Annual Report Diabetic Retinopathy Screening Service (Croydon Diabetic Eye Screening Programme) 1 st June 2010 30 th November 2011 1
Content Page i Chairs Message 3 1.0 Mission Statement, Aims and Objectives 5 2.0 Diabetic Retinopathy Screening Programme 5 3.0 Diabetic Retinal Screening Pathway 5 4.0 Screening Population 6 5.0 Screening Uptake 7 6.0 Exclusions 8 7.0 KPI Performance 8 8.0 External Quality Assurance Visit 9 9.0 Multidisciplinary Meetings 10 10.0 IT Delivery Model 10 11.0 Financial Report 10 12.0 Quality Domains 10 12.1 Staff Training and accreditation 10 12.2 Effectiveness/Audit Activity 11 12.3 Safety 12 12.4 Patient Experience 12 12.5 Complaints and Compliments 13 13.0 DRSS Programme Board 13 Appendix 1 Screening Uptake by GP 15 Appendix 2 Exclusions by GP 16 Appendix 3 Minutes of DRSS Programme Board 17 Appendix 4 EQA Action Plan 18 Appendix 5 DRSS Incidents 19 2
i. Message from the Chair of the Croydon Diabetic Retinopathy Screening Service (DRSS) Programme Board Diabetes is a major health problem nationally and for Croydon. Over 18,000 people in Croydon have been diagnosed with diabetes and this figure is increasing rapidly. Poorly controlled diabetes leads to a range of complications including damage to the eye leading to loss of vision and blindness if left untreated. Diabetes is one of the main causes of preventable visual loss and blindness in the UK. The NHS Diabetic Eye Screening Programme (NDESP) is a population based screening programme that aims to reduce the risk of sight loss among people with diabetes through early detection and appropriate treatment. In Croydon, the Diabetic Eye Screening Programme is delivered by Croydon Health Services Diabetic Retinopathy Screening Service working with Croydon University Hospital s Hospital Eye Service. The first annual report This first report covers a challenging time of adjustments and restructuring for the service. Immediately prior to the period covered by the report, the service received an External Quality Assurance Visit from the NDESP. A number of improvements as recommended by the NDESP were implemented over the ensuing months. These improvements included transforming the DRSS Steering Group into a fully functioning Programme Board leading on strategic planning, performance management and governance. Areas of good performance During the reporting period, the service has performed well on the proportion of patients taking up screening and the speed with which their results were issued. It also achieves a high score in terms of positive feedback from patients. Areas in need for improvement A number of areas are currently being investigated in order to improve the quality of care received by Croydon patients having their eyes screened for diabetic retinopathy. One of these is that a significant number of patients are temporarily excluded from screening while they are under the care of the hospital eye service. During the reporting period the programme was not meeting the threshold for patients with R3 (proliferative retinopathy, requiring urgent referral) receiving a consultation within a four week period, primarily due to patients cancelling or not attending appointments. There is also a significant variation in screening uptake between GPs in Croydon. Looking to the future Over the next few months, a number of challenges lie ahead of the service and all partners involved in the provision of high quality and safe services from people with diabetes in Croydon. The implementation of the new NHS Diabetic Eye Screening Programme pathway fit for service from April 2013 will be a priority. The service will be working with the Hospital Eye Service to ensure that the length of time spent by patients under the care of the eye department is reduced so that they are excluded from the screening programme for as short a period as possible. 3
Work towards reducing the variation in uptake from GP practices will continue and the referral rates of patients with proliferative retinopathy will have to be improved. As a result of all this work, we will continue to improve the quality of care for individual patients and most importantly reduce the risk of visual loss and blindness. Dr Ellen Schwartz Consultant in Public Health 4
This is the annual report for Croydon s Diabetic Retinopathy Screening Service. The reporting period is between 1 st June 2010 and 30 th November 2011. It covers an 18 month period so that data relating to patients referred to the Opthalmology Department following identification of retinopathy / maculopathy is able to be incorporated. 1.0 Mission Statement, Aims and Objectives The NHS Diabetic Eye Screening Programme delivered at Croydon Health Services NHS Trust aims to reduce the risk of sight loss amongst people with diabetes by the prompt identification and if necessary effective treatment of sight threatening diabetic retinopathy at the appropriate stage of the disease process. Numbers (per million population) of new cases of registrable visual impairment due primarily to diabetic retinopathy will reduce over time, against the local baseline established for 2008-09. The English National Screening Programme for Diabetic Retinopathy (ENSPDR) expectation is that a reduction of 10% over five years is the minimum required, and that a reduction of 40% is achievable. The programme objectives are to ensure that: all people registered with Croydon GPs who have a diagnosis of diabetes are included on a single collated list held by the service all eligible patients are invited for screening at least once a year the screening process from invitation to completed grading is carried out in line with national guidance and standards screen positive patients are referred to the designated Eye Unit in a timely way ophthalmological assessment and, if appropriate, treatment are provided within the nationally set timescales 2.0 Croydon Diabetic Eye Screening Programme Diabetic retinopathy is one of the leading causes of blindness in the working age population and prevalence rates are on the increase. Retinopathy is symptom-free until it is in the late stages; retinal screening can reduce the risk of blindness in a diabetic population by detecting retinopathy at an early stage. If it is detected at an early enough stage then laser treatment can prevent it from progressing and therefore save sight. The Croydon Diabetic Retinopathy Screening Service (DRSS) programme was established in 1999 but did not offer screening to the entire Croydon cohort of patients until 2008/2009. The English National Screening Programme for Diabetic Retinopathy (now known as NHS Diabetic Eye Screening Programme) commenced in 2003 and implementation of the programme across the whole of England took place between 2003 and early 2008. National Quality Assurance Standards were introduced, which programmes have to report against and the first Quality Assurance visits started in 2007. 3.0 Diabetic Retinal Screening Pathway All patients with diabetes over the age of 12 are offered diabetic retinopathy screening using digital photography. An invitation to patients is automatically sent on an annual basis inviting them to screening or more frequently if the screening programme requires it. Patients are also contacted by phone to remind them of their appointment. Patients who fail to attend are sent another appointment and 5
their GP is informed. If they fail to attend on two occasions they will automatically be moved on one year. Patients and their GP are sent result letters within 20 working days of their appointment. The result letter will inform patients of the following outcomes: No retinopathy Mild retinopathy Referable maculopathy / referable background retinopathy/ proliferative retinopathy 4.0 Screening Population Source: Data from Croydon general practices, 30 September 2009 There are around 364,000 people living in the Borough of Croydon. Croydon currently has in the region of 18,000 patients over the age of 12 who are eligible for DRSS screening. This represents an increase of approximately 800 patients since last year. All patients are invited to a screening appointment on an annual basis. Croydon DRSS has a single commissioner/provider Croydon Healthcare Services NHS Trust (CHS). CHS has two fixed sites one at Croydon University Hospital and one at Purley Memorial Hospital The map above indicates the prevalence of diabetes in the Borough - the higher rates of diabetes are in the North and East of Croydon and the lowest are in the Centre and South, suggesting strong links with deprivation. There are significant differences in the diabetes prevalence between people of different ethnicities in Croydon. Mixed and Asian groups have the highest prevalence rates. Croydon`s population is highly transient with patients moving in and out of the area. 6
5.0 Screening Uptake DRSS Croydon offers a fixed appointment system whereby patients are allocated an appointment in one of two locations, Croydon University Hospital or Purley War Memorial Hospital. In the reporting period 1 st June 2010 30 th November 2011 (18 months) a total of 19488 patients received screening. 1539 patients were referred on to the ophthalmology department with retinopathy/maculopathy. 220 of these patients were placed on the 2 week pathway (Urgent) There are significant variations in screening uptake across Croydon s 63 GP practices. Between 1 st September 2011 and 30 th November 2011, 12 general practices had an uptake of only 50-70%. Further data is shown in Appendix 1 A minimum of 80% of people screened are sent the result in writing within 4 weeks (20 working days) of the photograph being taken The table below shows rolling annual figures, updated on a monthly basis, for the number of eligible diabetic patients, the number of patients excluded from screening, the number of patients who were invited for screening, the actual number of patients who were screened in the DRSS service and uptake and exclusions in terms of percentages. Reporting Period Number of patients with Diabetes identified by practices in the PCT Number of patients with diabetes excluded from screening Number of patients with diabetes offered Screening Number of patients actually screened % uptake Over/ under performance % patients excluded 01/04/10-31/03/11 17974 2782 15351 15192 98% 0.9% 15.5% 01/05/10-30/04/11 19794 2915 14866 16879 113% 1-10.2% 14.7% 01/06/10-31/05/11 17869 3059 15667 14810 94% 4.8% 17.1% 01/07/10-30/06/11 17861 3136 16658 14725 88% 10.8% 17.6% 01/08/10-31/07/11 17954 3250 17313 14704 84% 14.5% 18.1% 01/09/10-31/08/11 17986 3365 17200 14621 85% 14.3% 18.7% 01/10/10-30/09/11 18098 3480 17029 14618 85% 13.3% 19.2% 01/11/10-31/10/11 18196 3581 16659 14615 87% 11.2% 19.7% 01/12/10-30/11/11 18210 3646 14719 14564 98% 0.9% 20.0% (During Q1 2010/11 there were approximately 800 patients invited who were not diabetic due to coding issues at the GP practices - those patients who booked for screening were screened) The number of eligible diabetic patients is defined as the number of living patients aged 12 yrs and over on the programme who are registered at the final day of the reporting period, who had not been withdrawn from screening prior to the end of the reporting period. The number of patients excluded from screening by DRSS is defined as the number of patients excluded from screening at the end of the reporting period. The number of patients invited to be screened by DRSS is defined as the number of patients who received screening at least once during the 12 months prior to the end of the reporting period. 1 More patients were screened than offered screening during this period as the screening invites for those patients being screening were sent out prior to this reporting period 7
The number of patients screened by DRSS is defined as the number of patients who received screening at least once during the 12 months prior to the end of the reporting period. In December 2011, a small percentage of patients were invited to attend for their follow up appointment at slightly less than the 1 year interval. This was to enable additional capacity provided at Purley Hospital to be utilised more effectively. Capacity at Purley Hospital has now been reduced in line with the required activity. Patients are currently being offered appointments for screening 6 weeks in advance those who were due for annual recalls at the end of February 2012 are currently being booked into appointments during the second week of March. The additional capacity required to meet demand is also being provided by offering Saturday clinics The reason for the reduction in invites in Q3 2010/11 was due to a change in the booking process. In Q1 & Q2 2010/11, patients were booked 13 weeks in advance therefore more patients were invited in those quarters. From Quarter 3 2011/12, patients have been booked 6 weeks in advance with the aim of reducing DNAs and cancellations both from the hospital and patient. 6.0 Exclusions Patients in the following categories are excluded from the screening programme: Permanent exclusions: Deceased; Moved away No perception of light in both eyes (NPL) Temporary exclusions: Under ophthalmic care Opt Out Under 12 yrs of age As of December 2011, 3661 patients were excluded from the programme. This was 20% of the eligible cohort. 3596 patients were under the care of the Ophthalmology Department, 60 patients had opted out of the programme and 5 patients were under 12 years of age. The NHS Diabetic Eye Screening Programme recommends that exclusion levels should be lower than 15%. There has been a steady increase in the number of patients excluded from the programme over the period of this report. The vast majority of these are temporarily excluded due to being under the care of the Ophthalmology Department. Once discharged, they are returned to the screening programme. The Ophthalmology department is currently undertaking an internal validation exercise on the OP waiting list to ensure that patients referred from DRSS do not experience delays. Joint plans with Moorfield s Eye Hospital are being considered to increase capacity in the Ophthalmology Department 7.0 KPI Performance DRSS reports on a quarterly basis to NHS Diabetic Eye Screening Programme against 3 KPIs. DR1 is the % of patients offered screening who attend screening. DR2 is the % of patients screened whose results are issued within 3 weeks DR3 is the % of patients identified with proliferative retinopathy receiving consultation within three weeks. During the reporting period DRSS has performed well against DR1 and DR2, but consistently below the threshold for DR3 (which was introduced during the reporting period). Achievement against this indicator will be reduced by patients not attending a consultation and also if they already are under 8
the care of another HES. Below is the KPI return for the final quarter of the reporting period. DR3 is a rolling annual figure reported on a quarterly basis, out of the 36 patients referred for a consultation, 3 were under the care of Hospital Eye Services at other hospitals, 2 rebooked their appointments, and 4 did not attend 2. NHS Diabetic Eye Screening Programme requires the reasons for not receiving a consultation within four weeks to be listed on KPI returns. 1 st July 2011 30 th September 2011 DR1 Indicator Threshold Threshold Threshold Achieved Diabetic Less than 70 79.9% 80% and retinopathy: 70% greater 82.3% Uptake of digital screening encounter Number of subjects tested Subjects tested (numerator) is the number of subjects offered screening who attended a digital screening encounter during the reporting period. [Annual Report line 3.4] DR2 Diabetic retinopathy : Results issued within 3 weeks of screening Less than 70% 70% - 94.9% 95% and greater Number of results issued within 3 weeks Results issued within 3 weeks (numerator) is the number of subjects attending for screening to whom a screening result letter was issued within 3 weeks (21 days) of the screening encounter. [Annual Report line 5.4a] 99.4% DR3 Diabetic retinopathy : Timely consultation for R3 screen positive Less than 95% 95% and greater Number of subjects receiving a consultation within4 weeks Subjects receiving consultation within 4 weeks (numerator) is the number of subjects referred with proliferative retinopathy receiving consultation within 4 weeks (28 days) of notification of positive test. [Annual Report line 7.3.1.b] 76.2% DRSS data 75.0% PCT data 8.0 External Quality Assessment Visit On 13th May 2010 Croydon DRSS received an External Quality Assurance Visit from the NHS Diabetic Eye Screening Programme. The external peer reviewers were of the opinion that errors in the single collated list of patients eligible for screening including exclusions, the lack of formal protocols relating to list and exclusion management and failsafe, the evidence that patients were presenting to laser treatment with established eye symptoms without being known to the programme or without a referral from the screening programme and the evidence of under-grading and discharging of patients from ophthalmology were sufficiently serious taken together to warrant a Serious Incident being declared. A planned pause in programme delivery was suggested to assist the PCT and Trust in bringing about change swiftly and securely. The action plan drafted in response to the EQA can be viewed at Appendix A. In May 2010, a planned pause took place over 7 weeks in order to enable actions to be put in place to meet EQA recommendations. As a result of this pause, the number of invites for new and follow up appointments in the following 6 months increased in order to accommodate the activity lost during the pause. 2 NDESP have since informed DRSS that patients under the care of HES at other hospitals do not need to be counted as exceptions in returns. 9
9.0 Multi-Disciplinary Team Meetings Regular MDT meetings were set up following the EQA with membership from DRSS, ophthalmology and the diabetes department. These are run by the clinical lead for DRSS. Teaching is given to the retinal screening team and grading is discussed. Audits are agreed upon and these meetings are also used as a forum to enable the team to discuss challenging cases. 10.0 IT Delivery Model Software is currently provided by Orion (CIS) Healthcare which is currently undergoing a merger with Digital Healthcare. The programme has used Orion since 2009. 11.0 Financial Report Financial Year April 2010 to March 2011 The value of the block contract from NHS Croydon for the 2010/11 financial year was 400,572 of which 358,986 (89.6%) was allocated as the DRSS budget for the year. DRSS spent 337,978 of which 85% was spent on pay and 15% on non-pay items, leading to an underspend of 21,008. Financial Year April 2011 to November 2011 The value of the block contract from NHS Croydon for the 2011/12 financial year is 441,585 of which 349,451 (79.1%) has been allocated as the DRSS budget for the year. From April 2011 to November 2011 the department has spent 201,133 of which 91% has been spent on pay and 9% on non-pay items, which is an underspend of 32,175 after 8 months. The new service line reports which include overheads and corporate costs attributable to the service show a loss of 20,037 for the DRSS service for the period April 2011 to September 2011 and a forecasted loss at current rates of 34k for the 2011/12 financial year. 12.0 Quality Domains 12.1 Staff Training and Accreditation Staff responsible for undertaking DRSS screening undergo appropriate training which leads to an accredited qualification. The core/mandatory units of this training include: Unit 1: National Screening Programme, Principles, Processes and Protocols Unit 2: Diabetes and its Relevance to Retinopathy Screening Unit 3: Anatomy, Physiology and Pathology of the Eye and its Clinical Relevance Optional units Unit 4: Preparing the Patient for Retinopathy Screening Unit 5: Measuring Visual Acuity and Performing Pharmacological Dilatation Unit 6: Imaging the Eye for the Detection of Diabetic Retinopathy Unit 7: Detecting Retinal Disease Unit 8: Classifying Diabetic Retinopathy Unit 9: Administration and Management Systems in a Retinopathy Screening Programme This qualification has been designed as an accreditation of the minimum level of competence which is required by all personnel involved in the identification of sight-threatening diabetic retinopathy in the English National Screening Programme. 10
The National Service Framework for Diabetes stipulates that people with diabetes should be confident that the member of staff they see is adequately trained. This ensures that the Trust provides high quality care underpinned by clinical and service protocols and audit and that staff involved in the screening process have the interpersonal skills to communicate effectively. All staff who currently screen and grade patients at Croydon Health Services have passed a minimum of 8 units. All administrative staff have to pass a minimum of three units (1,2 & 9). 12.2 Effectiveness/Audit Activity Sight impairment Audit This is an annual audit carried out to monitor the incidence of visual impairment predominantly due to diabetic retinopathy in the London Borough of Croydon. It is a requirement of the NHS Diabetic Eye Screening Programme and the Royal College of Ophthalmologists and to fulfil the external quality assurance requirement that levels of visual impairment in Croydon a monitored annually. The audit will be presented at Programme Board, Quality Board and Clinical Governance in February 2012. Vitrectomy Audit The victrectomy audit is carried out as part of the requirements of the ENSPDR External Quality Assurance visit. The initial treatment for patients with proliferative retinopathy is pan retinal photocoagulation. A small number of these patients may need vitrectomy for a number of reasons. Repeated vitreous haemorrhage which does not clear or gets organised can lead to vitreous opacity affecting vision and preretinal fibrosis leading to tractional retinal detachment involving the macula. The aim of the audit is to look into the number of patients with proliferative diabetic retinopathy who have had a vitrectomy in the last year. Laser Audit The aim of the laser audit is to minimise the overall delay between the screening event and the first laser treatment (Objective 12 - ENSPDR Quality Standards). This audit has been registered with the clinical audit department but has not been completed. Screening to Treatment Timeline Screening to treatment audits are carried out on a monthly basis and patients pathways are tracked through this system. Their progress is checked at MDT meetings and regular team meetings. Essential components of the screening to treatment timeline are: All eligible people have a written invitation to attend for screening at least once every year Screening uptake is monitored at DRSS Programme Board level and action taken where targets are not achieved 11
The DNA/Failsafe protocol is followed for the management of non-attendees, both those who fail to attend appointments in screening and in ophthalmology and those who actively opt out of the screening programme, taking into account patient choice All staff involved in call-recall receive training in using the call-recall IT system before undertaking unsupervised work. Photographs are taken using equipment and techniques in accordance with national guidelines. All staff have full training and have to pass competencies in retinal screening before working unsupervised and all staff receive training in new techniques. All patients who are screened are sent the result in writing within 4 weeks (20 working days) of the photograph being taken. Graders must see a minimum of 1000 images per annum The DRSS service must submit national minimum dataset returns All DRSS staff complete on-line test and training image sets on a monthly basis and all ophthalmologists seeing retinal patients in clinic to complete once a year 12.3 Safety Incidents and Adverse Events All clinical and non clinical incidents are logged on the Trust`s DATIX system and are discussed at the Planned Care Directorate Quality Board. All incidents relating to DRSS are listed at Appendix 5. The majority of incidents relate to Croydon University Hospital s Ophthalmology Department As a result of a patient complaint regarding the Ophthalmology Department, a Serious Untoward Incident was declared on 21 st September 2011. The patient had been referred to the Eye Unit by DRSS and had had her outpatient appointment cancelled six times. Recommendations following the Root Cause Analysis Investigation were made to update the DRSS Failsafe Officer role and developing the eye unit Failsafe Officer role. Quality Assurance All DRSS staff have completed on-line test and training image sets on a monthly basis and all ophthalmologists who review retinal patients complete these tests annually. Clinical Governance All DRSS staff participate in monthly clinical governance sessions which are closely linked with the ophthalmology department 12.4. Patient Experience Croydon Healthcare Services obtain patient feedback using Just a Minute cards, which ask patients to score from 1(low) to 10 (high) how much they agree with the following statement: would you recommend this service to a friend or relative in a similar situation to you? The proportion of patients giving a low score is subtracted from the number of patients giving as high score to arrive at what is known as a Net Provider Score (NPS). Internationally, any score over 60% is considered a high achievement and DRSS consistently receives both a large volume of feedback and a high NPS. Week Ending NPS Score No. of Cards 04/11/12 62% 58 11/11/12 63% 224 18/11/12 77% 70 25/11/12 67% 110 12
12.5 Complaints Any complaints received in the DRSS service are dealt with in line with the Trust`s complaints procedure. These are discussed at the Directorate`s monthly Quality and Performance Board meetings and any lessons learnt are used to improve the service During the period 1 st June 2010 30 th November 2011 a total of 4 complaints were received. Three were about the Ophthalmology Department and related to cancelled appointments and waiting times and one was about a faulty light bulb in a lightbox at Purley Hospital a new lightbox was purchased 13.0 DRSS Programme Board The DRSS Programme Board was set up following the External Quality Assurance visit in 2010 / 11 The Board is responsible for overseeing delivery of the Diabetic Retinal Screening Programme in Croydon, to national standards as set by ENSPDR. This programme includes both the screening stage of the pathway, delivered by the Diabetic Retinal Screening Service (currently based at Croydon University Hospital), and the specialist assessment and treatment stage of the pathway, delivered by the designated Hospital Eye Service (currently the Eye Unit at Croydon University Hospital). Membership Role Name Consultant in Public Health, NHS Croydon Commissioning Manager, SWL Acute Commissioning Unit ENSPDR Regional Quality Assurance Manager Associate Director, Planned Care Out-Patient Services Manager DRSS Programme Manager Clinical Lead for DRSS Consultant Ophthalmologist Head of IM&T NHS Croydon DRSS Administrator Clinical Lead, Planned Care Primary Care Champion/GP Lead Consultant Diabetologist Management Accountant, Croydon Health Services Local Optometric Committee Representative User Representative Admin Support Associate Director, Integrated Healthcare Governance Frequency of Meetings Quarterly or as required Standing Items on the Agenda Service Specification Activity & Spend Reports from MDT meetings Audit Programme Annual Report Incidents and Complaints Grading Quality Assessments Annual on line report to ENSPDR 13
Staff Training Plan Evaluation and Review of Staff Training Plan Service Protocols and Operational Policy Log of new/updated Guidance received and action taken Quality Assurance List Validation and upkeep Vital Sign Monitoring reports Screening Uptake by GP practice DNA rates by GP practice Exclusion rates by reason and GP practice Screening Outcomes Service Monitoring Adherence to required timelines Accountability Annual Reports on the work of the Programme Board will be published and circulated formally to the following: Croydon Heath Services Integrated Governance Committee Clinical Quality Review Group (Croydon Health Services/Acute Commissioning Unit) Croydon Clinical Commissioning Group Performance data (including quality measures) will be reviewed by the Clinical Quality Review group on a regular basis, at least annually. Quoracy The Chair (or nominated Deputy) plus the Clinical Lead, the Programme Manager, the GP lead and the ACU representative are required to sign off all reports for external dissemination. Minutes from the 2010/11 DRSS Programme Boards are in Appendix 4 14
Appendix 1: Screening uptake by GP Practice 1 September 30 November 2011 SCREENING UPTAKE BY GP PRACTICE.doc 15
Appendix 2: Exclusions by GP Practice - 1 September 30 November 2011 EXCLUSIONS BY REASON AND PRACTI 16
Appendix 3: Minutes of DRSS Programme Board 23 June 2011 & 28 September 2011 DRSS Programme Board - 23 06 11 Minu DRSS Programme Board - 28 09 11 Minu 17
Appendix 4: Action Plan from EQA visit Copy of Copy of Copy of EQA Action P 18
Appendix 5: DRSS Incidents DRSS Incidents 06.10-11.11.xlsx 19