Diabetes

Hybrid closed loop systems (HCLs), also referred to as ‘artificial pancreases’, are devices that include an insulin pump and a continuous glucose monitor (CGM). These devices use technology to automatically monitor and deliver the required amount of insulin simply and with ease. This helps to keep glucose levels within a desirable range for a person living with type 1 diabetes.

National Institute for Care and Excellence (NICE) Technology Appraisal TA943 for people living with type 1 diabetes

Q: Has NICE approved hybrid closed loop (HCL) technology for people living with type 1 diabetes, if yes, when can start using this device?

A: NICE has recommended that HCL technology should be offered as an option for managing blood glucose in people with type 1 diabetes if other methods have not achieved the desired results.

This means that if a diabetes specialist feels that you would benefit from a HCL and you meet the criteria for a HCL, they will discuss this approach with you at a routine appointment.4The NICE guidance also has a 5-year national implementation strategy. It will take time to implement this strategy and incorporate it into local services. Clinical risk and individual circumstances will be taken into consideration.

Q: How long may I have to wait to be offered hybrid closed loop, even if I’m eligible?

A: It is likely it will take up to a few years for some people who are eligible to be offered HCL.

The rollout will be over five years as the NHS via Integrated Care Boards (ICBs) have to put systems into place to enable us to support people with diabetes in starting up and continuing HCL. We are currently in the process setting up how this is rolled out and clinicians will require time to do this safely and effectively.

The plan is to provide this to those in most clinical need first, starting with children and young people, those who are pregnant or planning a pregnancy and those with the most need for improved control as per NICE guidelines. We will follow the national approach to guard against inequities in access.  

Q: Do I need to contact my specialist or diabetes team?

A: No, your specialist knows who you are and will either contact you or review your eligibility at your next appointment.

However, if you are not currently under the care of a hospital diabetes specialist your GP will be able to make a referral for you to be seen as appropriate and in line with the clinical criteria.

Q: What is the reason for phasing the rollout over a five-year implementation period in this way? 

A: In normal circumstances the NHS would have to implement technical appraisal recommendations from NICE within three months but there currently isn’t the clinical capacity to do this anywhere in the country, given the need for additional recruitment and training of specialist staff required to establish a diabetes workforce sufficiently trained to manage a rollout of this scale.

As healthcare teams would be unable to offer HCL to everyone eligible straight away, steps need to be taken to start the rollout whilst allowing time to prepare the diabetes teams and equip them with skills to help people to use the technology effectively.

Doing so will also help tackle health inequalities, which is another important part of the strategy. An unplanned rollout which does not address these foundational issues around staff capacity and variation in what services can offer would have a greater risk of making gaps in access to diabetes technology worse.

Q: Will all people with type 1 diabetes have access to the technology?

A: No, these recommendations don’t include everyone with type 1 diabetes and there are additional national criteria for adults over 18 years old who aren’t pregnant or planning to become pregnant will have to meet before being offered the HCL system. 

Q: Which pumps/HCL will you be offering?

A: NICE and NHS England have negotiated a national deal to provide cost effective hybrid closed loop systems.

This process was able to identify a small selection of systems that we are able to select from. As new devices come to market, technology progresses and if prices change, the cost effectiveness point may change, therefore the range of devices will be under constant review. This means that the devices/systems available for us, to offer you, may change over time.

We will review our selection locally based on the needs of our population and the devices made available by the above process. As with the rest of the NHS, we will be restricted to offering only the devices on the national framework.

Q: I have been contacted by my diabetes devices (CGM or pump) company or representative who told me that I am eligible for HCL and to contact my clinical team and ICB, what should I do?

A: No action needed, your usual clinical team will contact you or discuss at your next planned review.

If you are contacted again by the company, we recommend you ask them to stop contacting you and advise them to speak with the NHS England national team as your local area is following their guidance.

If you are eligible for HCL you should not have to pay for any of your pump therapy costs, the NHS cover this, so please do not agree to buy direct from the company before checking with your clinical team.

Q: Will I be able to pick the hybrid closed loop system I want?

A: As with the rest of the NHS, we will be restricted to offering only the devices on the national framework. This means that you will be offered what has been identified as the most cost-effective solution for you and your individual needs.

The framework has been designed so that it can be adapted over time to keep up with changes in technology as systems develop and new ones are launched. Some aspects of this work are still being finalised and we will share more details when they are available.

Q. Will patients in our region or nationally be offered a HCL system immediately?

Each area has varying levels of pump clinician staffing, expertise, and capacity. Part of the plan is to equalise this in line with local demands.

In the meantime, we have set up an HCL steering group to work together across Surrey Heartlands (which covers areas such as Guildford, Woking, Staines, Weybridge, Epsom, Leatherhead, Reigate and Oxted) to support each other so our patients are able to access HCL as soon as we are able to offer it. 

This NICE guidance is welcomed by local services; however, we are only at the very beginning of a very long road. There is a lot of planning that will need to be put into place before we can start implementing it. We are still awaiting many of the details of the national strategy.

We are working hard to ensure that our systems will be able to provide the most efficient, cost effective, and above all fair process to ensure that those who will benefit from this technology are offered it as soon as possible. Please be patient with your diabetes team.

If you would like to understand hybrid closed loop systems more and prepare yourselves in the interim, there is information available online. We advise starting here:

• Hybrid Closed Loop (diabetes.org.uk)
• Hybrid Closed Loop technology guide (jdrf.org.uk)

The Healthier You NHS Diabetes Prevention Programme, also known as the Healthier You programme, identifies people at risk of developing type 2 diabetes and refers them onto a nine-month, evidence-based lifestyle change programme.

The Healthier You programme is available both as a face-to-face group service and as a digital service. When referred into the programme, people are free to choose between the two. The provider for Surrey Heartlands is Living Well, Taking Control.

The NHS Digital Weight Management Programme supports adults living with obesity who also have a diagnosis of diabetes, hypertension or both, to manage their weight and improve their health.

It is a 12-week online behavioural and lifestyle programme that people can access via a smartphone or computer with internet access. The programme is:

• for adults living with obesity (BMI 30 or greater (adjusted to 27.5 for people from black, Asian and minority ethnic backgrounds) plus a diagnosis of diabetes or hypertension or both
• available via referral from general practice and community pharmacies in England
• able to provide behavioural and lifestyle interventions delivered over 12 consecutive weeks
• available for service users to participate via an App or web-based platform.

Healthy Living is a free NHS online structured education programme designed to help patients learn more about and live well with type 2 diabetes. The easy-to-use programme includes information and advice about:

• type 2 diabetes
• eating well
• becoming more active
• how to look after your body and mind
• other NHS services and support
• living with diabetes, including driving, working and travelling.

The NHS Type 2 Diabetes Path to Remission Programme is a joint initiative between NHS England and Diabetes UK available to eligible people in England.

This programme provides a low calorie, total diet replacement treatment for people who are living with type 2 diabetes and obesity or overweight.

The NHS Type 2 Diabetes Path to Remission Programme will not be suitable for everyone and there are some eligibility requirements that people must meet to be involved. These include that individuals must:

• be aged 18 – 65 years
• have a diagnosis of type 2 diabetes within the last 6 years
• have a BMI over 27 kg/m2 (where individuals are from White ethnic groups) or over 25 kg/m2 (where individuals are from Black, Asian and other ethnic groups).

Individuals who are interested in joining the programme can discuss their individual circumstances with their GP at their next appointment to find out whether it is suitable for them. The provider for Surrey Heartlands is Oviva UK.