Majority of Type 1 Diabetes Patients Denied Flash Glucose Monitoring 

Becky McCall

November 08, 2018

Flash glucose monitoring devices are being denied to tens of thousands of patients in England, a year after the only device available on the NHS, the FreeStyle Libre (Abbott), became available, despite patients meeting NHS prescribing criteria.

The findings come from a BMJ investigation and are published in this week's edition of the journal. NHS England has advised clinical commissioning groups (CCGs) which patients should get prescriptions for the devices, but around a quarter of CCGs in England are still not recommending it. The paper, written by Gareth Iacobucci, senior reporter at The BMJ, is published in this week's edition of the journal.

Dr Partha Kar, NHS England's associate national clinical director for diabetes, estimates that only around 3-5% of patients with type 1 diabetes in England currently have access to the device on the NHS. He says that if CCGs were following guidance correctly, this figure would be closer to 20-25%, at least. According to the paper, he notes that 'some CCGs were merely paying 'lip service' to offering access to the devices and that variation in how the criteria were being applied had led to an unacceptable postcode lottery.'

In fact, as of July 2018, GP prescribing data showed that only two of the 195 CCGs in England had prescribed FreeStyle Libre to more than 20% of patients with type 1 diabetes, and only 15 CCGs had prescribed it to more than 10%. Furthermore, 25 CCGs had issued no prescriptions at all.

Dr Emma Wilmot, is a consultant diabetologist at Derby Hospitals NHS Foundation Trust. She believes that the FreeStyle Libre is a 'life changing' advance in type 1 diabetes care. She told Medscape News UK that she had seen so many users achieve their lifetime best HbA1c through their use of the device. "It provides insight into glucose values throughout the day and, more importantly, the glucose direction of travel, allowing users to prevent hypoglycaemia."

Wide Variability in Access Across CCGs in England

The BMJ used Freedom of Information requests to investigate the access given to patients who are served by different CCGs across the country. There is wide variability with some CCGs having made flash glucose monitoring available to hundreds of patients via GPs, while other CCGs say that the devices can only be prescribed by secondary care. 

Nick Cahm is a diabetes campaigner and helps to run the global Abbott Freestyle Libre users group for the UK on Facebook, which has 19,000 members. He helped provide data for the BMJ investigation. "There's an aversion to risk and loss of control over prescribing in the CCGs. Some CCGs are giving Libre a 'red list' status [only to be prescribed in secondary care], but this means the purchasing is liable to VAT [value added tax] because it is prescribed in hospital. But VAT aside, prescribing of Libre should happen in primary care not secondary," he pointed out.

For a member of the public to buy FreeStyle Libre out of pocket costs £48.29 (excluding VAT) per fortnight, while the NHS pays £35 per fortnight. Nick Cahm has self-funded Libre since it became available in the UK in October 2014, and is a firm believer in the benefits of using the device. "It just involves a quick scan to get a glucose reading and it also provides a history of glucose levels. Postprandial spikes are clearly visible, and with Libre it is possible to nearly eliminate these, which would be very difficult without the device. This is encouraging because the literature suggests that postprandial spikes have impact on long-term outcomes."  

Another key advantage highlighted by Nick Cahm relates to paediatric use. The device means parents can take a glucose reading in the night without waking the child for a finger prick test. "I think the case for paediatric access is even stronger than for the adult, and I think this is often missed."

He gathered official primary care prescribing data that are featured in the paper. These data show only 2% of type 1 diabetes patients in England receive FreeStyle Libre on GP prescription, while this figure rises to 11% in Scotland, 16% in Wales, and 35% in Northern Ireland.

"The areas where prescribing of FreeStyle Libre differ so dramatically are often bordering on each other, so Leicester and Nottingham; Derby and Burton, for example," said Cahm. "But there's also variation within areas governed by advice from the NHS's Regional Medicines Optimisation Committee [RMOC is a group which provides advice to CCGs over medicines and technology for which guidance from the National Institute for Health and Care Excellence (NICE) has not yet been issued]. The majority of CCGs have adopted the RMOC advice, but some have tweaked it to make it easier or more difficult to be prescribed the device."

Dr Wilmot finds herself caring for patients from Burton and Derby, and in a situation where she cannot prescribe to around half of her patients but can to the other half, despite them all attending the same clinic. "It is a really tricky situation. Some people with diabetes come to clinic on the understanding that they meet RMOC guidance only to find out their CCG does not fund it," she told Medscape News UK. "It is a heart-breaking situation for both them and myself. This device can have a huge impact on people's quality of life and it does not sit well that only some have access, depending on where they live."

Birmingham and Solihull GPs Reject CCG Advice Highlighting Postcode Lottery

Birmingham and Solihull CCG, is the largest in England with approximately 6560 patients with type 1 diabetes. It provides a case in point of the disparate nature of prescribing habits across CCG boundaries.

GPs operating under the Birmingham and Solihull CCG were told FreeStyle Libre could only be prescribed following an individual funding request. The neighbouring CCG - Wolverhampton and Dudley CCGs - made the sensor available for GPs to prescribe as they saw fit. After a challenge from the Birmingham Local Medical Committee (LMC), stating that the CCG did not have the legal or professional jurisdiction to impose such restrictions on GPs, the CCG sent a clarification of its position to the LMC, acknowledging that it could not demand individual funding requests from GPs.

According to the BMJ investigation, Dr Bob Morley, secretary of Birmingham LMC said, "Clearly the CCG's position put practices in a very difficult position, so we challenged it robustly. It breached the GMS/PMS contract regulations that the GP must provide a prescription if something is available on NHS prescription and a GP feels that their patient will benefit from it. And professionally, the CCG was trying to interfere with the clinical autonomy of GPs, who must act in the best interests of the patients."

Asked what action he would like to see taken with respect to access to FreeStyle Libre, Cahm said that: "This shouldn't be based on where you live but on clinical evidence and need, with the experts controlling this."

Dr Wilmot believes it is time that NICE updated its guidance. "I suspect that in years to come we will look back at the NICE guidance, which recommends 4-10 blood tests per day, and reflect on how barbaric a recommendation this was. The FreeStyle Libre is a humane, safe way of replacing fingerstick tests and hopefully, with time, more people with diabetes with have access to this and other emerging technologies in diabetes." 

COI: Mr Cahm declares no conflicts of interest. Dr Wilmot declares personal fees from Abbott, Dexcom and Medtronic.

Published in this week's edition of The BMJ.

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