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Home Networks & Partnerships Northern Ireland Diabetes Network Diabetes Network Programmes Regional Insulin Pump Service Types of Treatment for Diabetes

Types of Treatment for Diabetes

There are several types of treatment for diabetes:

Glucose Monitoring

What is Continuous Glucose Monitoring?

Continuous Glucose Monitoring (CGM) is a less invasive way of measuring glucose compared to testing blood with a finger-prick meter and can be used whether a person wears an insulin pump or uses injections for insulin delivery.  The system works 24 hours a day and can include an alarm to indicate when glucose levels are too high or too low.

Continuous Glucose Monitors are becoming a popular way of monitoring diabetes control for people on intensive insulin therapy. Continuous Glucose Monitoring is not blood glucose monitoring as the sensors with a CGM machine are placed into the body, but not into the bloodstream.  The sensors measure the glucose in a person’s interstitial fluid (i.e. the fluid in and around the body’s cells).

What is the difference between CGM and FGM?

Both Continuous Glucose Monitoring (CGM) and Flash Glucose Monitoring (FGM) are glucose monitoring devices.

There is currently only one FGM device (Freestyle Libre 2®) still on the market for people who use a standalone reader.

With a CGM, your latest glucose levels show up on a device or mobile automatically, transmitted by Bluetooth. With a flash glucose monitor, you have to scan your device over your sensor to get glucose readings.

Unlike FGM, some CGMs can ‘talk’ to an insulin pump, which is important if you want to use a closed loop system for insulin therapy.

Who can use it or who will benefit from it?

Continuous Glucose Monitors let you check your sugar levels without you having to prick your fingers.  Generally, people living with Type 1 diabetes may benefit from using a CGM or FGM to help manage their diabetes. However, CGM systems may not be appropriate for all patients to manage diabetes. A small number of people living with Type 2 Diabetes may also benefit from a CGM or FGM to help manage their diabetes. This would be considered as part of the clinical decision-making process with the HSC Trust Diabetes Care team.

There are many CGM systems available to support people living with diabetes. However, the most appropriate system for each individual is the responsibility of the HSC Trust Diabetes Care Team to agree in consultation, with the patient and/or the patient’s carer.

CGM in Northern Ireland

NI Diabetes Network are working towards improving access to Continuous Glucose Monitoring devices.  The Network has developed a Regional Northern Ireland Pathway for the Managed Access of Continuous and Flash Glucose Monitoring Devices for People aged 16 years and over living with Type 1 Diabetes.  The pathway is for use by Diabetes healthcare professionals in Secondary Care to assess if people aged 16 years and over living with Type 1 Diabetes are suitable for Continuous Glucose Monitoring (CGM) or intermittent Flash Glucose Monitoring (FGM) devices.

The pathway provides criteria to support clinical decision-making processes.  These criteria are in line with NICE Guideline ‘Type 1 diabetes in adults: diagnosis and management (NG17)’. The Regional NI Pathway was approved in September 2022 for implementation and guidance was issued to HSC Trusts and healthcare professionals to support this.

There are many CGM systems available to support people living with diabetes. However, the most appropriate system for each individual is the responsibility of the HSC Trust Diabetes Care Team to agree in consultation with the patient and/or the patient’s carer.

Dexcom One® (CGM) and Freestyle Libre 2® (FGM) are glucose monitor devices which are currently listed on the NI Drug Tariff and can be accessed as a treatment option as deemed clinically appropriate.

Higher specification CGM devices, e.g. Dexcom G6 are currently not listed on the NI Drug tariff and therefore cannot be prescribed in Primary Care. Funding for CGM devices which are not listed on the NI Drug Tariff are not commissioned on a routine basis.  Some families have been self-funding these devices as they enable closed loop technology.

How can I get support?

Speak to your Diabetes Care team about CGMs at your next clinic appointment.

More information about Continuous Glucose Monitoring is available online via Diabetes UK and JDRF websites.

Hybrid Closed Loop

What is Hybrid Closed Loop?

Hybrid Closed Loop (HCL) systems are the next phase of technology in diabetes management. These systems link continuous glucose monitoring (CGM) and insulin pump technology to provide People Living with Type 1 Diabetes with support 24 hours a day.

Sometimes referred to as an ‘artificial pancreas’, HCL has many benefits. These include the potential to reduce mental burden and improve quality of life by helping People Living with Type 1 Diabetes to improve their blood sugar levels, have less ‘hypos’ and make self-managing the condition easier.

How does it work?

Hybrid Closed Loop (HCL) systems use a mathematical process to deliver insulin automatically by calculating the amount of insulin someone needs based on continuously monitored blood sugar readings so the pump can automatically give accurate and timely doses. A combination of real-time glucose monitoring from a continuous glucose monitor (CGM) device and a control algorithm to direct insulin delivery through Continuous subcutaneous insulin infusion (CSII) is used. Manual input is still needed to alert the system when eating or doing exercise.

Various HCL systems are available, therefore due to the large number of combinations of parts available to the NHS, this NICE appraisal considers HCL systems as a group of technologies rather than individual parts or systems.

Who can use it or who will benefit from it?

NICE recommends that HCL systems can be used as an option for managing blood glucose levels in Type 1 diabetes for adults who have an HbA1c of 58 mmol/mol (7.5%) or more, or have disabling hypoglycaemia, despite best possible management with at least 1 of the following:
• continuous subcutaneous insulin infusion (CSII)
• real-time continuous glucose monitoring (rtCGM)
• intermittently scanned continuous glucose monitoring (isCGM)

Other priority groups identified in the NICE guidance include children and young people living with Type 1 Diabetes and women, trans men and non-binary people living with Type 1 Diabetes who are pregnant or planning to become pregnant.

When it will be implemented in NI?

In December 2023, the National Institute for Health and Care Excellence (NICE) Clinical updated guidance with recommendations on the use of Hybrid Closed Loop (HCL) systems. This guidance provides evidence-based recommendations on Hybrid Closed Loop systems for managing blood glucose levels in Type 1 Diabetes.

Following the formal endorsement of NICE guidance by Department of Health in February 2024, the Strategic Planning and Performance Group is considering the commissioning arrangements for Northern Ireland. A Service Notification will be published soon, in line with the required timeframe.

Work is being undertaken to consider priority groups; system costs; workforce and communication requirements to both enable and support. This information will inform commissioning arrangements for Northern Ireland and final decision-making regarding implementation. It is worth noting that NHS England has developed a phased implementation strategy over a 5-year period in response to the guidance, owing to the scale and scope of this recommendation.

Additional funding is not automatically provided to support the rollout of the NICE guidance. Funding is required for the devices as well as resources to upskill and recruit the workforce needed to offer Hybrid Closed Loop widely and equitably across the region.

The full guidance can be viewed following the link below.
NICE Technology Appraisal – TA943

How can I get support?

NI Diabetes Network will communicate with all stakeholders following decision making in relation to Hybrid Closed Loop (HCL) systems implementation in Northern Ireland. Once the commission of HCL systems is implemented in Northern Ireland, there is nothing else you need to do, your Health and Social Care Trust Diabetes Care team will contact you or review eligibility at your next appointment.

More information about Hybrid Closed Loop systems is available online via the Diabetes UK and JDRF websites.

You can also get in touch with Diabetes UK’s highly trained advisors for support, advice or just a chat by calling the Diabetes UK helpline on 0345 123 2399 or contact helpline@diabetes.org.uk, Monday to Friday, 9am to 6pm, or contact the Helpline’s homepage

Timeframe for implementation

Owing to the scale and scope of the NICE recommendations, similar to NHS England and the Welsh government, Northern Ireland is considering a multi-year phased implementation strategy, once additional investment is available. It will take time to implement this strategy and incorporate it into local services.

The Diabetes Network will continue to work to support People Living with Diabetes and to improve access to insulin pump therapies.

Information will be widely published once a timeline has been agreed to make both People Living with Diabetes and Health Care Professional aware of decisions made.

May 2024

Frequently Asked Questions

  • I’ve heard that NICE have approved Hybrid Closed Loop technology for patients living with Type 1 diabetes, when can I be started on this?

    NICE have recommended that Hybrid Closed Loop (HCL) technology should be offered as an option for managing blood glucose in Type 1 Diabetes if other methods have not achieved the desired results. NI Diabetes Network is currently developing an options appraisal in partnership with key stakeholder to understand how this service can be provided in NI including the additional investment needed to support this delivery. We cannot provide details on when People Living with Diabetes can start this technology until this work has concluded and a decision has been made for Northern Ireland implementation.

  • How long may I have to wait to be offered Hybrid Closed Loop, if I’m eligible?

    It is likely it will take up to a few years for some people who are eligible to be offered HCL, as clinicians require time to do this safely and effectively. Implementation considerations are under review and we are closely following the approach of our neighbours NHS England, who agreed a 5-year implementation period, and decision of the Welsh government.

     

    Within the NHS England 5-year implementation plan, the provision of HCL will be to those in most clinical need first, starting with children and young people, those who are pregnant, and those with the most need for improved control as per NICE guidelines. However, if a person is outside of those priority groups and a clinician feels that they would benefit from the technology sooner, it may still be offered during a routine appointment. In Northern Ireland, a regional approach will be agreed, considering the approach used by NHS England, to support equity of access for all PLWD across NI.

  • Do I need to contact my specialist or diabetes team?

    No, you don’t need to do anything. NI Diabetes Network will communicate with all stakeholders following decision making in relation to Hybrid Closed Loop systems implementation in Northern Ireland.  Your Diabetes Care team knows who you are and will either contact you or review your eligibility at your next appointment.

  • Why is NHS England phasing the rollout over a five-year implementation period in this way?

    In normal circumstances the NHS would have to implement technical appraisal recommendations within three months but there currently isn’t the clinical capacity to do this.  Following consideration, NHS England has considered the additional recruitment and training of specialist staff required to establish a diabetes workforce sufficiently trained to manage a rollout of this scale. In Northern Ireland, implementation requirements are under review and we are considering the approach of our neighbours NHS England.

    As Diabetes Care teams would be unable to offer Hybrid Closed Loop systems to everyone eligible straight away, steps need to be taken to start the rollout whilst allowing for more time to recruit to diabetes teams and equip them with skills to help people to use the technology effectively. This is part of service planning and consideration of an appropriate delivery period to support decision making.

     

    Taking time now to understand an appropriate timeline and consider workforce requirements will also help tackle health inequalities, which is another important part of the strategy. HCL roll out must be considered in terms of both existing services which need to be maintained and the availability of staff to support these alongside introducing this new technology to PLWD across NI.

  • Will all people with Type 1 diabetes have access to the technology?

    No, these recommendations don’t include everyone with Type 1 diabetes.  There will be additional criteria for adults over 18 years old who are not pregnant or planning to become pregnant. These criteria will have to be met before being offered the HCL system.

  • Which pumps/HCL will you be offering?

    NICE states that HCL systems are only recommended if they are procured at a cost-effective agreed price.  As new devices come to market, as technology progresses and if prices change, the cost effectiveness point may change. As such, the range of devices will be under constant review. This means that the devices/systems available for the NHS to offer you, may change over time. The selection will be reviewed locally based on the needs of our population and the devices made available.

     

    In Northern Ireland, we use the National Procurement Scotland Framework for Insulin Pumps and Consumables, which enables the current delivery arrangements for Northern Ireland.

    The Regional Insulin Pumps Services, on behalf of the region, works alongside partners, to support the procurement processes. Existing arrangements are considered to ensure the most suitable product offering and delivery arrangements for all Northern Ireland.

  • I have been contacted by a diabetes device (CGM or pump) company or representative who told me that I am eligible for HCL and to contact my clinical team and HSC Trust, what should I do?

    You do not need to take any action. Your usual Diabetes clinical team will contact you or discuss this with you at your next planned review. If you are contacted again by the company, you can ask them to stop contacting you. If eligible, you should not have to pay for any of your pump therapy costs, the NHS cover this. Please do not agree to buy direct from the company before checking with your Diabetes clinical team.

  • Will I be able to pick the Hybrid Closed Loop system I want?

    Yes, you will be able to choose from the HCL systems that become available to the NHS at a cost-effective price. This will be determined by the Strategic Planning and Performance Group of the Department of Health and can be adapted over time to keep up with changes in the technology as systems develop and new ones are launched.

    In Northern Ireland, we use the National Procurement Scotland Framework for Insulin Pumps and Consumables, which enables the current delivery arrangements for Northern Ireland.

    This means that you will be offered what has been identified as the most cost-effective solution for you to support your individual needs.

  • Will patients in our Trust or regionally be offered HCL system immediately?

    The Regional Insulin Pump Service has been fully operational since March 2024 and will support the implementation of the NICE guidance once an implementation plan is finalised and additional investment has been agreed.  This will support equality of access across Northern Ireland, however assessment for HCL systems will remain at Local Trust level.

    This is a welcome decision for everyone in NI, both PLWD and HCPs, but implementation will take time. We must ensure service roll out is efficient and sits alongside all other service delivery with all provision maintained.  We are working very hard to ensure that our systems will be able to provide the most efficient, cost effective, and above all fair process to ensure that those who will benefit from this technology are offered it as soon as possible. Please be patient with your Diabetes care team who will be working hard to support this service roll out.

  • Where can I get further support, including emotional support?

    More information about Hybrid Closed Loop systems is available online via the Diabetes UK and JDRF websites.

    You can also get in touch with Diabetes UK’s highly trained advisors for support, advice or just a chat by calling the Diabetes UK helpline on 0345 123 2399 or contact helpline@diabetes.org.uk, Monday to Friday, 9am to 6pm, or contact the Helpline’s homepage https://www.diabetes.org.uk/how_we_help/helpline

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