If you live in the Social Media bubble for T1D in the UK, you can’t fail to have noticed that there was a press release this morning that stated that from November 1st, the Abbott Freestyle Libre will be available on the NHS for those living with T1D. It looked like this:
https://jdrf.org.uk/news/flash-glucose-sensing-available-nhs-type-1-diabetes/
And is the result of a significant campaign from Diabetes UK, Partha Kar, INPUT and Abbott. There have been months of speculation and rumour, and three years after introduction to the UK and take up in other European countries, it will finally be available for access via prescription.
First up let me be very clear that this is good news. It’s a significant improvement over finger pricking, and in spite of some of the issues that all systems have, I’ve written many posts about it and its benefits. And how Abbott think it should be used.
At the same time, the detail within the press release leaves me a little deflated. Firstly, the third paragraph says the following:
The device will, subject to local health authority approval, be available on the NHS across the United Kingdom from 1st November 2017.
Okay, so while it’s “on the NHS” from 1st November, that doesn’t mean anyone is going to pay for it. It means that each individual CCG has to approve spend on these devices. That requires that a strong evidence base is put forward to the CCG or Health Authority. Many of us know about the fights to get CGM through. Well now this will be required for Libre, for each local jurisdiction. That’s a big deal, and reopens the “postcode lottery” question that many feel is an issue with NHS accessible services. Partha says that he has plans to make this easier, but if previous experience is anything to go by, it will consume time from both patients and the various HCPs seeking to get these approved.
Secondly, this product is not covered by NICE guidelines. If we just go back and check what this means, NICE Guidelines provide a national, evidence based set of guidance to which patients and HCPs can refer to in order to understand how to get access to various services and products. CGM is a classic example. It means there is no “official” lever for use and begs the question, “Is there an update coming?”.
Instead we have Diabetes UK Guidelines. The high level recommendations are shown below:
Now while this is welcome, and having a form of guidance to encourage uptake by local Health Authorities is an important step, and I’m pleased to see that the desire to retain the NICE guidance for CGM is reinforced in this, I wonder how some of these will be interpreted?
We know, for example, that in some places, the recommendation for Education prior to going on a pump results in a requirement for education, and until you comply with that requirement, you won’t be getting a pump, regardless of whether you need it.
There has been a lot of discussion on Twitter (already) about the cost comparability of Libre versus use of glucose strips, and while this can be used to inform the dishing out of these devices, it needs to be treated carefully. For example, where someone finds finger pricking painful and inconvenient, and doesn’t test a lot, the introduction of one prick every two weeks is potentially life changing. But using cost as a comparison here would be detrimental to the user. This is why ongoing review of the benefits, as identified in the guidelines above, is probably more beneficial. I think steering away from the cost as much as possible is going to be important.
In addition to this, the DVLA prior to driving, and every two hours whilst driving, Libre values that are “abnormal”, low or high, and most bolus calculators on pumps still require finger pricking. The likelihood is that the reduction in test strip numbers is lower than many have put forth and if cost is used as too large a part of the equation, CCGs may look to reduce strips.
So, whilst the announcement is a step in the right direction, ensuring access is truly available is going to be a significantly bigger job for both people with diabetes and healthcare professionals, with perhaps more challenges than a NICE recommended product.
I look forward to seeing the plans that Partha has to ease access.
What other effects does this have? Even though the DiabetesUK guideline states that this should not affect the provision of CGM to those who meet NICE guidelines for it, I question the impact of what looks like an alternative. I am hopeful that it won’t be affected, but it’s not hard to imagine a CCG saying, “before we try CGM, you have to try Flash”.
On the other hand, given the announcement this week at EASD2017 that the next generation of the Dexcom transmitters and sensors will be cheaper, and the noises coming from Medtrum that they may finally start selling their CGM system this autumn (and if the prices on the mock up website are to be believed, which at this point I don’t, a lot cheaper than Libre), we may start to see an opening up of this market place at a price point that the NHS can support.
And what about those who have had issues with reactions to the Libre adhesive. I think there are two choices. Try again, using some form of barrier, and hope (for some this is simply not an option) or continue to use the self-funded alternative that you already use, and see if you can convince your CCG to pay the equivalent out for your alternative.
That brings up the point of those already using CGM very nicely. From here, with a continuous recording device available on the NHS and presumably paid for by your CCG, it makes for an interesting conversation with a CCG about CGM.
If my CCG will pay for Libre, as a result of all the benefits mentioned, then making a case for partial payment for CGM should be easier. What do I mean?
Once the Libre is on the NHS prescription database, we will have complete access to see what the NHS is paying. That will set a benchmark for the level that other CGMs will need to reach per 14 days of use, and ahead of anything moving in terms of funding there, we will have a figure that we can use to construct an argument for CCG funding for non-Libre CGM.
It won’t cover the full cost, but at £35 per sensor for Libre, you can get 16 Dexcom sensors over a year, and that contribution for Dexcom sensors as part of a GP supported case to the CCG would be beneficial for most people using them. Given the length of time we use them off license, it could be enough for a year’s supply.
While this announcement isn’t the panacea of CGM and Artificial Pancreases for all, it opens up the possibility of access to more advanced monitoring technology for everyone in an effective way. But we also need to take care on this path and make sure that we don’t shoot ourselves in the foot in our march forward.
Let’s take this with the applause it deserves, but be wary of the traps it may set. The law of unforeseen consequences can have some strange effects.
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