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Diabetic Retinopathy Screening Services in Scotland: Recommendations for Implementation



Diabetic Retinopathy Screening: Introduction

1. There is a national epidemic of diabetes. It is believed to affect about 3% of the population, and 5% of the population aged over 50 years. The number of people with this condition is forecast to double by the year 2015, largely due to an increase in the prevalence of Type 2 diabetes. Diabetes is associated with significant morbidity and early mortality. It increases the risk of blindness, renal failure and amputation. Much of this could be prevented by provision of effective integrated care.

2. Diabetic retinopathy is the biggest single cause of blindness and visual impairment amongst working age people in Scotland. (1) Up to 10% of people with diabetes have retinopathy requiring ophthalmological follow-up or treatment. (2,3,4) In its early stages, diabetic retinopathy is symptom-free and progression of disease can be prevented by laser treatment or by improved metabolic (2,5,6,7) and blood pressure control, (7) so detection by regular screening is beneficial.

3. The importance of eye screening as part of high quality diabetes care was recognised by Our National Health: A plan for action, plan for change(8) which indicated that: "The Framework will include plans to establish a national screening strategy for diabetic retinopathy." The Scottish Diabetes Framework (9) highlighted eye care as one of the 'first stage priorities' of diabetes and undertook to implement the recommendations of the Health Technology Board for Scotland (HTBS).

4. The Health Technology Board for Scotland has determined the most effective and efficient approach to achieving, implementing and sustaining a quality assured, national screening programme for diabetic retinopathy that takes account of patient preferences. (10) In his statement that launched the report in April 2002, Malcolm Chisholm, the Minister for Health and Community Care expressed his support for the introduction of a screening programme, establishing a group chaired by Dr Jeffrey Jay - the Diabetic Retinopathy Screening Implementation Group (DRSIG) - to define key national and local requirements to establish the programme. Membership of the Group is set out in Annex B.

5. NHS Boards are expected to implement a diabetic retinopathy screening programme in line with the recommendations of the Health Technology Board for Scotland. This report sets out the expected timetable for action and the work in hand to support implementation. Although some elements of diabetic retinopathy screening will take some time to develop, this should not constrain NHS Boards from making progress to improve the availability of screening to people with diabetes.

Key statement 1: The Health Technology Assessment report by HTBS sets out the model of eye screening for diabetic retinopathy to be implemented in Scotland. This report by the Diabetic Retinopathy Screening Implementation Group (DRSIG) endorses the recommendations of HTBS whilst extending and developing some of the report's themes, particularly the practical issues of implementation.

Key statement 2: NHS Boards are responsible for ensuring that all appropriate people with diabetes in their area are offered diabetic retinopathy screening (DRS). The responsibilities of the National Services Division (NSD), NHS Quality Improvement Scotland and the Scottish Executive to support and monitor DRS are outlined in this report.

6. The position with regard to the application of HTBS advice has been clarified by the Minister for Health in a Parliamentary Answer of 12th March 2002: "NHSScotland should take account of advice and evidence from the Health Technology Board for Scotland (HTBS) and ensure that recommended drugs or treatments are made available to meet clinical need. The Executive will monitor NHS Boards' adherence to HTBS advice and will follow up any non-adherence". However, the Scottish Executive acknowledges that a comprehensive diabetic retinopathy screening programme will be introduced gradually. All NHS Boards are expected to have fully implemented diabetic retinopathy screening by March 2006, although it is anticipated that most boards will be able to implement a full service considerably earlier.

Key statement 3: All patients with diabetes aged 12 and over in Scotland will be offered diabetic retinopathy screening using digital photography within an organised NHS Board programme that meets the recommendations of the HTBS report and this report produced by the DRSIG. A comprehensive programme will be fully operational throughout Scotland by March 2006.

7. A significant proportion of people with diabetes are currently being screened for retinopathy. There must be no diminution of service during the transition from current screening arrangements to a more systematic, comprehensive programme based on digital photography. In developing diabetic retinopathy screening services, NHS Boards should initially target patients who have not been screened at all or who have not been screened for a long time.

8. The DRSIG strongly endorses the approach to the screening process recommended by the HTBS. The key features of this approach (such as the use of digital photography, the three-stage process in relation to the use of mydriasis and the three-level grading procedure) are outlined in Annex F. Full details can be found in the HTBS report.

Key statement 4: In order to implement appropriate quality assurance, NHS Boards which have established schemes based on slit lamp examination will need to implement a digital camera scheme by March 2006.

9. The DRSIG acknowledges that further modifications to diabetic retinopathy screening in Scotland will be required as the programme is developed. The HTBS report recommends a number of areas for further research (e.g. clinical effectiveness, organisational issues, patient issues and economic evaluation). Additional research needs will also be identified in the light of experience. Research is considered in more detail below ( see paragraph 98).

10. Implementation of diabetic retinopathy screening in Scotland will require a number of supporting documents. The purpose and content of these documents is outlined below. These documents will be available within the next nine months.