The exclusion further disadvantages those with the most to fear from diabetes, while belittling GP expertise.
Every Australian with type 1 diabetes can now access subsidised continuous glucose monitoring (CGM) products, but their general practitioner cannot directly help.
CGM and flash glucose monitoring products were already subsidised for children and young adults under 21, concession card holders and pregnant people with type 1 diabetes. These groups will continue to receive products free of charge under the expanded criteria, which took effect on 1 July.
People aged 18-21 from financially disadvantaged backgrounds will also now be able to get an additional 35 fully subsidised insulin pumps each year. Previously, this was limited to under-18s.
The big change is for people over 21 with type 1 diabetes, who will now be able to access CGM products through community pharmacies at a co-payment of $32.50 per month.
The CGM initiative is delivered by the National Diabetes Services Scheme (NDSS), meaning that anyone who wants to get their hands on a subsidised product has to first register with the scheme and then apply for access to the program.
To apply for access, one must fill out a form. The form must be certified by an authorised health professional whose usual scope of practice includes the ongoing management and care of people with type 1 diabetes.
If you thought a general practitioner would fit that description, you have another think coming.
GPs and practice nurses are not authorised to sign off on CGM forms, but credentialled diabetes educators, endocrinologists, nurse practitioners, physicians and paediatricians are.
When The Medical Republic queried the exact definition of a physician for the purpose of certifying a CGM form with the Department of Health, it said: “A physician is defined by the NDSS as an individual registered with AHPRA as a physician – usually a Fellow of the Royal Australian College of Physicians – with a diabetes specialty.”
The DoH said that the decision to exclude GPs and practice nurses from the authorised certifier group was based on expert advice from the Australian Diabetes Society and the Australian Diabetes Educators Association, which had advised that type 1 diabetes was a complex condition and required specialist care.
“Health professionals authorised to certify CGM/flash GM access forms are those for whom diabetes is the main scope of their practice,” the department said.
“The field of diabetes technology use (insulin pumps, CGM/Flash GM, etc.) in type 1 diabetes is rapidly evolving and requires training and experience to stay abreast of changes in type 1 diabetes management options and use of new diabetes technology.”
Nurse practitioners, it said, completed post-graduate training and had specialised in diabetes management and care.
Australian Diabetes Society CEO Associate Professor Sof Andrikopoulos gave more context.
“In general, most people with type 1 diabetes would be cared for by endocrinologists, paediatricians, [credentialled diabetes educators] and diabetes nurse practitioners,” he told TMR.
“While there are some GPs that have a strong understanding of type 1 diabetes and CGM/flash GM, in general, most GPs do not possess the knowledge or understanding of diabetes management technology to educate and support the person with type 1 diabetes.”
Diabetes management technology is complex, according to Professor Andrikopoulos, and requires specialised training to interpret.
“Advancements in technology are occurring rapidly and require continuous update by health professionals,” he said.
These sentiments were echoed by a spokesman for Diabetes Australia.
“Staying abreast of changes in type 1 diabetes management options and use of diabetes technology is very challenging, even for diabetes health professionals,” the spokesman told TMR.
“The general practitioner has an important role in the ongoing care of individuals with type 1 diabetes and will work in tandem with these diabetes health professionals to enable the best outcomes for their patients.”
The type of specialist care required, according to Diabetes Australia, involves assessing the clinical benefit a patient may get from a CGM product, selection of the appropriate device and education on its appropriate use to ensure capability and commitment to using the technology.
Dear @NDSS_AUS,
— QLDCountry GP (@QLDCountryGP) July 2, 2022
As a GP with type 1 diabetic patients who would greatly benefit from CGM, I’d like to (sarcastically) thank you for stuffing them around by not letting their GP certify the new CGM access forms. 10+ years of medical education FFS! #diabetes #accessblock pic.twitter.com/j0qY4V1F1C
The RACGP agreed that international and national guidelines do indicate that the technology behind CGM is complex and evolving, but argued that GPs could play a bigger role.
“Health care teams ideally can include a credentialled educator and a diabetes trained specialist as well as the treating and coordinating GP,” RACGP president Adjunct Professor Karen Price said.
“Therefore, the hurdle of getting this form signed should be managed in a model of current care and this includes the coordinating GP.”
Not allowing GPs to certify the form, according to Professor Price, put rural and regional patients who may rely completely on their GP at a disadvantage.
“Telehealth and electronic form transmission can help but general practice has just had Medicare resources removed for long telephone consultations,” she said.
Data from 2020 indicated that rural and regional diabetes patients tended to have worse outcomes, with a hospitalisation rate almost three times higher than their metro-based peers.
Diabetes death rates were also twice as high for people living in remote and very remote areas.
The most troubling aspect for the RACGP president, though, was the disregard for GP knowledge and training.
“The form is concerning for its generalised disrespect towards general practitioners providing a high level of diabetes care,” she said.
“GPs remain the coordinators of continuous and team-based care and to exclude them from this form will disadvantage patients.
“Fragmentation of care should be guarded against in any high performing health system and patients will not understand that the first point of access to the health system is not supported by the NDSS form.”
The college intends to raise this with the government.
The RACGP, along with the National Aboriginal Community Controlled Health Organisation, is also calling for a more integrated, comprehensive approach to managing diabetes in primary care.
Professor Price said the college wanted to see the introduction of a rebate for GP consults that last 60 minutes or more and a 10% increase to the existing Medicare rebates for consults lasting 20 minutes or more.
“Greater support for longer consultations and GP-led team care will make a huge difference for people with chronic conditions,” she said.
Additional investment in the Workforce Incentive Program, Professor Price said, could also help boost multidisciplinary care for people with diabetes.
NACCHO called for continued funding for the Integrating Pharmacists within Aboriginal Community Controlled Health Services to Improve Chronic Disease Management, better known as the IPAC project.
It has recently been described by the Medical Services Advisory Committee as an “excellent example of an integrated, collaborative, patient-centred approach to primary care”.
People with diabetes were one of the cohorts which had benefitted from the project so far, according to NACCHO medicines policy and programs director Mike Stephens.
“Given the project’s demonstrable acceptability and effectiveness, it is time for government to provide a sustained investment in integrating pharmacists into team-based primary care settings, including ACCHOs,” he said.
“One existing program that provides a suitable framework for funding includes the WIP.”
