Roundtable: How can the NHS best deliver hybrid closed-loop technology’s benefits?

For many people with type 1 diabetes, new technologies to help them manage their condition and avoid life-altering complications have transformed their lives over the last decade.

Among the latest of these is hybrid closed-loop technology (HCL), which combines automated insulin delivery with continuous glucose monitoring, using an algorithm to deliver precise dosing. Ample evidence shows that this both lowers blood glucose levels and keeps users within a safe and acceptable blood glucose range.

The National Institute for Health and Care Excellence has recommended this technology for all children and young people with type 1 diabetes and around 60 per cent of the adult T1D population. NHS England has promised £440m over five years to fund implementation: allocations for the third year (from April 2026) were announced in December, and confirmation of funding for the fourth and fifth years of the plan.

This HSJ  roundtable, in association with Insulet, discussed what progress the NHS has made with introducing this technology and what it needs to do to overcome implementation issues, while also addressing inequalities.

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Sarah de Biase, senior programme manager, improving population health, West Yorkshire Integrated Care Board

Kelly Broad, deputy chief pharmacist, Cambridgeshire and Peterborough Integrated Care System

Rajni Cairns, associate director, system engagement, uptake and adoption, NICE

Ali Chakera, consultant in diabetes and endocrinology, University Hospitals Sussex Foundation Trust

Kelly Harper, mum to Skye, a teenager with type 1 diabetes

Hjalte Hojsgaard, vice president and general manager for the UK/Benelux and DACH (Germany, Austria, Switzerland) regions, Insulet International Ltd

Lesley Jordan, technology access lead, Breakthrough T1D

Partha Kar, type 1 diabetes and technology lead, NHSE, and consultant at Portsmouth Hospitals University Trust

Alistair Lumb, chair, Diabetes Technology Network-UK, and consultant, Oxford University Hospitals FT

Habib Naqvi, chief executive, NHS Race and Health Observatory

Alison Moore, HSJ (roundtable chair)

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More than 70 per cent of children and young people with type 1 diabetes have already received access to HCL, along with many pregnant women.

While this is a generally positive picture, there are challenges in rolling out the technology to the more than 160,000 other adults who meet the NICE criteria to access it on the NHS. A five-year plan for rollout among both children and adults is approaching its mid-point in 2026.

But it is not possible to suddenly start all eligible adults on this technology, and a key issue for many clinicians is who to prioritise and how to avoid creating or extending inequalities through the rollout. Alistair Lumb, Diabetes Technology Network-UK chair, said: “Someone has to be at the front of that queue and someone has to be at the back of that queue – even though that feels unfair.”

Inequality can take many forms – one is around which diabetes unit patients are being treated by, said Lesley Jordan, technology access lead, Breakthrough T1D, rather than deprivation or ethnicity. Units are at different points in rolling out the technology to adult patients, with some more advanced than others.

Habib Naqvi, NHS Race and Health Observatory, chief executive, called for more data to help understand what was happening. “Determining who is at the front of the queue based on need will be critically important… There is a need to be clear and realistic,” he said, adding that data could help ensure that particular needs were identified and met with tailored interventions.

[Half] of people sit down with our doctors and nurses, learn the system and go, ‘you know what, I’m good’

Some groups will be more challenging to initiate on HCL for various reasons, and there is a tension between treating everyone equally and trying to maximise the number of people started with the technology in the short term. Dr Lumb – whose service has been focusing on those who are more difficult to start on HCL – added: “Just because it is difficult, we don’t want to deny them the benefit. We are trying to do this earlier so we can learn earlier and include those people in the five-year and beyond rollout.”

In West Yorkshire, discussions had taken place about whether to focus on people in the most deprived areas to ensure they had access to the technology, said Sarah de Biase, senior programme manager, improving population health, West Yorkshire ICB.

But there is also a question of how many people with type 1 diabetes will choose to use the technology, rather than other forms of managing their diabetes, such as daily injections.

While there was agreement around the table that HCL should be standard treatment for eligible adults, Partha Kar – NHSE’s diabetes technology lead, as well as a consultant in Portsmouth – said he saw significant numbers of eligible adults – predominantly elderly – who did not want HCL, even after discussing the technology with their clinicians. “[Half] of people sit down with our doctors and nurses, learn the system and go, ‘you know what, I’m good’,” he said.

Meanwhile, Ali Chakera, consultant in diabetes and endocrinology, University Hospitals Sussex FT, said about 20 per cent of patients were declining it in his area, but suggested over time the number of people choosing not to have HCL would decrease as it increasingly became the standard of care. “The potential saving because people don’t want it is soon going to be lost,” he added.

This was an area where data on how large a proportion this would be was important, said Dr Kar, as it would help commissioners see what it meant for their area.

Trust may be a vital part in persuading some groups to take up the technology, said Mr Naqvi. He pointed to the pandemic when trust was important, including in persuading some groups to have vaccinations.

Freedom of choice around which HCL systems are used can also be an issue: Kelly Harper, whose daughter has type 1 diabetes, said that some parents in her ICB area did not have that choice. There was also concern about what happens when children using HCL technology transition into adult care, with some fearing their pumps would be taken away from them – although this was not an issue with the hospital her daughter attended.

But, from a commissioner’s perspective, choice can be a challenge. Kelly Broad, deputy chief pharmacist, Cambridgeshire and Peterborough ICS, said that offering choice could lead to fewer patients overall being offered the technology if patients opted for more expensive HCLs. Ms Jordan said in some areas, money seemed to be reaching ICBs but not necessarily the grassroots.

Panellists were keen to see a multiyear settlement, giving ICBs certainty about what funding they had for HCLs. Shortly after the roundtable, the global amount for each of the next three years was announced.

 We know that the benefit is coming, but it does not come quickly enough

But will diabetes remain high up the health service agenda going forward? Dr Kar pointed out that it had not been a priority in the past but had become one in the NHS long-term plan. References to it were fewer in the 10-Year Health Plan. “Commissioners have to work on priorities,” he said. He is stepping down from his NHSE job at the end of March, but stressed that a strong lead to drive forward the work was still needed.

However, he added that a great deal of money had been invested in diabetes in recent years and this investment’s results, in terms of improved outcomes and reduced complications, needed to be clear. He was keen to address this during the rest of his term in office.

And panellists called for some form of mid-way review or revised implementation plan for the HCL programme.

Hjalte Hojsgaard, Insulet vice president, pointed out that NICE had done a cost-benefit analysis as part of the technology appraisal, but real-world data could also help to demonstrate the benefits – work which Dr Kar said was starting.

But even where evidence already exists, it can still be very hard to persuade commissioners to invest. “The pushback we have had over the year from commissioners is, ‘yeah, but what are the in-year savings’,” said Dr Lumb. Enormous savings are coming, not just for healthcare systems but for individuals in terms of quality of life and wider society. “We know that the benefit is coming, but it does not come quickly enough. It also does not come from the diabetes budget,” he said.

In many ways, the HCL rollout has been extremely successful and well planned. Former ICB commissioner Rajni Cairns – now associate director system engagement, uptake and adoption, NICE – said that it had been unusual in that ICBs had started planning for adoption months before the NICE appraisal was published, and relationships had been built up so they could hit the road running.

Ms de Biase said the value the technology added had been recognised, with commissioners, managers and clinicians working together – a whole systems approach. But she warned that the goal to get everyone eligible onto the technology by 31 March 2029 would be missed.

She added the changes to ICBs also meant some of the work being done may “fall off a cliff,” with learnings also being lost.

“I think the barriers are the resources within the clinical teams,” said Ms Broad. Diverse workforces between trusts could create inequalities, and her area also had differences in deprivation and ethnicity. As ICBs’ geographies grew, some of these challenges would become greater.

The workforce to deliver wrap-around care – not just initiating patients on HCL – was important, she added. However, Ms Broad questioned if hospitals were the right setting for this care, adding it might be a barrier for some patients, and called for more care in the community.

It is not just specialist doctors and nurses who are involved, especially as recruiting specialist diabetes nurses is difficult. In Oxford, band four staff had been important in supporting people with technology, said Dr Lumb. The unit needed to onboard about 35 people a month and had been able to do this because it was working differently, with band four staff taking on some of the administrative tasks, releasing nurses to do other tasks.

“I think where industry can help is if we find ways of automating the administrative processes so we can apply those people’s time where it is best spent,” said Dr Lumb.

Once people are onboarded, they may need relatively little ongoing care – Dr Chakera said that some of his patients were seen once a year once they were established on HCL.

Dr Kar suggested that paediatric departments, where most children started HCL, might be able to release staff to support the process of onboarding adults. He advocated for developing centres of excellence within ICB areas.

Industry can help ease the burden on diabetes units, suggested Mr Hojsgaard. It was already involved in onboarding and finding novel ways to provide virtual support. “We do have the ability to play a greater role – there’s tech, and then there’s what happens after that,” he said. The industry was already thinking about how it could add capacity and value-added services, rather than just providing the technology, he said.

Ms Harper’s daughter, Skye, was diagnosed with type 1 diabetes five years ago and now uses HCL technology to measure and control her blood glucose levels. It has been transformative for both her and her wider family.

Her mother told the roundtable that they had had to push, along with other families, to access the technology, even though Skye met the criteria.

Previously, Skye had been on a monitor which would alert her mum if her blood glucose levels were dropping. In one case, she had been at a sleepover when her glucose levels dropped, and Ms Harper had to drive to the house at 4 am and bang on the door. “She was absolutely mortified,” she recalled. “Now she has that pump, I don’t worry so much.”

She has had the chance to have experiences like other children because she has that technology

“The closed loop pump [the HCL system] has given her the good [HbA1c] numbers, it is keeping her in range, but it is also giving her freedom back,” Ms Harper added. “Her mental health and wellbeing is really good.” Skye has been able to go on a school trip to France, go out with her friends and live a normal teenager’s life. Stress had previously led to very high blood glucose levels, but the HCL had changed that, and she was now coping with GCSE mocks.

“She has had the chance to have experiences like other children because she has that technology,” she said.

But the NHS has also benefitted, she added: although Skye still has regular appointments, she has needed little support in between them since she got the HCL technology.

Note: Kelly Harper participated in this roundtable as an independent contributor. At the time of publication, Kelly and her daughter Skye undertake other unpaid advocacy activities on behalf of Insulet.