LTP Priority: Diabetes
Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service
Type of Interventions: Improved access to technologies – Flash Glucose Monitors for people with type 1 diabetes and Continuous Glucose Monitoring for pregnant women
Major driver of health inequalities in your area of work
There is variation in provision of and access to services and technologies for patients with both Type 1 and Type 2 diabetes. The NHS Long Term Plan includes a commitment to target variation in access to and uptake of services by widening uptake and access to key technologies, such as continual glucose monitoring devices.
There continues to be significant variation on access policies for such products, despite the economic modelling for a number of devices showing them being cost-saving or cost-neutral, once the effect of the demand on wider services is taken into account. This has meant that in some parts of England access to Flash Glucose Monitors was restricted to patients who could afford to pay for them. The Long-term plan therefore committed to improving access to flash glucose monitoring devices for people with Type 1 Diabetes and Continuous Glucose Monitoring for pregnant women with Type 1 Diabetes.
“The NHS will ensure that, in line with clinical guidelines, patients with type 1 diabetes benefit from life changing flash glucose monitors from April 2019, ending the variation patients in some parts of the country are facing. In addition, by 2020/21, all pregnant women with type 1 diabetes will be offered continuous glucose monitoring, helping to improve neonatal outcomes.”
There is evidence that take up of CGM is skewed towards lowest quintile of deprivation.
The criteria developed by NHS England & NHS Improvement for Flash Glucose Monitoring stipulates that reimbursement to CCGs for the provision of Flash Glucose Monitoring is for specific groups of patients which is linked to reducing inequalities and prioritises groups who are most likely to benefit but also who might find access and adherence to other more mainstream ways of managing their care more difficult. NHS England has committed to reimbursing CCGs for prescribing Flash Glucose devices to up to 20% of their population with a diagnosis of Type 1 diabetes, which aligns with our estimates of the size of the cohort that would meet the clinical criteria.
People in deprived areas and protected groups. It is understood that there is currently greater uptake of technologies in the more affluent groups. By implication therefore there is likely to be an impact on ethnicity as BAME groups are under-represented in most affluent quintiles.
Thereby by improving access to flash glucose monitoring across England this has the potential to:
- Reduce current inequalities in population access to these technologies across STPs and CCGs
- Reduce health inequalities amongst people from deprived and BAME communities in access to flash glucose monitoring by patients with Type 1 diabetes.
- The plan to offer continuous glucose monitoring to all pregnant women with Type 1 diabetes from 2020/21 will improve access to this effective treatment for women from deprived and BAME communities.
Addressing inequalities in Diabetes Treatment – Improved access to technologies – Flash Glucose Monitors for people with type 1 diabetes and Continuous Glucose Monitoring for pregnant women
The NHS Long Term plan includes a commitment to support greater adoption of new technologies, such as Continuous Glucose Monitoring (CGM) devices. Freestyle Libre has had a high profile, but there are a range of existing and expected developments, particularly in relation to CGM and insulin pumps. There continues to be significant variation on access policies for such products, despite the economic modelling for a number of them showing them being cost-saving or cost-neutral, once the effect of the demand on wider services is taken into account.
Provision of continuous glucose monitoring to pregnant women with Type 1 Diabetes helps to improve neonatal outcomes.
The benefits for Freestyle Libre (Flash Glucose Monitor) developed by Abbott and reviewed by the Department of Health as part of the considerations on whether to place it on the Drug Tariff included direct benefits in terms of reduced numbers of blood glucose tests being needed by patients and improved blood glucose control which impacted on reduced number of hypoglycaemic episodes and hospital admission. Similar considerations of direct and indirect impacts on health outcomes will be considered when considering which technological interventions to focus use of the technology fund upon.
Modelling by Kings College London indicates that around 50% of Type 1 diabetes patients are currently unable to maintain optimal glycaemic control. If these individuals could be supported to achieve normo-glycaemia (which technologies could play a role in supporting), micro-and macro vascular complications would be reduced from 6.8 to 1.2 per 100 patients/year. DKA events also would be reduced from 14.5 to 1.0 per 100 patients/year.
Guidance for commissioners
Addressing inequalities in Diabetes Treatment
Note of elements to include in How to Guide:
- STPs to review prescribing data on prescribing of flash glucose monitors to achieve a target of 20% of people with Type 1 diabetes in receipt of this technology.
- STPs to ask hospitals to monitor uptake of flash glucose monitors by age, BAME groups and deprivation quintile.
- STP to work with hospitals and GP practices to undertake a Health Equity Audit to review uptake of flash glucose monitors by age, BAME groups and deprivation and implement an action plan to improve uptake and retention amongst priority population groups identified locally.
- STP to review current provision of continuous glucose monitors to pregnant women.
- STP to update local prescribing guidelines to match with long term plan target for all pregnant women with type 1 diabetes by 2020/21 to be offered continuous glucose monitoring, helping to improve neonatal outcomes.