Reducing the cost of SMBG test strips

Reducing the cost of SMBG test strips 

With the latest news from NHS England highlighting that £700 million cost savings have been achieved by maximising the use of best value medicines, there is an increasing focus on ensuring every NHS pound is “spent wisely” and that “patients have access to innovative medicines”.

Blood glucose (SMBG) test strips form a significant part of the cost of caring for diabetes patients. During 2017 / 18, the NHS spent £173m on them in England alone (NHS BSA). There are many different blood glucose meters and strips available in the UK, with a wide range of prices. The NHS has analysed the spend variation between CCGs and identified the opportunity for efficiency savings¹, while retaining high standards of accuracy. Proposed pricing^1,2 was put out for consultation which, subject to final recommendations³, may recommend a ceiling of £10 or less for 50 strips.

With increasing numbers of people being diagnosed with T2D, there is a clear desire – indeed need^1,2 - to realise these cost savings. Moreover, rationalising the number of SMBG systems in use will make it easier to educate healthcare professionals², who in turn can better assist patients with their testing.

The intention is not to limit the use of the strips, but to encourage CCGs and prescribers to consider more cost-effective alternatives with an evidence-base of clinical accuracy and adherence to an appropriate level of quality standard. With high quality SMBG strips available for under £10, David Englefield, Spirit Healthcare outlines why the question will increasingly become how CCGs can change how they manage and implement their formulary. 

Significant Savings  

The savings achievable by undertaking SMBG formulary change are demonstrable.

During 2015 & 2016, NHS Bury and Heywood, Middleton and Rochdale (HMR) CCGs undertook an exercise to reduce their spend on SMBG strips³, while also improving patient care and the quality of prescribing. The objective was to

simplify the choice of blood glucose meters to those that were cost effective and accurate, against predefined patient parameters and with appropriate support systems in place.  

The CCGs evaluated a number of SMBG systems against a range of criteria that included the cost of test strips and accuracy to the international standard ISO 15197:2013. Based on the evaluation, the CCGs selected a more cost-effective meter as the first choice for people with type 2 diabetes.

The results for both CCGs were impressive: in the two years preceding the change programmes, both CCGs had an increase in monthly costs of around £10,000. In the 12 months following the change, both CCGs had a monthly reduction of around £10,000. In addition, HMR CCG had a reduction of 15.8% in the mean unit cost of SMBG strips, and Bury CCG had a reduction of 13.9%.

The annualised savings from March 2015-2016 were £85,591 and £154,120 in Bury CCG and HMR CCG respectively.

Managed Implementation

It is well documented⁴ that actively implementing formulary changes with effective training, support and education makes a big difference to reducing costs – and this was also reflected in the change programmes at Bury and HMR CCGs. Analysis showed that savings were almost 700% greater when the change was actively implemented, compared to similar CCGs with no implementation programme⁴.

Best practice in medicines optimisation should ideally involve a team of experienced clinical pharmacists and nurse who work together to develop a programme that is tailored to meet the needs of both patients and CCGs, built upon three tiers of support:

• Tier 1 – Product training and support for the practice nurse and local pharmacy teams. This includes explaining the ongoing support that is available to support local resources.
• Tier 2 – Audit on the practice system to identify suitable patients for review, based on criteria agreed with the CCG. This should include a check where the GP signs off the audit before any intervention is made.
• Tier 3 – Training clinics for patients, where they learn to use their new SMBG system. These clinics should ideally be small group sessions (or one-to-one meetings if required) where there is time for discussion and questions.

Such a flexible implementation model allows for additional services and could factor in any local priorities such as educating people with type 2 diabetes on the importance of diet, lifestyle and exercise – whilst undertaking meter training.

Consistency across Care Settings

In another changeover project, the Isle of Wight CCG evaluated a number of blood glucose meters and SMBG strips in December 2017. The subsequent implementation programme included training courses being run in practices across the island.

To date, the implementation programme has achieved an 89% changeover of the target patient population on the Isle of Wight and is delivering consistency across different care settings. In the first six months, the CCG has seen a reduction of £2.34 in average unit cost, with overall cost savings of 11% in the first 11 months.

Furthermore, 36% of patients who replied to a local survey had a self-reported reduction in their blood glucose levels.

Conclusion

With the cost and standard⁵ of SMBG strips varying significantly across the NHS, it is proven that an active implementation approach to formulary change can take CCGs from being within the worst performing group (the 10% of CCGs with the highest unit costs for SMBG strips) to within the best performing group (the 10% of CCGs with the lowest unit costs).

Change is coming, and CCGs will be under increasing pressure to spend less in this area while ensuring adherence to quality standards. As such, it is time to recognise and adopt best practice in formulary implementation.

References

1. NHS England Board Paper, 28 November 2018, Page 4 Point 16 g and Page 5 Point 18, https://www.england.nhs.uk/wp-content/uploads/2018/11/06-pb-28-11-2018-low-priority-prescribing-consultation-gluten-free-food-guidance.pdf
2. NHS England, “Items which should not routinely be prescribed in primary care: an update and a consultation on further guidance for CCGs”, 28 November 2018, Section 5.4, https://www.engage.england.nhs.uk/consultation/items-routinely-prescribed-update/user_uploads/low-priority-prescribing-consultation-guidance.pdf
3. NHS, “Items which should not routinely be prescribed in primary care: Guidance for CCGs”, Version 2, June 2019, Page 10, https://www.england.nhs.uk/wp-content/uploads/2017/11/items-which-should-not-be-routinely-precscribed-in-pc-ccg-guidance-v2.pdf
4. Jim Swift et al, “Implementing formulary change in diabetes”, British Journal of Healthcare Management, Vol. 23, No. 4,  https://www.magonlinelibrary.com/doi/abs/10.12968/bjhc.2017.23.4.167

1. https://diabetestimes.co.uk/wp-content/uploads/2018/11/7571-IDEAL-White-Paper-V3-EMBARGO.pdf