Guidance

Diabetic eye screening pathway requirements specification

Updated 2 October 2023

Applies to England

This document provides an overview of the NHS Diabetic Eye Screening (DES) Programme by describing what should happen at each stage of the pathway. Read it alongside other guidance for the DES including:

• programme standards
• the screening quality assurance service (SQAS) programme specific operating model (PSOM)
• operational guidance for NHS DES

Local commissioners and providers should also review schedules 2 and 4 of the diabetic eye screening specification (number 24) held by the NHS England (NHSE) public health commissioning and operations team.

Please also read the general information relevant to all NHS screening programme pathways.

Diabetic eye screening

A range of eye problems can affect people with diabetes. One of these conditions is diabetic retinopathy – a complication of diabetes caused by high blood sugar levels damaging the back of the eye (retina). Diabetic retinopathy can cause blindness if it is left undiagnosed and untreated.

The aim of DES is to reduce the risk of sight loss among people with diabetes. Screening can find problems before they affect an individual’s sight.

The NHS invites people with diabetes aged 12 years old or over for screening at least every 24 months depending on the outcome. The DES test usually lasts about 30 minutes and involves:

• asking the person to read letters on a chart
• putting eye drops into each eye
• taking a photo of the back of their eyes

End-to-end pathway

The pathway for the programme consists of the following elements.

The dotted boxes and numbered labels show how the different parts of the screening pathway map to the generic pathway themes used below.

An accessible text-only version of this pathway is also available.

1. Before screening test

These requirements relate to making sure that screening is offered to the correct people.

Providers should have systems in place to:

• identify people eligible for screening using the GP2DRS IT system (see ‘GP2DRS IT system’ in Diabetic eye screening: use of personal information) or an NHSE commissioner-approved alternative
• make sure the eligible population is offered screening in line with diabetic eye screening operational pathways
• make sure people with diabetes have the information they need to make an informed choice about attending screening by using nationally agreed public information
• provide easy read and translated versions of the public information on diabetic eye screening and offer access to local interpretation resources where appropriate
• manage individuals who have been excluded or suspended in accordance with screening cohort management guidance
• carry out regular excluded and suspended audits (see ‘Excluded and suspended audit’ in Diabetic eye screening: audit schedule)
• make people aware that some of their personal information is used by the screening programmes
• track the progress of each person along the screening pathway and correctly manage referrals to hospital eye services (HES) using the appropriate software
• link with other services involved in the screening pathway (for example primary care, diabetology, HES and maternity services) to share information where appropriate
• submit data to the national diabetes audit

Uptake and coverage

Providers should have systems in place to validate the appropriate data relating to:

• uptake standard DES-S01: completeness of offer for routine digital screening
• uptake standard DES-S02: invitation for first routine digital screening appointment
• uptake standard DES-S03: timely recall for routine digital screening
• uptake standard DES-S04: timely recall for slit lamp biomicroscopy
• uptake standard DES-S05: timely recall for digital surveillance
• coverage standard DES-S06: pregnant women seen in digital surveillance
• uptake standard DES-S07: routine digital screening (KPI DE1)
• uptake standard DES-S08: repeat non-attenders (KPI DE4)

In line with the health equity audit, the provider should work with local stakeholders to:

• carry out regular uptake analysis to identify groups who either access screening at lower levels, or do not access screening at all
• make sure appropriate policies and processes are in place so uptake is as high as it can be

2. Screening test

These requirements relate to the processes of carrying out the screening test.

Providers should have systems in place to:

• make sure screeners and graders are trained in accordance with DES education and training requirements
• record visual acuity in both eyes
• give dilation drops, provide advice on any contraindications, and advise people that they should not drive after their appointment
• follow the approved cameras and settings guidance for digital eye screening
• make sure primary, secondary and arbitration grading is carried out in accordance with patient, grading, referral, surveillance guidance
• make sure a referral outcome grade is carried out for any images where referable disease is detected by either:
  • the clinical lead
  • a senior accredited grader designated and supervised by the clinical lead
• grade images in accordance with the retinal image grading criteria
• implement internal quality assurance and take action for continual service improvement in line with assuring the quality of grading guidance
• make sure all grading staff use the test and training (TAT) quality assurance tool
• return and validate data for test standard DES-S09: ungradable images
• follow the slit lamp biomicroscopy (SLB) examiner framework
• return and validate data for diagnosis/intervention standard DES-S13: timely consultation for people with diabetes whose images are recorded as ungradable
• offer an appointment at a digital surveillance clinic as described in the DES operational pathways for:
  • people who need 3, 6 or 9 monthly assessment
  • pregnant women

Digital surveillance clinics may use optical coherence tomography (OCT) using the OCT in surveillance pathway and appropriate technology. Surveillance clinics may link in with OCT assessment where this has been agreed with HES commissioners.

Providers should:

• use template result letters to send to:
  • people who attended screening
  • their GPs
  • other appropriate clinical practitioners involved in individuals’ diabetes care
• return and validate data for test standard DES-S10: timeliness of results letters (KPI DE2)

3. After screening test (diagnosis)

These requirements relate to the process of following-up screen positive results to get a confirmed result.

Referral

Providers should have systems in place to:

• make sure referrals have been processed according to the managing referrals to HES guidance
• monitor individuals suspended from routine digital screening to make sure they enter the correct care pathway in accordance with screening timescales and cohort management guidance
• make sure individuals are referred into treatment services in line with referral standard DES-S11: timely referral of people with diabetes with positive screening results

4. After screening test (intervention)

These requirements relate to the process of following-up people with a confirmed diagnosis and maximising the overall benefits from screening in terms of the final outcome to the person being screened.

Providers should have systems in place to:

• return and validate data for intervention/treatment standard DES-S12: timely consultation for people with diabetes who are screen positive (KPI DE3)
• complete the audits schedule
• make sure people who no longer need care in HES are returned to routine digital screening (RDS) or digital surveillance (DS)
• return people who no longer need DS to RDS

Pathway outcome

The screening pathway ends when a person is screened, and the result is:

• screen negative (where there is no referable DR and they will be re-invited for RDS)
• screen positive (when DR is detected and the individual is re-invited for RDS or referred to DS or HES, and suspended from RDS)
• assessed as medically unfit (in which case they are excluded from the screening pathway)
• screen negative but other eye pathology is present (in which case they are referred to the GP or directly to HES according to local protocol, and still need RDS)