Is 'designer insulin' an expense too far?

A report on BBC news last week caught our eye. It was about some new research from Cardiff University that showed that the amount the NHS spends on insulin has risen massively in recent years. The researchers put this down to the use of more expensive, modern insulins that they dubbed ‘designer insulins’. These insulins are more commonly known as analogues, where their structure has been altered to provide a more even absorption or a shorter or longer length of action. The study reported that possible savings of £625m could have been made by the NHS if these insulins were not so widely used in Type 2 diabetes, and more traditional human insulin prescribed instead. This report raised several questions in our mind:

Firstly, how many people with any type of diabetes on analogue insulin would consider themselves to be the recipient of a designer product? They should be so lucky! Our experience is that most people think that if they have to be on insulin, then an insulin that causes them the least amount of hassle in their daily life might be preferable. It’s true that no insulin is perfect, but analogue insulins are a huge step forward in diabetes management. They are much easier to use in terms of timing, and also have got some track record in making both hypos and weight gain– two well known and hated side effects of insulin treatment – less likely.

Secondly – how does the idea of wholesale changing of insulin prescriptions fit with the health policy rhetoric of ‘no decision about me, without me’?  We would be the first to support this statement and whilst we admit that collaboration in consultations is not always all it might be, the thought of researchers telling prescribers how to cut back on their bills, leaving the person taking the medicine with no say in the matter and no chance to weigh up the pros and cons of a change, does not quite seem to be the way forward.

Thirdly, and maybe most importantly, the huge ongoing expense, in both physical and emotional terms, of the consequences of undiagnosed type 2 diabetes, the frequent delay in starting any kind of insulin (designer or otherwise), and the lack among many services of fundamental annual check ups (revealed by the most recently published national diabetes audit) and support for self management, would easily swallow up any savings that a purge on insulin prescriptions would make. These are the real health challenges in diabetes, not the type of insulin prescribed. In a way, it’s an easy win for the NHS to focus on prescribing costs, rather than investing in changing what happens within diabetes clinics. Designer insulin?  What we really need is designer diabetes services.

Specialist Diabetes Care at Your Doctor's?

A recent diabetes journal for health professionals discussed the issue of increasing demands on the NHS and on diabetes services in particular. These discussions highlighted the changing NHS and the proposals now going through Parliament, for services to be provided in general practice where possible, rather than people being referred to specialist services in hospitals.

The journal highlighted four different models that had been developed in different areas of England. They all have commonalities, for example they all emphasise working in partnership with other health professionals to ensure services are integrated, and they all recognise that up until now, services have mainly been organised around the hospital-based system.

Where the models differ is in their approaches. For example, one of them offers a ‘top-down’ approach that talks about key services that should always be provided by a specialist team, and thereafter focuses on the relationship and support services that their specialist diabetes team provide to primary care colleagues.

Another is presented from the point of view of people with diabetes, who found that their care providers were too authoritarian, and that the model of care did not support self-care or shared decision making.

A third is written from the perspective of a limited company of general practitioners (GPs) providing an integrated diabetes service for their local population.

A fourth and final model is written from the hospital specialist team’s perspective but based on the local vision of ensuring that care is of good quality and equally available to all people with diabetes.

So which is the right approach? How diabetes services are organised has been debated for at least 20 years, mainly among health professionals, and mainly from an ‘opposite sides’ point of view, with both specialist services and general practice both arguing that no-one else can provide care in the way that they do. The result has been that within these services, people with diabetes have at times been bewildered and left with very little explanation about their local system of care, or why they see who they see.

The last decade or more has seen the Government’s health policy firmly pointed towards greater accessibility of services locally, alongside holding managers and commissioners to account for how money is spent on services and how best value for money can be achieved without reducing quality of care.

Assuming there is no one model that fits everywhere – and the NHS has consistently failed to provide a single system of care which works throughout the country – how can you tell if your local diabetes service is delivering what it should? We believe you should be able to get the answers locally, whichever country in the UK you live in, to the following questions:

í    What objective information can you be provided with to tell you why you are being seen by the specific health professionals that provide your care?

í    Can your diabetes service explain exactly what their model is?

í   Are there additional diabetes-related services on offer that you could take advantage of?

í    Where can you find information about the design of your local diabetes service, with information about when or where you might expect to need expertise from outside your ‘usual’ diabetes team?

í    How are decisions made about the design of your local diabetes services, and how can you have a say in those decisions?

í    How well are people with diabetes, their families and carers represented in the decision-making system – for example is there a token ‘person with diabetes’ among a vast panel of health professionals and managers, or is a more equal voice apparent, such as a representation group or discussion forum for people living with diabetes?

The answers to these questions may of course lead you to want to know even more of course, as the answers may be complex and potentially difficult to find. But you have the right to know not only what care you should expect, but what your local healthcare managers are doing to make sure you get it.  The government has vowed that we all experience an NHS where there is ‘no decision about me, without me’ and in our view, this applies as much to the design of services as to their delivery.

Professional development in diabetes care – How to make good choices

As we enter the new academic year, how’s your professional development portfolio looking? We’ve noticed that every diabetes journal holds at least a few, if not a rainforest full, of flyers showing the exciting number of educational opportunities for people working in the field of diabetes care.

In our experience, attendance at courses and conferences often provides gems of information that are really helpful in practice and make a huge difference. Equally, we’ve found it is possible to attend a conference and come away feeling dissatisfied that the one thing you hoped to get out of it wasn’t covered. So although it is fantastic that there are so many opportunities available, the sheer variety of choice and opportunities can be overwhelming. It can raise feelings of ‘how on earth could I go to all of the ones that interest me?’ – followed by ‘how on earth do I choose which will be of most use to me?’ And there is usually a £ sign attached, if only for travel and subsistence, so these thoughts come alongside the perennial ‘how do I spend the money I have available for education wisely?’

The question seems to be: how can we ensure that the conferences, workshops or other educational opportunities that are attended are the ones that will be most useful to us? We’ve put together some considerations to help get through this tricky dilemma.

First, take a moment to jot down some ideas of what kind of training you actually want at the moment – where are the gaps in your knowledge or skills? What do you struggle to get your head around? What topics make your heart sink when someone asks you a question in a consultation?

The next question to ask yourself is: what kind of learning do you want to experience? Are you happy to sit in front of a series of lectures, taking notes and having a quiet ‘aha!’ moment? Perhaps you prefer something a bit more interactive, where you can share your ‘ahas’ and learn about everyone else’s? Also consider if you like to be able to ask questions throughout the sessions or are happy to wait until question time after a presentation. Do you get frustrated if you don’t get a chance to comment on or debate the information you are being given? Perhaps the thought of having to contribute fills you with dread and sitting quietly at the back is more your thing?

A final deliberation is about money. Are you looking to take advantage of free or sponsored events only, or are you able to pay or have funds for a certain amount? Perhaps you’re in a position to choose the most appropriate event, regardless of the cost?  

Once you have considered all these questions, you can look again at the adverts and flyers for educational events. Armed with exactly what you are looking for, you’ll be able to focus on the topics, the method of presentation and the cost and quickly narrow down your options. When you sign up, you can feel confident that what you choose will be of real benefit and a good use of your valuable time.

Good luck and happy learning!