NHS England » Screening Quality Assurance visit report – Bristol, North Somerset and South Gloucestershire Diabetic Eye Screening Service

To note: Quality Assurance Visit Report: NHS Diabetic Eye Screening Programme – InHealth Intelligence centralised functions 26 July 2022 covers all aspects in scope delivered by IHI centralised office functions.

Scope of this report

Topic	Covered by this report?	If ‘no’, where you can find information about this part of the pathway
Underpinning functions
Uptake and coverage	Yes	See note above on centralised functions.
Workforce	Yes	See note above on centralised functions.
IT and equipment	Yes	See note above on centralised functions.
Commissioning	Partly	NHS England Public Health Commissioning Team South West
Leadership and governance	Yes	See note above on centralised functions.
Pathway
Cohort identification	Yes	See note above on centralised functions.
Invitation and information	Yes	See note above on centralised functions.
Testing	Yes	See note above on centralised functions.
Results and referral	Yes	See note above on centralised functions.
Diagnosis	No	Not applicable
Intervention / treatment	Yes	See note above on centralised functions.

Summary

The NHS Diabetic Eye Screening Programme aims to reduce the risk of sight loss among people with diabetes by the prompt identification and effective treatment of sight-threatening diabetic retinopathy, at the appropriate stage of the disease process.

The findings in this report relate to the quality assurance visit on 16 March 2023 to Bristol, North Somerset and South Gloucestershire (BNSSG) Diabetic Eye Screening Service (DESS) which is commissioned by NHS England (South-West) Public Health Commissioning team. Any commissioning findings are outside the scope of this report and will be followed up directly with the commissioner.

Quality assurance purpose and approach

Quality assurance (QA) aims to achieve and maintain national standards, promote continuous improvement in diabetic eye screening (DES) and support reducing health inequalities. This is to ensure all eligible people have access to a consistent high quality, effective, equitable and safe service wherever they live.

QA visits are carried out by the NHS England Screening Quality Assurance Service (SQAS).

The evidence for this report comes from the following sources:

monitoring of routine data collected by the NHS England
data and reports from external organisations
evidence submitted by the provider(s) and external organisations.
discussion with the commissioner in advance of the visit
administration review at Canningford House, Bristol on 28 February 2023, as well as pre-visit clinical observations at the Bedminster Family Practice and Parish Wharf Leisure Centre clinics on 1 March 2023
information shared with the south regional SQAS as part of the visit process

The screening service

NHS England (South-West) Public Health Commissioning Team (PHCT) commissions the BNSSG DESS using the using the NHS public health functions agreement 2022/23 service specification No.22.

The BNSSG service area service operates across 3 local authorities and is coterminous with 1 NHS England Integrated Care Board (ICB) – NHS Bristol, North Somerset and South Gloucestershire.

BNSSG DESS was originally established in 2005 and has been hosted by InHealth Intelligence (IHI) since April 2020. IHI are the provider for 11 DESS across the country. All these services benefit from IHI’s centralised functions based at Winsford in Cheshire including central failsafe management, bookings for call/recall, letter distribution, grading and customer operations.

The IHI centralised functions office received their first Quality Assurance (QA) visit in July 2022 and an associated report with recommendations has been published. An associated action plan has also been developed and will be monitored accordingly by NHS England. The findings within this report should be read in conjunction with the centralised functions report.

A population of c.55,000 people with diabetes are registered on the screening database (as of September 2022).

People with diabetes access screening in BNSSG at 3 fixed-sites and 24 ‘mobile’ locations in the community, including supermarkets and General Practitioner (GP) clinics. ‘mobile’ sites are facilitated by a subcontracted transport service whereby vans move cameras to scheduled clinic locations.

Screening is provided to eligible people in 4 prisons, 2 secure mental health institutions and 1 military site.

Screen-positive people with diabetes requiring ophthalmological assessment or treatment are referred to a single treatment centre at Bristol Eye Hospital, part of the University Hospitals Bristol and Weston NHS Foundation Trust (UHBW).

Findings

This is a high-quality service. The current provider mobilised at the outset of the COVID-19 pandemic and despite this the team have made substantial improvements, consolidating experience, adapting to and embedding new processes, finding solutions for some long-standing challenges and achieving new heights of performance.

Immediate concerns

No immediate concerns were identified.

High priority findings

The QA visit team identified no high priority findings.

Key themes in the recommendations made include:

the risk of insufficient capacity in the screener team which needs to be understood and mitigated
there is a need for work to analyse and address health inequalities

Examples of practice that can be shared

The QA visit team identified several areas of practice for sharing, including:

comprehensive suite of standard operating procedures (SOPs)
implementation of effective and up to date information technology supporting remote operation and service resilience
consistent and effective engagement with local maternity services
an effective fast-track referral procedure for urgent cases
clinical leadership is proactive with successful advocacy for diabetic eye screening

Recommendations

The following recommendations are for the provider to action unless otherwise stated.

No.	Recommendation	Reference	Timescale	Priority	Evidence required
Service provider and population served
No recommendations made in this section
Governance and leadership
01	Manage all screening patient safety incidents and serious incidents in accordance with ‘Managing Safety Incidents in NHS Screening Programmes‘.	Managing Safety Incidents in NHS Screening Programmes	6 months	Standard	Confirmation all staff are aware of national screening incident policy and are aware of how to report incidents. Reported to programme board. Summary of IHI Sentinel incident reports presented to programme board for discussion.
02	Analyse available demographic and service performance data to understand who within their eligible population requires support to access screening, and where they are.	Service specification Guidance for NHS Commissioners on equality and health inequality duties 2015	6 months	Standard	Summary of the data analysis and findings shared for discussion at programme board.
03	Use findings from data review to develop and implement an action plan to identify and reduce screening inequalities.	Service specification Guidance for NHS Commissioners on equality and health inequality duties 2015	12 months	Standard	Action plan presented to programme board.
04	Undertake analysis of the Did Not Attend (DNA) audit for people not attending screening in 3 years (KPI DE4) and identify areas of potential service improvement.	Service specification Programme standards	6 months	Standard	Audit summary report shared at the programme board
05	Develop and implement processes to involve service users, including those with protected characteristics or from underserved groups, in the development and evaluation of the service.	Service specification	12 months	Standard	Annual patient satisfaction survey presented to programme board
Infrastructure
06	Develop a process to ensure feedback from regular clinic checks is used to drive service improvement.	Service specification	6 months	Standard	Summary review of clinic compliance shared at programme board. Action plan developed to address gaps in accessibility, health and safety and/or quality of venue.
Identification of cohort
07	Update policies and protocols relating to management and audit of exclusions to confirm the role of the Clinical Lead in overseeing processes to exclude.	Service specification Diabetic eye screening: roles and responsibilities of clinical leads	6 months	Standard	Updated exclusions SOP shared with programme board. Updated exclusions audit shared with programme board.
Invitation, access and uptake
08	Undertake capacity/demand modelling exercise for routine digital screening (RDS), digital surveillance (DS) and grading.	Service specification	6 months	Standard	Summary report including scenario models for current capacity and full recruitment submitted to programme board.
09	Develop a process to mitigate challenges of working alongside patient transport by optimising the scheduling of people known to need transport.	Service specification Guidance for NHS Commissioners on equality and health inequality duties 2015	6 months	Standard	Proposal for process to optimise booking submitted to programme board.
10	Undertake capacity/demand modelling exercise for the slit lamp biomicroscopy (SLB) surveillance pathway	Service specification	6 months	Standard	Summary report including scenario models for current capacity and fully trained submitted to programme board.
The screening test – accuracy and quality
11	Update local screening protocols to include policy on storage and transport of Tropicamide.	NDESP Tropicamide manufacturer’s guidance	3 Months	Standard	Updated policy authorised by Clinical Lead and shared with programme board. Confirmation that Tropicamide storage risk assessments have been completed.
12	Develop a term of reference (ToR), agenda and minutes for the Multi-Disciplinary Team (MDT) meetings.	Service specification	12 months	Standard	Minutes for x3 MDT meetings to be submitted to the programme board. ToR in place, including standard agenda. Schedule and minutes of team meetings (to include attendance) provided to programme board.
13	Establish a standard process for assuring grading quality in Digital Surveillance (DS) and for ensuring the feedback and supervision of all Referral Outcome (ROG) and DS graders, in-line with national guidance	Service specification Diabetic eye screening: roles of clinical leads: Diabetic eye screening: roles of clinical leads – GOV.UK (www.gov.uk)	12 months	Standard	Documented policy in place, signed-off by the Clinical Lead and agreed by the programme board
Referral
14	Establish a protocol for completion of a regular summary review of R3 downgrades in HES.		6 months	Standard	Summary review of downgrade cases shared at programme board.
15	Ensure failsafe processes cover confirmation of ongoing diabetic retinopathy checks, in line with national guidance.	Service specification Programme standards Diabetic eye screening: managing referrals to hospital eye services	3 months	Standard	Updated protocol confirmed to programme board.
16	Revisit information-sharing agreement with HES as to expected level of feedback supporting DES failsafe.	Service specification Programme standards Diabetic eye screening: managing referrals to hospital eye services	3 months	Standard	Updated protocol confirmed to programme board. Tracking outcomes reported to programme board.
Intervention and outcome
No recommendations made in this section.

Next steps

The screening service is responsible for developing an action plan in collaboration with the commissioners to complete the recommendations contained within this report.

SQAS will work with commissioners to monitor activity and progress of the recommendations for 12 months after the report is published. After this point SQAS will send a letter to the provider and commissioners summarising progress made and will outline any further action(s) needed.

Appendix A: References

Approved cameras and settings Diabetic eye screening: approved cameras and settings
Assuring the quality of grading Diabetic eye screening: assuring the quality of grading
Cohort management Diabetic eye screening: cohort management
Diabetes prevalence estimates for local populations Diabetes prevalence estimates for local populations
Diabetic eye screening standards valid for data collected Diabetic eye screening standards valid for data collected from 1 April 2019
Managing patients not on the register Diabetic eye screening: managing patients not on the register
Managing referrals to hospital eye services Diabetic eye screening: managing referrals to hospital eye services
Managing safety incidents in NHS screening programmes Managing safety incidents in NHS screening programmes
NHS England Serious Incident Framework Serious incident framework
Optical coherence tomography (OCT) in surveillance Diabetic eye screening: optical coherence tomography in surveillance
Programmes that do not arbitrate on R0 or R1 Diabetic eye screening: programmes that do not arbitrate on R0 or R1
Public health profiles Health Profile
Roles of clinical leads Diabetic eye screening: roles of clinical leads
Screening pathway requirements specification Diabetic eye screening pathway requirements specification
Slit lamp biomicroscopy (SLB) examiner framework Diabetic eye screening: slit lamp biomicroscopy examiner framework
Surveillance pathways Diabetic eye screening: surveillance pathways
Test and training participation Diabetic eye screening: test and training participation
The Royal College of Ophthalmologists: The Delivery of Diabetic Eye Care Diabetic Retinopathy Guidelines | The Royal College of Ophthalmologists

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