Guidance

Diabetic eye screening: Diploma for health screeners rules of combination

Updated 29 April 2026

1. Overview

The Level 3 Diploma for health screeners is  the mandatory national training programme for new screening staff in the NHS Diabetic Eye Screening (DES) Programme..

It provides screening staff with a nationally recognised qualification to ensure they have the knowledge and skills required to work in a healthcare setting and in the screening programme. They can use the qualification to support career progression and their own personal development.

The qualification is designed to reflect work-based learning. Learners need to provide evidence of achieving the learning outcomes for a number of generic units that are based on the provision of quality care in a healthcare setting.

There is a range of training pathways to choose from depending on the staff roles working within diabetic eye screening. This guidance provides local DES providers with additional information about the appropriate units that must be undertaken by those roles.

New staff performing screening and/or grading need to undertake the Level 3 Diploma for Health Screeners. The previous City & Guilds qualifications are still valid for existing staff.

However, staff who have completed individual units from the previous qualification but not obtained the City & Guilds qualification need to complete the appropriate Level 3 Diploma units if they want to undertake additional roles. This applies, for example, for staff moving from assistant to screener or screener to screener grader. The HSD awarding body will discuss prior learning on registration for the Diploma in these circumstances.

The qualification has a number of generic and screening programme role-specific units that must be undertaken by the different staff roles. Learners progress through the different units required with support from their local screening service and an assessor who holds a current Certificate in Assessing Vocational Achievement (CAVA).

2. Generic units

Generic units provide screening staff with the basic understanding and core knowledge and skills for working in a healthcare setting.

3. Role-specific units

There are 6 role-specific units for DES staff. These are:

• anatomy, physiology, and pathology of the eye
• understanding diabetes and diabetic retinopathy
• preparing for diabetic retinopathy screening
• undertaking diabetic retinopathy imaging
• detection of retinal disease and classification of diabetic retinopathy

In addition, any screening clinician, who is commencing OCT interpretation after April 1st, 2026, must complete the OCT in digital surveillance unit.

The OCT in DS unit is mandatory recognised unit for staff who perform and capture OCT scans within DES. Those with prior external OCT training may be assessed locally by the Clinical Lead and, if deemed competent, are exempt from the unit.

3.1 Screener

The screener prepares the person for their screening test by:

• recording their consent to be screened
• undertaking a visual acuity test
• instilling mydriatic drops
• preparing and using the retinal camera and screening equipment for obtaining images of the eye
• assessing the quality of images
• determining the appropriate grading queue for the screening subject

Screeners must complete the generic units and the role-specific units as described in section 4 below.

Trainee screeners and unsupervised screening requirements:

Trainee screeners can only screen unsupervised if they have completed the National Competency Assessment for Unsupervised Screening in DES each local screening service should have a process in place to record when their manager is satisfied a trainee screener has completed this competency, is safe to screen unsupervised and has been signed-off by the Clinical Lead.

This process should include:

• evidence of completion of the National Competency Assessment for Unsupervised Screening
• evidence of completion of local mandatory training required for the role.
• timescales and plans for completion of the programme specific units, the generic units of the HSD within the 2-year time frame.

Services should retain documented evidence of this process.

3.2 Grader

Graders use the feature-based grading technique to identify features in the retina. The screening software then assigns the correct grade (up to arbitration level) according to those features.

Graders must complete the generic units and the role-specific units as described in section 4 below.

Trainee graders and unsupervised grading requirements

Trainee graders are those learning to grade who have not passed the diploma unit Detect Retinal Disease and Classify Diabetic Retinopathy. All new graders must complete and pass this unit before they undertake unsupervised grading. They must also complete the diploma for health screeners within 2 years of initial registration.

Trainee graders can only grade ‘live’ on DES software in a supervised capacity. To gain the appropriate grading experience required for the unit they should be overseen by a senior grader in their learning environment. Trainee graders must not independently complete any live grading within DES software for a ‘live’ patient until this unit is completed and the clinical lead is satisfied that the trainee is fully competent.

A learning outcome for the grading unit requires learners to evidence that they have assessed 200 image grades to a satisfactory standard and achieved satisfactory scores (minimum of 80% specificity and sensitivity) in 3 live monthly test sets as a trainee grader or fully observed and supervised training sets. This is to ensure trainee graders have been given the appropriate level of supervision, oversight, and training essential to complete the learning outcome.

DES providers should determine the best way to enable access to the appropriate number of supervised grades using existing educational resources, image libraries, test and training and grading software. Local services can determine if an image set constitutes 1 or 2 grades depending on each individual learner and training resources. An inter-grader agreement or Cohen’s Kappa is not required as assessment evidence.

Learners should develop a logbook locally to record their training grades. They should use this logbook to provide evidence of successful completion of the minimum 200 grades requirement.

The logbook should include as a minimum:

• identification number for reference (non-patient identifiable)
• trainee grader grade RXMX
• trainee grader outcome: RDS or DS or Referral (urgent or non-urgent) or U or SLB
• any additional comments the learner feels are relevant
• assessor or senior grader grade RXMX
• assessor or senior grader outcome RDS or DS or Referral (urgent or non-urgent) or U or SLB
• agreement in grade Y or N

This is the minimum requirement and local DES services may have additional competencies and procedures in place before unsupervised grading can occur. Completion of the 200 supervised grading and 3 live monthly test sets does not provide confirmation of competence in grading. This should be determined for each individual learner by the Clinical Lead.

3.3 Non-clinical grading staff

There may occasionally be non-clinical grading staff, such as centralised grading teams, working within a local DES service. They may not be able to complete some of the clinical observations associated with the qualification. In these cases, learners should complete the appropriate units for their roles, including:

• principles of health screening
• anatomy and physiology of the eye
• understanding diabetes and diabetic retinopathy
• detection of retinal disease and classification of diabetic retinopathy
• Non-clinical graders should complete their organisations mandatory training as required.

3.4 Screener grader

This is a combination of the screener and grader roles.

Screener graders must complete the generic units and role-specific units as described in section 4 below.

3.5 Optometrist

Some DES services sub-contract screening activity to local optometry practices.

Optometrists must maintain the appropriate professional registration (e.g. membership of the College of Optometrists, professional indemnity cover, and General Optical Council registration) and act within their scope of practice. In recognition of their professional registration status and prior learning Optometrists, to undertake all of the units and must complete the units as mandated in the rules of combination table, in section. They must also undertake any appropriate role-specific units for their position within the DES service.

Optometrists who also hold the Professional Certificate in Medical Retina have covered all the requirements for the Level 3 Diploma for Health Screeners (Diabetic Eye) with the exception of the ‘Undertake Diabetic Retinopathy Imaging’ unit and the assessment element of 3.1 of the ‘Detect Retinal Disease and Classify Diabetic Retinopathy’ unit.

Optometrists who gained the certificate in medical retina before October 2017 can apply for recognition of prior learning for some or all of the role-specific units. This should be done via their local DES service.

Additional requirements for optometrists holding the professional certificate in medical retina are to:

• have 200 supervised grades to satisfactory standard
• achieve satisfactory scores in 3 tests and training sets

Optometrists undertaking SLB examination for the programme must comply with the accreditation guidance as set out in DES slit lamp bio microscopy examiner framework

3.6 Assistant and support workers within an optometry practice

The role of assistant and support workers within an optometry practice can be used across the screening programme to support services in the provision of DES. It can involve undertaking initial patient verification, consent, visual acuity test, the instillation of mydriatic eye drops, decontamination of equipment and associated infection control measures.

Assistants and support workers within an optometry practice must not undertake photography, triage or grading of images.

Individuals undertaking this role must always be always supervised by an appropriately qualified Optometry clinical member of staff. If drops are instilled this should be in line with the Use of Mydriatic Eye Drops in the Diabetic Eye Screening Programme guidance

Assistants and support workers within an optometry practice are required to undertake the role-specific units as described in section 4 below.

Individuals will also be required to complete any local mandatory and clinical training requirements for this level of working and their role.

3.7 Assistant/Support workers not working within an optometry practice

Assistants and support workers not working within an optometry practice but working within the DES programme should not be instilling drops to individuals unless they have completed the appropriate units for the role of screener in the rules of combination table below. This is in line with the Medicines and Healthcare products Regulatory Agency advice in the ‘Use of mydriatic drops in the Diabetic eye screening programme’ guidance.

4. Rules of combination table

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           

Mandatory	Qualification structure			DES role
Unit number	Unit title	Level	Credits	Screener	Screener / grader	Non clinical grader	Optometrist	Optometrist with professional certificate	Optometrist based assistant screener	Non optometrist based assistant screener
1	Your role and responsibilities working in health screening	3	2	X	X	X	X	X	X	X
2	Communication, conflict resolution, equality and inclusion	3	3	X	X	-	-	-	-	X
3	Consent	3	3	X	X	-	-	-	-	X
4	Health and safety	3	6	X	X	-	-	-	-	X
5	Infection, prevention and control	3	3	X	X	-	-	-	-	X
6	Principles of safeguarding	3	3	X	X	-	-	-	-	X
7	Data protection and confidentiality	3	3	X	X	-	-	-	-	X
DES specific
15	Anatomy, physiology and pathology of the eye	3	6	X	X	X	-	-	-	X
16	Understanding diabetes and diabetic retinopathy	3	4	X	X	-	X	-	X	X
17	Prepare for diabetic retinopathy screening	3	4	X	X	-	-	-	X	X
18	Undertake diabetic retinopathy imaging	3	5	X	X	-	Role specific	Role specific	-	-
19	Detect retinal disease and classify diabetic retinopathy	3	8	-	X	X	Role specific	Role specific	-	-
20	OCT in digital surveillance	3	8	-	Role specific	Role specific	Role specific	Role specific	-	-