Publication of new guidance by NICE was finalised on the 31^st March 2022. The advice recommends full NHS access to intermittently scanned continuous glucose monitoring (isCGM) and real-time continuous glucose monitoring (rtCGM) for people living with type 1 diabetes (NICE, 2022a; NICE 2022b). It further recommends that some people with type 2 diabetes that are on multiple daily insulin therapy (four or more injections a day) should have access to isCGM in certain circumstances (NICE, 2022c). These are if they experience recurrent or severe hypoglycaemia, if they have a disability that means they cannot finger-prick test, or if they would otherwise be advised to test eight or more times a day.

These recommendations represent a positive and significant shift in improving access to rtCGM and isCGM, whereas the previous NICE guidelines in both children and adults with type 1 diabetes had stipulated that CGM would only be accessible if certain stringent criteria were met. With publication of the new NICE guidelines, these recommendations are likely to result in broader access to rtCGM and isCGM devices for all people with type 1 diabetes. This will undoubtedly lead to an increase in costs, but it should reduce inequalities and enable more people to access the technology that will have a long-term impact on better health outcomes.

Choosing a device

Shared decision making is very important in identifying the child or young person’s needs and preferences. They should be offered an appropriate device based on the following (NICE, 2022a):

• Accuracy of the device.

• Whether the device provides predictive alerts or alarms and if these need to be shared with anyone else, for example, a parent or carer.

• Whether using the device requires access to particular technologies (such as a smartphone and up-to-date phone software).

• How easy the device is to use and take readings from, including for people with limited dexterity (taking into account the age and abilities of the child or young person and also whether the device needs to be used by others).

• Fear, frequency, awareness and severity of hypoglycaemia.

• Psychosocial factors.

• The child or young person’s insulin regimen or type of insulin pump, if relevant (taking into account whether a particular device integrates with their pump as part of a hybrid closed-loop or insulin-suspend function).

• Whether, how often and how the device needs to be calibrated, and how easy it is for the person to do this themselves.

• How data can be collected, compatibility of the device with other technology, and whether data can be shared with the person’s healthcare provider to help inform treatment.

• How unpredictable the child or young person’s activity and blood glucose levels are and whether erratic blood glucose is affecting their quality of life.

• Whether the choice of device will impact on the child or young person’s ability to attend school or education, or to do their job.

• Whether the child or young person takes part in sports or exercise when glucose levels will need additional management.

• Whether the child or young person has situations when symptoms of hypoglycaemia cannot be communicated or can be confused, for example, during exercise.

• Clinical factors that may make devices easier or harder to use.

• Frequency of sensor replacement.

• Sensitivities to the device, for example, local skin reactions.

• Body image concerns.

Importantly, rtCGM and isCGM should be provided by a team with expertise in their use, alongside education to support children and young people and their families and carers.

Implementation

As these guidelines are recently published, the implementation in many local areas and Clinical Commissioning Groups will take time. Clinical teams are advised to start early discussions with their local commissioning group. It is not acceptable to disregard NICE guidance as discretionary advice. Recent jurisprudence has ruled that NICE guidelines are important in determining the legal standards of healthcare (Ng, 2022). This is because NICE guidance is developed with the highest levels of evidence and is strongly supported by government policy.

Acknowledgement and disclaimer

Professor Sze May Ng is a committee member of the NICE Diabetes Update Guideline Development Group 2020–2022 and is Chair of the Association of Children’s Diabetes Clinicians, UK. She is also the Chair of the UK Diabetes Research Steering Group for Children and is the Guideline Officer for the British Society of Paediatric Endocrinology. She has received no financial payments for work from a body with a commercial interest in the condition. She has an MSc, PhD, MBA and a Master’s in Law with over 15 years’ experience in medicolegal work related to the field of paediatric endocrinology and diabetes.