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Outcome of implementing the national services framework guidelines for diabetic retinopathy screening: results of an audit in a primary care trust
  1. M J Saldanha,
  2. U Meyer-Bothling
  1. Ashford and St Peter’s NHS Trust
  1. Correspondence to: MrMario J Saldanha Ashford and St Peter’s NHS Trust, Ashford, TW15 3AA, UK; mariosaldanha{at}

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Systematic screening for diabetic retinopathy is the key to achieving the targets set out in the recently published national service framework (NSF) guidelines.1,2 One of the two priorities and planning framework (PPF) targets is that by March 2006 a minimum of 80% of people with diabetes are to be offered screening, rising to 100% by December 2007.3,4 Digital photography is the modality for screening.5–8 The British Diabetic Association has established standards for any diabetic retinopathy screening programme of at least 80% sensitivity and 95% specificity.

Screening programme

Our screening programme was set up to evaluate the existing nationally recommended diabetic retinopathy screening service.

In all, 2165 patients were invited over a period of 12 months; 909 participated. At the screening mydriatric drops (1% tropicamide and 2.5% phenylephrine) were instilled. The patients were photographed with a Topcon fundus camera and each photograph was screened and graded by consultant ophthalmologists (table 1).

Table 1

 Referred patients

Of the total 909; there were 198 patients with retinopathy (grades R1, M, R2, and R3), 644 patients without retinopathy (grade 0), 63 patients with OL (other lesions), and one was (grade U) ungradeable (tables 2 and 3). The sensitivity was 98% and specificity 97%. The retinopathy present was 21% and the referral rate for retinopathy (STDR) was 7%; 59% did not take up the offer to be screened. Some of the reasons cited: 956 (44%) declined or did not respond, 251 (11%) are being screened elsewhere, 11 (0.5%) are not diabetic, five (0.18%) are dead, six (0.27%) are registered blind, and 21 (1%) have moved.

Table 2

 Outcome by grade

Table 3

 Final data


Our screening methods surpassed the standards set by the NICE guidelines. However 59% of patients did not take up the offer. The achievable standard to which strategic health authorities and primary care trusts are working is 90% uptake of those offered screening with the minimum standards of 70%–80%, but even though quality assurance systems are in place uptake is still very poor.

In the intercollegiate audit, led by the Royal College of Ophthalmologists, data were analysed from 9827 patients with diabetes from 129 general practices in 25 health authorities. The lowest level of coverage in a district was 38% and the highest 85%. In general practice the coverage ranged from 14% to 97%. The likelihood of having an eye examination was marginally higher in districts with a systematic examination rather than opportunistic or without recognised schemes at all.

In the Hounslow Primary Care Trust our hospital episode statistics (HES) are the only existing screening programme. Patients registered with a GP are referred to the HES for the screening. The reasons for the 44% who did not respond were that some did not have the time, some were elderly living on their own with nobody to take them, some did not understand the screening leaflet, and some just forgot.

Problems about coverage could be tackled if we had a central electronic database linked to all screening programmes. Although software providers have been agreed for such a data collection exercise, primary care trusts have yet to implement this. People unable to attend during the week could be accommodated in weekend or evening clinics. These clinics could also be reserved, with bilingual support workers to explain the importance of screening for the ethnic patients. Community networks like the rotary, patient groups, ethnic resource centres, and senior citizens groups can be used. The National Service Framework targets will be achieved only if the diabetic population is convinced of the importance of screening.



  • Competing interests: none.