Needles and Pins

“Oh, I thought I was smart, […] Why can’t I stop, and tell myself I’m wrong, I’m wrong, so wrong?”
Needles and Pins – Jack Nitzsche and Sonny Bono

I think we have all been here before! NHS England is on an economy drive and has decided to review some items that it considers to be of “low clinical effectiveness” (NHS England, 2018a). And guess what it includes: blood glucose test strips and insulin pen needles. No one would deny that there is a need for value for money in our cash-strapped times, but how can items associated with injecting insulin and blood glucose test strips be described as of low clinical value, despite a plethora of evidence to the contrary?

This is all very strange considering that the last “diktat” on this subject resulted in difficulties for people with diabetes in obtaining their test strips and has still left its emotional scars (Diabetes UK, 2013). Both Diabetes UK (2017a) and NHS England (2018b) acknowledge that many people with diabetes are still being restricted with the number of blood glucose test strips they are prescribed. The irony, of course, is that intensification of insulin management often means that people with diabetes actually need to test more often to optimise their glycaemic control, not less. Analysis of the results of a Diabetes UK survey indicates that some individuals are still not provided with enough test strips to monitor their glycaemic control effectively, let alone test before they drive (Diabetes UK, 2017a). Indeed, the problem is so great that the charity has developed an advocacy pack for those experiencing problems obtaining sufficient blood glucose test strips (available at: https://bit.ly/2qhdP3u).

At first glance, the proposed NHS guidance has an undertone suggesting that further restriction of blood glucose strips is in order, and it advises Clinical Commissioning Groups (CCGs) that only blood glucose test strips which cost no more than £10 for 50 should be prescribed (NHS England, 2018a). However, if you do the maths, those individuals who use insulin and drive to work 5 days a week will use a minimum of 40 test strips per month just to stay within the law, and that is without the additional monitoring required for general glycaemic control. As usual, the consultation document does contain various platitudes, including one that suggests the changes to obtaining blood glucose test strips are only designed to affect those with type 2 diabetes (with the caveat that if the individual is carbohydrate counting and using a carb-counting meter they are exempt).

NICE (2017) guidance, however, very much supports blood glucose monitoring for individuals with type 2 diabetes in certain situations; so are NHS England just reinventing the wheel? If this consultation is adopted, we know what is likely to happen: an interpretation that testing strips should be further rationed or restricted. Primary care will find it difficult to identify the nuances of the exceptional circumstances, and it will likely apply the guidance indiscriminately to all types of diabetes in an obdurate fashion familiar to everyone, in an attempt to fall in line with the CCG’s “guideline”.

Given that individuals with type 2 diabetes are often older and have specific needs associated with dexterity or find it difficult to switch technologies, the “official” type 2 diabetes equipment may not be suitable. The consultation document does state that its intention is not to remove the clinical discretion of the prescriber, but the reality will be different, as individual clinicians will be fearful of breaching these financial constraints.

Diabetes is an awful condition to self-manage, so why make it harder by disempowering and removing the element of choice? Potentially, not only will an individual’s favorite blood glucose meter need to go, but there will also be no choice regarding the brand of insulin pen needle to be used. I wonder how the NHS mandarins would feel if their iPads were replaced with Android Donut – after all, both can access the internet!

The economic argument is easy: look after the pennies and the pounds will look after themselves. On a serious note, though, we know the outcome of making diabetes less convenient to manage: yep, deterioration in glycaemic control. When will the accountants learn that one size does not fit all and that in the long run, rather than saving money, these measures could actually increase overall expenditure? But then again, the NHS has never been any good at joined-up thinking or long-term planning; the pharmacy budget may be in the black now but the financial burden for managing the complications associated with diabetes will increase.

The significant cost of professional time that will be required, not only in developing the guidance itself but also in the development and implementation of local policy, should not be underestimated; even the consultation document acknowledges that this will be an issue. And, of course, don’t forget the amount of time taken from clinical duties dealing with complaints and advocating for our patients, which again the document recognises will happen. Further time will also be required to educate patients how to use alternative equipment. Then there is the postcode lottery debate; although NHS England is ostensibly keen to stop this, some CCGs will have “guidelines” which are more generous and amenable than others!

So here is the dichotomy: many parts of NHS England stress the need for access to blood glucose strips (NHS England, 2018b), whilst others want to restrict it (NHS England, 2018a). Perhaps if I were cynical, given the timing of the consultation, I would go so far to suggest that the hidden agenda could be to prevent individuals with type 2 diabetes from accessing the FreeStyle Libre system.

Dare I say there could be an easy solution: why don’t NHS commissioners work in partnership with manufacturers to set a fair cost tariff for blood glucose test strips and pen needles that is acceptable to both parties? Surely this is preferable to causing upset, confusion and work for everyone else.

Have your say
The fact that the NHS consultation committee does not have members on it who specifically work in diabetes is concerning. The consultation, which closes on 28^th February 2019, can be accessed at https://bit.ly/2zvWKoO, so please let your feelings be known. Let’s have some long-term thinking!