Today’s guest post comes from Dr Conor Farrington a Research Associate at the University of Cambridge School of Clinical Medicine, where his research focuses on patient and clinician interactions with new diabetes technology, particularly artificial pancreas systems. This post explores the barriers to use of an artificial pancreas in the NHS.
As a recent blog post on this website noted, the global diabetes community is abuzz with the prospect of artificial pancreas systems entering widespread usage in the next decade. However, while artificial pancreas systems undoubtedly represent a major advance in diabetic technology, they are likely to face a number of challenges in terms of uptake and usage in the NHS.
In the next years, advanced trials of artificial pancreas systems will contribute to the long and difficult process of obtaining regulatory approval from agencies such as the FDA in the USA and the MHRA in the UK. Yet regulatory approval alone does not guarantee appropriate usage levels, as demonstrated by the low and variable uptake of insulin pumps in the UK compared to other wealthy countries such as the USA, Germany and Norway. If this is anything to go by, artificial pancreas systems are likely to face significant barriers to usage – all the more so since these systems are considerably more complex than insulin pumps alone.
Some of these barriers are likely to be organisational barriers at the health service level. Considerable variation currently exists between different diabetes clinics with regard to the provision of diabetes care, specific areas of expertise of staff members, and resources for dealing with new technologies. This means that patients encountering artificial pancreas systems for the first time may have widely differing experiences, potentially leading to variable usage over time.
There are also NHS-wide challenges in terms of training and staffing resources, as illustrated by the 2014 Diabetes UK pump audit. The audit included the finding that less than a third of centers for adults run pump training programmes that meet NICE guidelines, and that 87% of paediatric diabetes centres involved pump company representatives in user training owing to staffing shortfalls. These findings suggest that patient training programmes are not only likely to be of variable quality but also may be delivered by personnel working outside the NHS, with potential implications for the neutrality of training delivered. If this state of affairs continues into the artificial pancreas era, it may impact negatively upon the appropriate uptake and usage of these new technologies.
More widely, the audit reported that as many as 300,000 people with Type 1 diabetes are not currently using pumps despite meeting NICE criteria for pump usage. Yet since relatively few funding requests are rejected by commissioners, it seems that the problem lies instead in staff members not recommending eligible patients for pump therapy. Recent research has suggested that healthcare professionals often have strong opinions about which patients will benefit from new diabetes technologies, and also that these opinions are sometimes proved wrong by patients participating in randomised trials (in which staff do not have the power to decide which patient should have which treatment regimen). More research is needed to investigate staff attitudes towards new technologies such as artificial pancreas systems, and to understand how the adoption of new diabetic technologies can best be facilitated in clinic settings.
Further challenges will likely emerge at the level of individual users, who may be disconcerted by the thought of a machine ‘controlling’ their bodies, or who may be overwhelmed by the logistical demands of maintaining a number of wearable devices. Some users may also find that the visibility of wearable devices leads to, or reinforces, stigma about diabetes, or that system alarms act as a reminder of their condition as well as disturbing social life or sleep.
None of these barriers is insurmountable. Interventions of various kinds can be designed in order to engage with challenges arising at organisational, clinical, and individual levels. Nevertheless, it cannot be assumed that artificial pancreas systems will automatically achieve appropriate uptake and usage. It may well be that controlling technology adoption in the NHS is as challenging as controlling blood sugar levels.