Diabetes care for the future

The interest in maintaining a strong involvement in the screening of diabetics for retinopathy was underlined by the fact that in excess of 140 delegates attended last week's meeting in Birmingham to discuss this issue. Of these delegates, there were representatives of over 80 per cent of local optometric committees, along with members of strategic health authorities and lay members of advisory panels who had themselves experienced vision loss due to diabetes.
The importance of adequate eye screening of diabetics is well known and re-emphasised in the opening presentation given by Richard Broughton, one of the optometrist representatives on the National Screening Committee (NSC), the body set up by the Government to assess the best ways of screening diabetic eyes in England. Before describing the English situation, Broughton spoke of how there was already variation across the UK. Wales had gone down the route of a mobile technician with a camera (a 'man in a van' scheme) as used in the Bro Taf screening programme (optician, February 28, 2003). This is despite concerns about poor attendance rates and high technical failures such schemes have reported.
Scotland has moved towards a mixed scheme, with screening carried out by mobile facilities, some fixed hospital outpatient clinics and some community optometrist programmes. For auditing the community optometrists, a minimum of 500 patients per annum must be screened (by examination and captured image review) by each optometrist to allow them to remain within the scheme.
The NSC had already published recommendations in 2001 stating that the preferred method of screening was by using digital mydriatic retinal photography in both community and secondary settings with image review and interpretation to be carried out by accredited (and therefore appropriately trained) individuals. The use of slit-lamp biomicroscopy alone was considered a 'suboptimal' approach. As there were many schemes currently in operation that relied on this technique, then the introduction of a nationally recognised standard for schemes would necessarily require some investment and reorganisation in the near future. The Department of Health's Delivery Strategy for the Diabetes National Service Framework (NSF) reported in 2002 that 'the least cost-effective option is to go for a digital system using optometrists only' recommending instead 'a digital system with a mobile van'.
The argument for image capture and analysis has been won and Trevor Warburton, NSC sub-group member and authority on matters digital, gave a useful summary of the technical requirements for adequate image capture, including specifications for cameras and software. Interestingly, although most delegates were familiar with the tools available, Warburton emphasised that the final link in any screening programme, the patient management software, was as yet not readily available and that there was still the possibility of non-compatibility. He recommended practitioners considered this software first, as it was likely that the same suppliers might also provide capture software (possibly at a more attractive rate) and that there would then be fewer problems of non-compatibility between the two sets of software and the camera. Delegates were advised to view the information on www.nscretinopathy.org.uk.

Quality assurance
The next speaker was Lyndon Taylor, AOP director and instrumental in the organisation of this meeting. He stated that for an optometrist-based scheme, the recommendations currently proposed had to satisfy certain conditions for purposes of quality assurance.
Most delegates prior to the meeting had suggested that this QA was what concerned them most about current proposals. For there to be adequate monitoring of participant reliability, every optometrist would be required to grade a minimum of 500 diabetics a year (two satisfactory dilated fundus photographs for each eye per diabetic taken either by the optometrist or a trained assistant). In cases where image quality was inadequate, for example where there was cataract, the optometrist might need to re-examine with indirect ophthalmoscopy. The minimum to be assessed by any optometrist registered on a scheme was 250, but they would then need to also re-grade a further 250 patients' images to remain accredited. Concerns over these restrictions were the core of the afternoon discussions, neatly summed up by Taylor as 'what we may have is a QA system that occasionally does some screening rather than vice versa'.
While most delegates accepted that QA was essential for public health and for maintaining high clinical standards, most were keen to hear ophthalmologist and national co-ordinator of the Diabetic Retinopathy Screening Programme Peter Scanlon and National QA Lead Linda Garvican explain the rationale behind the proposed plans. Scanlon suggested that the proposal was fair in reducing the maximum of patients viewed from 500 to 250, so including optometrists where otherwise mobile technicians might have been. Garvican explained the figures were calculated with experience gained from previously successful programmes in breast and cervical screening programmes. The established minimum screening number was now officially 250.
Some delegates expressed concern that previous screening programmes were not comparable with retinopathy screening and, perhaps more specifically, when deciding 'man in van' schemes were more cost-effective, had not included the full costs of administration and analysis. Indeed the contention that optometrist-based schemes were more expensive was plainly wrong. Perhaps most importantly from the discussion, it was clear that optometrists should now be influencing PCTs in how to use the allocated money in the best interests of the patients; all agreed that this had to be one with the optometrist involved.
The interest in maintaining a strong involvement in the screening of diabetics for retinopathy was underlined by the fact that in excess of 140 delegates attended last week's meeting in Birmingham to discuss this issue. Of these delegates, there were representatives of over 80 per cent of local optometric committees, along with members of strategic health authorities and lay members of advisory panels who had themselves experienced vision loss due to diabetes.
The importance of adequate eye screening of diabetics is well known and re-emphasised in the opening presentation given by Richard Broughton, one of the optometrist representatives on the National Screening Committee (NSC), the body set up by the Government to assess the best ways of screening diabetic eyes in England. Before describing the English situation, Broughton spoke of how there was already variation across the UK. Wales had gone down the route of a mobile technician with a camera (a 'man in a van' scheme) as used in the Bro Taf screening programme (optician, February 28, 2003). This is despite concerns about poor attendance rates and high technical failures such schemes have reported.
Scotland has moved towards a mixed scheme, with screening carried out by mobile facilities, some fixed hospital outpatient clinics and some community optometrist programmes. For auditing the community optometrists, a minimum of 500 patients per annum must be screened (by examination and captured image review) by each optometrist to allow them to remain within the scheme.
The NSC had already published recommendations in 2001 stating that the preferred method of screening was by using digital mydriatic retinal photography in both community and secondary settings with image review and interpretation to be carried out by accredited (and therefore appropriately trained) individuals. The use of slit-lamp biomicroscopy alone was considered a 'suboptimal' approach. As there were many schemes currently in operation that relied on this technique, then the introduction of a nationally recognised standard for schemes would necessarily require some investment and reorganisation in the near future. The Department of Health's Delivery Strategy for the Diabetes National Service Framework (NSF) reported in 2002 that 'the least cost-effective option is to go for a digital system using optometrists only' recommending instead 'a digital system with a mobile van'.
The argument for image capture and analysis has been won and Trevor Warburton, NSC sub-group member and authority on matters digital, gave a useful summary of the technical requirements for adequate image capture, including specifications for cameras and software. Interestingly, although most delegates were familiar with the tools available, Warburton emphasised that the final link in any screening programme, the patient management software, was as yet not readily available and that there was still the possibility of non-compatibility. He recommended practitioners considered this software first, as it was likely that the same suppliers might also provide capture software (possibly at a more attractive rate) and that there would then be fewer problems of non-compatibility between the two sets of software and the camera. Delegates were advised to view the information on www.nscretinopathy.org.uk.

Quality assurance
The next speaker was Lyndon Taylor, AOP director and instrumental in the organisation of this meeting. He stated that for an optometrist-based scheme, the recommendations currently proposed had to satisfy certain conditions for purposes of quality assurance.
Most delegates prior to the meeting had suggested that this QA was what concerned them most about current proposals. For there to be adequate monitoring of participant reliability, every optometrist would be required to grade a minimum of 500 diabetics a year (two satisfactory dilated fundus photographs for each eye per diabetic taken either by the optometrist or a trained assistant). In cases where image quality was inadequate, for example where there was cataract, the optometrist might need to re-examine with indirect ophthalmoscopy. The minimum to be assessed by any optometrist registered on a scheme was 250, but they would then need to also re-grade a further 250 patients' images to remain accredited. Concerns over these restrictions were the core of the afternoon discussions, neatly summed up by Taylor as 'what we may have is a QA system that occasionally does some screening rather than vice versa'.
While most delegates accepted that QA was essential for public health and for maintaining high clinical standards, most were keen to hear ophthalmologist and national co-ordinator of the Diabetic Retinopathy Screening Programme Peter Scanlon and National QA Lead Linda Garvican explain the rationale behind the proposed plans. Scanlon suggested that the proposal was fair in reducing the maximum of patients viewed from 500 to 250, so including optometrists where otherwise mobile technicians might have been. Garvican explained the figures were calculated with experience gained from previously successful programmes in breast and cervical screening programmes. The established minimum screening number was now officially 250.
Some delegates expressed concern that previous screening programmes were not comparable with retinopathy screening and, perhaps more specifically, when deciding 'man in van' schemes were more cost-effective, had not included the full costs of administration and analysis. Indeed the contention that optometrist-based schemes were more expensive was plainly wrong. Perhaps most importantly from the discussion, it was clear that optometrists should now be influencing PCTs in how to use the allocated money in the best interests of the patients; all agreed that this had to be one with the optometrist involved.
The interest in maintaining a strong involvement in the screening of diabetics for retinopathy was underlined by the fact that in excess of 140 delegates attended last week's meeting in Birmingham to discuss this issue. Of these delegates, there were representatives of over 80 per cent of local optometric committees, along with members of strategic health authorities and lay members of advisory panels who had themselves experienced vision loss due to diabetes.
The importance of adequate eye screening of diabetics is well known and re-emphasised in the opening presentation given by Richard Broughton, one of the optometrist representatives on the National Screening Committee (NSC), the body set up by the Government to assess the best ways of screening diabetic eyes in England. Before describing the English situation, Broughton spoke of how there was already variation across the UK. Wales had gone down the route of a mobile technician with a camera (a 'man in a van' scheme) as used in the Bro Taf screening programme (optician, February 28, 2003). This is despite concerns about poor attendance rates and high technical failures such schemes have reported.
Scotland has moved towards a mixed scheme, with screening carried out by mobile facilities, some fixed hospital outpatient clinics and some community optometrist programmes. For auditing the community optometrists, a minimum of 500 patients per annum must be screened (by examination and captured image review) by each optometrist to allow them to remain within the scheme.
The NSC had already published recommendations in 2001 stating that the preferred method of screening was by using digital mydriatic retinal photography in both community and secondary settings with image review and interpretation to be carried out by accredited (and therefore appropriately trained) individuals. The use of slit-lamp biomicroscopy alone was considered a 'suboptimal' approach. As there were many schemes currently in operation that relied on this technique, then the introduction of a nationally recognised standard for schemes would necessarily require some investment and reorganisation in the near future. The Department of Health's Delivery Strategy for the Diabetes National Service Framework (NSF) reported in 2002 that 'the least cost-effective option is to go for a digital system using optometrists only' recommending instead 'a digital system with a mobile van'.
The argument for image capture and analysis has been won and Trevor Warburton, NSC sub-group member and authority on matters digital, gave a useful summary of the technical requirements for adequate image capture, including specifications for cameras and software. Interestingly, although most delegates were familiar with the tools available, Warburton emphasised that the final link in any screening programme, the patient management software, was as yet not readily available and that there was still the possibility of non-compatibility. He recommended practitioners considered this software first, as it was likely that the same suppliers might also provide capture software (possibly at a more attractive rate) and that there would then be fewer problems of non-compatibility between the two sets of software and the camera. Delegates were advised to view the information on www.nscretinopathy.org.uk.

Quality assurance
The next speaker was Lyndon Taylor, AOP director and instrumental in the organisation of this meeting. He stated that for an optometrist-based scheme, the recommendations currently proposed had to satisfy certain conditions for purposes of quality assurance.
Most delegates prior to the meeting had suggested that this QA was what concerned them most about current proposals. For there to be adequate monitoring of participant reliability, every optometrist would be required to grade a minimum of 500 diabetics a year (two satisfactory dilated fundus photographs for each eye per diabetic taken either by the optometrist or a trained assistant). In cases where image quality was inadequate, for example where there was cataract, the optometrist might need to re-examine with indirect ophthalmoscopy. The minimum to be assessed by any optometrist registered on a scheme was 250, but they would then need to also re-grade a further 250 patients' images to remain accredited. Concerns over these restrictions were the core of the afternoon discussions, neatly summed up by Taylor as 'what we may have is a QA system that occasionally does some screening rather than vice versa'.
While most delegates accepted that QA was essential for public health and for maintaining high clinical standards, most were keen to hear ophthalmologist and national co-ordinator of the Diabetic Retinopathy Screening Programme Peter Scanlon and National QA Lead Linda Garvican explain the rationale behind the proposed plans. Scanlon suggested that the proposal was fair in reducing the maximum of patients viewed from 500 to 250, so including optometrists where otherwise mobile technicians might have been. Garvican explained the figures were calculated with experience gained from previously successful programmes in breast and cervical screening programmes. The established minimum screening number was now officially 250.
Some delegates expressed concern that previous screening programmes were not comparable with retinopathy screening and, perhaps more specifically, when deciding 'man in van' schemes were more cost-effective, had not included the full costs of administration and analysis. Indeed the contention that optometrist-based schemes were more expensive was plainly wrong. Perhaps most importantly from the discussion, it was clear that optometrists should now be influencing PCTs in how to use the allocated money in the best interests of the patients; all agreed that this had to be one with the optometrist involved.
From left:Linda Garvican Trevor Warburton, David Cartwright and Richard Broughton