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 |
|
|
Workforce |
Yes |
|
|
IT and equipment |
Yes |
|
|
Commissioning |
Partly |
NHS England, East of England public health commissioning team. |
|
Leadership and governance |
Yes |
|
|
Pathway | ||
|
Cohort identification |
Yes |
|
|
Invitation and information |
Yes |
|
|
Testing |
Yes |
|
|
Results and referral |
Yes |
|
|
Diagnosis |
Yes |
|
|
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 June 2025 to Hertfordshire and West Essex diabetic eye screening service which is commissioned by NHS England East of England 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 aims to achieve and maintain national standards, promote continuous improvement in diabetic eye screening 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.
The evidence for this report comes from the following sources:
- monitoring of routine data collected by 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
- information collected during pre-review visits
- familiarisation review 25 February 2025
- clinical observation 13 May 2025
- administration and failsafe 13 May 2025
- information shared with the Midlands and East Screening Quality Assurance Service as part of the visit process.
The screening service
The Hertfordshire and West Essex Diabetic Eye Screening service (the service) is provided by Hertfordshire Community NHS Trust and was established on 1 April 2024 following a reprocurement process. Prior to this diabetic eye screening was provided and commissioned as 3 separate screening services, East and North Hertfordshire, West Hertfordshire and West Essex as part of the Essex programme. NHS England, East of England is the commissioner and there is one integrated care board which covers the area served. The service provides screening for approximately 94,500 people with diabetes from 133 GP practices.
Screeners, graders and the clinical lead from the East and North Hertfordshire area continue to be employed by East and North Hertfordshire Trust and work directly for the HWE DES under a sub contract arrangement. All other staff are employed by HCT. Screener/graders employed by East and North Hertfordshire Trust provide screening in East and North Hertfordshire area. Screener/graders employed by Hertfordshire Community Trust provide screening in the West Hertfordshire and West Essex localities.
The service provides all elements of the diabetic eye screening pathway (including programme management, call/recall, failsafe, image capture and grading) up to the point of referral for any screen positive individuals. Letter printing and mailing is subcontracted to a mailing bureau. Individuals requiring ophthalmic assessment or treatment are referred to 1 of 8 referral centres.
Screener/grader technicians provide screening from 25 locations including hospitals, community venues, health centres, and one detained estate setting.
Findings
This is the first Quality Assurance visit to the Hertfordshire and West Essex Diabetic Eye Screening service. The team were found to be professional, patient focussed and supportive of each other. There is a clear commitment to deliver a quality screening service for individuals with diabetes. There has been an emphasis on bringing the services together over the last year and making sure that staff are fully integrated into one team.
The service has challenges around capacity and backlogs and is unable to offer people routine digital screening and slit lamp biomicroscopy examination appointments at the point they are due. There is a need for a recovery plan to enable all people with diabetes to be offered timely screening in line with national guidance.
Some initiatives have been carried out that will contribute to reducing health inequalities and improving access, but prioritising team integration and the capacity challenges has delayed the development of a structured service improvement plan.
Rolling annual data up to 30 September 2024 (which includes data from previous services for the period October 2023 to March 2024) shows the service met 6 out of the 13 measurable national quality standards. The standards not met are reflective of the capacity and backlogs as at the reporting period.
Immediate concerns
The Quality Assurance visit team identified no immediate concerns.
High priority findings
The Quality Assurance visit team identified one high priority finding as summarised below:
- People with diabetes are not offered appointments at the point they are due for screening in either routine digital screening or slit lamp biomicroscopy.
Examples of practice that can be shared
The Quality Assurance visit team identified several areas of practice for sharing, including:
- Effective staff integration to form a new service with a focus on training, team working, wellbeing and clinical education
- Effective Trust engagement with a focus on quality of service delivery
- Engagement work for newly diagnosed people with diabetes to facilitate future attendance, including double appointment slots and guidance for staff to use at a first screening appointment
- Effective use of telephone monitoring to improve access for service users
- Screeners are diligent in the process of image capture to obtain the best possible quality
- Post screening information sheet regarding eye drops, side effects and giving feedback.
Recommendations
The following recommendations are for the provider to action unless otherwise stated.
| No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
|
Governance and leadership | |||||
|
01 |
Review and update the standard operating procedures in line with Trust QMS guidelines included within Appendix B | 1 |
6 months |
Standard |
Confirmation of documents that have been reviewed and updated |
|
02 |
Implement a series of initiatives to support service improvements, using the table at Appendix C as a guide |
1 |
12 months |
Standard |
Service improvement plan developed with progress and outcomes regularly shared |
|
03 |
Make sure that national and locally agreed audits are completed for the whole service area |
1 |
12 months |
Standard |
Audit schedule developed and summary findings shared |
|
Infrastructure | |||||
|
04 |
Review and update the clinical lead job description in line with both contractual arrangement and national guidance |
1, 15 |
6 months |
Standard |
Confirmation received |
|
05 |
Confirm if there is a documented camera replacement plan in place |
1, 2 |
6 months |
Standard |
Confirmation received |
|
Identification of cohort | |||||
|
06 |
Re-confirm the cross border practice arrangements with the Oxfordshire and Buckinghamshire diabetic eye screening service |
1, 4 |
3 months |
Standard |
Confirmation received |
|
Invitation, access and uptake | |||||
|
07 |
Develop and implement a recovery plan to enable all people with diabetes to be offered timely screening |
1, 6 |
3 months |
High |
Coverage related pathway standards met Recovery plan, modelling and impact assessment shared with commissioners and Screening Quality Assurance Service |
|
The screening test – accuracy and quality | |||||
|
08 |
Include the use of Phenylephrine in local Standard Operating Procedures and make sure screeners are appropriately trained on the risks and contraindications for its use |
1, 7
|
3 months |
Standard |
Updated Standard Operating Procedures and training in place confirmed |
|
09 |
Make sure that the Trust infection, prevention and control measures policies are consistently applied at the screening encounter and a reference/link added to the screening encounter Standard Operating Procedures |
1, 25 |
12 months |
Standard |
Confirmation that the Standard Operating Procedures has been updated and Trust policy is followed |
|
10 |
Conduct a prospective audit to determine if some people in slit lamp biomicroscopy pathway can be returned to routine screening or should be excluded |
1
|
3 months |
Standard |
Audit results and actions shared |
|
11 |
Make sure all staff who grade in the service undertake test and training in line with national guidance |
1, 3, 20 |
6 months |
Standard |
Confirmation received |
|
Referral | |||||
|
12 |
Make sure that the pregnant women with referrable retinopathy are referred to ophthalmology in line with national guidance. |
18, 19
|
3 months |
Standard |
Confirmation received |
|
13 |
Make sure that people with R3S that become ungradable are referred to ophthalmology in line with national guidelines |
9, 18,19
|
3 months |
Standard |
Confirmation received |
|
14 |
Hertfordshire Community Trust and commissioner should support the service to develop an effective relationship and improve engagement with ophthalmology colleagues from Princess Alexandra Hospital NHS Trust |
1, 9
|
6 months |
Standard |
Timely outcomes provided for referrals and follow up from Princess Alexandra Hospital and updates shared with programme board |
|
Intervention and outcome | |||||
|
None | |||||
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.
The Screening Quality Assurance Service will work with commissioners to monitor activity and progress of the recommendations for 12 months after the report is published. After this point the Screening Quality Assurance Service will send a letter to the provider and commissioners summarising progress made and will outline any further action(s) needed.
Appendix D: References
- Diabetic eye screening programme. Service Schedule 2. (no.23) 2025-2026. 2025-2026 NHS Diabetic Eye Screening Programme Service Schedule 2_FINAL – Vaccinations and Screening – Futures
- 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
- Use of mydriatic eye drops. Use of mydriatic eye drops in the NHS diabetic eye screening programme – GOV.UK
- 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 Profiles & Local Authority Health Profiles – Data | Fingertips | Department of Health and Social Care
- 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
- Patient grading referral surveillance Diabetic Eye Screening pathway overviews
- 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
- Herts insight Census 2021 Profile for Hertfordshire. Census 2021 Profile – County | Hertfordshire | Report Builder for ArcGISHerts insight – Census 2021 Profile for Hertfordshire
- West Essex. Locality Context. https://www.essexproviderhub.org/the-essex-market/market-position-statement/locality-based-commissioning/west-essex/
- Indices of deprivation 2019 scores for Local Authorities: https://www.gov.uk/government/statistics/english-indices-of-deprivation-2019
- The College of Optometrists. Guidance for professional practice. Methods of preventing infection transmission from person to person – College of Optometrists