Dr Matthew Lockyer applauds Scotland's plan to introduce a national screening programme for diabetic retinopathy
In April this year the Health Technology Board for Scotland issued advice to NHS Scotland on the implementation of the world's first national screening programme for diabetic retinopathy (see News).
The logic that has led to this initiative is hard to refute. Diabetic retinopathy is the biggest single cause of blindness in people below retirement age. It is readily detectable with noninvasive tests, and largely preventable with treatment. The number of individuals with both type 1 and type 2 diabetes is increasing and with it the burden of all diabetes complications including retinopathy.
The catalyst for this step is probably the acknowledgement that the most sensitive and specific screening tool also turns out to be the most user-friendly and mobile - namely, digital retinal photography.
With such a strong case for screening, could similar programmes be introduced throughout the UK? I suspect that this would be difficult at present.
The Scottish announcement is based on more than just a commitment to eye screening. It carries an implicit promise to expand the necessary IT infrastructure to run the programme. All the other national screening programmes are population, not disease, based. For the new screening programme to work a national database of diabetes patients will be essential. This opens the door to streamlining care between agencies for other aspects of diabetes care.
Scotland already has a good record in this area. In Dundee, for example, IT allows information to flow between primary care, secondary care and community pharmacies. This achieves better care with less duplication of effort, as the DARTS study found.1
In the district in which I work we have a long way to go to achieve the levels of information sharing needed. Our local hospital has virtually no clinically useful IT links with local practices. Even the facility we once had to download pathology results has not worked for several months. I am sure that as our hospital was listed among the top 30 in the UK things are probably no better in many other districts.
Our trust has accepted that digital retinal screening is the way forward. It was fortunate to appoint an impeccably qualified expert in the field to create a locality screening programme. Support from ophthalmology and diabetology departments has been enthusiastic. After set-up costs the savings made in preventing complications are thought to render the screening programme approximately cost neutral - but with greatly improved patient outcomes.
Unfortunately, there is no locality database of diabetes patients. I have been attending the local diabetes liaison group for a decade during which time the importance of a county-wide register has been accepted. However, it has not happened, with issues of data confidentiality being one of the perennial arguments raised against it.
As a result, each practice diabetes register will form the basis of the initial invitations for retinopathy screening. Some databases will be more complete than others. Against a background of funding being offered, withdrawn and re-instated, the scheme was launched. Instead of being welcomed as a huge step forward, fierce debate has raged over who will pay for the rooms used for screening and who will be responsible for calling and recalling patients.
The Scots have announced their screening programme in a way that makes it quite clear that there will be a funded national strategy to screen individuals with diabetes. If the programme succeeds it will be an illustration of the importance of a coherent IT policy as well as a commitment to diabetes patients.
- Morris AD, Boyle DIR, MacAlpine R et al. The diabetes audit and research in Tayside Scotland (darts) study: electronic record linkage to create a diabetes register. Br Med J 1997; 315: 524-8.