NHS England » Screening Quality Assurance visit report

Scope of this report

Topic	Shropshire	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	NHS England Midlands Public Health Commissioning Team
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	Yes	Not applicable
Intervention / treatment	Yes	Not applicable

Summary

The NHS Diabetic Eye Screening Programme aims to reduce the risk of sight loss among individuals 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 7 March 2023 to the Staffordshire and Shropshire Screening service which is commissioned by NHS England Midlands 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 make sure all eligible individuals 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 NHS England
data and reports from external organisations
evidence submitted by the provider
evidence submitted by associated hospital eye service providers
discussions with the commissioner
information collected during pre-visits (9 February 2023) to the service main office at Crooked Bridge Road and to screening and grading venues within the service boundary
information shared with the Midlands and East SQAS as part of the visit process.

The Staffordshire and Shropshire DES service was established in 2020 following a reprocurement process. Prior to this they were commissioned as two separate services. The service is provided by Midlands Partnership NHS Foundation Trust (MPFT) who were previously responsible for the Staffordshire DES service. NHS England Midlands Public Health Commissioning team commission the service to provide all aspects of the screening pathway in line with the NHS public health functions agreement 2022/23 service specification No.22.

The Staffordshire and Shropshire DES service covers a population of just over 1 million in Staffordshire and Stoke on Trent, 323,000 in Shropshire, and 185,600 in Telford and Wrekin. The service covers the whole of Staffordshire including Stoke and Trent and the districts of Stafford, Cannock Chase, East Staffordshire, Lichfield, Tamworth, South Staffordshire, Staffordshire Moorlands and Newcastle-under-Lyme. The Shropshire geography includes, Shrewsbury, Telford and Wrekin, Bridgnorth, Oswestry and Ludlow. The service provides diabetic eye screening for a population of approximately 112,500 individuals with diabetes across Staffordshire and Shropshire, registered at 203 GP practices and covered by 11 local authorities (LAs) and 2 integrated care boards (ICBs).

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 Envoy Hybrid Mailing.

Screener/grader technicians provide screening from 34 static locations including hospitals, community venues and health centres. In November 2021, the service introduced the use of mobile screening vans at an additional 7 locations across the services geography. The service also provide screening for 9 prisons and one mental health facility. Grading takes place at clinic venues, office-based and home-based locations.

Screen positive individuals requiring ophthalmic assessment or treatment are referred to 1 of 8 referral centres. These are:

University Hospital North Midlands NHS Trust (UHNM), Royal Stoke Hospital
Royal Wolverhampton NHS Trust, New Cross Hospital (RWT)
University Hospitals Derby and Burton NHS Foundation Trust, Queens Hospital, Burton (UHDB)
Royal Shrewsbury Hospital – Shrewsbury and Telford Hospital NHS Trust (SaTH)
Princess Royal Hospital, Telford – Shrewsbury and Telford Hospital NHS Trust
County Hospital, Stafford – part of University Hospitals North Midlands NHS Trust (for assessment only)
Sir Robert Peel hospital, Tamworth – part of University Hospitals Derby and Burton NHS Foundation Trust (for assessment only)
Samuel Johnson, Lichfield – part of University Hospitals Derby and Burton NHS Foundation Trust (for assessment only).

The prevalence of diabetes in England is 7.3% (2021/2022). Diabetes prevalence varies across areas covered by the service:

Staffordshire is 7.7%
Stoke on Trent is 8.8%
Shropshire is 7.1 %
Telford and Wrekin is 8.0%.

Staffordshire is a rural county. The population is mainly white apart from East Staffordshire where 6.2% of the population are from minority ethnic groups. Stoke on Trent area is largely urban and has the greatest ethnic mix with 10.4% of the population from minority ethnic groups.

The health of people in Staffordshire is varied compared with the England average. Life expectancy in Staffordshire (2016-2018 period) was 79.7 years for men and 83.1 years for women which is similar to the England average of 79.6 years for men and 83.2 years for women. However, life expectancy is 8.5 years lower for men and 7.0 years lower for women in the most deprived areas of Staffordshire (compared to the least deprived areas). The health of people in Stoke-on-Trent is generally worse than the England average. Stoke-on-Trent is one of the 20% most deprived districts/unitary authorities in England. Life expectancy for both men and women is lower than the England average.

Shropshire is a large rural county with urban areas in Telford and other towns across the county. Shropshire has a higher proportion of older people with an estimated 23% aged over 65 in comparison to the England and West Midlands average of 18%. The population in Shropshire and Telford is mainly white. Latest profiles show that 1.8% of the Shropshire population are from minority ethnic groups with Telford having the greatest ethnic mix of 5.3%.

The health of people in Shropshire and Telford and Wrekin is varied compared with the England average. Life expectancy in Shropshire is 80.5 years for men and 83.5 years for women which is higher than the England average. However, life expectancy is 5.4 years lower for men and 2.1 years lower for women in the most deprived areas of Shropshire (compared to the least deprived areas). Life

expectancy is 10.1 years lower for men and 8.7 years lower for women in the most deprived areas of Telford and Wrekin (compared to the least deprived areas).

Findings

This is the first QA visit to the Staffordshire and Shropshire DES service. The visit team observed a keen, compassionate, well led, motivated, and invested workforce, all of whom demonstrated a commitment to deliver a quality screening service for individuals with diabetes. It was clear to the visiting team that the service has a focus on increasing staff satisfaction and making sure that staff with different responsibilities are fully integrated within the team.

The service has challenges ahead in being able to deliver an annual screening interval and encourage uptake in individuals who have not previously engaged with screening. The service has completed a health equity assessment tool and has started some specific targeted initiatives to contribute to reducing health inequalities that requires further consolidation.

The service met 7 out of the 11 measurable national quality standards (annual 2021 to 2022). Standards for timely hospital eye service consultation for both urgent and routine screen positive cases were not met, although the service referred individuals to eye services within achievable timescales. The standards for offering a routine digital screening appointment and the proportion of people offered their appointment no later than 6 weeks after their recall date were not met along with the standard for people not attending screening within the last 3 years.

Immediate concerns

The QA visit team identified no immediate concerns.

High priority findings

The QA visit team identified 3 high priority findings as summarised below:

The service should develop a plan of how they intend to modify their screening model to achieve an annual recall interval. This should include capacity and demand modelling, a review of venue/clinic sites and an impact assessment which must be shared with commissioners
The service should be compliant with the national service specification and make sure that core service roles are permanent posts within the service structure for resilience and business continuity
The service should make sure that mydriasis is performed as part of the screening test for all individuals, unless contra-indicated.

Examples of practice that can be shared

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

Effective links with maternity services, diabetes services and prisons to make sure the eligible population are offered screening and their results shared
Engagement of non-attenders to facilitate future attendance, including phoning individuals on the day that they do not attend, and prompt escalation of pregnant individuals and children that do not attend
Use of a text message link to allow individuals to digitally opt out of screening for a specified time period
Provision of skill mix opportunities to encourage staff personal development and support business continuity and service resilience
Clear terms of reference and varied agenda for the multi-disciplinary team (MDT) meetings which are recorded so that any staff unable to attend do not miss out
Well documented and detailed risk assessments for screening sites and for grading at home so that key requirements and quality is maintained, and any risks identified can be mitigated
Provision of slit lamp biomicroscopy (SLB) included as part of the prison screening clinics so that an individual identified with unassessable images does not need to wait for an additional appointment
Freedom to speak up champions in all four ‘regional’ teams to support staff to speak up about any concerns and a management commitment to improving staff satisfaction for those working within the screening service

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 were made in this section
Governance and leadership
01	Update the service’s organisational structure to detail the reporting lines and escalation routes of the clinical lead and programme manager	National service specification Diabetic Eye Screening: roles of clinical leads	3 months	Standard	Organisational structure shared at programme board
02	Make core service roles permanent posts	National service specification Diabetic eye screening role descriptions	3 months	High	Confirmation that the programme manager and clinical manager posts are permanent posts reported to programme board
03	Update SOPs and local documented process/protocols using a standard template	National service specification	12 months	Standard	SOPs contained in Appendix C updated and reviewed and shared at programme board
04	Produce and share a service annual report	National service specification	12 months	Standard	Annual report produced and signed off in line with internal governance arrangements and shared at programme board
05	Develop a plan of how the current screening model intends to be modified to achieve an annual recall interval. The plan should include demand and capacity modelling, a review of venue/clinic sites and an impact assessment which must be shared with commissioners	National service specification National pathway standards	3 months	High	Plan, modelling, and impact assessment to be shared with commissioners and SQAS Service to strive to achieve an annual recall interval within the next 6 months and meet the acceptable pathway standard
06	Review and update the service’s incident management policy to make sure it is in line with national guidance and that staff are aware of what constitutes, and how to report, a screening incident	National service specification Managing safety incidents in NHS screening programmes NHS England Serious Incident Framework	3 months	Standard	Reviewed SOP shared with programme board Confirmation of policy recorded in team meeting minutes/training sessions
07	Develop and implement an action plan to consolidate work already undertaken and work planned to identify and reduce screening inequalities	National service specification Guidance for NHS commissioners on equality and health inequality duties 2015 NHS Accessible information standard	6 months	Standard	Action plan shared at programme board
Infrastructure
No recommendations were made in this section
Identification of cohort
No recommendations were made in this section
Invitation, access and uptake
No recommendations were made in this section
The screening test – accuracy and quality
08	Continue to monitor and audit the unassessable rate, taking action to make sure that the national pathway standard can be achieved. Review the use of non height adjustable chairs at screening venues as part of this audit	National service specification Diabetic Eye Screening audit schedule National pathway standards	6 months	Standard	Audit results and actions presented to programme board Service to meet the national pathway standard for unassessable rate (4% or below) Outcome of review of use of non height adjustable chairs shared at programme board
09	Review and update leaflet to include contact details and reference to acute angle glaucoma and make sure screeners communicate this information during the pre-screening process	National service specification Use of mydriatic eye drops in the NHS diabetic eye screening programme guidance			Reviewed SOP and leaflet shared with programme board
10	Make sure that eye drops are used for all individuals unless contra-indicated	National service specification Use of mydriatic eye drops in the NHS diabetic eye screening programme guidance	3 months	High	Reviewed SOP shared with programme board Confirmation of policy recorded in screener training sessions
11	Review triage policy so that triage is consistent and effective for those with potential urgent disease	National service specification The management of grading quality: good practice in the quality assurance of grading	3 months	Standard	Reviewed SOP shared with programme board Confirmation of policy recorded in MDT/screener/grader training sessions
12	Include the appropriate use of enlargement and manipulation tools in training sessions for graders	NHS Diabetic Eye Screening Programme: Grading definitions for referrable disease The management of grading quality: good practice in the quality assurance of grading	6 months	Standard	Outcomes recorded in MDT or grader training sessions SOPs amended as/if appropriate
Referral
13	Re-establish and improve two-way communication links with associated HES referral centres to include access to screening images and feedback of information to facilitate audits (such as sight impairment/severe sight impairment and laser/treatment information)	National service specification Diabetic eye screening managing referrals to hospital eye services Diabetic Eye Screening audit schedule The Royal College of Ophthalmologists: The Delivery of Diabetic Eye Care	6 months	Standard	Feedback from meetings with associated HES services to be provided at programme board. Confirmation that screening images can be viewed in UHDB HES clinics to be provided at programme board. SOP for sight impairment data collection from all associated HES developed and shared at programme board. SOP for laser/treatment data collection from all associated HES developed and shared at programme board.
Intervention and outcome
No recommendations were 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

Diabetes profile data – profile-group.cardiovascular-disease-diabetes-kidney-disease/profile/diabetes-data
Ethnicity data – Public – Public helath profiles
Public health profiles Health Profiles

Older People profile – Shropshire older-people-in-shropshire-profile-and-forecast
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 201
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
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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