The availability of diabetes technologies such as continuous glucose monitors (CGMs), insulin pumps, hybrid closed loop (HCL) systems and smart insulin pens remains inconsistent across England, an investigation has found.
A report identified concerns linked to the availability of diabetes technologies, insulin pen design, workforce capability and issues with coordination between healthcare services.
The investigation also sets out four safety recommendations aimed at tackling inequalities in access to diabetes technology, improving insulin pen design and strengthening support for patients in community settings. It highlights concerns about gaps in staff training, with some community nurses expressing "fear" about supporting patients using HCL systems.
The Health Services Safety Investigations Body (HSSIB) heard from patients, clinicians and national stakeholders about variations in the availability of CGMs, smart insulin pens and HCL systems. The report describes a "postcode lottery" in access, with provision varying depending on where patients live. Factors contributing to this included local funding and commissioning decisions, assumptions about patients' ability to use the technology and limited engagement with people who may benefit from it.
HSSIB also highlighted patient safety risks linked to diabetes technology, limited guidance to help individual patient needs and inadequate support for people with disabilities.
The report, Insulin: supporting safe self-administration for patients in the community – inequalities in technology and access to care, published "3 November 2026'' brings together findings from a series of investigations examining the self-administration of insulin by people who may be at increased risk of harm because of mental health problems, learning disabilities or other physical and cognitive impairments.
HSSIB said that people who require insulin may be at risk of harm due to inadequate support to manage their treatments safely. Insulin is a time-critical, high-risk medicine, and incorrect or delayed administration can lead to serious complications.
The investigation gathered evidence through engagement with patients, families, healthcare professionals and organizations involved in primary, community and secondary care. It also reviewed policy and academic literature, patient-safety incident databases and coroners' reports, using thematic analysis to identify key findings.
HSSIB is an independent organization that investigates patient safety concerns across healthcare to identify risks and make recommendations to improve patient safety.
Inequitable access to diabetes technology
The report, the final in a series of four investigations, found that, while they can improve patient safety and wellbeing, only around two-thirds' of eligible patients with type 2 diabetes used CGMs on average, although access varied according to funding, local NHS decisions, geography, deprivation, and age.
It was also found that no specific data was available on CGM provision and uptake among people with learning disabilities or mental health problems.
HSSIB further highlighted concerns about the implementation of HCL systems. At the time of the investigation, "12" per cent of eligible adults and "76" per cent of eligible children and young people aged up to 18 had an HCL system.
Clinicians raised concerns about limited funding for adults, uncertainty over long-term financial support and whether healthcare services had the capacity to support patients with complex needs.
Insulin pen design may not meet patients’ needs
Further investigation identified shortcomings in the design of some insulin pen devices, which may make safe administration difficult for people with visual impairments, reduced dexterity, learning disabilities or memory-related ailments.
Issues included small or unclear lettering and numbers, poor color contrast, difficulty selecting the correct device or dose, and inadequate feedback to confirm that the full dose had been administered. Manufacturers told the investigation about improvements being made for the same.
However, HSSIB identified a gap between manufacturers’ assurances of user-centered design and the experiences reported by patients and healthcare professionals.
A search of NHS England’s "Learn From Patient Safety Events" (LFPSE) service identified more than "100" incidents involving insulin pen devices in December 2025, including misuse, abnormal use and device malfunctions.
The report also highlighted that information about device-related incidents was held across different reporting systems, potentially limiting manufacturers’ awareness of the risks.
DIY insulin systems
The investigation also examined the use of "do-it-yourself" (DIY) closed loop insulin systems, which some people with type 1 diabetes have built using open-source information and a few patients described experiencing physical and psychological benefits and a greater sense of control over their insulin management.
However, healthcare professionals raised concerns about possible complications if the systems did not function properly and the lack of regulatory assurance and guidance for NHS staff.
HSSIB noted that it could not establish official figures for their use and did not undertake a full assessment of their safety because of limited evidence.
Workforce capability
The report found that workforce knowledge and confidence in general have not kept up with the increasing use of diabetes technology.
Community nursing teams and other non-specialist staff are increasingly encountering patients using CGMs and HCL systems, but some reported limited training and confidence in supporting them.
HSSIB noted that a national competency framework for diabetes technologies, including CGMs and HCL systems, was published in July 2026. However, it highlighted the need for further collaboration and education to ensure staff can safely support patients.
Gaps in community care and coordination
The investigation identified wider problems in the way diabetes care is organized and delivered in community settings.
HSSIB found that collaboration between general practice, community nursing, specialist diabetes, mental health and learning disability services was inconsistent.
Staff also reported difficulties accessing clinical advice, sharing information and coordinating care plans. Disconnected IT systems and limited interoperability between services further affected the availability of relevant patient information.
The report highlighted that proactive safety planning for these circumstances was limited.
National stakeholders described the absence of a clear and cohesive strategy for improving patient safety in community-based diabetes care.
HSSIB calls for action to improve insulin safety
HSSIB has issued four safety recommendations to address inequalities in diabetes care and reduce risks associated with insulin administration.
It called on NHS England and the Department of Health and Social Care (DHSC) to develop national guidance for the implementation, provision and management of diabetes technologies, including HCL systems, informed by real-world evidence and the needs of patients with different disabilities and health conditions.
The Medicines and Healthcare products Regulatory Agency (MHRA) was asked to strengthen oversight of device conformity assessments, ensuring insulin-related devices consider diverse users and address risks linked to intentional and unintentional misuse.
HSSIB also recommended that the Association of British Health-Tech Industries (ABHI) and the Association of the British Pharmaceutical Industry (ABPI) work with manufacturers, healthcare professionals and people with lived experience to improve the inclusive and user-centered design of insulin pens.
A further recommendation calls for NHS England, DHSC and integrated care boards (ICBs) to develop specifications for community and home-based diabetes care, covering access to specialist services, shared-care arrangements, workforce capability and health inequalities.
The report additionally encouraged organizations and individuals to report misuse, abnormal use and incidents involving diabetes technologies and insulin pens to the MHRA through its Yellow Card scheme.
What patients and healthcare professionals told HSSIB
The report included concerns raised by healthcare professionals about their preparedness to support patients using newer diabetes technologies.
Community nursing teams described “fear” around supporting HCL systems, with some saying they “wouldn’t touch” them because they had not received appropriate education.
One patient described the growing demand for support as an “avalanche” approaching adult services without a workforce ready to manage it.
HSSIB also reported that stakeholders believed people with learning disabilities and mental health problems were “missed out” when it came to accessing diabetes technology.
In relation to insulin pen design, diabetes specialists described devices as appearing to be designed for a theoretical “standard person” who could read the information, remember the steps and physically operate the device.
The report also noted that ABHI and ABPI recognised the concerns raised about insulin pen design and supported future collaboration between the NHS and industry to explore design for safety.
Improving safety across community diabetes care
The findings across the investigation series highlights the need for more equitable access to diabetes technology, better-designed devices and stronger coordination between healthcare services.
It emphasises that patients with disabilities or impairments should receive individualised support to manage insulin safely, with services equipped to meet their varying needs.
The final report calls for action from healthcare organisations, regulators and manufacturers to ensure that advances in diabetes technology translate into safer and more accessible care for patients in the community.
