Partha Kar: Don’t obstruct changeBMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o949 (Published 26 April 2022) Cite this as: BMJ 2022;377:o949
- Partha Kar, consultant in diabetes and endocrinology
Follow Partha on Twitter: @parthaskar
When it comes to managing the adoption of new technology, change always takes time. The question is how long it takes and how long we’re willing to wait.
The NHS has an interesting approach as it juggles the need to modernise, to catch up with the wider world, and to consider the evidence supporting new technologies, while maintaining aspirations to be a world leader in healthcare. Its desire to have more and more evidence gnaws away at time. Yet technology evolves at pace, leaving no time for the NHS to catch up. And as the NHS tries to deliver a central steer through local leadership, variations inevitably take hold alongside a mystifying unwillingness of organisations to learn from each other.
Among all of this, at the end of March the National Institute for Health and Care Excellence (NICE) finally released updated guidelines on glucose monitoring in diabetes,1 and suddenly the NHS is on the cusp of an enormous leap from being a global also-ran in healthcare technology to being a world leader. The guidelines say that, for type 1 diabetes, the choice of glucose monitoring should involve non-invasive methods such as continuous glucose monitors or flash technology, not the finger prick method.
This has been a journey I’ve personally invested much time and effort in since November 2017, and the experiences I allude to are a mixture of partnerships and willing colleagues—yet with barriers set in place by fellow clinicians, academia, and colleagues in policy. From a policy point of view, it’s been a long road. We’ve reached this point through painstaking data collection, continual efforts to push the technology through the process, and ensuring that this was a commitment in the NHS long term plan. Throw in a randomised controlled trial with data on quality adjusted life years to satisfy the uber-sceptical, and all angles were covered in getting this from policy into people’s lives.
We have evidence of a technology that boosts quality of life, improves diabetes control, and reduces hospital admissions, coupled with an evidence review by NICE on cost effectiveness. This, one would hope, should be enough.
Yet the NHS has an inordinate capacity to stall progress. Some organisations, such as area prescribing committees or medicines optimisation groups, will believe that they have a role to play in doing yet another analysis of cost effectiveness, even if they have no reason or legal mandate to do so. Take a step back: if cost effectiveness work has been done by an internationally and nationally feted organisation called NICE, why would you feel the need to do so any more, or indeed have the jurisdiction? And some specialists or committees will feel the need to add extra criteria to “make best use of the device,” oblivious to the fact that such additions widen disparity and stall progress for those who need it most.
Criteria such as making education mandatory go against the principle of working together with patients or creating an equal system for all. Education to use the device is important, but forcing people to attend face-to-face appointments when free online ones are available2 is silly, creating more work for ourselves and widening the gap based on deprivation and ethnicity. For those who can’t do online courses we should consider peer support or group sessions, to avoid unnecessary barriers to access. Adding criteria can widen disparities, and if your system is committed to lessening these, don’t add in unnecessary, non-evidence based interventions.
Despite all of that, we’re at a point where nearly 60% of people with type 1 diabetes are using this method of glucose monitoring, and people with type 2 diabetes are now very much the group for whom we need to plan the rollout of this technology. The key to this will be for local medicine management teams to accept the NICE guidelines and work to help people with an intervention that improves lives and is cost effective. Anything else is obfuscation or delaying the inevitable. To get access to this device if you have type 1 diabetes, the only requirement should be to have type 1 diabetes—nothing else. It’s now on a par with insulin, and education or support to use these devices should be provided simultaneously or as part of the journey, not used as a barrier to access.
Specialists also need to appreciate that they have no place in stalling progress and should embrace working with primary care, appreciating that this is where disparities can even out. An example is setting criteria such as “must attend specialist units to get access.” How does that help a person who is struggling to fund their heating, working on a zero hour contract, who can’t afford time off or the fare to attend hospital clinics?
Primary care should be able to prescribe it without restrictions. If glucose strips can be given out by GP colleagues, then whatever replaces them as modernisation takes place should be no different. And we, as a health system, need to empower all people with diabetes who are eligible for this technology and are denied by a local system to ask, “Why not?” Free education modules have also been built, for those so inclined.3 There’s is no feasible barrier to deny this—especially in a health system that seems to find money to pay for consultancy to redesign services, yet none for evidence based interventions.
Beyond local systems come national leaders, and my role is as one of those. My message to all leaders, in any system, is simple—make it happen, without any compromise in that plan. That’s how we become a world leader in improving care: by using data and analysis and by listening to those whose lives we feel able to pass judgment on.
Competing interests: www.bmj.com/about-bmj/freelance-contributors
Provenance and peer review: Commissioned; not externally peer reviewed.