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Diabetic Retinopathy Screening Services in Scotland: Recommendations for Implementation



Diabetic Retinopathy Screening: Annex H: Barriers to Implementation

Barriers to Implementation

Argyll and Clyde

Ayrshire and Arran


Dumfries and Galloway


Forth Valley


Greater Glasgow







Western Isles

Links to CHI

CHI contact block downloaded from Sema every 6 months

No direct links to CHI. Diabetes register updated with CHI from practice returns

Access database populated manually by CHI

No data returned

Area register on Access database. No links to CHI

CHI data entered manually

Plans to obtain one of CHI download to populate register/retinal screening system

Not at present

CHI data are linkage to Labs/SCI Store and register

Preferred option - automatic linkage between register and CHI. Issues of consent outstanding

CHI - on register record record


No link to Board CHI at present

Yes - electronic link with nightly updates

No links - entered manually

Validity of local registers

Access database updated by Diabetes Facilitator - validated by registered GP

LDS system updated on yearly basis with info from practices. Random check done yearly

No validation at present

No data returned

Validation in primary care all practices signed up to maintaining register

Register updated manually - facilitator visits practices. 20-month cycle

No formal validation at present

Will be done through SCI - Clinical

Diabetes facilitator visits practices, inputs data directly. No formal validation

Updating done in real time in clinics No validation.

Data collected manually on laptop. Six practices have online access to Lanarkshire system

Register in planning, to be linked to SCI network

GP returns put on computer database

Manual validation of data and web-based for primary/secondary care

Register validated and updated person daily by one

Variability of QA

Annual post-grad meetings for optometrists and other key players

Regular feedback to practices of RS data. QA systems under review

No QA at present

No formal QA at present

No formal QA

1st QA sampling practices of RS data QA systems under review

10% of all 1st level images, 10% all 2nd level images not passed on for 3rd level grading

In planning as part of new programme

No current QA of optometrists. 10% hospital images checked by Cons Ophthalmologist

Almost all images rechecked by Cons in clinics

No formal QA at present. Some audit of referral to ophthalmology


Informal feedback from ophthalmologist on optometrist referral

10% all images double graded and monthly reports produced

Current QA undertaken by Ninewells

Systematic approach to screening

Current screening covers >1/3 of patients via accreditated optometrists or hospital clinic

Current screening by accreditated optometrists + GPs. 73% patients on register have been screened

Dilated fundoscopy/ VA at GPs, hospital clinics and optometrists

Approx 80% diabetic population screened by optometrists.Majority by direct ophthalmoscopy

40 optometrists provide community-based screening - approx10,000 patients with diabetes

SDS - 78% screened Hospital-based. optometry programme

Current system exceeds HTBS recommendations

Implementation stage - four fixed cameras at four hospitals, non- mydriatic protocol

One digital camera in hospital clinic. GPs refer to local optometrists - slit lamp examination

90% patients screened in hospital clinics. Now also run GP only clinic

Clinics - approx 50% diabetic population Sixty optometrists - slit. lamp examination

Early stages of planning. Three options - buy in other service, fixed camera/hospital, local optometrist

Options paper drafted - plan to link to Grampian service?

Pre-implementation stage - combine static and mobile eye screening to meet national recommendations

HB contract with Tayside mobile unit to screen at all GP practices in Western Isles

Call/recall standardised

No comprehensive system in place - either done by GP, hospital clinic or optometrist

No specific system in place - plans to develop local system while waiting for SCI-DC

Hospital clinics check date of last screening in GP letter. Primary care - unsure

Currently main by ad hoc arrangements between GPs and optometrists

Done by optometrists

Currently run from hospital diabetes system- will lose this when move to SCI Clinical Develop one locally?

Call/recall for retinal screening via Access database. Currently RS software does not support this

None at present - bid submitted for more funding to support this

Currently GP is responsible. Some optometrists operate call/recall

Call/recall operated as part of normal clinic procedures

Hospital clinics/GPs - standard systems Optometrists do in islolation

No call/recall system at present

Done by practices or ophthalmology clinic

Call/recall arranged at practice level - awaiting national dev. of SCI-DC

None at present. Possibly develop system with Strathclyde University

Access to digital technology

No digital camera in use at present. Bid submitted

Three digital cameras, two hospital sites, one optometry practice

No access at present. One optometrist has digital camera

One digital camera in Eye Clinic. Possible use of camera in one optometrist practice

None at present - proposal for optometrists to purchase

Two digital cameras - Stirling, Falkirk, Do not meet recommended standard. Bids submitted to update/extend current service

Three digital cameras Two mobile and one fixed1 CR5/2 CR6 plus D30s

Four digital cameras procured

One CR5/Sony One CR6/D30 on order

Three digital cameras(Topcon) in place at hospital sites. No plans to update

One camera meets HTBS standard Four cameras/hospital clinics 2/3 in optometry

One camera that meets HTBS spec. in optometrist/Kirkwall

Ophthalmologists use mobile cameras. One optometrist has digital camera does not meet HTBS requirements

One static/one mobile plan to buy third one, appoint additional screener/grader

Using Tayside mobile. Clinicians do not see requirement to upgrade to HTBS recommendations


Annual post-grad meetings funded out of QA budget. Optometrists willing to be involved in audit/ clinical effectiveness

Retraining of optometrists/GPs on a yearly basis by Cons Ophthalmologist

Optometrists undertake training test by Consultant Ophthalmologist

No formal training/ accreditation programme in place

Accreditation programme in planning for optometrists


Accreditation of screeners through QA process

New staff will be trained and accreditated

Training course and accreditation by Cons Ophthalmologist and Diabetologist

No formal accreditation procedures in place

Optometrists accredited by Cons Ophthalmologist on. hold pending national training course

None at present

Visiting ophthalmologists

No accreditation currently



Funding for current system reached ceiling. Bids for digital cameras, software plus personnel submitted to Board

Optometrists paid 25/ examination Sub-group just set up. undertaking options appraisal

Optometrists receive standard HB fees x 2(check amount?) Bid submitted for diabetes facilitator

Pre-implementation stage, draft plan and estimated costings submitted

Recurring funding -12.50/optometrist/ screen. NHS grant to purchase digital cameras

Current funding - 40/50K, recurring About to review current programme in light of HTBS recommendations

Revenue funding in place

Capital, recurring funding allocated

Bid being submitted to Board for capital and revenue funding

Submitted bid to for funding since HTBS HB report - to increase clinic sessions and provide programme manager

Draft report being prepared to upgrade system and bid for further funding

No specific funding identified at present

Opportunistic screening at present, mentioned in Health Plan, no figures available

Recently obtained recurring funding implement programme to meets national standards

Ongoing funding for mobile screening in place

General comments

Keen to implement programme - require standardised pump priming to do so, however, part of HB prioritisation process

Clinical concerns re non-mydriasis lack of digital cameras in optometry practices - substantial capital investment training

RS sub group set up recently to look implementing HTBS recommendations. Diabetes dev. seen secondary care issue as

Plans to introduce mobile digital screening. Community optometrists retest screening failures

3 optometrists shown strong interest in being involved in new screening service

Hardware issues Ophthalmology issues Software issues Financial issues

Wide geographical area - issues of patient travel and equity of access

Key issue - must have register in place. Foresee huge health gain with implementation of RS programme

Claryifying and agreeing role of optometrists. Overcoming tensions between primary and secondary care

Key issue - QA of service because so many people involved not planning to involve optometrists

Keen to see national standards for call/recall fail-safe, training and patient information

Key issues - funding and establishment of diabetes register

Issues with logistics - small numbers, long distances, optometrists not viable because of QA

Limited by funding until recently - now ready to move forward

Wish to continue non- mydriatic protocol. Screening in van limits disabled access. Difficult to screen patients not picked up by van in remote/rural areas


No formal training at present

Done by Consultant Ophthalmologist

Done by Consultant Ophthalmologist

No formal training at present

Training done by ophthalmologists/ optometrists

Dept of Ophthalmology

Training course developed locally - providing standard for national course

Training to be provided by national RS training group

Current 'in house' training provided

Currently 'on the job' training provided by Diabetologists and Ophthalmologists

No formal training at present. Would use national training course for graders

No formal training/ accreditation at present


Will participate in HTBS training programme Currently in-house supervision/dev. of staff


IT - screening software, etc.

IT support poor - particularly in Acute Trust. Obtain optometry data via CD-ROM?

No specific software. Limited IT support - funding withdrawn for development of LDS system

No support from IT for local register. Desire to implement SCI-DC

No IM&T system at present. Awaiting national roll out of SCI-DC

Plans to link optometrists to NHS Net and then to SCI network

Greatest concern implementation of - SCI-DC means loss of call/recall

Plan to use JPEG compressed images for grading

IM&T system that meets requirements being implemented as part of a new programme

Bid for retinal screening system about to go to tender

Priority to link cameras to LDS system. Poor after sales advice and support from camera company

SCI-DC Clinical and Network to be implemented by end of year. IT support has been a problem

Options appraisal - bandwith problems if provide distributed service, online transfer, e.g. to Grampian difficult. Could use CD-ROM.

Agreed data record(including RS data) between GPs, Cons, diabetologists. To be integrated with local ECCI system

Elements of national system implemented through SCI DC audit tool. New software incorporates all screening reporting for HTBS

Paper-based recording identification, invitation, recall, attendance and results