Catriona Khetyar: Head of Medicines Optimisation: East Berks Clinical Commissioning Group (CCG) to provide an update on the provision of the Freestyle Libre, flash glucose monitoring system to Type 1 diabetic patients within the Borough of Bracknell Forest.
Catriona Khetyar, Head of Medicines Optimisation: East Berkshire Clinical Commissioning Group (CCG) attended the Panel and explained the commissioning position on the provision of the Freestyle Libre, flash glucose monitoring system for Type 1 diabetics and explained that:
· The current prescribing recommendation was on the public website. https://www.eastberkshireccg.nhs.uk/wp-content/uploads/2018/06/EPPG-policy-22-Freestyle-Libre.pdf
· Freestyle Libre was the first flash glucose monitor on the market, others were in the pipeline.
· It had been possible to recharge the National Health Service (NHS) for Freestyle Libre since Nov 2017.
· The Clinical Commissioning Group (CCG) had taken time to consider the evidence surrounding the use of Freestyle Libre and they had balanced the clinical and cost effectiveness evidence available at the time.
· Concerns had been raised about the limited available evidence base surrounding this new technology.
· The National Institute for Clinical Excellence (NICE) information MedTech Innovation Briefing, at the point of CCG review did not mandate its use as a NICE Technology Appraisal would.
· At the point of review, there was no NICE Technology Appraisal in progress.
· The CCG had also discussed patient experiences and, although anecdotal evidence, they had been noted.
· At the time of evaluating, the CCG had considered that, on balance, Freestyle Libre would not be recommended for prescribing down to a lack of data on proven clinical benefit and lack of cost versus benefit evidence.
· The CCG agreed to revisit and review that decision again in April 2019.
· Last November, NHS England (NHSE) announced that the Freestyle Libre flash glucose monitoring system would be made available to Type 1 diabetic patients. The CCG welcomed that announcement.
· Prior to the announcement by NHS England on 14 November 2018 Freestyle Libre had been considered by NHSE Regional Medical Optimisation Committees (RMOC), these are advisory bodies only.
· Flash glucose monitoring systems had been mentioned in the NHS long term plan.
· The CCG was working in partnership with all health organisations in the Frimley Integrated Care System (ICS) to agree consistency in provision and an agreed process to ensure equity of access from 01 April 2019.
· NHS England (NHSE) still needed to provide clarity as to which Type 1 diabetic patients Flash Glucose Monitoring systems should be made available for.
· The CCG was working to the current RMOC statement and will amend if necessary in line with awaited NHSE criteria.
Following questions from Members, Catriona Khetyar, Head of Medicines Optimisation: East Berkshire Clinical Commissioning Group (CCG) advised that:
· The RMOC Freestyle Libre position statement looked at Type 1 diabetics who were testing 8 or more times a day. The exact numbers of patients locally were difficult to identify, but it was in the hundreds when test strip usage was looked at.
· Some patients were looked after by hospital specialists, some were cared for in community by GPs,
· There was no definitive number as to how many patients Freestyle Libre would be used by. To try to gauge the estimated usage, some numbers had been worked through in collaboration with clinicians locally.
· NHS England had made an announcement but hadn’t said which Type 1 patients Flash Glucose Monitoring Systems would be available for. It was expected that the patients who would have Freestyle Libre made available to them would be in accordance with RMOC position statement .
· The East Berks CCG were waiting to hear from NHS England on the specific criteria that Type 1 diabetics should fulfil to receive Freestyle Libre. This was not determined locally but would be set by NHS England.
· The Frimley ICS had a diabetes group and prevention work was part of that group. The cost savings associated with prevention could not be provided as Catriona Khetyar did not have that information.
· The East Berkshire CCG did not have to wait for permission to provide Freestyle Libre if there was a cost saving, they could provide it of their own volition, but it was felt that there was limited cost saving evidence available when they had made their decision in 2018.
· Consistent national access to providing Freestyle Libre was a good thing to do. Some areas that had chosen to provide Freestyle Libre and had locally collected audit data. It was unknown how that data would be made available nationally to be able to clinically and cost effectively measure Freestyle Libre’s effectiveness. Going forwards, the East Berkshire CCG would collect clinical audit data to monitor outcomes.
· The whole conversation and decision process had looked at where the patients would be seen, who would see them, the amount of specialist input required, dietary and lifestyle input needs and patient engagement with diabetes care. Information needed to be collected to understand the impact of provision and outcomes.
It was pointed out that the collection of sharps boxes was an issue. Patients using sharps were no longer able to take them back to GP surgeries, the boxes had to be left out in patients front gardens between 7am and midnight for collection. Strangers had entered people’s gardens and were looking at the sharps boxes. It was suggested that there needed to be a central point to drop off sharps boxes.
Catriona Khetyar, Head of Medicines Optimisation: East Berkshire Clinical Commissioning Group (CCG) agreed to take this suggestion back to the CCG for consideration.
· There were other CCGs in Frimley Health and Care Integrated Care System. There were North East Hampshire and Farnham CCG and Surrey Heath CCG. East Berkshire CCG and Surrey Heath CCG both made the decision not to commission flash glucose monitors but North East Hampshire CCG decided they would supply Freestyle Libre.
· North East Hampshire and Farnham CCG based their decision to fund on the Southampton, Isle of Wight and Portsmouth CCGs (SHIP) Priorities Committee recommendation for flash glucose monitoring systems, which includes some patients not included in RMOC advice.
· Locally in light of NHSE announcement, East Berkshire CCG wanted all patients within the Frimley Health and Care ICS to have equitable access to Flash Glucose Monitoring Systems.
· All CCGs and healthcare providers within Frimley Health and Care ICS were working to provide flash glucose monitoring systems. The points of difference were around the provision of Flash Glucose Monitoring System for gestational diabetes.
· The announcement from NHS England recognised variation in the provision of Freestyle Libre across the country. This may have resulted from by the advisory nature of the RMOC position statement compared to a NICE Technology Appraisal which would place a legal duty on the NHS to make any treatment recommended available.
· East Berkshire CCG were putting plans in place to ensure that Freestyle Libre was available from April 2019.
· It was unclear what the optimal number and type of patients was to effect a cost/benefit saving from use of flash glucose monitoring systems and it was not known if that information existed.
· The original decision made by the East Berkshire CCG to not offer Freestyle Libre had been made using evidence that looked at clinical effectiveness and cost effectiveness evidence. Clinicians and patient representation had been involved in the original decision group.
· Cost / benefit and outcomes data sharing had been discussed with other CCGs within the Frimley ICS footprint and neighbouring systems, but that data was less than a year of collection so not known if able to provide any useful insights as yet.
· If a Type 1 diabetic patient was self-funding and well controlled currently, the assessment of whether they would be funded for Freestyle Libre would be made from the criteria at the point they were prior to starting use of Freestyle Libre.
· Local Frimley ICS guidance had been developed by the local diabetes clinical group to ensure all CCGs and providers were engaged in the conversation to ensure equal access to patients across the Frimley ICS footprint. That guidance will go to the relevant group for noting and to adopt the recommendation
· An estimate had been made on the amount of uptake of Freestyle Libre and funding had been put aside from 01 April 2019.
The Chairman gave thanks to Catriona Khetyar, Head of Medicines Optimisation: East Berkshire Clinical Commissioning Group (CCG) for updating the Panel and highlighted that the provision of Freestyle Libre was an improvement in service for residents. The Council was keen on preventative services. The NHS Long Term Plan included prevention measures and it was hoped this move would improve the health of the local population.