Commissioning an insulin pump therapy service
NICE technology appraisal TA151 on insulin pump therapy recommends continuous subcutaneous insulin infusion (CSII or ‘insulin pump') as a clinically and cost-effective treatment option for adults and children 12 years and older with type 1 diabetes mellitus, where certain criteria are met.
In relation to insulin therapy the NICE quality standard for diabetes in adults includes the following statement:
Trained healthcare professionals initiate and manage therapy with insulin within a structured programme that includes dose titration by the person with diabetes (statement 7, NICE quality standard for diabetes in adults).
Type 1 diabetes mellitus is a long-term condition that requires lifelong treatment with insulin. The estimated prevalence in 2007/08 in England was 0.45% (approximately 225,000 people). The incidence has been increasing over time, with the greatest increase in children younger than 5 years.
Insulin pump therapy makes use of an external pump that delivers insulin continuously from a refillable storage reservoir by means of a cannula placed under the skin. The pump can be programmed to deliver a basal rate of insulin throughout the day, with higher infusion rates triggered by the push of a button at meal times. An illustration of an insulin pump in use can be viewed here.
Insulin pump services: report of the Insulin Pumps Working Group indicates that current access and provision of insulin pump therapy is variable across England and that the estimated uptake is lower than elsewhere in Europe. NICE technology appraisal TA151 on insulin pump therapy was published in July 2008, and primary care trusts had a statutory obligation to provide funding for insulin pumps within 3 months of the guidance being published.
Diabetes mellitus can cause short-term and long-term complications. Short-term complications include low blood glucose levels (hypoglycaemia) caused by treatment. Severe hypoglycaemia can cause convulsions, coma and, very occasionally, death. In children, especially those younger than 5 years, severe hypoglycaemia can cause long-term cognitive impairment. Insulin pump therapy yields quality of life benefits, such as flexibility, autonomy, and improved sleep and socialisation.
The long-term microvascular and macrovascular complications of chronically elevated blood glucose levels include retinopathy and blindness, nephropathy and renal failure, ischaemic heart disease, stroke, neuropathy, and foot ulceration and amputation. When used appropriately insulin pumps have the potential to be cost effective because of the avoidance of some of these long-term complications of diabetes.
The potential benefits of robustly commissioning an effective insulin pump therapy service include:
- reducing inequalities by improving access to insulin pump therapy
- increasing patient choice, and improving partnership working, patient experience and engagement
- improving quality of life for people with type 1 diabetes
- enhancing ability to self care
- reducing the frequency and severity of hypoglycaemic episodes and thereby fear of their reoccurrence
- increasing the proportion of patients who achieve good glucose control and achieving a target HbA1c in line with NICE clinical guideline CG15 on type 1 diabetes
- reducing risk of long-term diabetes complications by achieving good control of blood glucose
- improving performance and patient-centred clinical care through implementing the recommendations outlined in NICE technology appraisal TA151 on insulin pump therapy.
Key clinical issues
Key clinical issues in providing an effective insulin pump therapy service are:
- ensuring the specialist team are competent to provide insulin pump education to patients and their carers
- accurately identifying all people who meet the criteria for insulin pump therapy outlined in NICE technology appraisal TA151 on insulin pump therapy
- ensuring that appropriate referral pathways are in place
- ensuring that the service is integrated into the local model of care for people with type 1 diabetes
- ensuring that people know who to contact in an emergency for both clinical and technology assistance
- providing a seamless transition for young people moving from paediatric to adult services
- providing a quality assured service.
National priorities and initiatives relevant to commissioning an insulin pump therapy service include:
- NHS Outcomes Framework 2012/13
- Public Health Outcomes Framework
- The NHS in England: The operating framework for 2012/13
- Liberating the NHS: legislative framework and next steps
- National service framework for diabetes and associated delivery strategy.
- Six years on: delivering the Diabetes National Service Framework
- Quality, innovation prevention and productivity (QIPP)
- Using the Commissioning for Quality and Innovation (CQUIN) payment framework - a summary guide
Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.
This page was last updated: 03 April 2012