Tuesday, 9 April 2019

The Meeting

Sunny garden with spherical allium flowers
Adhisthana, June 2018
It was some time ago, but you may remember I was anticipating a meeting at work to talk about the new technology that is known as 'Flash Glucose Monitoring', a generic term covering only one device at present, called the 'Libre'. It consists of a large coin-sized disc that is stuck to the back of the upper arm with a tiny cannula residing in the interstitial fluid below the skin surface. This samples glucose levels every 5 minutes, and the numbers are transmitted by passing a handset or mobile phone over it and displaying the results graphically to help someone manage their diabetes.

The meeting took place. Everyone that was supposed to attend was there: Pharmacy, Finance, Procurement, Doctors, Nurses, and me.

I can safely say it was one of the most extraordinary meetings I have ever attended. (I was going to place it at number one in the list of extraordinary meetings I have attended, but then I remembered a meeting in 1992 when I was working in the Psychotherapy department of Manchester Royal Infirmary. As you can imagine, the fact that I still recollect that extraordinary meeting may explain why this one doesn't quite make it to the top of the table.)

I was in charge of writing the minutes - this was probably the only reason I was invited, with flattering words about how good I am at writing minutes, which is true, but still. I'd like to think I was there for my knowledge and contribution, but realistically, no. Writing the minutes meant I had to pay attention, which really only made things worse.

As usual, the whole situation is complicated by the fact that I still have no idea how the NHS works. What I wrote in the minutes is that our local Clinical Commissioning Group (CCG) published their commissioning policy for this device in May 2018, and in November 2018 NHS England announced that by April 2019 it should be possible to prescribe the device for all eligible patients no matter where they live. In our department we had already put together a plan for what we'd need to do in terms of initiation, record keeping and review, and the main discussion point was about how patients would actually get their hands on it.

In effect, the Libre serves the same purpose as a blood glucose meter and testing strips, which are prescribed by doctors in community and hospital settings and stocked and dispensed by pharmacies throughout the land. But for some reason, the pharmacists in our Trust have taken the position that they do not have the physical room to store the device nor enough staff to take on a new prescribable item. They proposed that instead of pharmacies, which have been dispensing prescriptions for as long as the NHS has existed and probably longer, the task of ordering, storing and dispensing the Libre should fall on the clinical staff, who have no facilities or experience whatsoever of carrying out any of the prescription process let alone the ability to handle payments and exemption certificates and whatever else it is that pharmacists do.

And that is where the issue has rested ever since, because we have no effective clinical leadership within the Trust at a level that would tackle the impasse. Two months later all I have seen is an email from one of the doctors who was at the meeting asking the pharmacist who was at the meeting if there had been any progress. I can't imagine that there has been any progress, because there is nobody at Trust management level who has any interest in the matter at all. Maybe this would change if either the CCG were to care that nothing has happened, or a parent or patient takes up the matter with a formal complaint to their MP or NHS England. But until then we continue to tell our patients that we would love them to have access to the Libre on the NHS, but at the moment they can't.

Of course, if ever the prescribing issue were to be resolved, those patients would still have to meet the prescribing criteria, which are extremely tight. Almost nobody would qualify except for a very few patients with Type 1 diabetes and learning disabilities. But that's another story.


  1. Fascinating. I suppose by "pharmacists" you mean "pharmacists working for the Trust in hospitals" and not Joe Bloggs MPS in the High Street. If so, can't an independent pharmacist with an interest (maybe even a relative) in diabetes offer to provide the service on receipt of a prescription, or do hospital prescriptions have to be dispensed by hospital pharmacies? Maybe Boots or another chain would take it on, on contract to the Trust. Or does it really have to wait until an aggrieved (hopefully not a grieving)relative complains to his MP?

  2. By "pharmacists" in this case I mean "pharmacists working for our particular Trust in our hospitals." As I understand it (which is a significant caveat), the CCG has stipulated that the device is only prescribable in secondary care at the moment. It is already stocked in various high street places if people wish to buy it for themselves.

    Why would you imagine that setting up a contract between the Trust and Boots or another chain would be any more possible than getting the hospital pharmacy to dispense?

    1. I had the impression that the hospital pharmacists would not discuss the matter as they had no space to store or time to manage.....

    2. The pharmacists will not discuss the problem with us, because we have no authority over them. The issue preventing the resolution of the problem is the lack of interest at the next level up, which is also where an external contract would have to be negotiated.


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