Scope of this report
| Covered by this report? | If ‘no’, where you can find information about this part of the pathway | |
| Underpinning functions | ||
| Uptake and coverage | Yes | Not applicable |
| Workforce | Yes | Not applicable |
| IT and equipment | Yes | Not applicable |
| Commissioning | Partly | Not applicable |
| Leadership and governance | Yes | Not applicable |
| Pathway | ||
| Cohort identification | Yes | Not applicable |
| Invitation and information | Yes | Not applicable |
| Testing | Yes | Not applicable |
| Results and referral | Yes | Not applicable |
| Diagnosis | No | Covered as part of intervention |
| Intervention / treatment | Yes | Not applicable |
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 23 March 2023 to Lancashire Diabetic Eye Screening Service which is commissioned by NHS England North West. 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 screening programme
- 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 pre-review visits
- administration and failsafe 17 January 2023
- clinical observation 18 January 2023
- familiarisation review 11 January 2023
- information shared with SQAS as part of the visit process
The screening service
The Lancashire DES service (the service) is provided by East Lancashire Hospitals NHS Trust (ELHT) and provides diabetic eye screening for approximately 101,100 people with diabetes from 173 GP practices. NHS England North West is the commissioner and there is one integrated care board (ICB) and five integrated care partnerships (ICP) within the service boundary.
The service offers fixed appointments for all pathways including routine digital screening (RDS), digital surveillance (DS) and slit lamp biomicroscopy (SLB). There are 36 clinic sites including four prison sites; HMP Garth, HMP Wymott, HMP Lancaster Farm and HMP Preston. There is one secure mental health facility, Calderstones Hospital, provided by Mersey Care NHS Foundation Trust.
The service refers people to four treatment and assessment hospitals:
- Royal Blackburn Hospital, East Lancashire Hospitals NHS Trust
- Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust
- Blackpool Victoria Hospital, Blackpool Teaching Hospitals NHS Foundation Trust
- Lancaster Royal Infirmary, University Hospitals of Morecambe Bay
- NHS Foundation Trust
Findings
All service staff were found to be motivated, well organised and knowledgeable in providing a quality patient centred service. Evidence and audit information provided was detailed and thorough.
Interviews during the QA visit were conducted with key members of the team for each part pathway. Consultant ophthalmologists or hospital representatives from the Royal Preston Hospital, Blackpool Victoria Hospital or Lancaster Royal Infirmary did not attend the visit day.
Immediate concerns
The QA visit team identified no immediate concerns.
High priority findings
The QA visit team identified three high priority findings as summarised below:
- develop a formal governance and assurance process with an ELHT steering group. This should enable effective senior management oversight of performance monitoring, screening and grading capacity, active management of the risk register and the implementation of post-audit action plans
- complete a review of the SLB pathway which includes, but is not limited to; capacity planning, enhancing the use and performance of the local contracted optometrist, clinic venue availability, sampling to determine accuracy and cleansing of the total number of people within the SLB pathway
- ELHT senior management should support the service to obtain signed memoranda of understanding (MOU) with each referral centre to support clinical governance and accountability.
Examples of practice that can be shared
The QA visit team identified several areas of practice for sharing, including:
- referrals to hospital eye services include a triage sheet template which includes the patient’s breach date to aid the arrangement of timely appointments
- the service has developed strong links with maternity units and thorough failsafe processes for pregnant women
- the service has many detailed audits on performance, the impact of screening, grader performance and ophthalmology interventions including CVI, non-DR referrals and laser-book
- dedicated diabetic clinics at the Royal Blackburn Hospital
- multi-lingual staff appropriately placed in screening venues
- a pilot for community based screening venues with Asda supermarkets as part of their wider health equity work.
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 | |||||
| Recommendations not made in this section | |||||
| Governance and leadership | |||||
| 01 | Develop a formal governance and assurance process with an East Lancashire Hospitals NHS Trust (ELHT) steering group. This should enable effective senior management oversight of performance monitoring, screening and grading capacity, active management of the risk register and the implementation of post-audit action plans. Membership of this group is to be determined but should include SQAS, SIT and NHS England commissioning representatives | National Service Specification | 3 months | High | Confirmation of revised governance arrangements Post-audit action plans which directly link actions to issues identified in each audit shared during operational group meetings |
| 02 | Review and update standard operating procedures (SOPs) included within Appendix C | National Service Specification | 12 months | Standard | Summary of the revised documents and sign-off process to be included in the recommendations action plan |
| 03 | Review all risks on the risk register, closing those which are open unnecessarily and have appropriate mitigating actions in place | National Service Specification | 6 months | Standard | Updated risk register approved by the ELHT senior management team Document shared during operational group meetings |
| 04 | Review the incident reporting arrangements to ensure there is sufficient level of senior management oversight and levels of escalation, and that all staff are actively engaged in using Datix and reporting incidents | Managing Safety Incidents in NHS Screening Programmes | 12 months | Standard | Confirmation of all staff trained in incident reporting using Datix and the screening incident assessment form (SIAF) |
| Infrastructure | |||||
| 05 | Complete a full camera image and artifact review | Approved cameras and settings Audit Schedule National Service Specification | 6 months | Standard | Image and artifact camera review findings |
| Identification of cohort | |||||
| Recommendations not made in this section | |||||
| Invitation, access and uptake | |||||
| 06 | Develop the existing capacity and demand planning spreadsheet into a formal document using ELHT senior management expertise to support local detailed pathway knowledge. Consideration should be given to utilising the NEC Care ‘smoothing tool’ application | National Service Specification | 6 months | Standard | Revised document developed in conjunction with ELHT senior managers to include: Details on inputs and outputs for each pathwayreporting triggers against pathway trajectoriesescalation of risk to senior management Document shared during operational group meetings |
| The screening test – accuracy and quality | |||||
| 07 | Carry out a formal audit on the number of ungradeable images to determine the reason for the high unassessable level and implement any corrective actions | Pathway standards reports Management of grading quality National Institute for Health and Care Excellence National Library of Medicine | 6 months | Standard | Audit document to include details on: increasing the dilation time periodgrader training specifically on unassessable how screeners obtain good quality images, jigsawing and anterior segment imagesClinical Lead oversight and engagement with screeners to develop learning opportunities |
| 08 | Develop a grading at home policy which includes home risk assessments, acceptability, the minimum requirements of grading monitors and the expected levels of grading activity | Management of grading quality | 12 months | Standard | Grading at home policy |
| 09 | Complete a review of the slit lamp biomicroscopy (SLB) pathway which includes, but is not limited to: capacity planning, enhancing the use and performance of the local contracted optometrist, clinic venue availability, sampling to determine accuracy and cleansing of the total number of people within the SLB pathway | Managing referrals to hospital eye services National Service Specification Slit lamp biomicroscopy examiner framework | 6 months | High | Complete review to be agreed/signed off by ELHT senior managers |
| Referral | |||||
| Recommendations not made in this section | |||||
| Intervention and outcome | |||||
| 10 | ELHT senior management should support the service to obtain signed memoranda of understanding (MOU) with each referral centre to support clinical governance and accountability Formal agreements should specify hospital eye service (HES) activity, data flows, the number of programmed activities (PAs) per week and the roles and responsibilities of the designated ophthalmology leads | National Service Specification Managing referrals to hospital eye services | 3 months | High | Confirmation of signed MOU documents for all hospital referral centres |
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: 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
- Audit Schedule Diabetic eye screening: audit schedule – GOV.UK (www.gov.uk)
- Diabetic eye screening standards valid for data collected Diabetic eye screening standards valid for data collected from 1 April 2019
- 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
- National Institute for Health and Care Excellence Mydriatics and cycloplegics | Treatment summaries | BNF | NICE
- National Library of Medicine Tropicamide – StatPearls – NCBI Bookshelf (nih.gov)
- NHS England Serious Incident Framework Serious incident framework
- Public Health Profiles https://fingertips.phe.org.uk/
- Slit lamp biomicroscopy (SLB) examiner framework Diabetic eye screening: slit lamp biomicroscopy examiner framework