The St. Vincent Declaration - origins and perspectives

Abstract

The St Vincent Declaration origins and perspectives. The notion that diabetes both Types 1 and 2 ‒ was a major public health concern with important environmental, nutritional and behavioural contributions to aetiology and requiring social action, large, complex support systems and public awareness campaigns, was first substantially expressed by the Expert Committee on Diabetes convened by the World Health Organisation (WHO) in the late 1970s. Its 1980 Report1 recognised that diabetes affected populations all over the world, dispelling the myth that the disorder was the ‘penalty of affluence’ and mainly a problem for wealthy countries. It gave clear notice that diabetes was not just a matter for health professionals but was an important issue for government concern, particularly involving national health departments. It gave prominence to the social and economic setting of diabetes and its complications and emphasized the central importance of empowering people with diabetes themselves to participate fully in their own care. It recommended the new, standardised diagnostic criteria for the disease, now internationally applied in modified form. The Expert Committee left WHO, with its challenging call for ‘Health for All by the Year 2000’, in no doubt that, with diabetes, it had an immense and growing problem on its hands. WHO recognition that the size and nature of the diabetes problem varies enormously from one part of the globe to another and, hence, demands regional, national and local strategies for its solution, was embodied in the first Recommendation of the 1985 WHO Study Group2, convened to review progress and update the 1980 Report. It stated: ‘Health system planning for, and research into, diabetes must be adaptable to the wide variation in social, economic and medical conditions and structures. Community‒based primary health care schemes should be linked to specialized levels to optimise the quality of care, depending on the requirements of the patient and the availability of resources….’ Further recommendations included ‘research into epidemiology and prevention…. appropriate for local conditions’, programmes of systematic education for people with diabetes, vigorous campaigns to correct the known risk factors for arterial disease in diabetes and, most tellingly, a new call for active collaboration between WHO and the International Diabetes Federation (IDF) at regional level, giving substance to another well‒worn but perceptive WHO slogan, ‘think globally, act locally’. Not entirely fortuitously, this last recommendation coincided with creation of formal regional structures of IDF, corresponding closely in number and location with the Regional Offices of WHO. It was in this new, European field of diabetes activity, IDF Brussels and WHO Copenhagen, that the seed of the European St Vincent initiative was planted, germinated and grew. Europe was first off the mark with a regional diabetes programme. A 1987 letter from Professor Jak Jervell3 as Chairman of the European Region of IDF proposed to Dr Jo Asvall, then European Regional Director of WHO in Copenhagen, that we should meet to discuss a joint diabetes strategy for Europe. The WHO Regional Office, already interested in diabetes and supporting research into the evaluation of innovative technology and quality of patient care, responded warmly and positively. WHO's Dr Kirsten Staehr‒Johansen readily picked up the challenge of a broadened commitment to diabetes and became a formidable driving force in the organisation of the St Vincent meeting and all that followed. It was soon agreed that a meeting should take place in the mountain township of St Vincent in Northern Italy with the ambitious objective of formulating the principles of a European diabetes strategy. This was to be a meeting with several differences. The principal stakeholders were to be the ‘electorate’, namely people with diabetes and their patient organisations in Europe, some ‘mature’, like the British Diabetic Association, and some new‒born from the newly independent states of Eastern Europe and the former Soviet Union. They all responded to the IDF Europe summons and sent patient/carer representatives. Another major component was made up of high ranking representatives of the health departments of all the European national governments even some ministers ‒ responding to invitations persuasively conveyed by WHO which has its emissary in the heart of government of each Member State. In addition, all the health care disciplines were represented, along with health economists and systems experts. The support of the pharmaceutical industry was immensely important to the success of the venture. Showing exemplary commercial disinterest, Boehringer Mannheim (now Roche Diagnostics) bankrolled and helped organise the whole operation and the strong and constructive partnership with many other companies has helped keep the St Vincent flag flying ever since. One of the unique, unforeseen but very fruitful features of the St Vincent meeting was the sight of people with diabetes between sessions, over coffee or at meals, sitting down with high‒ranking government health politicians and talking about the reality of life with diabetes. The special and very productive tone that this gave to the meeting contributed in no small way to the vigour of discussion and the fervour with which the event culminated in the one‒page St Vincent Declaration4. Genuine enthusiasm played an unquestionable part in the outcome, but it may have also helped that there was nowhere to go outside the meeting. The presentations and comments of delegates made it clear from the start that conditions facing people with diabetes and those who cared for them varied immensely across the continent of Europe, that we were starting from different stages of development and with very different structures of health care provision. Nevertheless, the interchanges in Working Groups and during plenary discussions, particularly the final debate around the draft Declaration made it abundantly clear that, though resources, methods, timetables and intermediate targets would inevitably differ, all sought the same ultimate common standards and shared common objectives. I had the privilege of taking the draft St Vincent Declaration, line by line, through that long, lively, and to me, unforgettable final plenary session. The Declaration, though brief, covered a very broad spectrum of the personal, social and medical aspects of life for people with diabetes at all ages and stages. It picked up particularly on the existing and proven potential for reducing the major threats of the vascular complications of diabetes, and it has been criticised for setting ambitious quantitative targets for their reduction; new retinopathic blindness and entry into renal failure to be cut by one third, loss of limbs from amputation by one half. These were all considered, on the basis of published evidence, to be achievable targets. If they have not yet been achieved universally and they certainly have not this is an indication of the as yet inadequate response to the challenge rather than a condemnation of the challenge itself. Put at last to the meeting by Jak Jervell, the Declaration was enthusiastically and unanimously adopted. All those present undertook to return to their home countries and try to make the Declaration work. The commitment and determination forged by the occasion, genuinely shared by the professionals, patients and politicians who were there, has been mightily reinforced by continued input both centrally from IDF and WHO and locally by patient associations, professional groups, national governmental support and the sustained backing and stimulation of industry, a creditable example of a productive partnership based upon the shared objectives of groups with otherwise differing agendas. The rest of St Vincent is history, much of it still in the making. During the early 90's, IDF and WHO were able to call upon the expertise and experience of people throughout Europe and to create a series of broad expert but practical guidelines5, built around the objectives of the Declaration, and widely distributed. Multidisciplinary Work Groups were set up to clarify, explore and make recommendations on a host of well‒defined issues. Progress was made with establishing some common definitions and clinical data reporting and recording formats so that we could at least start to communicate in the same diabetes language in polylingual Europe; and inroads were made into establishing European diabetes information systems, evolving year by year as the information revolution buzzed, clicked and beeped around us. In this era of a thousand blossoms, innovative and experimental activities, proudly and sometimes somewhat predatorily appropriating the name of St Vincent, flowered in many centres. The succession of St Vincent meetings, convened through the decade by WHO and IDF (and as ever with the help of industry), in Budapest (1992), Athens (1995), Lisbon (1997) and, most recently, the Tenth Anniversary meeting in 1999 in Istanbul as Turkey recovered from its dreadful earthquake7, updated us all on the European progress of this vigorous St Vincent Initiative. Inevitably, the pace varied immensely from country to country, but nowhere had nothing happened, and in some, advances had been almost dramatic. One of the very heartening by‒products was the European Twinning Initiative, with supportive and effective working links established between individuals, associations, hospitals and planning and research groups with help to offer to those with problems to solve. Run on an ad hoc, spontaneous and largely bilaterally negotiated basis, this expression of mutual self‒help may become more organised and institutionalised in the new ‘Diabetes Network International’ (DNI) currently coming into existence7. In the United Kingdom, both the BDA and the Department of Health warmly endorsed the Declaration. Following discussions between the DH and the BDA, in 1992 Sir Kenneth Calman, Chief Medical Officer for England and Wales, set up a joint DH/BDA St Vincent Task Force with two main aims: (i) to review the Declaration and make recommendations for priority action in the UK context and then (ii) to construct proposals for implementation. The Joint DH/BDA St Vincent Task Force, (with formal and valuable representation from Scotland, Wales and Northern Ireland) set up under the Chairmanship of Professor David Shaw of Newcastle and with very broadly based representation which included patients, care providers, academia, government and industry, began work in 1992. Its report8 was presented to ministers and the Board of Trustees of the BDA in 1995. Eleven specialist sub‒groups, each drawn from the broad range of ‘stakeholders’, produced valuable focused reviews of the state of knowledge and potentials, relating their conclusions to the goals of the Task Force. Published as a supplement to Diabetic Medicine9, these reviews constituted a valuable and still much quoted resource. Sadly, by the time we were due to turn recommendations into implementation, the process began to fray. The Task Force initiative had been overtaken by NHS reorganisation and responsibility for deciding how clinical issues should be tackled had passed from the DH to the Health Authorities. Increasing numbers of people with diabetes were being managed in primary care but links between primary care and local hospital‒based specialist groups were non‒existent or even adversarial. Without additional earmarked Treasury funding it seemed highly unlikely that already overstretched Authorities would welcome new calls on their resources to implement the proposed reorganised diabetes service which integrated the strengths of both primary care and locality specialist diabetes centres for the greater good of the patient. Frustratingly, the Task Force proposals were passed on to a newly formed diabetes sub‒group of a body of uncertain purposes, the Clinical Outcomes Group (COG). After labouring mightily for a further couple of years in an unquestionably well intentioned but toothless, largely management orientated committee, we concluded that NHS implementation of the Declaration was being backwatered. By 1997, in an atmosphere of growing political turmoil, we succeeded in producing a worthy but modest document, Key features of a good diabetes service10. The advent of a new health department in 1997 enabled us to raise the St Vincent standard once more and we welcomed a restatement of government concern about the diabetes problem. Through the newly created Minister for Public Health, the interest of the Secretary of State and renewed diabetes activity in and around the NHS Executive, momentum was re‒established. The Prime Minister sent a personal message of support for St Vincent to the Istanbul meeting and the project now goes forward now in the form of the government's National Service Framework for Diabetes (NSF,11). The NSF will set country‒wide standards of care for people with diabetes, tackling the issues identified by the Task Force and with the added strength of the new acronymic health support agencies like NICE and CHIMP which are designed to ensure adequate, equitable and effective implementation. The incorporation of the quality‒based ideal into day‒to‒day diabetes practice is good news for people with diabetes. Implementing the National Service Framework for diabetes will be a major test, but also a great learning opportunity, for these new structures of the new NHS. There can be few conditions with its patients and carers, its care providers and its management staff as well mobilised and readied for action as diabetes. The NSF can reasonably look forward to a generally positive and supportive response from the many interests and groups that go to make up the ‘diabetes community’, all of them preparing for a decade to introduce a step‒change improvement in the quality of diabetes care and anxious to accelerate the achievement of the ambitious goals of the St Vincent Declaration.