This blog examines access to diabetes technology in Scotland. It summarises what diabetes is and its prevalence in Scotland, before outlining the different types of diabetes technology used to manage the condition. It also explores the number of patients currently using diabetes technology, and issues affecting access to the technology.
Diabetes in Scotland
Diabetes is a chronic metabolic disease which causes a person’s level of blood glucose (blood sugar) to become too high. The level of glucose in the blood is controlled by the hormone insulin, which is produced by the pancreas. Symptoms of diabetes can include excessive thirst, frequent urination, tiredness, and unintended weight loss. These symptoms can develop quickly in cases of type 1 diabetes. However, some people with type 2 diabetes may not realise they have developed symptoms for years, as the symptoms can develop gradually and be general in nature.
Over time, high blood glucose levels can cause chronic complications including damage to the eyes, feet, and internal organs. Some people with diabetes may also experience acute complications such as hypo- and hyperglycaemic attacks, and sometimes life-threatening medical emergencies such as diabetic ketoacidosis or hyperosmolar hyperglycaemic state. Effective monitoring and management of blood glucose levels can help to reduce the risk of complications. It is estimated that 55% of NHS spending on diabetes in Scotland is used to treat diabetes-related complications, rather than managing the condition itself.
Most people with diabetes are living with either type 1 or type 2 diabetes. Type 1 diabetes is an autoimmune condition, occurring when the body’s immune system attacks the cells that produce insulin, leaving the pancreas unable to produce it. It normally develops in children and young adults. Type 1 diabetes accounts for 10.3% of diabetes cases in Scotland. It cannot currently be cured, though it can be managed through blood glucose monitoring, dietary management, and insulin treatment.
Type 2 diabetes occurs when the body does not produce enough insulin, or does not properly react to insulin, known as insulin resistance. It is significantly more common than type 1 diabetes, accounting for 88% of cases of diabetes in Scotland as of 2023. Type 2 diabetes is associated with being overweight or sedentary, and lifestyle changes can help to manage a patient’s blood glucose levels, though medication is usually also necessary. Other risk factors for type 2 diabetes include having a family history of type 2 diabetes, being older than 40, or being from an Asian, Black African, or Black Caribbean ethnic background.
Around 2% of cases of diabetes are attributed to less common forms of the condition, such as gestational diabetes, which develops during pregnancy, and diabetes caused by genetic conditions. Some people may also experience prediabetes, where their blood glucose level is higher than normal, but not high enough to meet the diagnostic criteria for type 2 diabetes. Patients with prediabetes may be advised to make lifestyle changes to reduce their risk of developing type 2 diabetes.
According to the Scottish Diabetes Survey 2023, there were 353,088 people living with diabetes in Scotland at the end of 2023, representing approximately 6.5% of Scotland’s total population. 36,249 of these patients were living with type 1 diabetes, 310,541 with type 2 diabetes, and 6,298 people with other forms of the condition. It is thought that a further 49,000 people in Scotland may be living with undiagnosed type 2 diabetes, and that 620,000 people are at high risk of developing type 2 diabetes.
Diabetes technology
Diabetes technology is an umbrella term encompassing many types of glucose monitoring and administration equipment. Broadly speaking, diabetes technology supports patients through three main functions:
- Administering insulin,
- Monitoring blood glucose levels,
- Supporting other measures to manage diabetes, such as tracking carbohydrate intake and ketone levels.
Recent advancements in diabetes technology include continuous glucose monitors, which involve sensors attached the skin and linked to a smartphone, allowing people with diabetes to monitor their blood glucose level at any time. These devices can be used in conjunction with insulin pumps to create a hybrid closed loop system. For patients with type 1 diabetes, hybrid closed loop systems can be used to automatically monitor blood glucose levels and administer insulin as needed. This can reduce the risk of complications associated with diabetes, and make it easier for patients to manage their condition. However, the systems may not be suitable for, or desired by, all patients living with type 1 diabetes.
In 2023, the National Institute for Health and care Excellence (NICE) updated its guidance on the management of type 1 diabetes. NICE recommended hybrid closed loop systems as a treatment option for adults with type 1 diabetes whose symptoms were not adequately controlled with their current device. Additionally, NICE advised the use of hybrid closed loop systems for children and young people with type 1 diabetes, and patients with type 1 diabetes who are pregnant or planning to conceive. The Scottish Intercollegiate Guidelines Network (SIGN) developed a decision-support toolkit to aid healthcare practitioners in advising patients with type 1 diabetes about their treatment options, including hybrid closed loop systems.
The Scottish Government has acknowledged the role of hybrid closed loop systems in the management of type 1 diabetes. In its Diabetes Improvement Plan 2021-26, the Scottish Government committed to “support[ing] the development and roll-out of innovative solutions to improve treatment, care and quality of life of people living with diabetes”, including access to hybrid closed loop systems.
Issues affecting access to diabetes technology in Scotland
Funding, waiting times, and provision across Boards
Provision of hybrid closed loop systems and other forms of diabetes technology can vary across Scotland’s Health Boards, with Board-level policies contributing to variations in access. Some Boards have concentrated their resources on rolling out technology to children and pregnant women with type 1 diabetes, with longer waits for adults living with the condition. Additionally, according to Diabetes UK, some patients have reported differing interpretation of the NICE guidelines across Board areas, with patients considered too high risk for hybrid closed loop technology, or their symptoms deemed to be adequately managed despite them self-reporting challenges with managing their diabetes. Some patients also reported not receiving information about their options regarding diabetes technology.
The Scottish Diabetes Survey 2023 (Table 56) noted that although most patients with type 1 diabetes in every Health Board area were using a continuous glucose monitoring (CGM) system, there was greater variability among the number of patients using an insulin pump that could work alongside a continuous glucose monitor to create a hybrid closed loop system. In NHS Forth Valley, 18% of patients with type 1 diabetes were using a CGM-compatible insulin pump as of 2023, compared with 4.2% in NHS Western Isles, and 4.6% in NHS Borders.
Waiting times for hybrid closed loop systems can be difficult to accurately determine, due to the way that waiting lists are managed, and overlaps between waiting lists for different types of diabetes technology. In 2024, the Scottish Government committed up to £8.8 million of funding to provide hybrid closed loop systems to all children with type 1 diabetes, and to increase provision for adults living with the condition. However, some patients living with type 1 diabetes report long waits for hybrid closed loop systems, with some waiting five years to access the technology.
SIGN’s guidance states that patients should be offered a choice of technology based on their needs. However, during a meeting of the Parliament on 7 January 2025, Members heard that some patients with type 1 diabetes are offered less expensive options which do not always fit their needs, and could potentially lead to less effective management of their condition.
Socioeconomic inequality and private provision
Diabetes UK noted in its 2023 Diabetes is Serious: Scotland report that access to wearable diabetes technology is significantly affected by socioeconomic inequality. 42.8% of survey respondents in Scotland’s least deprived quintile reported that they used wearable diabetes technology, compared to 28.3% of respondents in the most deprived quintile. The report identified the ability to self-fund as a key factor in access to diabetes technology. The initial purchase of a hybrid closed loop system can cost between £2,000-3,000, in addition to an annual cost of approximately £1,500 for the cannulas, reservoirs, and tubing required for its use.
Sarah Swift
SPICe Research
Featured image attribution: Thirunavukkarasye-Raveendran, CC BY 4.0 https://creativecommons.org/licenses/by/4.0, via Wikimedia Commons