NOTIFICATION ONLY

Flash Glucose Monitoring System – funding application for the initiation of use in adults, young people and children 4 years of age and older with diabetes mellitus as defined in NHSE criteria, March 2019.

Patient NHS No.

Trust	GP name
Patient hospital number	Consultant making request	GP code/ Practice code
Patient initials and date of birth	Consultant contact details	GP post code
Only fully completed forms will be accepted for consideration.

If the patient does not meet routine commissioning criteria, please consider if there are any individual exceptional clinical circumstances. If so, a full individual funding request (IFR) form will need to be completed. Please see http://www.miltonkeynesccg.nhs.uk/referrals-and-priorities-policies/

Confirm that the person is under the care of the Diabetes Specialist Team

Yes
2. Confirm which indication category applies to this person (please tick box or type X and provide details requested)
2.1 The person has Type 1 diabetes OR has any form of diabetes on haemodialysis and on insulin treatment, and the person is clinically indicated as requiring intensive monitoring > 8 times daily as demonstrated on a meter download/review over the past 3 months

The person has type 1 diabetes OR

The person has any form of diabetes on haemodialysis and on insulin treatment	Yes
Baseline HbA1c

Target HbA1c

Average number of blood glucose tests performed per day over the last 3 months	Evidence confirmed by	BG meter data download

Diagnostic CGM
2.2 The person has diabetes associated with cystic fibrosis on insulin treatment	Yes
Baseline HbA1c

Target HbA1c

Average number of blood glucose tests performed per day over the last 3 months	Evidence confirmed by	BG meter data download

Diagnostic CGM
2.3 The person has type 1 diabetes and is pregnant (N.B. funding will be for 12 months total, inclusive of post-delivery period)

Yes
Average number of blood glucose tests performed per day over the last 3 months	Evidence confirmed by	BG meter data download

Diagnostic CGM	Baseline HbA1c

Target HbA1c

Due date:
2.4 The person has type 1 diabetes and is unable to routinely self-monitor blood glucose due to disability that requires carers to support glucose monitoring and insulin management	Yes
Baseline HbA1c

Target HbA1c

Average number of blood glucose tests performed per day over the last 3 months	Evidence confirmed by	BG meter data download

Diagnostic CGM
2.5 The person has Type 1 diabetes and the specialist diabetes MDT have determined a 6-month trial of flash glucose monitoring with appropriate adjunct support due to the following conditions:

The person’s occupational (e.g. working in insufficiently hygienic conditions to safely facilitate finger-prick testing)

Please state occupation……………………………………..…………………………………………………. OR

The person’s psychosocial circumstances

Please give details …………………………………………………………………………………………………....

Yes No

Yes No
Baseline HbA1c

Target HbA1c

Average number of blood glucose tests performed per day over the last 3 months	Evidence confirmed by	BG meter data download

Diagnostic CGM
2.6 The person has Type 1 diabetes and is a previous self-funder of Flash Glucose Monitors whereby those with clinical responsibility for the person’s diabetes care are satisfied that the person’s clinical history suggests that they would have satisfied one or more of the NHSE criteria prior to them commencing use of Flash Glucose Monitoring had these criteria been in place prior to April 2019 AND has shown improvement in HbA1c since self-funding	Yes
Please state which indication(s) the person meets	Type 1 diabetes OR other form of diabetes on haemodialysis and on insulin treatment with intense monitoring > 8 times a day

Diabetes associated with cystic fibrosis on insulin treatment

Type 1 diabetes and pregnant please state due date………………………………………………………………………………………………….

Type 1 diabetes with disability that requires carers to support management

Type 1 diabetes with occupational circumstances please state occupation…………………………………………………………………………

Type 1 diabetes with psychosocial circumstances please state details………………………………………………………………………………

Type 1 diabetes with recurrent severe hypoglycaemia

Type 1 diabetes with impaired awareness of hypoglycaemia
Baseline HbA1c

Target HbA1c

Current HbA1c

Average number of blood glucose tests performed per day over the last 3 months	Evidence confirmed by	BG meter data download

Diagnostic CGM
2.7 The person has Type 1 diabetes and impaired awareness of hypoglycaemia, and their clinician considers that a Flash Glucose Monitoring system would be more appropriate than other evidence based interventions* for the individual’s specific situation

*Examples of other evidence based interventions include: Continuous Glucose Monitoring with an alarm (NICE standard recommendation) pump therapy (NICE guidance and NICE TA), psychological support, structured education, islet transplantation and whole pancreas transplantation.	Yes
Duration of hypo glycaemic episode	Evidence of hypoglycaemia confirmed by	BG meter data download

Diagnostic CGM	Confirm hypoglycaemia awareness scale used	Clarke Gold

Actual score
Baseline HbA1c

Target HbA1c

Average number of blood glucose tests performed per day over the last 3 months	Evidence confirmed by	BG meter data download

Diagnostic CGM

2.8 The person has Type 1 diabetes and recurrent severe hypoglycaemia, and their clinician considers that a Flash Glucose Monitoring system would be more appropriate than other evidence based interventions* for the individual’s specific situation

*Examples of other evidence based interventions include: Continuous Glucose Monitoring with an alarm (NICE standard recommendation) pump therapy (NICE guidance and NICE TA), psychological support, structured education, islet transplantation and whole pancreas transplantation.	Yes
Baseline HbA1c

Target HbA1c

Evidence of hypoglycaemia confirmed by	BG meter data download

Diagnostic CGM
Average number of blood glucose tests performed per day over the last 3 months	Evidence confirmed by	BG meter data download

Diagnostic CGM

3. Confirm that the patient contract has been completed (signed by the patient/ carer and member of the specialist team) and that the patient is aware that if they do not use the technology appropriately it will be discontinued, and that funding policy will be subject to review and may be stopped in the future (please tick box or type X)	Yes

4. Confirm that the patient has received approved training in the use of FGS, and that they/parents/carers have been assessed as able to use the device, interpret readings and take appropriate action as documented in the patient contract e.g. appointment attendance, scanning at least eight times a day, data sharing, participation in national audit and use of a formulary cost effective strip (please tick box or type X)	Yes

5. I confirm that the specialist diabetes team will provide the patient with the flash glucose starter kit (e.g. Freestyle Libre Starter Pack) at point of initiation (please tick box or type X)	Yes

6. I confirm that the specialist diabetes team will send timely communication to the GP, to continue the supply of the sensors, following the initiation of flash glucose monitoring system in clinic (please tick box or type X)	Yes

7. Continuation of funding

Funding will initially be provided for a 6 month period (with the exception of people meeting the ‘type 1 diabetes and pregnant’ criteria – funding will be provided for 12 months in total, inclusive of post-delivery period)
Funding will be provided for continuation of treatment where there is clear evidence of an initial and ongoing adequate response to treatment. This information should be submitted via a follow-up form which will require Prior Approval
8. Please provide any other relevant information

9. I confirm that the patient (or in the case of a minor or vulnerable adult where the parent/guardian or legal carer) has given consent for the patient identifiable data on this form to be shared with the CCG Medicines Management / Optimisation or Contracts Team. This data may then be used 1. In the interests of the care of the patient 2. For clinical audit purposes 3. To validate against subsequent invoices.	Yes No

Form completed by
Date:

I confirm that the patient meets the criteria for the technology: Consultant/Specialist Diabetes Nurse/Dietician signature*
Date

*Electronic signatures are acceptable

NHSE Criteria, March 2019, for Flash Glucose Monitoring Funding:-

1. People with Type 1 diabetes

OR with any form of diabetes on haemodialysis and on insulin treatment

who, in either of the above, are clinically indicated as requiring intensive monitoring >8 times daily, as demonstrated on a meter download/review over the past 3 months

OR with diabetes associated with cystic fibrosis on insulin treatment

2. Pregnant women with Type 1 Diabetes - 12 months in total inclusive of post-delivery period.

3. People with Type 1 diabetes unable to routinely self-monitor blood glucose due to disability who require carers to support glucose monitoring and insulin management.

4. People with Type 1 diabetes for whom the specialist diabetes MDT determines have occupational (e.g. working in insufficiently hygienic conditions to safely facilitate finger-prick testing) or psychosocial circumstances that warrant a 6-month trial of Libre with appropriate adjunct support.

5. Previous self-funders of Flash Glucose Monitors with Type 1 diabetes where those with clinical responsibility for their diabetes care are satisfied that their clinical history suggests that they would have satisfied one or more of these criteria prior to them commencing use of Flash Glucose Monitoring had these criteria been in place prior to April 2019 AND has shown improvement in HbA1c since self-funding.

6. For those with Type 1 diabetes and recurrent severe hypoglycaemia or impaired awareness of hypoglycaemia, NICE suggests that Continuous Glucose Monitoring with an alarm is the standard. Other evidence-based alternatives with NICE guidance or NICE TA support are pump therapy, psychological support, structured education, islet transplantation and whole pancreas transplantation. However, if the person with diabetes and their clinician consider that a Flash Glucose Monitoring system would be more appropriate for the individual’s specific situation, then this can be considered.

Other requirements:

1. Education on Flash Glucose Monitoring has been provided (online or in person)

2. Agree to scan glucose levels no less than 8 times per day and use the sensor >70% of the time.

3. Agree to regular reviews with the local clinical team.

4. Previous attendance, or due consideration given to future attendance, at a Type 1 diabetes structured education programme (DAFNE or equivalent if available locally)

Note: Continuing prescription for long-term use of Flash Glucose Monitoring-post initial 6 months- would be contingent upon evidence of agreeing with the above conditions and that on-going use of the Flash Glucose Monitoring is demonstrably improving an individual’s diabetes self-management- for example improvement of HbA1c or Time In Range; improvement in symptoms such as DKA or hypoglycaemia; or improvement in psycho-social wellbeing.

5

This form should be returned to mkccgpharmacy@nhs.net

Etanercept and Infliximab for the treatment of Rheumatoid Arthritis

clarejohns

2019-04-01

Dupe Fagbenro

East Elmbridge & Mid Surrey PCT