diabetes of 2006, the UN high-level meeting in 2011 and follow-up in July 2014, and at the European level, with the European Parliament Resolution in 2012 and the EU Summit of NCDs in 2014. The political declaration by the UN General Assembly, resulting from the 2011 high-level meeting, can be found in the UN summit report. Yet while commitment exists, it has not been fully translated into action, begging the question: what further actions can be taken to curb the escalating burden of diabetes? As parliamentarians, together with the IDF President, Sir Michael Hirst, we have regular contact with European and national parliamentarians and with many of our constituents who live with the worry and risks of diabetes. Concerted political action is required urgently across all European states and with national diabetes associations and relevant European NGOs. A coherent strategy on diabetes public awareness, research, prevention and treatment, and long-term monitoring is a sine qua non. Unified European action led by the EU, the Council of Europe and WHO is vital if the wellbeing of our citizens and the economies of European nations are to be protected. In September 2011, Heads of State and Government and representatives of State and Government attended a UN High-Level Meeting in New York on non-communicable diseases. The resulting Political Declaration of the UN General Assembly can be found in the UN summit report. Action now can improve lives and make evidence-based practice a reality across the whole of Europe. Sir Michael Hirst Marisa Matias President of the International Member of Diabetes Federation the European Parliament Adrian Sanders, MP (UK) Head of Parliamentarians for Diabetes Christel Schaldemose Global Network (PDGN) and European Policy Member of Action Network on Diabetes (ExPAND) the European Parliament 5 PREFACE DIABETES IN EUROPE This audit once again covers the entire European region. It is produced by the same four non-governmental diabetes organisations responsible for the 3rd edition: IDF Europe, FEND, PCDE and EURADIA. We share a conviction that providing sustained and comparative documentary evidence on the epidemic levels and disparities in diabetes care services across the European region will help to persuade governments and healthcare providers that action to deal with this condition is imperative. This update of the 2011 report on national policies and practices relating to the prevention, screening and management of diabetes is published amidst an alarming increase in diabetes incidence, not only in Europe, but throughout the world. According to IDF, diabetes affects around 382 million people worldwide. In Europe, prevalence estimates now stand at 8.5% of the population aged between 20 and 79 years – meaning that 56.3 million people are living with diabetes in the whole of Europe. This is forecast to rise to 68.9 million by 2035. Despite this background, our audit reveals striking differences in the relative priorities that the countries surveyed place on research, prevention, treatment, management and self-management of this often-preventable chronic disease. This audit represents a vital contribution to our common fight against diabetes by compiling data and national practices in a way that helps to promote best practice and facilitates the task of national and European policy makers to make diabetes a national, European and global priority. The excellent state of knowledge and consensus on risk factors, prevention and treatment of diabetes argue for an intense campaign and coherent strategy to combat diabetes and its complications. In addressing the complications of diabetes, we