I was beginning to think I’d dreamt that on the Radio 4 Today programme on the way to work (October 16) I heard Professor Sir Mike Richards talking about his review of adult screening services in the UK. He revealed that the major adult screening programmes, though proven effective, could be better. By offering them from more locations and at more convenient times, participation rates among target audiences, who are virtually all of working age, would be improved from current rates of a little over 60%. Diabetic retinopathy screening was mentioned by name and I got excited for a moment that this might be the lever those that represent primary eye care optometrists need to widen the commissioning of diabetic screening via primary eye care optical practices.
I say dreamt because there was no space for this important news on either mainstream TV or any of the half dozen newspapers I looked at that day or over the next couple of days – another opportunity missed no doubt – but the details are on BBC online.
It’s been a while since I’ve worked in a practice that’s had any involvement in diabetic eye screening and I’m not sure I’d want to see it back in practice in my area unless practices received assurances that it was for the long term. In the past I’ve seen a practice invest in hospital specification field screening equipment at very considerable expense only to see the service recommissioned less than a year later and their investment go effectively to waste, or at least not generate the expected marginal return on investment.
Worse, however, was the uproar among patients who had gone from a seven day per week service in a choice of a dozen local practices with no waiting list and immediate reassurance/diagnosis, to a new ‘man with a van service’ where they were told where and when to attend and penalised if they rearranged their appointment more than once. Things got a little better for patients when the hospital took control – at least the camera works when it doesn’t spend its days rattling around in the back of a Ford Transit. There were other benefits too.
While I’m sure opticians could provide a better service I’m not convinced that the service should come back out into practice unless the way things are done fundamentally changes. My uncertainty has been as a result of attending CPD events relating to diabetes and hearing other points of view.
At one Diabetes UK event we heard first hand from a consultant diabetologist that retinal screening has been a resounding success, it is the flagship, the standard bearer, for screening in general because it has the highest attendance rates and the evidence suggests that as a result visual impairment due to diabetic eye disease, despite diabetes itself increasing, has fallen. Diabetic eye disease has dropped off the top spot as the number one cause of visual impairment in people of working age and has now fallen below hereditary retinal conditions.
On the face of it improving service access and thereby improving participation rates can only be a good thing, however the next speaker sowed the seeds of doubt in my mind. He spoke about foot ulcers, the result of peripheral neuropathy, and I was glad to have seen the slides after the buffet rather than before. The take home message was a person with a diabetic foot ulcer has more chance of being dead within two years than someone with a recent diagnosis of cancer and although most diabetics religiously attend their eye appointments they don’t attend to their feet with the same regularity.
The event was multidisciplinary, with doctors, nurses, optometrists, dieticians and others involved in diabetic care in the audience as well as students and a large number of patients whose attendance caught some of the speakers by surprise at question time.
The problem had already been solved in one hospital represented at the event. They had recently started checking blood sugar and feet when people attended for retinopathy screening – after drops were instilled patients were instructed to remove their shoes and socks and the examination could be carried out in the time it took for the pupils to dilate. Patients were delighted that three hospital trips had been reduced to a single visit but more importantly, dietary compliance, blood sugar control and foot problems all improved as a result of increased monitoring. It became clear that primary care optometrist led retinopathy screening was a barrier to this multidisciplinary approach and led to fractious debate.
The question is not whether screening should go back under hospital control but whether primary care optometry practices should develop the skills to do blood tests and employ the personnel to take care of feet so patients (and the system) benefit from a reduced time burden and better health outcomes. Is Professor Sir Mike Richards right to want more screening outside of the hospital environment or not?