Libre in London - Some Analysis

[tim2000s]

For those interested, I've done a little research into Libre in London, which is available here:

https://www.diabettech.com/uncatego...oan-area-where-this-wasnt-supposed-to-happen/

This is what the current availability looks like:

RMOC = using national guidelines
RMOC+ = more stringent than national guidelines
RMOC- = less stringent than national guidelines

 

[Deleted Account]

I assume your Policy column is Regional Regional Medicines Optimisation Committee guidelines which state

It is recommended that Freestyle Libre® should only be used for people with Type 1 diabetes, aged four and above, attending specialist Type 1 care using multiple daily injections or insulin pump therapy, who have been assessed by the specialist clinician and deemed to meet one or more of the following:
1. Patients who undertake intensive monitoring >8 times daily

2. Those who meet the current NICE criteria for insulin pump therapy (HbA1c >8.5% (69.4mmol/mol) or disabling hypoglycemia as described in NICE TA151) where a successful trial of FreeStyle Libre® may avoid the need for pump therapy.

3. Those who have recently developed impaired awareness of hypoglycaemia. It is noted that for persistent hypoglycaemia unawareness, NICE recommend continuous glucose monitoring with alarms and Freestyle Libre does currently not have that function.

4. Frequent admissions (>2 per year) with DKA or hypoglycaemia.

5. Those who require third parties to carry out monitoring and where conventional blood testing is not possible.​

The second of these is interesting- it suggests Libre may be funded instead of a pump. I guess it is a case of which is cheapest.

 

[tim2000s]

Hi @helensaramay - yes it is (there's a little citation at the bottom!).

What's really interesting is point 5, which should mean all children should be given it.

 

[Mr_Pot]

For those interested, I've done a little research into Libre in London, which is available here:

https://www.diabettech.com/uncatego...oan-area-where-this-wasnt-supposed-to-happen/

This is what the current availability looks like:

RMOC = using national guidelines
RMOC+ = more stringent than national guidelines
RMOC- = less stringent than national guidelines

This illustrates the inefficiency of the NHS. All those CCGs and hundreds more have had to spend time considering what to do. If there is a national guideline why don't they just stick to it.

 

[tim2000s]

This illustrates the inefficiency of the NHS. All those CCGs and hundreds more have had to spend time considering what to do. If there is a national guideline why don't they just stick to it.

That's the crazy piece. They could have just said "Yes we'll adopt the guideline".

 

[Alison54321]

The only criteria for freestyle libre, really, ought to be that it is reasonable to expect that using it will improve the ability of the person with diabetes to manage it, better than they were before.

Should someone be excluded if they only test 7 times a day, and haven't been in hospital twice a year with DKA or hypos?

The whole thing is totally ridiculous, and it reveals a very worrying mindset. It suggests that a widespread view of diabetes treatment in the NHS is not about helping people with diabetes to manage it as well as they can, but instead to do the minimum necessary, to stop something really bad happening.

This is not good enough, it's economically illiterate, given the cost of complications, but it's also mean, stingy, life denying, and just horrible.

 

[tim2000s]

I don’t disagree, but the issue is that the NHS doesn’t operate on long term budgeting just on the next 12 months. Future Complications cost doesn’t factor into that.

 

[masonbason63]

Funny, I handed in three letters I composed about the benefits I could get with my Libre if the Sensors were funded by my Surgery which comes under THURROCK into my doctors this morning as I meet the criteria according to my diabetic team.

I must’ve ruffled their cages as I’m sure they wasn’t to sure what the Libre was but I think they had done a quick bit of research. I’d pointed out that the 200 sticks wasn’t enough and I’m buying another 100 myself to get my control so tight.

If these were all funded by the practice they could probably provide two sensors for the same or less price, but the answer was a flat NO !

As I have good HbA1c levels with a lot of dammed hard word on my part that they see on paper every 3-6 months but I’m gradually losing my sight through the problems I have, severe neuropathy, no hypo awareness and the list goes on but in there reply basically “ I Am Stable”

I’d taken evidence from this site as backup and other information about Flash monitoring that’s easily available.

They’ve come back with the answer that when their diabetes specialist comes back from leave to see about having a talk with the amount I need. I know I’m not the only one out there with this and there’s other illnesses with funding needed, but I’d offered to meet them half way they supply 1 sensor I’d buy the other each month.

I feel a little deflated to be honest

 

[Boo1979]

I don’t disagree, but the issue is that the NHS doesn’t operate on long term budgeting just on the next 12 months. Future Complications cost doesn’t factor into that.

Have to agree - the number of NHS trust senior management meetings I sat in trying unsuccesfully to persuade people of the need to adopt a “speculate to accumulate” mindset in order to make a substantial impact on service design and improve clinical outcomes was a major reason behind me taking early retirement

 

[Scott-C]

The short term-ism is pitiful. But if we need to play them at that game, it would be interesting to know whether the areas now liberally prescribing libre are noticing any differences in the number of severe events requiring NHS assistance, which obviously cost the NHS money.

Some docs in NHS Lothian, where we've had it on script since March, have reported substantial reductions in a1c. It would be fascinating to know what they're seeing in severe events. I may ask at my December checkup.

The Scottish Health Technology Group published a paper in July on the clinical and cost effectiveness of libre, coming out in favour of it, with a few hedges and caveats (as an aside, the Northern Scotland NHS areas had been waiting for it, NHS Grampian have now said yes based on the paper, the others are expected to follow suit shortly, catching up with the Southern areas, some of whom have been scripting it since March).

A lot of the focus was on longer term aspects like a1c etc, but there's a few mentions of the impact on reducing short term costs of severe event admissions and blue lights.

For example, page 14 of the Evidence Note refers to a few studies, and says that on an assumption that libre reduced severe hypos by 48%, factoring the savings from that in made it cost neutral. I suppose it will take input from the real world to show whether that assumption stands up. My own n=1 experience of it suggests yes - I've only had one "cold sweat" bad un in the last 2 yrs and that wouldn't have been the case sans libre.

On page 18, table 6 suggests a monitoring cost per patient of £370, but then subtracts £227 for reduced hypo costs, netting out at £144 overall impact.

Statistics, planning etc ain't my thing but it seems like a fairly comprehensive review of available materials, which has recently persuaded NHS Grampian to play ball.

It would be interesting to know whether any areas down South have paid attention to it, or whether they've got their tech bods doing the same stuff all over again from scratch.

Here's a link to the Advice Statement, the Evidence Note link is further down the page:

http://www.healthcareimprovementsco...dvice_statements/advice_statement_009-18.aspx

 

[urbanracer]

..........It would be interesting to know whether any areas down South have paid attention to it, or whether they've got their tech bods doing the same stuff all over again from scratch.....

I live on the south coast and I recently had scripts for Libre refused by my endo'. Apparently I'm too well controlled. The logic regarding being well controlled because I self fund seemed to elude them.
GP also told me they couldn't afford both Libre and strips as I would need strips for driving.

 

[Scott-C]

I live on the south coast and I recently had scripts for Libre refused by my endo'. Apparently I'm too well controlled. The logic regarding being well controlled because I self fund seemed to elude them.
GP also told me they couldn't afford both Libre and strips as I would need strips for driving.

It's hugely frustrating at the moment. I don't know any of the behind the scenes funding politics going on, but I wouldn't be at all surprised if a few Board members were saying things like, "they've managed ok on strips, why change?" or, "my aunt's T2 and she doesn't need it."

It would be a useful training/awareness development exercise, or whatever buzzwords Boards and HR are using at the moment, to pin some of the reluctant funders down, inject them with 15u, chuck them some strips, and ask how do like them kittens. Unfortunately, it would be illegal.

I've not been following prescribing policies across the country that closely. The ones which worry me the most are the ones which say it'll only be prescribed where the patient has had incidences of dka and hospitalised hypos. I imagine there's probably been a few people who've said to themselves, right, I'm going to deliberately engineer a major hospitalization event just to get on script.

I'm lucky enough to live in an area where if you're T1 and want it, you get it. I wonder sometimes whether CEOs from across the country sat down in a smoke filled room and said, look, we're not too sure about this yet, how about we draw straws and the shortest ones have to run it for a while to see how it pans out...

I think it's generally going in the right direction. The ones with tight policies will loosen them over time, it's just the way these things work.

I try to remember that this a major step change in diabetes management. It's bound to be messy, uncertain and infuriating for a while.

 

[tim2000s]

@Scott-C - there’s a ton of evidence merging across the country about reduced Hba1C and reduced diabetes distress, both of which are know to be drivers of severe hypos as well as complications. These are coming from the DTN-UK audit questions that are capturing all of this stuff to provide a UK wide picture of the benefits. I’ve had conversations with a DSNs about it in Portsmouth area.

 

[Scott-C]

@Scott-C - there’s a ton of evidence merging across the country about reduced Hba1C and reduced diabetes distress, both of which are know to be drivers of severe hypos as well as complications. These are coming from the DTN-UK audit questions that are capturing all of this stuff to provide a UK wide picture of the benefits. I’ve had conversations with a DSNs about it in Portsmouth area.

It would be interesting to be a fly on the wall at some of the behind the scenes discussions which are undoubtedly going on re funding.

When libre went on script in Lothian back in March, I had to go to a short 1 hour lecture on how to use it as part of their terms and conditions.

Quite amusing really as the six of us there plainly knew more about it than the doc (there was a looper there too, didn't catch his name), but we did get the opportunity of asking him why Lothian had decided to script it on very liberal terms when other areas were still swithering.

I'm sure there was much more to it than he said, but his answer was, "we know how difficult T1 is, if we were T1 ourselves, we'd want libre, so there's no way we're going to deny it to you guys".

I'm struggling to understand how some areas can take such a pragmatic, practical and humane approach to it (which seems to have been borne out by Dr Gibb's and others reporting of results), whereas others are still humming and hawing.

Who knows how the politics of these things work. Maybe the holdouts are just procrastinating for the sake of it, when they know it will have to be done eventually. It all comes back to how much f'ing evidence do they need - isn't there enough already?


By the by, I was amused by Vaughan's tweet on his dsn's take on his blinged libre. I had the same, with one asking whether it was, "legal".

 

[tim2000s]

That's the trouble. In many areas you do anything off piste and people don't understand why. There's a real mix of responses from HCPs.

The "Libre Lottery" has demonstrably proved the issues with a number of NHS areas relating to uptake of tech, how funding works and how costs are calculated at a local level. The reality is that the NHS isn't really set up to deal properly with long term conditions that are best treated through anything other than drugs, and therefore to discount cashflows back to now for reductions in risk of complications, at least at a local level. NICE is a whole other question, but of course there's no NICE model for Libre. It's wholly frustrating.