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| Lily, June 2018 |
In our little team we were hoping that the doctors and/or the Clinical Commissioning Group (CCG) would feel the pressure from patients and organisations like Diabetes UK with all the media announcements that FGM (an unfortunately acronym) technology is now available on NHS prescriptions. Not in our area, it isn't. It has made it onto the local 'Formulary', which is a list of things that can be prescribed, but no protocol or procedure was forthcoming which would make it actually possible to prescribe it. In the end we gave up on the idea that the doctors would do anything at all, so the nurses and I have tried to come up with our own local protocol to put forward for approval Trust-wide.
It is quite an interesting process, because the device is so different from what you normally get when you hand over a prescription to your pharmacist. The Libre consists of a handset as a one-off device at the start, and disposable sensors that last two weeks at a time. At the moment we also believe that users should have some initial training (or at least guidance) about how to make best use of the device. The CCG has defined the criteria that have to be met before the device can be prescribed at all, and other criteria that have to be met if it is not to be withdrawn after six months. A bit different from a prescription for a 10-day course of antibiotics or a tube of ointment.
The criteria for prescription are quite restrictive - Type 1 only, appropriate blood glucose monitoring 8 or more times daily, and one of the following: where success with the Libre would avoid the need for an insulin pump; impaired awareness of low blood glucose; more than 2 admissions a year; or where a third party is needed (e.g. learning or physical disability). And the prescription has to be for a six-month trial period, during which we have to collect data on eight different indicators, and if fewer than two indicators have improved then the trial is discontinued and no more sensors on the NHS.
The Pharmacists have said that they don't want to have anything to do with it, thank you very much, which is fine for the first prescription - we would be happy to handle that, given that we want to have a role in starting people off with some training. After that, though, we aren't in a position to be dispensing sensors every month, so we've got to try to persuade the pharmacists to take that job on. And the Procurement people will have to decide how exactly the handset and sensors will be ordered and recorded, and the Finance people will need to define how the budgets will work and how we will charge the cost to the CCG (because although it's prescribable, it comes from a different budget than for 'normal' prescriptions). And the Doctors are clinically responsible for the prescription so they have to fulfil the criteria set by the CCG. So all of these people have to approve our proposal.
Can you imagine trying to arrange a meeting with people from five different professional groups, at least three of whom are not in the least interested in the extra work that this might entail?
We have started by finding a date convenient to ourselves and our paediatric colleagues (at least the paediatric nurses; I doubt whether there will be a dietitian involved). None of the doctors has replied to the invitation, and we know and work with them (update - one doctor thinks he can probably be there). The Head of Procurement has said that he will find someone to attend; Pharmacist representation is still unconfirmed - we don't have any routine contact with these guys, so I'm not expecting much - and I have no idea about Finance. I'll let you know.
The other issue all over the news is the effect of rapid weight loss on Type 2 diabetes, which in some cases can induce diabetes 'remission' - a return of blood glucose to non-diabetic levels. The research trial that has generated all the stories is not yet finished, but many people seem to want to try the diet. There's also Michael Mosley who keeps making TV programmes, and the family behind 'Fixing Dad' which also led to a TV programme and more, and every two minutes there's something else in the Daily Mail or on ITV about how you can live forever if you adopt some version of a simplistic and entirely unrealistic lifestyle.
The trouble is that the Calorie* restricted diet used in the (unfinished) research trial was not the sole intervention that led to remission - there was a whole team approach within GP practices, supported by the research team, including dietitians. And not everyone who tried it achieved remission. But the main concern for me is that we know weight loss is difficult to sustain, and the research has not yet uncovered what happens to people who lose the weight but then regain it again. If they experience more serious consequences than if they had done nothing then that changes the complexion of the outcome considerably. We just don't know.
It's still worth losing weight, though, and not eating (or drinking) excessive carbohydrate if you're at risk of Type 2 diabetes, or if you already have it. Even if you do it in a more measured way than by cutting down to 600 or 800 Calories* per day.
(* I tried to write 'calories' because that's how we generally refer to kilocalories, but I couldn't, because it's not accurate and I am a pedant. It's either kcal or Calories with a capital C.)
Three out of five of my team of adult diabetes dietitians are new, and with fresh eyes they have pointed out that we don't really provide much support to people who want to lose weight. We obviously can't compete with successful and rigorous programmes like Slimming World or WeightWatchers (now stupidly rebranded to be just WW), but we don't even have any leaflets that could help people think about losing weight, let alone provide the intensive and expert dietetic input to a rapid weight loss programme for diabetes remission. So we're going to have a couple of new leaflets, and we'll follow the course of the research and maybe work out how to apply the results within our practice. At some point. Maybe.
