Also known as continuous subcutaneous insulin infusion (CSII)
Insulin pump therapy should be offered as a treatment to people with Type 1 diabetes as part of a cohesive and comprehensive diabetes service. Insulin pumps could also have a role to play in the treatment of some people with Type 2 diabetes, but further research is required to identify the clinical and cost effectiveness of the use of insulin pump therapy in people with Type 2 diabetes. Anecdotal evidence has also shown the potential benefits of insulin pump therapy for people with cystic fibrosis related diabetes and those who have undergone pancreatic surgery.
The appropriate use of insulin pump therapy should be determined by the clinical need and suitability of the person and their personal choice. An appropriately trained team of healthcare professionals should be available to initiate and supervise treatment. Access to insulin pump therapy should not be on the basis of where a person lives or ability to pay. Revised guidance for insulin pump therapy was issued in July 2008 by NICE. The guidance is relevant to all four nations of the UK, and the DHSSPS in Northern Ireland recommended the revised Insulin Pumps Guidance when certain criteria are met, through a Circular in June 2009. In Scotland implementation guidance is not currently available; however, recently published SIGN Guidance on the Management of Diabetes provides recommendations based on an assessment of current evidence on insulin pump therapy.
While insulin pump therapy is not the only treatment option for insulin delivery available, it is an increasingly popular treatment option and will be the choice for some people with diabetes. It offers significant benefit over Multiple Daily Injections (MDI) for some in terms of diabetes management and quality of life. Published evidence also shows the benefit of insulin pump therapy for those prone to frequent hypoglycaemia, elevated HbA1c, or significant variability in day-to-day blood glucose levels.
Insulin pump therapy has been recognised for its potential benefits as a treatment option among children and young people. Factors such as increased sensitivity to insulin, smaller size, irregular lifestyle and the need for smaller doses of insulin make insulin pump therapy a useful treatment option in very young children. Owing to hormonal and psychosocial changes, adolescence too is a period where young people may experience difficulties with blood glucose control and where insulin pump therapy can be of benefit.
Whereas the NICE guidance is a step forward in increasing the accessibility of insulin pump therapy for adults and children with Type 1 diabetes, not enough credence has been given to the quality of life benefits, such as increased lifestyle flexibility associated with insulin pump therapy. The NICE recommendation has set limits on those who would be eligible for a pump.
The guidance should still be locally implemented in a uniform manner in order to put an end to the existing UK postcode lottery. The following problems have been identified by people with diabetes, demonstrating the variability in access to insulin pump therapy:
- Difficulties being assessed
- Difficulties in accessing funding for the pump/consumables
- Difficulties in accessing experienced specialist teams for clinical support
- Hesitance by some healthcare teams to consider insulin pump therapy as a treatment option as they have concerns about the technology and /or their ability to support individuals on this type of therapy.
Implementation Criteria – solutions to the existing post code lottery
- Pump therapy is an alternative insulin delivery option and awareness of its potential as a treatment option should be raised amongst healthcare professionals and people with Type 1 diabetes alike.
- Transparent, consistent and equitable protocols should be in place in all localities covering:
– awareness raising, assessment, referral, choice of insulin pump, support during initiation, follow-up, ongoing support including out of hours, education, supply of consumables (and associated necessary equipment such as blood glucose testing strips), discontinuation, staff training and competencies.
- Audit of insulin pump therapy services should include the implementation of these protocols. In England, the National Diabetes Support Team working group report on Insulin Pump Therapy contains further detail surrounding implementation. The general service specification for delivering a pump service includes a minimum team comprising a physician with an interest in diabetes, diabetes specialist nurse and dietician. This is also reflected in the NICE guidance recommendations.
- Funding for pumps and consumables should be available when criteria are met. In England and Wales it is mandatory to fund technologies approved by NICE. In Scotland implementation guidance is not currently available although local plans are being developed.
- The development of local pump centres, with appropriate infrastructure, staff, education and training, is essential to meet the growing demand for this therapy. Local arrangements must be put in place to support this. Whilst this expertise is developing, the aim should be to provide insulin pump services as locally as possible whilst still maintaining an appropriate level of expertise. Shared care arrangements with diabetes centres with specialist expertise may be available and should be encouraged to ensure provision until appropriate local implementation is possible.
- Training in flexible insulin therapy and insulin pump therapy should be a key part of ongoing learning and should form part of the curriculum for diabetes specialist healthcare professionals. This is because a competent healthcare professional team must be initiating, providing education, training, and on going support to people with diabetes using insulin pumps. As this should be part of ongoing care for people with diabetes, it should not be provided by insulin pump manufacturers. The healthcare professional team will also need to provide support and education to other healthcare professionals who provide care to an insulin pump user. The ultimate goal is that all diabetes specialist teams should be competent and have capacity to provide pump therapy.
- Resource allocation should be able to support those already using insulin pumps to continue, whilst also supporting new starters. Service planners will need to ensure service specifications for pump services include resource for services initiating and supporting people on pumps. NICE has developed a commissioning guide to assist with the commissioning and implementation of NICE guidance, where relevant to national commissioning processes.
- The NHS Technology Adoption Centre has produced a How To Why To guide to support the implementation of insulin pump therapy. The guide identifies some of the barriers to the implementation of pump therapy and how these have been overcome at a local level. The guide can be used to help inform the implementation of insulin pump therapy.
- Teams delivering pump therapy services should establish databases to support quality assurance, adverse events reporting and national audit. Standardised curricula should be developed for the training of specialists in pump therapy. NICE have developed a tool to support the audit process.
- Decisions about treatment alterations should be made between the healthcare professional, the individual, and their carer. Service providers/ commissioners must respect these decisions. Young people between the ages of 12 and 18 years who are doing well on insulin pump therapy and who have not previously had a trial of MDI should not be arbitrarily required to undergo this trial between the ages of 12–18 years or when they are transferred to adult services. Where an individual moves area they should be able to continue their treatment. Moving area alone should not be a reason for re-assessment of suitability for insulin pump therapy. Local areas will need to ensure they fund and support insulin pump users that have moved to their area. The insulin pump should move with the individual.
- Healthcare organisations must replace an insulin pump once the guarantee expires regardless of whether the pump continues to function.
- People with diabetes have reported being asked to insure their insulin pump themselves, despite the insulin pump being the property of the NHS. Diabetes UK believes this is an unfair burden that should not fall to the individual with diabetes and/or their carers. The NHS and pump suppliers should work towards resolution of this issue.
People with diabetes in partnership with their healthcare professional must be the ones to decide if insulin pump therapy is an appropriate treatment option in line with NICE guidance. This decision must be respected by those planning and arranging services. It is fundamental they endorse the agreed plan of the person with diabetes and their healthcare professional. As demand for this therapy increases, particularly in line with NICE guidance, it is imperative that training, and the development of competence in insulin pump therapy is the norm for diabetes specialist team members. This should assist in tackling an implementation postcode lottery.
Download the full position statement (PDF, 125KB).
Full NICE Guidance www.nice.nhs.uk.
The advocacy group improving access to pump therapy, INPUT. www.input.me.uk
Insulin Pumpers UK is an internet based discussion group. www.insulin-pumpers.org.uk
Pump management for professionals (PUMP). www.insulin-pump.info