NHS England » Screening quality assurance visit report – Dorset Diabetic Eye Screening Service

Scope of this report

To note: Quality Assurance Visit Report: NHS Diabetic Eye Screening Programme – NEC Care centralised functions 7 September 2022 covers all aspects in scope delivered by NEC centralised office functions.

	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
Intervention / treatment	Yes

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 19 September 2024 to Dorset Diabetic Eye Screening Service (DESS) which is commissioned by NHS England (South-West) Public Health Commissioning team.

Any commissioning-specific 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 conducted 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 and external organisations
discussion with the commissioner in advance of the visit
information collected during an administration review at Bournemouth Life Centre, Bournemouth on 21 August 2024
pre-visit clinical observations on 20 August 2024 at:
- Bournemouth Life Centre, Bournemouth (clinic and grading)
- Allendale House, Wimborne (clinic)
- Highcliffe Medical Centre, Christchurch (clinic)
information shared with the national SQAS as part of the visit process

The screening service

NHS England (South West) Public Health Commissioning Team (PHCT) commissions the Dorset DESS to cover the Dorset ICB footprint using the using the NHS public health functions agreement 2022/23 service specification No.22.

The Dorset diabetic eye screening service (DESS) area is coterminous with 1 NHS England Integrated Care Board (ICB): NHS Dorset.

The service operates across 2 local authorities:

Bournemouth, Christchurch and Poole (BCP)
Dorset

The Dorset DESS was established in the 1980s and for a long time was primarily operated by local opticians. This is their third QA visit, the previous being on 27 September 2018.

NEC Care (NEC) have provided the service since April 2022. Prior to that, the service was provided by InHealth Intelligence (2017-2022).

Local NEC services deliver screening in co-ordination with a centralised functions office. Linked services benefit from NEC’s centralised functions based in Worcester including central failsafe management, bookings for call/recall, letter distribution, customer operations and corporate services.

The NEC centralised functions received their first QA visit in September 2022 and an associated report with recommendations has been published.

An action plan was developed by NEC in response to QA recommendations. The findings within this report should be read in conjunction with the centralised functions report.

A population of approximately 52,000 people with diabetes are registered on the Dorset DESS database (as at March 2024).

People with diabetes access screening in Dorset at 19 sites across the service area, including:

7 hospitals
3 prisons
3 GP practices
6 community centres

The service does not visit any secure/mental health units. Armed forces personnel and their families living in Dorset are registered with civilian GPs and screened at community locations alongside the civilian cohort.

Screen-positive people with diabetes requiring ophthalmological assessment or treatment are referred to one of 4 hospital eye service (HESs):

University Hospital Dorset (UHD) (including Royal Bournemouth (RBH) & Poole Hospitals)
Dorset County Hospital, Dorchester (DCH)
Salisbury District Hospital (SDH)
Yeovil District Hospital (YDH)

Findings

This service has faced fundamental operational challenges mobilising under a new provider following the most recent round of procurement in April 2022.

Recovery of the service from disruption due to the COVID-19 pandemic was completed prior to the reprocurement.

Since mobilisation, the team have made substantial improvements, consolidating experience, adapting to, and embedding new processes and finding solutions to some unprecedented challenges.

Immediate concerns

The QA visit team identified 1 immediate concern related to the local hospital eye service (HES) recall project.

Under this initiative, people in care of HES for diabetic retinopathy awaiting follow up appointments are discharged and reactivated in DESS rather than remaining in HES on surveillance.

The main aims of the project are understood to be supporting timely care for screening-referred patients and improving performance in DES pathway standards 12.1 and 12.2.

A letter was sent to the Executive Director of Health and Services at NEC Care, on 23 September 2024 asking that the following items were addressed within 7 working days:

establish a written protocol for the ‘HES Recall Project’ to demonstrate the process to review relevant patients in HES, and discharge. It should be made clear how discharge is being communicated to the DESS failsafe so that they can appropriately reinstate these people in screening
review cases previously reinstated in screening under this project and confirm that only people included on the DESS eligible list are made active in the screening pathway under this project
undertake a harm assessment for all patients reinstated under this project who have been re-referred to HES following recall to screening
provide assurance that accountability for the governance and leadership of this initiative sits within the HES and is not being owned by the DESS

Responses were received within 7 working days which assured the visiting QA team that the DESS provider, DESS commissioners and individual local HES sites concerned acknowledge the risks identified.

Their responses assure some of the uncertainties highlighted and all stakeholders are keen to continue work to mitigate the risks identified.

Collaborative work to establish safe, clinically appropriate, consistent processes that produce the system efficiency benefits intended by the HES Recall Project will continue.

High priority findings

The QA visit team identified 4 high priority findings as summarised below:

complete audit of the cohort who did not attend (DNA) screening in the last 3 years (KPI DE4)
provide assurance of the 2023/24 submission for the NHS Data Security and Protection Toolkit (DSPT)
develop an action plan for the implementation of optical coherence tomography (OCT) in the Dorset DESS pathway
provide assurance that urgent referral cases are not being reviewed virtually in all treatment pathways

Examples of practice that can be shared

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

regular NEC DESS manager meetings with centralised NEC team helps to support operational clarity on local roles but also to share learning form the experiences of the group
efforts to undertake local community engagement activities and service promotion, alongside recovering service performance
- this has helped develop a strong team identity and positive, cohesive team culture
seeking to minimise environmental impact by replacing regular-use products with more sustainable alternatives
the team is remarkably effective in identifying and capitalising on opportunities to engage, increase uptake and meet population needs
the service has received positive customer feedback and good volume of feedback is generated from the text message-based approach
excellent support for slit lamp examiner training that allows trainees to progress quickly while well supported by a structured training framework
effective collaboration with neighbouring DESS across service area boundary where a general practitioner (GP) cohort is distributed on both sides
collaboration with previous provider during mobilisation mitigated some risks of transition
- learning should be collated to guide future mobilisations

Recommendations

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

No.	Recommendation	Pathway theme	Reference	Timescale	Priority	Evidence required
Immediate concerns
01a	Review cases previously reinstated in screening under this project and confirm that there only people included on the DESS eligible list being managed in screening as part of this project.	Referral	Diabetic eye screening: managing referrals to hospital eye services	7 days	Immediate	DESS check on individuals managed through the project previously to confirm that no people being managed by the DESS who have not had a confirmed diabetes diagnosis.
01b	Undertake a harm assessment for all patients reinstated under this project who have been re-referred following recall to screening.	Referral	Diabetic eye screening: managing referrals to hospital eye services	7 days	Immediate	Establish a protocol and undertake a review of screening outcomes and referrals for all people reactivated in the DESS under this project.
01c	Provide assurance that accountability for the governance and leadership of this initiative sits within the HES and is not being owned by the DESS.	Referral	Diabetic eye screening: managing referrals to hospital eye services	7 days	Immediate	Written confirmation from HES provider and clinical governance at each participating HES that they acknowledge clinical responsibility for managing people in their care and that the DESS cannot accept a direct transfer of care for patients not clinically assessed as safe for discharge into the community.
01d	Establish a written protocol for the ‘HES Recall Project’ to demonstrate the process to review relevant patients in each participating HES and discharge.	Referral	Diabetic eye screening: managing referrals to hospital eye services	7 days	Immediate	Written protocol describing HES processes, approved by HES governance. Updated DESS failsafe protocol confirming that there is no direct transfer of care from HES to DESS. DESS protocol should include processes to audit cases ‘re-referred’ to HES for assurance and learning.

No.	Recommendation	Pathway theme	Reference	Timescale	Priority	Evidence required
Urgent recommendations
None

No.	Recommendation	Reference	Timescale	Priority	Evidence required
Service provider and population served
None

No.	Recommendation	Reference	Timescale	Priority	Evidence required
Governance and leadership
02	Ensure that job descriptions and local team structure chart accurately describe management relationships and lines of accountability.	Service specification	6 months	Standard	Updated Dorset organisational structure with confirmation it has been inserted into all current job descriptions. Confirmation of changes to roles due to OCT implementation and that job descriptions have been updated.
03	Review all DESS policies and protocols to ensure that all sections are complete, that they include version control, dates of authorisation and dates for review and refresh.	Service specification	6 months	Standard	Confirmation of any documents that have been updated. Finalised copies of updated disaster recovery procedure and administration handbook.
04	Provide assurance of the 2023/24 submission for the NHS Data Security and Protection Toolkit (DSPT).	Service specification	3 months	High	Assurance on reasons standards are recorded as not met for 2023/24. Update on any issues with the 2023/24 submission are addressed and that standards of the DSPT have been met for the current period.
05	Update the NEC incident management policy to ensure that principles of Managing Safety Incidents in NHS Screening Programmes guidance are incorporated.	Managing Safety Incidents in NHS Screening Programmes	6 months	Standard	Updated incident management policy. All staff trained in principles of screening incident assessment form (SIAF) reporting.
06	Undertake an audit of the cohort who did not attend (DNA) screening in the last 3 years (pathway standard 8/KPI DE4) and identify areas of potential service improvement.	Service specification Programme standards	6 months	High	Long-term non-attenders audit summary report.
07	Develop and implement an action plan to identify and reduce screening inequalities.	Service specification NHS Guidance on equality and health inequality duties 2015	6 months	Standard	Updated health equity action plan.
08	Develop 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	User feedback findings referenced in quarterly and DE4 DNA audits and DNA audit findings referenced in service user feedback survey.

No.	Recommendation	Reference	Timescale	Priority	Evidence required
Infrastructure
09	Seek confirmation from the Health Screener Diploma (HSD) assessment body that they are content that trainees are progressing in their training and that they are happy for them to continue.	Service specification NHS population screening: diploma for health screeners	3 months	Standard	Training log updated and assurance of discussion with HSD assessment body reported.
10	Undertake a demand and capacity analysis for the slit lamp biomicroscopy (SLB) surveillance pathway and grading team.	Service specification	6 months	Standard	Summary demand and capacity analysis for the SLB surveillance pathway and grading function, highlighting capacity available within the Dorset team.
11	Ensure SLB facilities are suitable for staff to appropriately deploy the test, including furniture and lighting arrangements.	Service specification	6 months	Standard	Assurance that facilities and equipment in SLB venues has been checked and confirmed suitable to meet requirements.

No.	Recommendation	Reference	Timescale	Priority	Evidence required
Identification of cohort
12	Complete the report summarising the annual audit of exclusions.	Service specification National audit schedule	6 months	Standard	Summary annual exclusions audit.

No.	Recommendation	Reference	Timescale	Priority	Evidence required
Invitation, access and uptake
None

No.	Recommendation	Reference	Timescale	Priority	Evidence required
The screening test – accuracy and quality
13	Refresh training for screeners on clinic protocol, ensuring that they are aware of the process to seek consent each time, provide appropriate information to service users and observe hygiene protocols.	Service specification National guidance on collection of demographic information	6 months	Standard	Confirm completion of refresher training on clinic process for all screeners.
14	Review and update the process and pathway for people who may be challenged in consenting, in line with the Mental Capacity Act 2005 (MCA).	Service specification Mental Capacity Act 2005 NHS Mental Capacity Act Guidance	6 months	Standard	Updated process documentation with confirmation that updates have been refreshed with the screening team.
15	Develop an action plan for the implementation of OCT in the Dorset DESS pathway.	Service specification National guidance on OCT	3 months	High	Plan for implementation of OCT.

No.	Recommendation	Reference	Timescale	Priority	Evidence required
Referral
See immediate concern outlined above.

No.	Recommendation	Reference	Timescale	Priority	Evidence required
Intervention and outcome
16	Undertake a collaborative audit of cases referred as R3.	NICE managing of diabetic retinopathy referrals from DES guidance	12 months	Standard	Summary report on R3-referred cases.
17	Provide assurance that urgent referral cases are not being reviewed virtually in all treatment pathways.	NICE managing of diabetic retinopathy referrals from DES guidance Managing referrals to hospital eye services	3 months	High	Confirmation of local HES processes.

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.

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