The Self Monitoring Fund. A mechanism to allow CGM for anyone on the NHS?

[tim2000s]

we'll need a self-monitoring director"

Right - I'm applying for that one.... Hands off everyone else...!

 

[Dillinger]

I think it's a great proposal; but I bet if it were raised as a possibility then there would be howls of protest about paying for the NHS at point of use. Even though it's an option not a requirement. If a tory government put it forward they would be hung out to dry for 'ending the free at the point of use' NHS model and Labour would never do this. That's because our politicians are not rational they are tribal and their tribal interests trump logic.

 

[tim2000s]

I think it's a great proposal; but I bet if it were raised as a possibility then there would be howls of protest about paying for the NHS at point of use. Even though it's an option not a requirement. If a tory government put it forward they would be hung out to dry for 'ending the free at the point of use' NHS model and Labour would never do this. That's because our politicians are not rational they are tribal and their tribal interests trump logic.

However, if this came from within the NHS....

 

[slip]

The problem with this is that if I sign up I am forcing the NHS to spend the whole £1059 just on me.

I use approx. 3 boxes of 50 strips a month, so currently my testing regime cost the NHS about £530 (using NICE's estimated cost) I'm sure I'm not the only one who doesn't test 10 times a day but likely to sign up for a CGM, then there are those that won't sign up but use more the 10 strips/day.................the budget now has to be re-budgeted............and if patient X gets more than 10 strips/day funded on the NHS then I should get more than the £1059..............

And then the NHS, to save money(!), suggests this scheme to other areas of treatment..............

 

[tim2000s]

The problem with this is that if I sign up I am forcing the NHS to spend the whole £1059 just on me.

I use approx. 3 boxes of 50 strips a month, so currently my testing regime cost the NHS about £530 (using NICE's estimated cost) I'm sure I'm not the only one who doesn't test 10 times a day but likely to sign up for a CGM, then there are those that won't sign up but use more the 10 strips/day.................the budget now has to be re-budgeted............and if patient X gets more than 10 strips/day funded on the NHS then I should get more than the £1059..............

And then the NHS, to save money(!), suggests this scheme to other areas of treatment..............

Well you don't get given £1059. You have a budget allocation of £1059. If you don't spend it all, then it's still the NHS budget. Given that something like 60% of people aren't even testing daily, I'm fairly sure that what I believe is the smallish number who would take this up won't bankrupt the NHS.

And no, you shouldn't get more if patient X gets more. Budgeting is based on the NICE models, not on individual care.

If you opt to stay in the standard model you can use as many strips as you like and if you want CGM you pay for it as and when. If you opt for the fund, it's up to you to manage how the money is allocated. That's a fair and equitable arrangement. And is no different to that which you'd get through an insurance policy.

 

[iHs]

@slip
I could not manage to keep my bg tests within target levels using just 150 strips per month and would demand more strips or a safer insulin regime. Testing bg just 5 times per day is not going to stop hypos or high bg levels or achieve a safe hba1c using bolus/basal or a pump. You shouldn't have to resort to using the Libre or cgm because of lack of teststrips.

 

[iHs]

Well you don't get given £1059. You have a budget allocation of £1059. If you don't spend it all, then it's still the NHS budget. Given that something like 60% of people aren't even testing daily, I'm fairly sure that what I believe is the smallish number who would take this up won't bankrupt the NHS.

And no, you shouldn't get more if patient X gets more. Budgeting is based on the NICE models, not on individual care.

If you opt to stay in the standard model you can use as many strips as you like and if you want CGM you pay for it as and when. If you opt for the fund, it's up to you to manage how the money is allocated. That's a fair and equitable arrangement. And is no different to that which you'd get through an insurance policy.

Is this budget just for bg testing technology or would it also need to cover prescription medicine as well?

 

[Diakat]

Just found out Dexcom has been approved for finding for insulin dependent diabetics in Germany. Don't know if evidence from that could feed into NHS calculations and availability in future.

 

[tim2000s]

Is this budget just for bg testing technology or would it also need to cover prescription medicine as well?

Purely for testing. Based completely on the cost of SMBG10 in the NICE models for SMBG.

 

[slip]

@iHs I didn't say I'm restricted to 'just' 150 strips per month! And quite rightly we shouldn't be restricted, which is where unfortunately Tims brilliant idea falls down, as it's partly based on the NHS having a more projected/protected ring fenced budget for self testing, the NHS currently has a budget which it can not control, and now we're saying some of that (read more than the NHS thought) will be ring fenced for those signing up, and the rest will still be uncontrolled.

@tim2000s I appreciate what you're saying but the only reason you're going to sign up is to spend all the money that's been allocated to you.

 

[slip]

How did the NHS handle the introduction of the first self blood glucose testing kits back in the day? I'm sure back then they were equally expensive as todays CGMs, and now they are a requirement (you're not a proper diabetic if you haven't got one ) T1Ds have to have one to drive at least.

Did people have to fight tooth and nail to get one?

 

[tim2000s]

How did the NHS handle the introduction of the first self blood glucose testing kits back in the day? I'm sure back then they were equally expensive as todays CGMs, and now they are a requirement (you're not a proper diabetic if you haven't got one ) T1Ds have to have one to drive at least.

Did people have to fight tooth and nail to get one?

When SMBG came out, the strips were visual, so you didn't need a meter. Thus, the NHS didn't supply them and you had to buy them. At the time (in the 80s) they cost 100s of pounds. With inflation, they would cost now about £600. Similar price to the CGM receiver + Transmitter now. They only became free on the NHS when the strips moved to completely electronic.

 

[iHs]

My hospital supplied me with the visual BM strips foc which is just as well as I definately would not buy them especially with that dreadful finger prick device. I was happy to use the Clinistix strips through my urine. My first bought meter was an Abbott cardsense which had a memory of 10 bg tests recorded with Exactech strips which are now known as Optium. Not sure how much I paid for the bg meter but at the time of purchase I was earning around £120 per week. My next bought meter was Bayer Esprit and then Therasense Freestyle which had the strips available on prescription so I no longer had to bu

 

[donnellysdogs]

I'm just waiting to hear whether I will get funding for a Libre, but additionally I have written to MP and the Chief Officer of my CCG asking them to respond to my questions on their policies for restricting funding.
Every medical person I have spoken to has said they wish more people would take such actions. These range from ambulance, GP, GP nurses, Dsn's, consultants etc.

The thing is that is being ignored here with NHS suggestions of budgets is that some CCG's DO fund CGM's to those needing them.... It's just whether you know what your CCG policy is.

The worst aspect is that NICE and NHS and CCG's following all the guidance is that everything is based upon hypo unawareness. NICE do not recognise the long term benefits of overall better control.

Until NICE change their guidelines, the CCGs are just following their guidance. It doesn't matter about NHS paying for it or how it is paid. It's the basics with NICE that need to be changed.

 

[AndBreathe]

Well you don't get given £1059. You have a budget allocation of £1059. If you don't spend it all, then it's still the NHS budget. Given that something like 60% of people aren't even testing daily, I'm fairly sure that what I believe is the smallish number who would take this up won't bankrupt the NHS.

And no, you shouldn't get more if patient X gets more. Budgeting is based on the NICE models, not on individual care.

If you opt to stay in the standard model you can use as many strips as you like and if you want CGM you pay for it as and when. If you opt for the fund, it's up to you to manage how the money is allocated. That's a fair and equitable arrangement. And is no different to that which you'd get through an insurance policy.

That could be open to abuse. There are already test strips on eBay that quite possibly have been found to be superfluous to the user's requirements, or prescribed erroneous and the Pharmacist finds themselves unable to take them back.

Much as I support that people should test to match their needs, then increased to accommodate their legal requirements (such as drivers), as a non-funded, for anything (aside from reviews and an annual safety net HbA1c), I'd find it hard if I found I was making a contribution to anyone's nice little earner.

Those statements aren't any personal slight on any poster's moral compass, I'm just expressing my view, which, if put to the test (pardon the pun), could be fairly common.

 

[tim2000s]

Those statements aren't any personal slight on any poster's moral compass, I'm just expressing my view, which, if put to the test (pardon the pun), could be fairly common.

And therein lies the rub. Essentially there are some details that need to be ironed out on this. One of the comments that's frequently made about use of CGM is that it needs to be used for a minimum of six days per week to be effectual.

To sign up for something like this, there needs to be a series of checks and balances, and they simply need to reflect what the evidence shows. In this case, when you sign up, part of your Ts and Cs reflects that you commit to this level of use and that you submit to regular review. Anyone caught working their way around it needs some level of reprimand.

In some ways though, if you abuse it, you do yourself an injustice. One of the key components of the system is that when the money has gone, it's gone. If you get strips on the NHS and just sell theme on ebay, you have an endless supply that you can sell. You are unlikely (not totally, bit still) to get caught up. You sign up to this scheme and you have a hard stop at £1,059. I'd suggest that you'd be better off sticking with the old system if you are going to do the abuse...

The thing is that is being ignored here with NHS suggestions of budgets is that some CCG's DO fund CGM's to those needing them.... It's just whether you know what your CCG policy is.

It's not ignored at all. Due to the limits of the forum, I can't post the entire blog post. In that I state that if you are within the NICE criteria your first and foremost approach should be to aim to get funding from your CCG. That should always be the first thing that is done. The idea of the "budget" or "fund" is to reach those that don't fall within the NICE criteria.

Many people who are self funding DO fall within the NICE criteria and don't realise it. By changing the model a bit, and hopefully the publicity that comes with it, I'd like to see far more people approaching their CCGs directly to ask for funding, and starting to change the way things work.

The worst aspect is that NICE and NHS and CCG's following all the guidance is that everything is based upon hypo unawareness. NICE do not recognise the long term benefits of overall better control.

That's not really true. CGM access is based on Hypo Awareness. NICE recognise the benefits of long term control. The target blood glucose levels and Hba1C values show this. They even demonstrate a level of recognition that Glycaemic Variation should be minimised.

What the NHS and NICE can't do is amortise the future savings against the use of technology now without some level of evidence that it really works. This happened with blood testing and will happen with CGM. As people who have used it for longer demonstrate as a population they have better management of their condition and fewer longer term complications so the picture will change. What we need is something like DCCT and EDIC using CGM over a long period.

This is where a state funded model runs slightly differently from an insurance based model, unfortunately.

 

[AndBreathe]

@tim2000s - Regarding your statement of: ".... I'd suggest that you'd be better off sticking with the old system if you are going to do the abuse...".

Come on Tim. Where an individual is mindful to turn themselves a quick buck (and some will feel that way, whether due to a questionable moral compass, or financial hardship or whatever), there are always going to be those who will think, "best not put temptation in my way", and those who just think, "Bring it on".

I'm not well up on the details, but when the benefits system changed to mean claimants received rent money to be passed to the landlord, rather than direct payment to the landlord, rent arrears spiralled. Of course the vast majority of benefit claimants are decent people who are experiencing difficult times, for whatever reason, and they genuinely need support, but your proposition is just another temptation.

 

[Brunneria]

The administrative cost of a scheme like this would HUGELY reduce the £ available to the patient.
- staff costs (salaries and oncosts)
- office space, documentation and equipment
- time and electronic (paper) shuffling

If these were factored in, the patient would see far less than that £1059 allocation.

The NHS is stretched enough. Introducing a scheme of this magnitude and expecting it to slot into the existing structure without huge additional investment is unrealistic, and if there was money allocated to set up the scheme, then it would probably come out of money that is used elsewhere on other vital services.

I actually love the idea of people getting CGMs if they are willing to use them sensibly and productively, but the set up and practicalities are prohibitive.

 

[tim2000s]

@tim2000s

Come on Tim. Where an individual is mindful to turn themselves a quick buck (and some will feel that way, whether due to a questionable moral compass, or financial hardship or whatever), there are always going to be those who will think, "best not put temptation in my way", and those who just think, "Bring it on".

I'm not well up on the details, but when the benefits system changed to mean claimants received rent money to be passed to the landlord, rather than direct payment to the landlord, rent arrears spiralled. Of course the vast majority of benefit claimants are decent people who are experiencing difficult times, for whatever reason, and they genuinely need support, but your proposition is just another temptation.

As I mentioned earlier, it isn't something done in isolation. There will be checks and balances. Namely:

1. HCPs need to be involved in the decision to go ahead with this approach. Check box 1.
2. You have to agree to terms. Those would need to be confirmed and followed up on a regular basis. Check box 2
3. There is no cash transfer.
4. You still have to order through the GP prescription service for funded items. Ordering 3 months of CGM supplies to sell on ebay at knock-off prices should raise suspicions at the GP surgery level. Surgeries already do this in my experience of supplies. Check box 3.

You won't completely remove abuse. It already exists.

 

[tim2000s]

The administrative cost of a scheme like this would HUGELY reduce the £ available to the patient.
- staff costs (salaries and oncosts)
- office space, documentation and equipment
- time and electronic (paper) shuffling

I don't think they are. GP systems currently account for the costs of items and the category they fall into. These are also attributed to each patient.

It's not a massive step to provide a tick box through the GP system that turns on a counter for a specific category and when the counter stops, prescriptions for that category stop being printed. It's part of the standard workflow of the surgery.

It is something that has the majority of the steps in place already.