27 March 2019

Consultation on the way the Northern Ireland diabetic eye screening programme is provided

Read our response to a consultation on the way the Northern Ireland Diabetic Eye Screening Programme is provided.

1. Do you believe that all of the advantages and disadvantages of the shortlisted models have been identified?

Answer: No

Further details: 
Diabetic patients are often already attending their optometrist for regular eye examinations, independent of the DESP. Fundus cameras are available in almost all high street optometry practices now and where available, optometrists are recording fundus photographs for these patients. There is clearly a ‘doubling up’ of the same service that could be refined. Advantage of option 5 means the NHS is not paying for double appointment/screening for each diabetic patient.

Advantage of option 5 – Commercial premises will have to meet the general premises costs covered in other options by the NHS. Practices also will be providing routine maintenance and repair to their own fundus cameras (rather than NHS cameras).

Advantage of option 5 – High Street optometrists are ideally placed to deliver this service. They are in convenient locations, open convenient times and are wheelchair accessible. Practices have the ability to arrange appointments for patients to have their screening conducted at a suitable and convenient time for the patient (evening and weekend opening times). With regard to commercial premises, the contract should say ‘no poaching’ of other practices’ patients, and patients will be made aware that they are going for the diabetic screening and nothing else, so this shouldn’t be considered a disadvantage.

Many optometry practices are now equipped with OCTs so are in a position to offer maculopathy triage clinics for those graded M1.

Technicians do not have the skills to offer these services and the capital outlay is significant. They could easily be provided by an optometry-based service, without significant capital outlay

It is likely that the additional costs of such services would be less if an optometrist practice led option was chosen for the primary eye screening service. This should be reflected as an advantage for option 5 and a disadvantage for option 2a and 2b.

2. To what extent do you agree that the shortlisted models could provide a safe, high quality service and meet the demands of Northern Ireland’s increasing diabetic population?

Option 2a – Fixed HSC Sites - neither agree nor disagree
Option 2b – Fixed Primary Care Sites - neither agree nor disagree
Option 5 – High Street Optometry - strongly agree

3. If you are a person living with diabetes would you be happy to attend screening at the shortlisted options?

Not applicable.

4. In planning the future model we would use a specification to choose screening sites. Please rank the criteria below in order of importance to you (1 = most important, 6 = least important) 

Availability of public transport - 4
Availability of car parking - 6
Extended opening hours (i.e. evenings/weekends) - 3
Proximity to your home - 2        
Accessibility for those with sensory/mobility issues - 1
Co-location with other diabetes care services, e.g. podiatry - 5

5. Do you believe that all key implications for equality groups have been identified?

Answer: No

Further details:
Diabetes increases with increasing age therefore access needs to be good for older patients. It is important to have a service that can be easily accessed by patient so they are not discouraged from attending. Diabetes also comes with complications which may limit mobility of some patients which needs to be considered: closeness to home, good parking and flexibility of timing so transport can be arranged are important. Accessibility to those living in rural areas needs to be addressed.

6. What do you suggest we could do to address the equality issues identified?

Recruit the majority of high street optometrists across the province to provide the service.

7. Do you believe that all key implications for rural areas have been identified?

Answer: No

Further details:
Same as above (question 5).

8. What do you suggest we could do to address the rurality issues identified? 

Same as above (question 6).

Final comments

More detail is needed on what the logistical, training, standardisation and governance issues are for providing in high street optometry (option 5).

Optometrists are highly skilled practitioners who are already competent at measuring visual acuity and taking and grading fundus images.  Some training will be required on ensuring standardisation, audit, governance and record keeping but these are requisites in other services that optometrists will be familiar with (e.g. PEARS, glaucoma referral refinement).  The vast majority of practices in Northern Ireland have now got NHS email addresses to produce e-referrals; screening information/fundus photos could be electronically delivered back into the NHS using this facility.  High quality training is available to optometrists delivered by the College’s Professional certificate in medical retina, available at the University of Ulster. The course has been mapped to the new Level Three Diploma for Health Screeners (Diabetic Eye), and successful candidates will be automatically exempt from the majority of the NHS England DESP training.

How were the costs determined and why is high street optometry the most expensive?  If high street optometrists are providing the service they will have the equipment in place, will be paying for the accommodation, heating/lighting, equipment service and repair.  It seemed odd that this was the most expensive.  

Savings will be made with regard to mileage for mobile services, wear and tear of equipment and accommodation/premises costs.

Disadvantage to participants “screening provided in commercial premises”.  

Most participants will be attending these premises for their routine eye examinations anyway and are familiar with the staff/premises. Patients need to be informed that they can attend their optometrist for health benefits as well as for obtaining spectacles.  

Optometrists higher qualification in medical retina has now been aligned with the national screening committee requirements for UK national screening committee.  The College of Optometrists’ accredited Professional Certificate in Medical Retina is available at Ulster University. Additional workforce needs may be met by optometrists by undertaking this higher qualification. 

Commercial premises, are often supported by better infrastructure with more convenient parking and public transport links than regional fixed HSC locations. 

A detailed geographic comparison should be considered.  This may also contribute to a lower levels of ‘non-attendance’. 

The failure of the current scheme to maintain a satisfactory screening interval has not been adequately considered in service redesign options.  There is an assumption that regional fixed clinics would improve the ability to met this standard, with no explanation as to why.  A review of why the standard is not being currently met should be provided and must inform future commissioning, the impact of greater traveling could be included as part of such as review. 

Submitted: March 2019

Related further reading

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Research, including work carried out in high-street optometry practices, is driving innovation in clinical practice and at a policy level, writes Mark Gould.