Specifying an insulin pump therapy service

Service components

The key components of developing a high-quality insulin pump therapy service are:

• identifying people suitable for insulin pump therapy
• ensuring appropriate composition of the specialist team
• monitoring and supporting patients using insulin pumps
• developing a high-quality insulin pump therapy service.

Identifying people suitable for insulin pump therapy

NICE technology appraisal TA151 on insulin pump therapy states that continuous subcutaneous insulin pump therapy is recommended as a treatment option for adults and children 12 years and older with type 1 diabetes mellitus provided that:

• Attempts to achieve target haemoglobin A1c (HbA1c) levels with multiple daily injections (MDIs) result in the person experiencing disabling hypoglycaemia. NICE guidance defines disabling hypoglycaemia as the repeated and unpredictable occurrence of hypoglycaemia that results in persistent anxiety about recurrence and is associated with a significant adverse effect on quality of life.

or

• HbA1c levels have remained high (that is, at 8.5% or above) on MDI therapy (including, if appropriate, the use of long-acting insulin analogues) despite a high level of care.

Insulin pump therapy is recommended as a treatment option for children younger than 12 years with type 1 diabetes mellitus provided that:

• MDI therapy is considered to be impractical or inappropriate, and
• children on insulin pumps would be expected to undergo a trial of MDI therapy between the ages of 12 and 18 years.

Insulin pump therapy is not recommended for the treatment of people with type 2 diabetes mellitus.

Ensuring appropriate composition of the specialist team

NICE technology appraisal TA151 on insulin pump therapy recommends that insulin pump therapy be initiated only by a trained specialist team, which should normally comprise a physician with a specialist interest in insulin pump therapy, a diabetes specialist nurse and a dietitian.

The topic-specific advisory group suggests that commissioners may wish to ensure that patients who may benefit from insulin pump therapy are referred to a centre with:

• a physician, nurse and dietitian who are specialised in insulin pump therapy and have received appropriate training to deliver a high quality insulin pump therapy service
• practitioners who have knowledge of and competence with different insulin pump devices.

Monitoring and supporting patients using insulin pumps

NICE technology appraisal TA151 on insulin pump therapy states that following initiation in adults and children 12 years and older, insulin pump therapy should only be continued if it results in a sustained improvement in glycaemic control, evidenced by a fall in HbA1c levels, or a sustained decrease in the rate of hypoglycaemic episodes. Appropriate targets for such improvements should be set by the responsible physician, in discussion with the person receiving the treatment or their carer. Also, children on insulin pumps would be expected to undergo a trial of MDI therapy between the ages of 12 and 18 years. Therefore commissioners may wish to ensure there is a mechanism in place to support the assessment of the trials of MDI therapy.

Developing a high-quality insulin pump therapy service

NICE guidance makes a number of recommendations that refer to patient education for people with type I diabetes. NICE technology appraisal TA151 on insulin pump therapy recommends that specialist teams should provide structured education programmes and advice on diet, lifestyle and exercise appropriate for people using insulin pumps.

NICE clinical guideline CG15 on type 1 diabetes recommends that:

• children and young people with type 1 diabetes and their families should be offered timely and ongoing opportunities to access information about the development, management and effects of type 1 diabetes
• the method of delivering education and content will depend on the individual and should be appropriate for the child's or young person's age, maturity, culture, wishes and existing knowledge within the family.

NICE technology appraisal TA60 on diabetes (type 1 and 2) patient education models recommends that structured patient education is made available to all people with diabetes at the time of initial diagnosis and then as required on an ongoing basis, based on a formal, regular assessment of need. The appraisal considers that the Dose Adjustment for Normal Eating (DAFNE) programme may be a suitable option for individuals with type 1 diabetes, being one means of enabling people to self-manage this condition.

The Structured patient education in diabetes - report from the Patient Education Working Group has examples of how local services are adapting the DAFNE programme while considering a range of issues to ensure that their education programmes meet the key criteria. The key criteria include health professional training, quality assurance and learning needs assessment.

As identified in Insulin pump services: report of the Insulin Pumps Working Group commissioners may wish to consider delivering an insulin pump therapy service using a model of shared care between a hospital physician with a specialist interest in insulin pumps and a diabetes specialist nurse. The service could be based in the community or the hospital and should consider how to provide 24 hour patient access to clinical and technical support. Commissioners will need to consider how best to provide an efficient model to deliver services, which may include novel ways of working - for example, networks of care across a geographical area.

Local stakeholders, including Local Education Authorities, Children's Trusts, service users and carers, should be involved in determining what is needed from an insulin pump therapy service in order to meet local needs. The service should be patient-centred and integrated with other elements of care for people with diabetes.

The service specification needs to consider:

• the required competencies of, and training for, staff responsible for providing the service
• the expected number of patients (this should take into account how quickly any changes in service provision are likely to take place)
• ease of access and service location; commissioners should engage with service users and other relevant individuals and organisations locally
• care and referral pathways
• information and audit requirements, including IT support and infrastructure
• planned service improvement, including redesign, quality and equitable access
• service monitoring criteria.

Useful sources of information may include:

• The NICE Pathway for diabetes care provides an information resource which visually organises NICE recommendations about diabetes management.
• The NICE Quality Standard for Diabetes in adults is a set of specific, concise statements which sets out high quality, cost-effective diabetes care.
• The NICE shared learning database offers examples of how organisations have implemented NICE guidance locally, including an example of an insulin pump service.
• Self care connect provides commissioning tools to promote self care.
• The Department of Health diabetes commissioning toolkit describes how to carry out a health needs assessment for a local diabetes population and provides a generic specification for diabetes care, signposting recognised quality markers and suggesting key outcomes for the service.
• Care planning in diabetes and Good care planning for people with long term conditions provides information on individualised care planning.