Radical Thoughts on Funding Diabetes Care

Published first in Diabetes Digest, 2012, Vol 11, No 3, page 126

Many a small thing has been made large by the right kind of advertising.” Mark Twain

The so called “black art” of marketing is a ubiquitous feature of modern life, and daily examples such as television commercials can reach levels of supreme irritation. Fortunately, when it comes to marketing pharmaceuticals and medical devices, official regulations are in place to prevent advertising overload and to control the way in which marketing can be used to attract potential prescribers. However, we should bear in mind that marketing is not a straightforward exercise, nor is it easy, with companies often having to maximise benefit from a small amount of data. But, as Mark Twain noted, “many a small thing has been made large by the right kind of advertising.”

At a time when the wind of austerity blows through the NHS, there is increasing pressure on drug and device spending. This is taking many forms and disguises, and the reality is that the days of enthusiastically embracing new (and invariably expensive) therapies and shiny technologies based on “feel-good” factors alone are over. However, universal adoption of this rationing approach must also be cautioned against as it can lead to people with diabetes being denied equitable access to beneficial new treatment approaches. This has been seen over recent years with insulin pump therapy, for which rates of uptake have been determined by “geography” – the UK still lags significantly behind most of Europe in terms of insulin pump provision.

To borrow a phrase from the lexicon of Tony Blair, perhaps there is a “third way” when it comes to the provision of new therapies and medical devices? This concept is simple and based on purchasing “outcomes” for people with diabetes. For new drugs, the NHS would “buy” treatment outcomes based on evidence yielded from clinical trials. If the drug is then offered to the target population and treatment achieves pre-determined outcomes (over an agreed pre-determined time), then the funding of this drug would continue. However, if pre-determined outcomes are not met, assuming that it was used appropriately, the NHS would receive a rebate.

The advantages of this approach would be as follows: (a) the clinical trial subject participants would need to reflect the background population for whom the drug is being considered; (b) clinical trial outcomes would need to be relevant to the tax payers; and (c) the pharmaceutical industry would be encouraged to act as more than simple purveyors of medicines by providing support to optimise the benefits of their products. The caveat would be to take into consideration factors such as treatment compliance, but the onus would be on the pharmaceutical companies to help develop new approaches to this perennial problem.

The “third way” approach to treatment provision in the UK would also be appropriate for the adoption of medical devices, for example for insulin pump therapy. It would make more sense to “buy” a pre-determined number of days of continuous subcutaneous insulin infusion with the cost including the device, consumables, insulin and blood-glucose monitoring as well as established outcomes around hypoglycaemia risk reduction and improved quality of life. The same would apply to glucose-sensing devices where people would purchase days of sensing rather than the device itself, therefore passing the risk from device failure onto the device manufacturers. The advent of outcomes-based risk-sharing schemes has seen some progress being made, but there is still much to do.

The polarisation of views on new approaches to therapies and monitoring devices in diabetes care is, I doubt, helpful nor is it reassuring for people living with the condition. Furthermore, the high-profile cases of unhealthy relationships between the industry and the professions have changed this particular landscape forever. The need now is for lateral thinking and avoidance of a siege mentality.

For the NHS, change is not often easy nor is it straightforward, but to quote Steve Jobs from his 2005 commencement speech to Stanford University graduates, “If today were the last day of my life, would I want to do what I am about to do today?”