Guidance

Individual choice for diabetic eye screening (DES) venues and managing boundary changes

Updated 5 October 2020

People with diabetes are included in the cohort of the local DES service linked to the GP practice where they are registered. GP practices have linked diagnosis and treatment services for people who screen positive for diabetic retinopathy. These individuals should be referred to the linked hospital eye services.

People in England can choose which GP practice they want to register with as part of the Patient Choice scheme. Someone may choose a practice:

• near their workplace, rather than the one closest to home
• that offers a digital-first approach where patients can easily access the advice, support and treatment they need using digital and online tools

Similarly, someone can choose to be screened by a different DES service from the one their GP is linked to. This guidance explains about what needs to happen when changes are made and is for:

• local screening services
• GPs
• local commissioners

Standard service provision

The NHS Diabetic Eye Screening Programme (DESP) recommends that people with diabetes are invited to a local screening service based on their GP practice. Practices should only use one local screening service to ensure safe identification and management of the cohort.

People with diabetes should be referred to a named linked hospital eye services (HES) provider if they have a positive screening result. The HES provider must have an established relationship with the screening service. This should include them supplying a timely feedback of outcomes.

The individual with diabetes should be sent to the most appropriate HES provider, if there is more than one, within an agreed referral pathway. This should ensure that:

• everybody invited to screening gets a test
• everybody who gets a test, gets a result
• referrals and treatment are appropriately managed

Alternative DES programmes

People with diabetes sometimes ask to use an alternative DESP not linked to their GP practice. Examples include when individuals with diabetes:

• want to be screened near work or another convenient place not in their linked local service programme area
• want to be screened in the same place as their other diabetes appointments
• have multiple residences
• want to use a different HES to the one linked to the screening programme registered with their GP

Sometimes people register with a GP practice offering online or digital-first consultations. Changing their GP will change the default location of their screening service. However, in some cases, the individual will want to keep their care with the previous screening service. People can be asked to use an alternative service if their GP practice is located on a boundary between local screening services.

Risks

There are several risks when a person with diabetes does not use the screening provider linked with their GP practice. The risks include:

• not identifying an individual who needs screening
• not inviting the individual for screening
• the GP2DRS data extraction IT system keeping a person on the extract for their registered GP (which is linked to the diabetic eye screening programme)
• sending the wrong invitations out for screening or digital surveillance
• failing to record an accurate screening history, which can lead to an inaccurate eye test
• not being able to accurately failsafe individuals through the screening pathways, including referral and discharge from HES

GP practices offering online or digital-first consultations

Individuals who choose to register with a GP practice offering digital-first consultations are sometimes asked to de-register from their existing GP and re-register with the new GP practice. This usually happens automatically during the sign-up process with the new GP.

If the practice is in the existing diabetic eye screening service coverage area, they will stay with the same screening service. However, if the new practice is based outside the coverage area of their original GP practice, they will automatically be removed from their existing screening service. They would be re-registered as a new patient with the screening service that is linked to the new GP practice that offers online consultations.

The individual with diabetes has 2 options in this case. They can choose to be screened by:

• the service associated with their new GP practice (this is the default option, but it may be a significant distance from their home or workplace)
• the service they were screened at before registering with the GP practice offering online consultations

The GP practice offering digital-first consultations must ensure that a person with diabetes is aware of the risks outlined in this guidance when they register. This includes making them aware it could impact where they are screened. The 2 options above should be explained to them.

If the person with diabetes chooses to have screening with an alternative DES service, then the GP practice offering online consultations is responsible for the failsafe of the individual.

The GP should make sure:

• individuals are invited for screening at the appropriate interval including digital surveillance
• appropriate and timely treatment is provided where needed

The GP practice offering online or digital first consultations should be able to audit these individuals.

Transferring to an alternative DES service

This guidance applies to all people with diabetes. Registration with a physical GP or a GP that offers digital-first consultations does not affect the individual’s choice to be screened by an alternative service.

Risk management

GPs, local screening services and individuals who wish to transfer to an alternative service must confirm that:

• the GP practice understands its responsibility for failsafe of the individual
• adequate failsafe processes are in place to ensure safe care and avoid individuals being lost in the system
• the individual is fully informed about the effects of any change

A person with diabetes can only ask to transfer their care following agreement of the:

• sending screening service
• receiving screening service
• GP practice where they are currently registered

Local procedures must be established to make sure individuals are properly accounted for by the sending and receiving service. The GP must accept overarching responsibility for making sure individuals receive screening and treatment. The individual must make an informed decision with knowledge of the risks.

The receiving service can screen the individual so long as it agrees to undertake the complete pathway. The individual must:

• be screened
• be sent their results (including digital surveillance and referral where indicated)
• be recalled according to guidance
• receive adequate failsafe processes

Sending service

The sending service should provide previous screening data for the receiving service if the software allows it. This must be sent by secure transfer.

The person with diabetes must be categorised as ‘off-register’ and ‘patient seen in another programme’ in the sending service. Do not count activity relating to this individual in the sending service’s annual reports. Their data will not count in the sender’s performance against standards. The name of the receiving screening service should be noted in the individual’s general notes within the screening software.

The sending service should keep an audit trail to show the person accepts the transfer and understands the implications.

The sending and receiving service should keep a copy of the GP’s agreement to the transfer and responsibility for failsafe. The GP should make an entry in the notes to state that a transfer has taken place.

The service should audit individuals who have requested a transfer out and record where they have moved to. Results should be presented to the programme board at least quarterly and kept for reference – for example, during a quality assurance (QA) visit. The sending service must tell the receiving service when the next screen is due.

Following a transfer, the sending service will continue to receive demographic updates via GP2DRS for individuals who have transferred out. This may include changes of address or telephone number. It is the responsibility of the sending service to pass this information on to the receiving service in good time. This will help avoid delays caused by out-of-date demographic information.

Receiving service

Register the individual with diabetes on the receiving service software as an eligible patient in the diabetic eye screening register. The receiving service should upload the screening data sent by the sending service where the software allows it. The receiving service must record the correct GP details against the transferred individual. This is to ensure the responsible GP does not miss the reports.

Decisions on where treatment is carried out will be made following a discussion with the person. Activity relating to screening and treatment will be accounted for in the annual report of the receiving service and its performance against standards.

The date of the next screen should be entered into the software upon transfer.

Using different diagnostic treatment services

GPs are responsible for referral if a person with diabetes wishes to be referred to another diagnostic and treatment service. Screening services must write to the GP practice and ask them to carry out the referral.

Send a standard letter to the GP practice, asking them to confirm that they will:

• carry out failsafe so the individual gets timely treatment
• make sure the individual with diabetes is returned to the screening service when appropriate
• provide screening results on request from the screening service

The patient should be offered an appointment to the linked diagnostic and treatment service if the GP practice does not provide this assurance. In all the above cases, the patient, GP and screening service must confirm they have considered whether:

• an adequate failsafe system is in place to ensure individuals receive safe care and are not lost in the system
• the individual understands the implications of any changes they have asked for
• the GP practice, by agreeing to transfer an individual, understands its responsibility in maintaining failsafe for that person

Funding for alternative arrangements

Where small numbers of individuals are involved, the administrative overhead of recharging costs may be more than the cost of the screening episodes. Where larger numbers are involved this should be formally commissioned and accounted for by the responsible commissioners.