Health Equity Audit – Diabetic Retinopathy Screening
Southampton City, Hampshire, Isle of Wight and Portsmouth City
PCTs
Dr Simon Fraser
Specialty Registrar in Public Health
NHS Southampton City
Dr Laura Edwards
GP Leadership Fellow
Hampshire PCT
July 2010
Dr Simon Fraser & Dr Laura Edwards
July 2010
1
Contents
Page
Introduction to this Health Equity Audit
3
Acknowledgements
4
Executive summary
5
Background
9
Overview of screening programmes
15
Aims, Objectives, and Methods
17
Results
GP data
19
Southampton, South West Hampshire and the Isle of Wight
21
Portsmouth and South East Hampshire
48
North Hampshire
73
Patient experience
88
Limitations of this audit
91
Conclusions and recommendations
92
References
93
Appendices
94
Appendix 1 – List of GP Practices referring to each programme
95
Appendix 2 – Data requested
101
Appendix 3 – Questionnaire
103
Appendix 4 – Descriptive summary of audit process
105
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Introduction to this Health Equity Audit
In 2009 the Southampton and South West Hampshire Diabetic Retinopathy Screening programme was one
of the first in the country to have a national quality assurance visit. One recommendation from the
subsequent quality assurance report was that a Health Equity Audit (HEA) should be undertaken within 6
months. Anyone who has undertaken a robust HEA will know that the timeframe was tight. As chair of
this retinal screening programme board I was delighted when Dr Simon Fraser, a SpR in Public Health,
asked me if I new of any project work that could be undertaken to meet his learning competencies. Not
only has Simon risen to the challenge of leading on this work, I compounded it by getting the agreement
of the four Directors of Public Health across Southampton, Hampshire, the Isle of Wight and Portsmouth
to extend this HEA to all their respective retinal screening programmes; three HEA’s under one remit. Dr
Laura Edwards a GP Leadership Fellow similarly fell into this trap. Gaining good quality validated data
has posed challenges with this audit. Whilst the nationally recognised IT systems to call and recall,
monitor the patient retinal screening pathway have improved in recent years, data cannot be easily
extracted. Currently the IT is not able to generate reports that can effortlessly assist the HEA process. I am
therefore indebted to the work of Simon and Laura on this mammoth task and to Dan King who ably
assisted with data analysis. Any worthwhile HEA has to result in action. I hope that this work will spur on
the commissioners and providers of this important public health service to improve the health of the
growing numbers of diabetics who depend on screening to detect and treat retinopathy, ultimately
protecting their sight.
Dr Graham Watkinson RN, MA, EdD, FHEA, FFPH
Consultant in Public Health
Trust Headquarters
Southampton City PCT
Oakley Road
Southampton SO16 4GX
Tel: 023 80725403
Mob: 07768555689
Email: graham.watkinson@scpct.nhs.uk
UKPHR 0209
Website Addresses:
www.southamptonhealth.nhs.uk
www.southamptonquitters.nhs.uk
www.dh.gov.uk/immunisation
http://www.screening.nhs.uk/home.htm
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Acknowledgements
We are grateful to all of the following for their input to this audit, without which it would not have been
possible
Graham Watkinson, Matthew Smith, Paul Bingham, Clare Simpson, Dan King, Rebecca Wilkinson, Tina
Woodcock, Emma Goss, Julia Warner, Steve McInnes, Louise Wells, Hugh Sanderson, Martin Davis
Christina Rennie, Roger Smith, David Webb, Fiona McCaul, Sian Wild, Richard Bolton, Bob Coates,
Debbie Chase, Mary O’Brien, Harriet Quast, Nigel Hall, Nicola Moss, Nigel Watson, Jill Ghanouni,
Dawn Buck, Lee Calladine, Richard Holt, Patrick Sharp, Vicky Boland, Joanne Wigley, Gerry Lewis
Julie Parkes, Mayank Patel, Samantha Cockings, Marie Casey.
The Wessex Local Medical Committee (LMC) for their support of this project.
All GP practices in Southampton, Portsmouth, Isle of Wight and Hampshire and their Practice and IT
managers who kindly contributed data.
Dr Simon Fraser
Dr Laura Edwards
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Executive summary
Background
The National Screening Programme for Diabetic Retinopathy outlines the aim of retinopathy screening as
follows:
‘The aim of the programme is to reduce the risk of sight loss amongst people with diabetes, by the prompt
identification and effective treatment if necessary of sight threatening diabetic retinopathy, at the
appropriate stage during the disease process. Systematic screening involves digital photography of the
retina followed by a two- or three- stage image grading process to identify the changes of sight-threatening
diabetic retinopathy in the retina.’ 1
Health Equity Audit is a process for identifying how fairly services or other resources are distributed in
relation to the health needs of different groups and areas, and the priority action to provide services
relative to need
Aims & objectives
To conduct a Health Equity Audit of the Diabetic Retinopathy Screening Service in Southampton,
Hampshire, Portsmouth, and the Isle of Wight.
1. To create an ‘equity profile’ of the diabetic retinopathy screening programmes in Southampton,
Hampshire, Isle of Wight and Portsmouth by identifying inequity in provision, access, uptake and
outcomes of the service.
2. To use this profile to identify local action to tackle inequity (in partnership with the relevant
diabetic retinopathy screening teams).
3. To use these locally identified actions in commissioning decisions and delivery of retinopathy
screening services coordinated by the Diabetic Retinopathy Screening Boards.
4. To develop a framework for a structure within which re-audit of the service can occur over time to
assess progress against targets and monitor performance.
Methods
Working in collaboration with the three screening programmes under the direction of a steering group
comprising Public Health leads from each of the four PCTS. Creating an equity profile for each of the
three screening programmes using data from the screening services, GP practices, the Hampshire Health
Record, and a survey of people with diabetes.
Results
The main results are given below for each of the screening programmes.
1.
National Screening Programme for Diabetic Retinopathy. http://www.retinalscreening.nhs.uk/pages/default.asp?id=2
Dr Simon Fraser & Dr Laura Edwards
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Southampton, South Hampshire and Isle of Wight
Population – There is a predominance of men, and a predominance of Type 2 diabetes, prevalence of
which is increasing. Significant areas of deprivation exist, particularly in Southampton City. There is some
variation of prevalence of diabetes between GP practices, but most are between 4 and 6%.
Programme – IT problems, recognised nationally, provide a challenge for interrogating the data,
obtaining information on people registered with the programme, and auditing the programme. Recording
of certain data could be improved e.g. type of diabetes, ethnicity. The ability to audit outcomes would be
greatly enhanced by being able to follow progress of patients referred into the hospital system. Lack of
available data on outcomes is particularly important in context of new NHS white paper.
Provision – There appears to be good coverage generally, except for some areas of Southampton with
relatively high deprivation levels and population subject to ‘financial stress’ who may not be able to
access services so easily.
Access – The programme covers a largely mobile population, with a higher proportion of younger people
among DNAs. It is possible that this is related to working-hours timing of screening appointments.
Consideration should be given to developing screening locations in areas of high daytime population.
Uptake – There is a high proportion of DNAs and those with no record of screening in GP records among
younger age groups (20 to 50), the very elderly, and people who live in more deprived areas, (particularly
younger men from deprived areas). Consideration should be given to optimising screening locations for
the elderly.
Outcomes – Accurate data is difficult to obtain on outcomes. It is therefore not possible to comment on
prevention of loss of vision with the data currently available. This is a priority to rectify as the national
programme is built on preventing visual impairment. There is a need for better recording of outcomes in
eye units, and improvements in the ability to follow people through the system. Those with no record of
screening in GP practices had a high prevalence of hypertension. This emphasises the importance of
working with GP colleagues to optimise control of risk factors and encourage engagement with screening.
Summary – There is some evidence for inequity of provision of the service in certain areas, though
coverage of the service and convenience of access is generally good. There is some evidence, however,
that there is inequity of access and uptake particularly affecting younger age groups, the very elderly, men
more than women, and those from more deprived areas. There is weak evidence of inequity of outcomes,
mainly because of lack of reliable data.
Portsmouth and South East Hampshire
Population – There is a predominance of men, and predominance of Type 2 diabetes, prevalence of which
is increasing. Significant areas of deprivation exist, particularly in Portsmouth City.
Programme – IT problems, recognised nationally, provide a challenge for interrogating the data,
obtaining information on people registered with the programme, and auditing the programme. Recording
of certain data could be improved e.g. type of diabetes, ethnicity. The ability to audit outcomes would be
greatly enhanced by being able to follow progress of patients referred into the hospital system. Lack of
available data on outcomes is particularly important in context of new NHS white paper.
Provision – There is evidence that the location of screening cameras does not match need in terms of
prevalence of diabetes and areas of more pronounced deprivation. There are areas of overlap with North
Hampshire programme, which raises questions about duplication of effort and offers the potential to work
together to improve the service for patients.
Access – Access appears to be difficult for some people based on DNAs in relation to location of cameras,
and comments from the survey. Consideration should be given to identifying alternative sites for screening
that are more convenient for patients.
Uptake – Good evidence that a higher proportion of deprived groups DNA. Younger, those in more
deprived areas, men, and type 1 diabetics are all more likely to have no record of screening in their GP
records. DNA mapping helps to demonstrate the areas of need.
Outcomes - Accurate data is difficult to obtain on outcomes. It is therefore not possible to comment on
prevention of loss of vision with the data currently available. This is a priority to rectify as the national
programme is built on preventing visual impairment. There is a need for better recording of outcomes in
Dr Simon Fraser & Dr Laura Edwards
July 2010
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eye units, and improvements in the ability to follow people through the system. Those with no record of
screening in GP practices had a high prevalence of hypertension. This emphasises the importance of
working with GP colleagues to optimise control of risk factors and encourage engagement with screening.
Summary – There is moderate evidence for inequity of provision of the service in certain areas. Evidence
that this is associated with inequity of access and uptake particularly affecting younger age groups, the
very elderly, men more than women, and strong evidence of inequity of uptake among people from more
deprived areas. Weak evidence of inequity of outcomes, mainly because of lack of reliable data.
North and West Hampshire
Population – There is a predominance of men, and predominance of Type 2 diabetes, prevalence of which
is increasing. The commonest affected age group 60 – 75. In contrast to Southampton and Portsmouth, the
majority of the population live in less deprived areas.
Programme – IT problems, recognised nationally, provide a challenge for interrogating the data,
obtaining information on people registered with the programme, and auditing the programme. Recording
of certain data could be improved e.g. type of diabetes, ethnicity. The ability to audit outcomes would be
greatly enhanced by being able to follow progress of patients referred into the hospital system. Lack of
available data on outcomes is particularly important in context of new NHS white paper. Training of
screeners and graders is ongoing.
Provision – Three areas have been identified where provision does not appear to be matching need –
North West of Basingstoke, Fleet/Hartley Wintney, and Alton/Bordon. There are areas of overlap with the
Portsmouth and South East Hampshire programme, which raises questions about duplication of effort, and
offers the potential to work together to improve the service for patients.
Access – The programme has limited screening locations over quite wide geographical area. Signposting
and public transport access to Rooksdown could be improved. The location may be a barrier to those
without their own transport. Current appointment times may provide a barrier to younger, working age
people.
Uptake – A higher proportion of younger people and very elderly have no record of screening in the GP
record. Reasons for this could be explored further. Biggest numbers of people with no record of screening
are in the 50 to 75 age group.
Outcomes - Accurate data is difficult to obtain on outcomes. It is therefore not possible to comment on
prevention of loss of vision with the data currently available. This is a priority to rectify as the national
programme is built on preventing visual impairment. There is a need for better recording of outcomes in
eye units, and improvements in the ability to follow people through the system. Those with no record of
screening in GP practices had a high prevalence of hypertension. This emphasises the importance of
working with GP colleagues to optimise control of risk factors and encourage engagement with screening.
Summary – There is moderate evidence for inequity of provision of the service in certain areas. There is
evidence that this is associated with inequity of access and uptake particularly affecting younger age
groups, the very elderly, and men more than women. There is some evidence of potential inequity through
people accessing optometry rather than the screening programme (particularly in older age groups). There
is weak evidence of inequity of outcomes, mainly because of lack of reliable data.
Patient experience
The majority of those surveyed were positive about screening programme. A few areas for potential
improvement of the service identified, such as comments about the screening locations in PSEH, the
difficulty of making appointments, particularly at hospital clinics, and the need for careful wording of
results letters (any abnormality can sound frightening). Weaknesses of the survey process were recognised
and more focused patient experience surveys should be considered for each of the programmes.
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Conclusions
This health equity audit has identified patient factors (such as the groups of people at most risk of
retinopathy, those less able to access and take up the opportunity for retinal screening), provider factors
(such as the need to reconsider the location and timing services to improve accessibility, and the need for
recording of important dimensions of equity), and system factors (such as the weaknesses of the current IT
systems, and geographical overlap between individual screening programmes). We therefore make the
following recommendations for the screening programmes
Recommendations for all programmes
• IT issues – recommendation to lobby national programme for improvements in IT system in order
to be able to query the database and more easily obtain information on people at each stage of the
system.
• Need to improve recording of important dimensions of potential inequity in order to be able to re
audit, for example improving type of diabetes and ethnicity recording.
• Need to improve the facility and uptake of recording of outcomes in the eye units, and seek IT
solutions to be able to link data from the screening service to the eye units and vice versa.
Linkage with GP systems has been demonstrated by the Hampshire Health Record, who may
therefore be well placed to be involved in this process.
• Consideration should be given to timing of appointments to make screening more accessible to
those in employment.
• Consideration should be given to location of services – particularly in Portsmouth and North
Hampshire, where the static cameras limit screening locations and potentially reduce accessibility.
• Consideration should be given to methods for targeting particular groups who have been shown to
have a higher chance of not being screened – particularly men, the young and the very elderly, and
those from more deprived areas
• Consideration should be given to awareness raising among GP practices of those with no record of
retinal screening in order to combat an ‘inverse care law’ effect in this population.
This audit has shown that there are examples of good practice in each of the three screening programmes
in Hampshire and the Isle of Wight. There is therefore potential to learn from one another and for
consideration to be given for a more coordinated, centralised, screening programme across SHIP with
adequate funding for IT and admin support.
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Background
Health equity audit - definition
Health Equity Audit is a process for identifying how fairly services or other resources are distributed in
relation to the health needs of different groups and areas, and the priority action to provide services
relative to need. 2
Equity is best thought of as ‘fairness’ (as opposed to equality, which is ‘same’) and can be divided into
‘horizontal equity’ (equal resources for equal need) and ‘vertical equity’ (unequal resources for unequal
need i.e. greater need attracts more resources). In considering equity of a health service, it refers to all of
the following:
•
•
•
•
Provision of the service
Access to the service
Uptake of the service
Outcomes of the service
Health equity audit – purposes
The purposes of conducting a health equity audit have been described as
1. Informing commissioning of services by identifying groups currently underserved, not accessing
or utilising services or for whom the clinical outcome is particularly poor.
2. Contributing to performance management of services by providing robust evidence about whether
needs are being met and informing the development of local health inequalities targets.
3. Supporting partnership working by providing a common inequity framework for local strategic
partnerships.
4. Informing allocation of resources according to need
5. Encouraging community involvement in the NHS. 3
Health Equity audit – process
There are six well-recognised stages in conducting a health equity audit. These are shown in Fig 1.
Fig.1 The Health Equity Audit Cycle. 2
6
Review progress
and impacts
against targets
5
Secure changes in
investment and
service delivery
1
Agree priorities
and partners
4
Agree local
targets with
partners
2
Equity profile:
identifying the
gap
3
Identify local
action to tackle
inequalities
2.
Health Equity Audit – a guide for the NHS. Department of Health. Dec 2003.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4084138
3.
Health Equity Audit made simple. A briefing for Primary Care Trusts and Local Strategic Partnerships. Health
Development Agency. Working document January 2003. Available at:
http://www.nice.org.uk/aboutnice/whoweare/aboutthehda/hdapublications/health_equity_audit_made_simple.jsp
Dr Simon Fraser & Dr Laura Edwards
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Health equity audit therefore needs to answer the following questions:
•
•
•
•
•
•
•
•
•
What are the significant equity issues in relation to provision/access to services, facilities and the
determinants of good health?
What are the known health inequalities for a particular population group or area?
Which of these are priorities for action?
What programmes already exist which might help reduce the inequities?
Are there any relevant national targets?
Should a local target be set?
What further action can be taken by existing public services or through more targeted action with
key groups and areas?
Have resources been reallocated to take the most effective action?
Has there been any impact on the inequities targeted?3
Dimensions of equity
In order to define what is being measured, there is a need to consider equity in several domains. This
includes gender, age, ethnicity, socioeconomic status, deprivation, area of residence and vulnerable groups
such as those with physical or learning disabilities, and the elderly.
Dr Simon Fraser & Dr Laura Edwards
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Diabetes
Diabetes is a common chronic condition in which the body cannot regulate control of glucose and the
amount of glucose in the blood is therefore too high. This happens because the pancreas does not produce
enough of the hormone insulin (or the insulin that is produced doesn’t work properly (known as insulin
resistance) which normally controls glucose metabolism by helping glucose enter the body’s cells, where
it is used for energy. Glucose comes from digesting carbohydrate from various kinds of food and drink,
including starchy foods such as breads, rice and potatoes, fruit, some dairy products, sugar and other sweet
foods.
There are two main types of diabetes:
• Type 1 diabetes
• Type 2 diabetes.
Type 1 diabetes develops when the body is unable to produce any insulin. Usually it appears before the
age of 40, often in childhood. It is treated with insulin either by injection or pump, a healthy diet and
regular physical activity.
Type 2 diabetes develops when the body doesn’t produce enough insulin or the insulin that is produced
doesn’t work properly. Usually it appears in people aged over 40, though it can affect younger age groups.
It is becoming more common in children and young people of all ethnicities. Type 2 diabetes is treated
with a healthy diet and regular physical activity, but medication and/or insulin is often required. 4
Diabetic retinopathy
There are a number of potential complications of diabetes, which are more likely to occur if control of the
blood sugar is not optimal. One important complication is diabetic retinopathy, of which there are two
main types: background (non-proliferative) and proliferative. In background diabetic retinopathy, small
vessels in the retina (at the back of the eye) become blocked and damaged. This can result in the damaged
vessels leaking small amounts of blood and the retina being starved of oxygen. If enough blood vessels
become blocked, new vessels start to grow within the eye in an attempt to provide oxygen to the damaged
retina. This is proliferative retinopathy. These new vessels are weak and can bleed and/or pull the retina
off the back of the eye (retinal detachment) resulting in loss of vision. Lastly, loss of vision can occur if
the centre of the retina, known as the macula, is affected by diabetic retinopathy. This is known as
maculopathy. Many patients are asymptomatic until the disease is advanced. Screening is therefore
required to identify patients at risk. 5
4.
5.
What is diabetes? Information from Diabetes UK. http://www.diabetes.org.uk/Guide-to-diabetes/Introduction-todiabetes/What_is_diabetes/
A Needs Assessment of Diabetic retinopathy screening in Southampton City Primary Care Trust (SCPCT) area. Dr D Chase,
January 2008.
Dr Simon Fraser & Dr Laura Edwards
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Examples of digital retinal images from the Southampton, South West Hampshire and Isle of Wight
screening programme.
Figure 2 Pre-proliferative retinopathy
Figure 3. Proliferative retinopathy
Figure 4. Maculopathy
Dr Simon Fraser & Dr Laura Edwards
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Diabetic retinopathy screening
There is a national screening programme that aims to reduce the risk of loss of vision in people with
diabetes by early detection and treatment of retinopathy. Screening involves digital photography of the
retina and subsequent treatment involves laser photocoagulation of the new blood vessels.1
Literature evidence on retinal screening and equity
A cross sectional study of data from the Bradford Low Vision Register in 2002, which analysed clinical
and demographic characteristics of those registered, showed that, among Asians, diabetes formed a higher
proportion of cause of blindness than among Caucasians (26.1% vs. 7.8%, confidence intervals not
given). 6
A Dutch study compared the degree of microvascular complications of diabetes at time of diagnosis
among those whose diabetes was diagnosed in General Practice and those whose diabetes was identified
through a targeted screening programme. This included presence of diabetic retinopathy. Diabetic
retinopathy was found in 7.6% of the screened group compared to 1.9% of the GP diagnosed group,
however the confidence intervals were 4.6-12.4 and 0.3-9.8 respectively and the difference between
groups is therefore not significant at the 5% level. 7
An equity audit of retinopathy screening in South East London showed that attendance rates for screening
were lower among younger patients, those with Type 1 diabetes, and among those residing in areas with
higher levels of deprivation. They also found that older patients, those with Type 1 diabetes and those
born abroad were more likely to present with diabetic retinopathy. 8
A review of the US literature concerning differences in retinopathy screening among racial and ethnic
minority populations identified three groups of barriers to screening:
• Patient-level factors, such as lack of education about retinopathy and treatment availability, noncompliance/refusal of the service, lack of access to care, and patient-provider communication
(such as language issues, health literacy, and trust).
• Provider-level factors, such as lack of awareness of screening guidelines, communication issues
with patients, time limitations, and primary care referral patterns.
• System-level factors, such as understaffing of eye units, obtaining diagnostic imaging, and long
waiting times for appointments.
As a result of this, the authors recommend various interventions at each level to reduce inequity in
provision, access, uptake and outcomes. These include addressing education of patients and primary care
providers, electronic record prompts, and mobile screening. 9
6.
Pardhan S, Mahomed I. The clinical characteristics of Asian and Caucasian patients on Bradford’s Low Vision Register. Eye
2002; 16: 572-576.
7.
Spijkerman AMW, Dekker JM, Nijpels G, Adriaanse MC, Kostense PJ, Ruwaard D, Stehouwer CDA, Bouter LM, Heine
RJ. Microvascular Complications at Time of Diagnosis of Type 2 Diabetes Are Similar Among Diabetic Patients Detected by
Targeted Screening and Patients Newly Diagnosed in General Practice. The Hoorn Screening Study. Diabetes Care 2003;
26(9): 2604-2608
8.
Millett, C, Dodhia H. Diabetes retinopathy screening: audit of equity in participation and selected outcomes in South East
London. Journal of Medical Screening 2006; 13(3): 152-5.
9.
Nsiah-Kumi P, Ortmeier SR, Brown AE. Disparities in Diabetic Retinopathy Screening and Disease for Racial and Ethnic
Minority Populations – A Literature Review. Journal of the National Medical Association 2009; 101(5): 430-437
Dr Simon Fraser & Dr Laura Edwards
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A Health Equity Audit of the Diabetic Retinopathy Screening Programme in NHS Wirral identified that
uptake of retinopathy screening at GP practice level was inversely related to GP practice deprivation
score. In this region, screening is provided by community optometrists. 10
A Diabetic Retinopathy Screening Programme in Derbyshire improved access to the service by improved
marketing techniques and targeting areas of high diabetes prevalence. In addition to this, the programme
identified gaps in provision and redistributed their screening cameras accordingly, and improved
availability of appointment times, telephone booking of appointments, and consideration of the specific
needs of ethnic groups. 11
A study of patients’ records from the Southampton Diabetic Retinopathy Screening service in 2002
showed no significant difference in a measure of deprivation (mean Townsend score) in people with and
without diabetic retinopathy at first screening after diagnosis of Type 2 diabetes. 12
A cross sectional study in the west of England investigated socioeconomic variations in diabetes
prevalence, uptake of screening for diabetic retinopathy, and prevalence of diabetic retinopathy. This study
showed that diabetes prevalence increased with quintile of deprivation, and the likelihood of having been
screened for retinopathy decreased. The prevalence of sight-threatening retinopathy was associated with
deprivation, but non sight-threatening retinopathy was not. 13
10. Farrington E. Wirral Digital Diabetic Retinopathy Screening Programme Health Equity Audit. Aug 209.
http://info.wirral.nhs.uk/document_uploads/Publications/DigitalDiabeticRetinopScreenEquitAudit_d37e6.pdf . Accessed
March 2010
11. Improving Access to Derbyshire Diabetic Retinopathy Screening Services
http://www.retinalscreening.nhs.uk/userFiles/File/DERBYSHIREStaff%20Celebration%20Event%202007%20Poster%20fin
al%20.pdf Accessed March 2010
12. Litwin AS, Clover A, Hodgkins PR, Luff AJ. Affluence is not related to delay in diagnosis of Type 2 diabetes as judged by
the development of diabetic retinopathy. Diabetic Medicine 2002; 19(10): 843-846
13. Scanlon PH, Carter SC, Foy C, Husband RFA, Abbas J, Bachmann MO. Diabetic retinopathy and socioeconomic deprivation
in Gloucestershire. J Med Screen 2008;15:118-121
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Diabetic Retinopathy Screening Programmes in Hampshire and the Isle of Wight
There are three diabetic retinopathy screening programmes that provide screening for the population of
Hampshire and the Isle of Wight. These are the Southampton, South West Hampshire and Isle of Wight
screening programme, the Portsmouth and South East Hampshire screening programme, and the North
Hampshire screening programme (provided by the Salisbury and Wiltshire programme). The total
population of people with diabetes registered with all three programmes is approximately 81,000.
Southampton, Hampshire and Isle of Wight Retinal Screening Programme
The Southampton, South West Hampshire and Isle of Wight programme covers a geographical area that
includes Southampton city, southern Hampshire (including Winchester, Romsey and the South Eastern
portion of the New Forest), Andover, and the Isle of Wight. The list of GP practices and their associated
Primary Care Trusts that refer patients to the programme is given in Appendix 1
In Southampton, South West Hampshire and the Isle of Wight, diabetic retinopathy screening is
provided by the service operating from Southampton which delivers screening via five mobile screening
units which visit GP surgeries to see patients from that practices list of diabetic patients. There is also
facility for patients to visit the screening van at neighbouring practices if this is more convenient, if the
van does not visit their practice, or if they have missed the screening opportunity at their own practice.
Screening is conducted every 12 months for the majority of patients, more frequently in pregnancy or if
possible retinopathy is detected. Screening can also occur at the static cameras located at the Royal South
Hants hospital in Southampton and St Mary’s Hospital Newport on the Isle of Wight.
Portsmouth and South East Hampshire Retinal Screening Programme
The Portsmouth and SE Hampshire service covers a geographical area that includes Portsmouth City and
South East Hampshire (including Fareham. Gosport, Havant, Hayling Island, Petersfield, and the Locks
Heath area) Screening is delivered via static cameras in five locations:
• St Mary’s NHS Treatment Centre, Portsmouth
• Gosport War Memorial Hospital
• Emsworth Victoria Cottage Hospital
• Sylvan Clinic, Coldeast Hospital
• Petersfield Community Hospital
Secondary grading occurs at Queen Alexandra Hospital, Cosham
North Hampshire Retinal Screening Programme
The North Hampshire service covers a geographical area that includes Basingstoke, Aldershot, and Alton
in the Northern part of Hampshire, but also north western parts of the New Forest, including Ringwood
and Fordingbridge. Screening is delivered via two static cameras located in Rooksdown Surgery (Park
Prewitt Medical Centre, Basingstoke), and at Aldershot Centre for Health. There is a current proposal for
an additional camera, which would be used at Bordon and Alton. The part of the service in the west of
Hampshire is covered by a screener visiting GP practices (an extension of the South Wiltshire service).
The maps on the following page show the areas of coverage and overlap between the screening
programmes, and the location of GP practices referring to each programme.
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Figure 5. Map of Hampshire and the Isle of Wight showing the coverage of the three diabetic retinopathy
screening programmes and geographical areas of overlap.
Figure 6. Map of Hampshire and the Isle of Wight showing locations of GP surgeries referring to each of
the retinopathy screening programmes.
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Aims, Objectives, and Methods of this Health Equity Audit
Aim
To conduct a Health Equity Audit of the Diabetic Retinopathy Screening Service in Southampton,
Hampshire, Portsmouth, and the Isle of Wight.
Objectives
1. To create an ‘equity profile’ of the diabetic retinopathy screening programmes in Southampton,
Hampshire, Isle of Wight and Portsmouth by identifying inequity in provision, access, uptake and
outcomes of the service.
2. To use this profile to identify local action to tackle inequity (in partnership with the relevant
diabetic retinopathy screening teams).
3. To use these locally-identified actions in commissioning decisions and delivery of retinopathy
screening services coordinated by the Diabetic Retinopathy Screening Boards.
4. To develop a framework for a structure within which re-audit of the service can occur over time to
assess progress against targets and monitor performance.
Methods
Agreeing priorities and partners
A steering group was formed which comprised the Public Health retinopathy screening leads from
Southampton, Hampshire, Isle of Wight and Portsmouth, the GP leadership fellow and the SpR in Public
Health. Meetings were held on a monthly basis to guide the priorities of the equity audit and provide
support within the individual PCTs.
Creating an equity profile
The dimensions of equity of interest were identified as:
•
Gender
•
Age
•
Type of diabetes
•
Ethnicity
•
Area of residence
•
Deprivation
•
GP practice
The measures considered by the audit include:
a.
Provision – how and where is the service delivered?
b.
Access – how easy is it for the right people to use it?
c.
Uptake – do the right people actually use the service?
d.
Outcomes - does the service achieve its aims in reducing the risks and complications of diabetic eye
disease? (To include proxy outcomes of screening – referral for laser treatment, stage of retinopathy
at referral etc as well as visual impairment and blindness where possible)
Data sources were identified which could provide information from the perspectives of the
screening programmes, general practices, and from patients using the programmes:
•
General Practice data was obtained from three sources.
1. MiQuest queries (proactive, bespoke searches of the individual practices’ electronic patient
databases for information related to diabetes)
2. Quality and Outcomes Framework data.
3. The Hampshire Health Record. The Hampshire Health Record (HHR) is a local combined
electronic health record that brings together information from different parts of the NHS in
Hampshire (see figure below).
Dr Simon Fraser & Dr Laura Edwards
July 2010
17
•
•
Retinopathy screening programmes data. This was obtained from the Southampton, South West
Hampshire and Isle of Wight screening programme, the Portsmouth and South East Hampshire
screening programme, and the North Hampshire screening programme.
Questionnaire surveys were undertaken of people with diabetes at a Diabetes Wellness event and
the Southampton Mela Festival.
(see Appendices for details of the data extracted)
Data analysis was undertaken for each of these data sources using the measures outlined above to create
an equity profile for each of the screening programmes.
Identifying local action to tackle inequity
Recommendations are made on the basis of this equity profile Summarising key equity issues by
Screening Programme area:
• Southampton, South West Hampshire and Isle of Wight screening programme
• Portsmouth and South East Hampshire screening programme
• North Hampshire screening programme.
Agree local targets with partners &
Securing changes in investment and delivery
The process of implementing any changes recommended by this health equity audit will be through the
retinopathy screening programmes boards and other existing structures
Review progress and impacts against targets
This report provides a framework that can be used in the future to re-audit the programme and assess the
success of the implemented changes. Recommendations are made for key equity measures and data
sources for ongoing surveillance and re-audit, and for a mechanism by which this can occur.
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Results
GP data
A total of 234 GP practices refer people with diabetes to the three retinopathy screening programmes (112
to the Southampton, South West Hampshire and Isle of Wight programme, 74 to the Portsmouth and
South East Hants programme, and 48 to the North Hants programme).
Of these, 157 practices that do not currently feed data to the Hampshire Health Record were requested to
undertake a bespoke Miquest search of their electronic database. 131 practices returned data (an overall
response rate of 83.4%). 75 practices’ data was obtained from the Hampshire Health Record.
For the Southampton, South West Hampshire and Isle of Wight programme, 67 of the 112 practices
(59.8%) were asked to conduct the Miquest searches and all (100%) returned the requested data. 42
practices’ data for this programme were obtained from the Hampshire Health Record.
For the Portsmouth and South East Hampshire programme, 57 of the 74 practices (77%) were asked to
conduct the Miquest searches and 42 (73.7%) returned the requested data. The remaining 17 practices’
data for this programme were obtained from the Hampshire Health Record.
For the North Hampshire programme, 33 of the 48 practices (68.8%) were asked to conduct the Miquest
searches and 22 (67 %) returned the requested data. The remaining 15 practices’ data for this programme
were obtained from the Hampshire Health Record. However, it became apparent that some of the data
requested was not available on the Hampshire Health record (HHR). The histogram below therefore shows
a summary of the data on which this audit is based
Figure 7. GP data sources for the Health Equity Audit
The total population of people with diabetes registered with the three screening programmes in Hampshire
and the Isle of Wight is approximately 81,000 people.
The total population of people with diabetes identified from the two methods of obtaining GP data was
approximately 71,100 people. The discrepancy between these two figures is attributed to incomplete data
obtained via the Hampshire Health Record. It is recognised that there are some limitations with the timely
uploading of data to the Hampshire Health record, which leads to incomplete records from some surgeries.
This is taken into consideration in the analysis of the results of this audit.
GP level data was therefore available for 35,183 people registered with GP practices that refer to the
Southampton, South West Hampshire, and Isle of Wight screening programme, 20,867 people registered
Dr Simon Fraser & Dr Laura Edwards
July 2010
19
with practices that refer to the Portsmouth and South East Hampshire screening programme, and 14,051
people registered with practices that refer to the North Hampshire screening programme.
It is worth noting that there were a number of records that had missing or invalid postcodes, which could
therefore not be matched to a lower super output area and are therefore excluded from the maps:
Southampton, South West Hampshire and Isle of Wight: 405 out of 39457 = 1.03%
Portsmouth and South East Hampshire: 102 out of 24774 = 0.41%
North Hampshire: 132 out of 16673 = 0.79%
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Southampton, South West Hampshire, and Isle of Wight
Diabetic Retinopathy Screening Programme
Dr Simon Fraser & Dr Laura Edwards
July 2010
21
Description of the population
There are approximately 39,500 people registered with the Southampton, South West Hampshire and Isle
of Wight diabetic retinopathy screening programme in total (the number varies because new people are
referred to the programme, some people are seen for eye problems elsewhere and are temporarily or
permanently lost to screening follow up within the programme, and some move away from the area or
die). The active programme size as at September 2009 was 30,300.
A simplified schema of the care pathway is shown below:
Age and gender
The age and gender distribution of those registered with the programme are shown in the two charts
below. They show that there are more men than women registered with the programme, that largest
proportion of men are between 60 and 80,and the largest proportion of women are between 70 and 85.
(Screening commences at 12 years of age, but some practices refer all diabetic people to the programme,
even at young ages).
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Figure S1. Age and gender distribution using data from the Southampton, South West Hampshire, and Isle
of Wight screening programme
Age and gender distribution of people registered with the
Southampton Hampshire and Isle of Wight Diabetic Retinopathy
Screening Programme
3500
3000
Number
2500
2000
1500
1000
500
Male
Female
105+
95 to 99
100 to 104
90 to 94
85 to 89
80 to 84
75 to 79
70 to 74
65 to 69
60 to 64
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
5 to 9
10 to 14
0 to 4
0
Unknown
Figure S2. Population pyramid showing proportions of each age group and gender registered with the
Southampton, South West Hampshire, and Isle of Wight screening programme
Population pyramid of people registered with the Southampton,
South West Hampshire, and Isle of Wight Retinopathy Screening
Programme
105+
100 to 104
95 to 99
90 to 94
85 to 89
80 to 84
75 to 79
70 to 74
age group
65 to 69
60 to 64
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
10 to 14
5 to 9
0 to 4
10.00% 8.00%
6.00%
4.00%
2.00%
0.00%
2.00%
4.00%
6.00%
8.00%
percentage of people
Male
Female
For male and female combined:
Mean age = 66, Median = 68, Range = 0 – 105yrs, Interquartile range 57 – 78
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Diabetes type
Type of diabetes has not always been routinely recorded within the screening programme, although
recording practices are improving and limitations of the electronic database and software are also being
addressed.
Information of type of diabetes, therefore comes from General Practice data, where recording of type of
diabetes is a requirement under the Quality and Outcomes Framework. (It should be remembered that the
numbers are less in the GP data because of the lack of completeness of data from the Hampshire Health
record). It is noticeable that by far the majority of the burden of diabetes in the population is from Type 2
diabetes.
Figure S3. Distribution of type of diabetes from Southampton, South West Hampshire, and Isle of Wight
GP data
Deprivation
The population registered with the programme comes from a wide variety of socio-demographic
backgrounds. One way of expressing this is to look at rankings of the Index of Multiple Deprivation (IMD
2007) - a deprivation index at a small area level known as Lower Super Output Areas (LSOAs). LSOAs
have between 1000 and 3000 people living in them with an average population of 1500 people. In most
cases, these are smaller than wards, thus allowing the identification of small pockets of deprivation. The
IMD combines a number of factors covering a range of health, economic, social and housing issues into a
single deprivation score for each small area in England. There are 32,482 LSOAs in England. The LSOA
ranked 1 by the IMD 2007 is the most deprived and that ranked 32,482 is the least deprived. A common
way to summarise IMD ranking is to divide the ranks into quintiles and deciles, in other words to describe
‘the most deprived 20% or 10%’ and ‘the least deprived 20% or 10%’. Southampton City PCT rank of
average Index of Multiple deprivation is 70th out of 152 PCTs (compared to Portsmouth 71st and
Hampshire 147th, where 1 is most deprived and 152 least deprived).
The chart below shows the number and gender of people registered with the Southampton, South West
Hampshire and Isle of Wight screening programme who live in each of the 10 national deciles of multiple
deprivation (where 1 is most deprived and 10 is least deprived).
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Figure S4. Index of Multiple Deprivation distribution for those registered with the Southampton, South
West Hampshire, and Isle of Wight screening programme
Gender distribution of IMD among people registered with the
SHIOW DRS prgramme
4500
4000
Number of people
3500
3000
2500
Male
2000
Female
1500
1000
500
10
9
8
7
6
5
4
3
2
1
No
t
re
co
rd
ed
0
IMD decile (1 = most deprived, 10 = least deprived)
This shows that the majority of people registered with the Southampton, South West Hampshire and Isle
of Wight screening programme live in areas that are not among the most deprived in the country.
However, there are still several thousand people in the programme who do come from more deprived
areas, so this remains an important dimension of equity to consider for this screening programme. 16% of
those registered with the programme live in areas within IMD deciles 1, 2, and 3, and 41% live in areas
within IMD deciles 8, 9, and 10.
Diabetes prevalence
The two charts below show the variation in prevalence of diabetes registered with practices in
Southampton and the Isle of Wight (areas for which GP data returns were complete).
Figure S5. Diabetes prevalence in Southampton City GP practices
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Figure S6. Diabetes prevalence in Isle of Wight GP practices
Ethnicity
Recording of ethnicity data is incomplete in many NHS contexts, and ethnicity definitions vary between
organisations and between different years of the national census. Despite these limitations, there is an
impression that ethnicity information is being more routinely collected, and ethnicity and language issues
may be important in terms of equity. The GP data requested therefore included a search for ethnicity
status. For practices referring to the Southampton, South West Hampshire, and Isle of Wight programme,
a summary of this information for the main groups for which data was recorded is given below:
Table S1. Ethnicity recording in Southampton, South West Hampshire, and Isle of Wight GP practices
Ethnic group
Not recorded
White British
White other
Indian
Other Asian
Black African
Black Caribbean
Number
21593
9975
1779
371
337
77
59
Proportion of total
61.37%
28.35%
5.06%
1.05%
0.96%
0.22%
0.17%
It can be seen from this that, for the majority of people registered with the screening programme, ethnicity
information is not recorded. This makes it difficult to draw conclusions about equity between ethnic
groups in the analysis of the data in this audit.
Dr Simon Fraser & Dr Laura Edwards
July 2010
26
Provision
The mobile screening units visit the majority of GP surgeries in Southampton, South West Hampshire, and
the Isle of Wight. Technical reasons, such as the need for a flat, level parking surface with access to a
power supply, limit the ability of the screening vans to access all GP premises in the screening catchment
area. For those practices that are not able to host the mobile screening unit, diabetic patients are screened
at neighbouring practices.
Figure S7. Proportion of Southampton, South West Hampshire, and Isle of Wight programme GP
practices visited by the screening van
Diabetic retinopathy screening service.
Proportion (and numbers) of practices attended / not attended by the
screening van
100%
80%
Attended by van
60%
Not attended by van (temporary)
40%
Not attended by van
20%
0%
Hampshire
Isle of Wight
Southampton
City
Attended by van
41
11
35
Not attended by
van (temporary)
3
0
0
Not attended by
van
11
6
4
The map below shows the distribution of screening locations in Southampton with the associated numbers
of people registered with the screening programme. It can be seen from this map that there is good
coverage of the city by screening units. However, there are areas of the city with relatively high
prevalence of diabetes that are less well served by the screening vans (for example Sholing and Weston
Common).
Dr Simon Fraser & Dr Laura Edwards
July 2010
27
Figure S8. Map of screening locations and numbers of patients in Southampton City registered with the
Southampton, South West Hampshire, and Isle of Wight screening programme
The maps below show the distribution of screening locations across the whole programme with the
associated registered population of people with diabetes, and the map for the Isle of Wight.
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Figure S9. Map of Screening locations and numbers of patients registered with the Southampton, South
West Hampshire, and Isle of Wight screening programme
The map of the Isle of Wight suggests that the population in the far south and west of the island may be
relatively underserved in terms of screening locations. However, uptake appears to be good for all
surgeries.
Figure S10. Map of screening locations and numbers of patients in the Isle of Wight registered with the
Southampton, South West Hampshire, and Isle of Wight screening programme
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Access
Access to the screening service is determined by several factors including the geographical location of
services, the timing of service provision, and the mobility of the population served. As described above,
the Southampton, South West Hampshire, and Isle of Wight screening programme sees the majority of
patients at their own GP surgery in mobile screening units, thereby reducing travel time and increasing
convenience for patients.
Thirty patients are normally screened in a day. Screening appointment times vary between Southampton
City, Hampshire, and the Isle of Wight to accommodate the differences in travel, and to allow for other
local issues. Screening in Southampton starts at 9:20am and the final patient arrival time is 3.40pm.
Screening on the Isle of Wight commences at 9am and concludes just after 3pm. Screening in Hampshire
starts at 9:50am to account for travel and the final patient arrival time is 3.40pm. Each patient take 20mins
approx and three people are booked together at 5-minute intervals to give time for visual acuity,
administration checks and administer eye drops (which take approximately 20 minutes to work).
Wheelchair patients have two slots, which reduces the total number seen in a clinic.
Screening also takes place four prisons: HMP Winchester, and the three prisons on the Isle of Wight. In
Winchester prison, 8 – 10 people are screened per session / quarter and the Isle of Wight has about 178
patients, who are seen through the year at a rate of one session each month. The screening programme
identifies that sessions conducted in the prisons are very resource hungry and take considerable planning.
The staff of the programme work effectively despite some system challenges. For example current access
issues have focused on technical problems with the telephone system (which understandably been
frustrating for patients trying to book appointments).
Southampton City Primary Care Trust commissioned Experian Ltd to map the locations of diabetic
registered with the screening programme using the Mosaic software, which allows determination of 10
minute walking zones around screening locations. In addition, it allocates characteristics to groups within
the population to better describe population types.
An example of these can be seen in the maps below. People who live outside a 10 minute walking distance
of a screening programme location may be less able to access the screening service and the Mosaic
profiles suggest that some people in this group may suffer financial stress which may also reduce the
ability to access services. Experian estimate that approximately 35% of the population registered with the
screening programme live outside a 10 minute walk time from a GP surgery that is visited by the
screening van.
Figure S11. Mosaic map showing population living outside a 10 minute walking distance from a GP
surgery in Southampton City
Dr Simon Fraser & Dr Laura Edwards
July 2010
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An explanation of the population profiles (segments) is given below
Segment
Name
Segment 1
Financially secure older couples living in owner occupied bungalows
Segment 2
Elderly singles with low mobility, reliant on public services for support
Segment 3
Low income older couples approaching retirement, living in low rise council housing
Segment 4
Childless, young, high rise council tenants with issues of social isolation
Segment 5
Vulnerable young families or lone parents living on council housing estates
Segment 6
Middle-aged owner occupiers making good use of public services
Segment 7
Ethnically diverse private renters in older terraced properties
Segment 8
Middle aged couples & families in right-to-buy homes
Segment 9
Comfortably-off, self serving families who lead active yet busy lifestyles
Segment 10
Young couples, new to the area, in privately rented purpose-built flats
Segment 11
Students living in shared houses or flats near to the city centre
Segment 12
Transient young singles with weak support networks, living in a mixture of housing
Segment 13
Young, active students living with like-minded people in halls of residence
Segment 14
Affluent professionals living in large detached properties out of the city centre
Segment 15
Well qualified, young professionals living in purpose-built waterside locations
Figure S12. Mosaic map showing percentage of population with ‘financial stress’ who live outside a 10
minute walking distance from a GP surgery that hosts retinopathy screening.
(Financial stress was defined as those from a TGI survey that answered they “Find it very difficult to live on
income”. The TGI survey is a continuous survey of consumer usage habits, lifestyles, media exposure, and attitudes).
Dr Simon Fraser & Dr Laura Edwards
July 2010
31
In addition to this information, modelling work done by Geographers at the University of Southampton
gives interesting insights into the distribution of the population during daytime working hours. An
example is shown below. This work suggests that, in the context of a medical service trying to maximise
ease of access and uptake such as the screening programme, the daytime location of patients should be
considered. Further modelling work, in conjunction with the University, specifically for the population of
people registered with the screening programme, may therefore be informative in the future.
Figure S13. 2am: residential “night-time” model of population distribution in Southampton; considerable
goods vehicle traffic on motorway & trunk roads
Figure S14. 9am: workplaces, educational institutions, “daytime” model; low residential; very high central
densities; peak traffic volume
14
14. Cockings S, Martin D, Leung S, Population24/7: space–time specific population surface modelling. Acknowledgements: Employee
data from the Annual Business Inquiry Service, National Online Manpower Information Service, licence NTC/ABI08-P0128. Office for
National Statistics 2001 Census: Standard Area Statistics (England and Wales): ESRC Census Programme, Census Dissemination Unit,
Mimas (University of Manchester). National Statistics Postcode Directory Data: Office for National Statistics, Postcode Directories: ESRC
Census Programme, Census Geography Data Unit (UKBORDERS), EDINA (University of Edinburgh). Quarterly Labour Force Survey,
Economic and Social Data Service, usage number 40023. MasterMap ITN layer: © Crown Copyright/database right 2009, an Ordnance
Survey/EDINA supplied service. AADF Data: © Crown Copyright, Department for Transport's Great Britain Road Traffic Survey. EduBase
School Data: © Crown Copyright, Department for Children, Schools and Families. Students in Higher Education Institutions 2005/06
Copyright © Higher Education Statistics Agency Limited 2007. Hospital Episode Statistics Copyright © 2005-2010, Health and Social Care
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Uptake
A summary of activity of the screening programme over the last few years is given by the table below:
Table S2. Trends in numbers of people offered screening in Southampton City
01/10/08 30/09/09
01/01/09 31/12/09
01/04/09 31/03/10
01/07/09 30/06/10
No. of Patients with
Diabetes Identified by
Practices in the PCT
9477.00
9916.00
10101.00
10335.00
Number of People with
Diabetes Offered
Screening for DR
7690.00
8331.00
9217.00
9417.00
No. of People with
Diabetes receiving
Screening for Early
Detection of DR
6566.00
6516.00
6452.00
6511.00
Description
During a six month period in 2009 (April to September), 77 people were referred on as ‘urgent’ referrals,
139 as ‘soon’ referrals, and 487 as ‘routine’ referrals.
Uptake of screening is challenging to assess for an annual screening programme.
Proxy measures, such as did not attend (DNA) rates can be used to measure uptake. From this audit, this
can be assessed from four perspectives:
• Those recorded as ‘DNA with no subsequent attendance in the following year’ by the screening
programme
• Those recorded as offered screening who were actually screened
• Exclusions from the screening programme
• Those recorded in GP records as not having attended retinopathy screening.
Each of these have limitations, such as uncertainty about the completeness of recording of screening at
practice level, and the problems encountered with accurately interrogating the screening programme
database(such as changing patterns with time). However, examining the characteristics of those not
attending using these groups gives interesting insights into the diabetic population, which may be useful in
reshaping aspects of the service.
DNA
Did not attend (DNA) refers to patients who had an appointment for retinal screening who did not attend
that appointment or arrange another within the time frame under consideration.
There were 925 DNAs to the Southampton, South West Hampshire, and Isle of Wight screening
programme in a one year period (April 2009 to March 2010). (496 male, 429 female). This represents a
DNA rate of 2.34% overall.
The chart below shows, for a 6 month period, the age/sex distribution of those who did not attend for
screening. This shows that a greater number of men, particularly in the middle age groups, tended to
DNA.
Information Centre. Crown Copyright Ordnance Survey. An EDINA/JISC supplied service. This research was undertaken at the University
of Southampton with funding as part of an ESRC standard research grant award (RES-062-23-1811).
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Figure S15. Age and gender distribution of people who did not attend screening in the Southampton,
South West Hampshire, and Isle of Wight retinal screening programme in a six month period.
Age / sex characteristics of people who DNAd the SHIOW retinopathy
screening programme April to September 2009 with no subsequent
attendance recorded
60
50
40
Male
30
Female
20
10
0
12 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 to 89 90 to 99
>100
Age group
If these figures are expressed as the proportion of people in each age group who did not attend, then the
younger age groups are more noticeably represented. (It should be noted that there are only very small
numbers of people in the >100 age group as might be expected). This has implications for the programme
in terms of targeting screening efforts to accommodate the needs of these age groups.
Figure S16. Distribution of age and gender among those who DNA as a proportion of the number of
people in each age group.
Proportion of age and gender groups that DNAd the SHIOW
DRS programme in a 6 month period
12.00%
10.00%
8.00%
Proportion DNA 6.00%
4.00%
2.00%
0.00%
12 to
19
20 to
29
30 to
39
40 to
49
50 to
59
Male
60 to
69
70 to
79
80 to
89
90 to
99
>100
Female
Deprivation is another variable with the potential to affect uptake of the screening service (and therefore
affect equity). It is therefore valuable to consider those who DNA in terms of the deprivation decile of
their home address. The chart below gives this distribution for a one year period for the number of people.
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Dr Simon Fraser & Dr Laura Edwards
July 2010
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Figure S17. Gender and deprivation distribution of people who DNA the Southampton, South West
Hampshire, and Isle of Wight retinal screening programme in a one year period
As for age, if this is represented in terms of the proportion of people in each IMD decile who did not
attend, the more deprived groups are more noticeably represented.
Figure S18. Gender and deprivation distribution of people who DNA the Southampton, South West
Hampshire, and Isle of Wight retinal screening programme in a one year period as a proportion of people
in each deprivation decile
Proportion of people registered with the SHIOW DRS Programme who
DNA'd in a one year period
6.00%
5.00%
4.00%
Proportion who
3.00%
DNA'd
2.00%
1.00%
0.00%
1
2
3
4
5
6
7
8
9
10
Index of Multiple Deprivation Decile (1 = most deprived, 2 = least deprived)
Proportion of men
Proportion of women
Proportion of total
Broadly speaking, a higher proportion of men who reside in the lower deciles of deprivation did not
attend, whereas a higher proportion of women from less deprived areas DNA. If age and deprivation are
combined, we can show that younger people who DNA tend to come from more deprived areas:
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Figure S19. Age and deprivation distribution of people who DNA the Southampton, South West
Hampshire, and Isle of Wight retinal screening programme in a one-year period as a proportion of people
in each deprivation decile.
Proportion of people who DNA the SHIOW DRS Programme in each age group
and quintile of deprivation
(1 = most deprived, 5 = least deprived)
12.00%
10.00%
8.00%
Proportion
6.00%
who DNA
4.00%
2.00%
0.00%
0 to 9
10 to
19
20 to
29
30 to
39
40 to
49
50 to
59
60 to
69
70 to
79
80 to
89
90 to
99
100+
Age group
1
2
3
4
5
Total
Offered and screened
An assessment was made of the uptake of screening by the location of the screening vans. The chart below
shows an example of this from the Isle of Wight. It shows the proportion of people offered screening in a
six month period who were actually screened (by GP practice). Those practices where the screening vans
did not visit are shown in red. This shows that, overall, the uptake of screening is good. It also shows that
being registered with a practice that is not a screening location does not predict the proportion actually
screened, suggesting that good mechanisms are in place to offer screening at neighbouring practices.
Figure S20. Proportion of people, registered with Isle of Wight GP surgeries, offered screening who were
actually screened
Percentage of Isle of Wight people with diabetes (by GP practice) offered retinopathy screening (April - September 2009)
who were actually screened . Practices not visited by the van shown in red.
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lC
G
en
ro
tre
ve
Ho
us
e
Su
rg
er
y
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Exclusions
The most recent figures from the Southampton, South West Hampshire, and Isle of Wight screening
programme for Southampton City PCT patients (from quarterly vital signs data 30th June 2010) shows the
following:
Dr Simon Fraser & Dr Laura Edwards
July 2010
37
Table S3. Numbers of people who are classified as exclusions from the screening programme in
Southampton City
Description
01/10/08 30/09/09
01/01/09 31/12/09
01/04/09 31/03/10
01/07/09 30/06/10
Number of people with diabetes
offered screening
7690.00
8331.00
9217.00
9417.00
Number of people with diabetes
classified as excluded from screening
587.00
604.00
879.00
1364.00
Proportion of people identified as
diabetic who are classified as
excluded from screening
6.19%
6.09%
8.70%
13.20%
Table S4. Reasons for exclusions from the Southampton, South West Hampshire, and Isle of Wight retinal
screening programme
Reason
Southampton Eye Unit - DR referral
Deceased
Assess future suitability for Mobile screening
Under ophthalmology care (Non DESS
referral)
Moved out of area
Patient has opted out of screening
No longer considered diabetic
Physically Incapable
No current contact details
Terminally Ill
Mentally Incapable
Blind - screening contraindicated
Winchester Eye Unit - DR referral
Under 12
Southampton City PCT Total
Number
877
637
155
135
126
87
86
81
52
52
9
8
3
2
2310
Proportion of total excluded
37.97%
27.58%
6.71%
5.84%
5.45%
3.77%
3.72%
3.51%
2.25%
2.25%
0.39%
0.35%
0.13%
0.09%
100.00%
GP records
Analysis of data by practice shows possible associations between practice diabetes prevalence and control
of diabetes and uptake of screening, which suggest that a higher prevalence of diabetes in the practice, and
better control of diabetes lead to a better uptake of screening. However, there are many potential
confounding factors (alternative explanations for this finding such as age of practice population) so it is
incorrect to make cause and effect assumptions.
Dr Simon Fraser & Dr Laura Edwards
July 2010
38
Figure S21. Scatterplot of Southampton and Isle of Wight GP practices’ registered prevalence of diabetes
and proportion screened for retinopathy in last year
Figure S22. Scatterplot of Southampton and Isle of Wight GP practices’ proportion of diabetics with last
Hba1c measurement less than 8mmol/l and proportion screened for retinopathy in last year
In order to better understand the population of people not being screened, analysis of GP records focused
on those people not recorded as having had retinal screening for two periods of time – in the last year and
in the last 3 years (since April 2009 and since April 2007 respectively).
Overall, for practices referring to the Southampton, South West Hampshire, and Isle of Wight screening
programme about 8,800 people with diabetes do not have a record of retinal screening in the last year, and
3,200 have no record of screening in the last three years.
Dr Simon Fraser & Dr Laura Edwards
July 2010
39
Unfortunately, the current lack of Super Output Area and deprivation measure in the Hampshire Health
record means that the picture of deprivation among people with diabetes registered with GPs in this
programme is incomplete as shown below.
Figure S23. Distribution of Index of Multiple deprivation deciles in GP surgeries referring to the
Southampton, South West Hampshire, and Isle of Wight screening programme.
However, the chart below shows the distributions for Southampton City and the Isle of Wight, where the
information is complete, because all practices submitted data directly for this audit.
Figure S24. Distribution of Index of Multiple deprivation deciles for people with diabetes in GP surgeries
in Southampton.
Dr Simon Fraser & Dr Laura Edwards
July 2010
40
This shows that the highest number of people with diabetes in Southampton live in areas within Lower
Super Output Areas in national deprivation deciles 2 to 5.
Figure S25. Distribution of Index of Multiple deprivation deciles for people with diabetes in GP surgeries
in the Isle of Wight.
This shows that the highest number of people with diabetes in the Isle of Wight live in areas within Lower
Super Output Areas in national deprivation deciles 3 to 5.
The following chart shows the distribution of degree of deprivation of place of residence of people with no
record of screening in the last year in their GP record (in those for whom the postcode was known). This
also suggests a higher proportion of those in lower deprivation deciles are not being screened. It must be
remembered, however, that the deprivation status was not known for many patients in the programme as a
whole.
Figure S26. Distribution of Index of Multiple deprivation deciles for people with diabetes in GP surgeries
referring to the Southampton, South West Hampshire, and Isle of Wight retinal screening programme
where the Lower Super Output Area of residence was known.
Number
Gender and IMD decile distribution for people registered with
GPs referring to the SHIOW DRS programe whose IMD status
is known and who have no record of screening since April
2009
500
450
400
350
300
250
200
150
100
50
0
1
2
3
4
5
6
7
8
9
10
IMD decile (1 = most deprived, 10 = least deprived)
Male
Dr Simon Fraser & Dr Laura Edwards
July 2010
Female
41
The following charts show the age, gender, deprivation, and type of diabetes distribution of those with no
record of screening in the last three years. These show that the majority of people with no record of
screening in the last three years are men, aged 50 to 70, but, for people with Type 1 diabetes, a younger
age group has no record of screening.
Figure S27. Age and gender of people from GP practices referring to the Southampton, South West
Hampshire, and Isle of Wight retinal screening programme with no record of screening
Age and gender distribution of people with diabetes registered with
GP practices referring to the SHIOW DRS programme who have no
record of screening in the last 3 years
450
400
350
Number
300
250
200
150
100
50
0
12 to
19
20 to
29
30 to
39
40 to
49
Male
50 to
59
60 to
69
70 to
79
80 to
89
90 to
99
100+
Female
Figure S28. Age and gender of people with Type 1 diabetes from GP practices referring to the
Southampton, South West Hampshire, and Isle of Wight retinal screening programme with no record of
screening
Dr Simon Fraser & Dr Laura Edwards
July 2010
42
Figure S29. Age and gender of people with Type 2 diabetes from GP practices referring to the
Southampton, South West Hampshire, and Isle of Wight retinal screening programme with no record of
screening
If this is represented as a proportion of people with diabetes in the practices referring to the Southampton,
South West Hampshire, and Isle of Wight screening programme, as shown in the chart below, it is striking
that young adults and the very elderly are more noticeably represented. This distribution is similar to that
for the DNAs to the programme represented above. If the proportion of those with no record of screening
in GP records is truly representative of those not screened, it is of concern that up to 20% of those between
20 and 40 have not been screened. This is particularly noticeable in men.
Figure S30. Proportion of people in each age and gender group from GP practices referring to the
Southampton, South West Hampshire, and Isle of Wight retinal screening programme with no record of
screening
Dr Simon Fraser & Dr Laura Edwards
July 2010
43
Figure S31. Proportion of people with specified type of diabetes from GP practices referring to the
Southampton, South West Hampshire, and Isle of Wight retinal screening programme with no record of
screening (Under 12s are excluded, and ‘Diabetes mellitus’ refers to those in whom a general diabetes
code was used rather than Type 1 or Type 2. ‘All types’ refers to the overall proportion when all are
considered together)
Proportion with no record of screening
Proportion of people with each type of diabetes in practices
referring to the SHIOW DRS programme with no record of
screening in the last 3 years
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
Diabetes mellitus
Type 1 diabetes
mellitus
Male
Type 2 diabetes
mellitus
Female
All types
Total
These charts show that more Type 2 diabetics, and those Type 1 diabetics in younger age groups have no
record of screening in the last 3 years, but that the proportions in each diabetes type are similar.
Dr Simon Fraser & Dr Laura Edwards
July 2010
44
Outcomes
Measuring success and equity in terms of outcomes of screening are difficult for a number of reasons:
• The need for annual screening
• A changing population (people moving into and away from the area, new cases, deaths)
• The low incidence of blindness and visual impairment due to diabetes
• The need for accurate recording of outcomes
• The limitations in ability to query screening and hospital IT systems for outcome data
For these reasons, proxy outcomes are often used to monitor the screening programme. Examples are the
numbers of referrals from the programme for ophthalmology opinion.
Some information for the Southampton, South West Hampshire and Isle of Wight programme is given
here. However, for IT reasons, accessing this information at patient level to assess some of the dimensions
of equity is problematic.
Table S5. Referral numbers from the Southampton, South West Hampshire, and Isle of Wight retinal
screening programme
Referral classification
Urgent referrals 1/4/200931/3/2010
Soon referrals 1/4/200931/3/2010
Routine Referral 1/4/200931/3/2010 (Unassessable)
Routine referral 1/4/200931/3/2010 (Maculopathy)
PCT
Hampshire PCT
Isle of Wight PCT
Southampton City PCT
Hampshire PCT
Isle of Wight PCT
Southampton City PCT
Hampshire PCT
Isle of Wight PCT
Southampton City PCT
Hampshire PCT
Isle of Wight PCT
Southampton City PCT
Number
76
22
33
149
41
79
14
10
11
439
150
208
Blindness
As part of the validation process of the numbers of patients for the Southampton retinopathy screening
programme, an audit was recently undertaken of practice data examining registration of blindness and
other degrees of visual impairment for practices in Southampton City PCT.
Of a GP-registered population of approximately 264,000 in Southampton city practices, there were 875
people (0.33% of total population) recorded as having some form of visual impairment in their GP
records. Of these 323 (37%) were registered blind, 371 (42%) were registered partially sighted, and 181
(21%) had non-specific ‘visual loss’ recorded. Of this 875 people with visual impairment, 141 (16%) have
a record of having diabetes. 197 of the 875 (22.5%) have a record of macular degeneration. However, as
shown in the chart below, there is a wide variation in the recorded prevalence of visual impairment in
different practices (range 0% to 1.2%). This may reflect differences in recording practices, differences in
the demography of practice populations, or a true difference in the prevalence of visual impairment in
different parts of the city. It is not possible to determine which of these possibilities is the case from
currently available data. An even greater range is seen in the proportion of those recorded as having visual
impairment that have a diagnosis of diabetes (0 – 67%). This wide variation means that firm conclusions
about causes of blindness in the city cannot be determined. Caution should therefore be exercised in
drawing conclusions from practice-level visual impairment data about the success or otherwise of the
retinopathy screening programme in preventing blindness from causes related to diabetes.
Dr Simon Fraser & Dr Laura Edwards
July 2010
45
Figure S32. Prevalence of all forms of visual impairment (including partial sight and blindness) as
recorded in GP records in Southampton
An alternative approach was therefore adopted in conducting this equity audit. In order to compare people
having screening with those who appear not to be having screening, the data obtained from GP databases
was analysed for two distinct groups of people:
• Those with a record in their electronic GP notes of having had retinal screening in the last year
(since April 2009)
• Those with no record of retinal screening in their electronic GP notes for the last three years (since
April 2007).
In doing this, it is recognised that there may be many reasons why there is no GP record of screening,
including those excluded from screening because of blindness or other reasons, lack of recording by GP
practices, or true lack of registration with the programme or non-attendance by the patient. However, this
approach was considered reasonable on the basis that recording of retinopathy screening is required as one
of the targets in the GP Quality and Outcomes Framework, and recording is therefore likely to be
optimized by practices. It was also considered reasonable as those identified are likely to include those
people who are either not registered with the screening programme at all, or are not attending. As there is
a possible correlation between attendance at retinal screening and other measures of good diabetes
management, this group are therefore also potentially at greater risk of other diabetic complications.
Identifying their characteristics may therefore be helpful to everyone involved in their diabetes care.
The results of this comparison for the Southampton, South West Hampshire and Isle of Wight programme
are shown in the table below.
Dr Simon Fraser & Dr Laura Edwards
July 2010
46
Table S6. Comparison of characteristics between people with a record of retinal screening in the last year
and people with no record of screening in 3 years in their GP records.
Number
SHIOW screened
within last year
SHIOW 3-year
no screening
recorded
11876
3287
Number
%
Number
%
6577
5299
55.38%
44.62%
1851
1436
56.30%
43.70%
5307
2896
3673
44.69%
24.39%
30.93%
239
433
2394
7.28%
13.16%
72.84%
946
7.97%
337
10.25%
2699
1236
7941
22.73%
10.41%
66.87%
1011
425
1909
30.76%
12.94%
58.08%
2204
110
9562
18.56%
0.93%
80.52%
860
57
2339
26.16%
1.72%
71.15%
868
7.31%
238
7.24%
Background
Proliferative or pre-proliferative
Maculopathy
47
8
12
0.40%
0.07%
0.10%
5
2
2
0.15%
0.06%
0.06%
Laser treatment recorded
122
1.03%
9
0.27%
58
119
5572
0.49%
1.00%
46.92%
35
31
1319
1.06%
0.94%
40.13%
Gender
Male
Female
Diabetes type
General 'diabetes' code used
Type 1
Type 2
Deprivation
Percentage in lowest IMD quintile
Ethnicity
White British
Other
No record
Language of choice
English
Other
No record
Retinal screening
Recorded as seeing optician /
optometrist
Retinopathy recorded
Visual impairment
Blind
Partial sight
Hypertension
This comparison suggests that a higher proportion of people in the ‘3-year non-attendance’ population
were male and lived in more deprived areas compared to the ‘screened in the last year’ population. There
may be differences in the type of diabetes between the groups, but given the high proportion of those in
which a general code for diabetes was used, it is not possible to comment on this. Similarly, for ethnicity
and language groups, there may be important differences, but they are obscured by lack of completeness
of recording. A similar proportion in each group appears to opt for optometrist attendance. A lower
proportion in the unscreened group had a record of retinopathy and laser treatment recorded, but a higher
proportion of blindness. The high prevalence of hypertension in both groups is a particular concern for the
unscreened group as high blood pressure is associated with an increased risk of developing retinopathy.
Dr Simon Fraser & Dr Laura Edwards
July 2010
47
Portsmouth and South East Hampshire
Diabetic Retinopathy Screening Programme
Dr Simon Fraser & Dr Laura Edwards
July 2010
48
Description of the population
There are approximately 24,700 people registered with the Portsmouth and South East Hampshire
retinopathy screening programme (the number varies because new people are referred to the programme,
some people are seen for eye problems elsewhere and are temporarily or permanently lost to screening
follow up within the programme, and some move away from the area or die). Of these, approximately 21,
800 are categorized as having ‘current’ status (i.e. the general status used for new and existing patients
who should continue to be screened). Approximately 1,300 are categorized as ‘care elsewhere’ status (i.e.
a patient is being screened during regular visits to an Eye Department clinic).
Age, gender, type of diabetes, measures of deprivation
The age and gender distribution of those registered with the programme are shown in the three charts
below. The first and third charts use data from the screening programme, and the second from GP
surgeries referring patients to the programme. (It should be remembered that the numbers are less in the
GP data because of the lack of completeness of data from the Hampshire Health record). They show that
there are more men than women registered with the programme, that largest proportion of men are
between 60 and 80,and the largest proportion of women are between 70 and 85.
Figure P1. Age and gender distribution using data from the Portsmouth and South East Hampshire
screening programme
Age and gender distribution of people registered with
the Portsmouth DRS service
2500
2000
1500
Number
1000
500
0
0 to 5 to 10 to 15 to 20 to 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to 75 to 80 to 85 to 90 to 95 to 100 105+
4
9
14 19 24 29 34 39 44 49 54 59 64 69 74 79 84 89 94 99
to
104
Male
Female
Not recorded
Figure P2. Age and gender distribution using data from GP practices referring to the Portsmouth and
South East Hampshire screening programme
Dr Simon Fraser & Dr Laura Edwards
July 2010
49
This shows that, despite the lack of completeness of GP data available, the population distributions are
very similar.
Figure P3. Population pyramid showing proportions of each age group and gender registered with the
Portsmouth and South East Hampshire screening programme
Population pyramid pf people registered with the Portsmouth
and SE Hants Diabetic Retinopathy Screening Programme
105+
100 to 104
95 to 99
90 to 94
85 to 89
80 to 84
75 to 79
70 to 74
65 to 69
age group
60 to 64
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
10 to 14
5 to 9
0 to 4
10.00% 8.00%
6.00%
4.00%
2.00%
0.00%
2.00%
4.00%
6.00%
8.00%
Percentage of people
Male
Female
Of the 24,700 people registered with the Portsmouth and SE Hants programme, approximately 13,000
(52%) have the type of diabetes recorded in the retinopathy screening database. The age and gender
distribution of those for whom type of diabetes is recorded is shown in the first two charts below. More
complete data on type of diabetes comes from the GP records, which is shown in the third chart below.
Dr Simon Fraser & Dr Laura Edwards
July 2010
50
Figures P4 & P5. Distribution of type of diabetes from Portsmouth and South East Hampshire screening
programme data
Age and gender distribution of people known to have Type 1
diabetes registered with the Portsmouth DRS Programme
250
200
150
100
50
95 to 99
100 to 104
105+
105+
90 to 94
85 to 89
80 to 84
75 to 79
70 to 74
65 to 69
60 to 64
95 to 99
Male
100 to 104
Female
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
5 to 9
10 to 14
0 to 4
0
Total
Age and gender distribution of those people known to have
Type 2 diabetes in the Portsmouth DRS Programme
2000
1800
1600
1400
1200
1000
800
600
400
Female
Male
Unknown
90 to 94
85 to 89
80 to 84
75 to 79
70 to 74
65 to 69
60 to 64
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
10 to 14
5 to 9
0 to 4
200
0
Total
Figure P6. Distribution of type of diabetes from GP data of practices referring to the Portsmouth and
South East Hampshire screening programme
Dr Simon Fraser & Dr Laura Edwards
July 2010
51
It is noticeable from these charts that the majority of the burden of disease due to diabetes in the
population is from Type 2 diabetes.
The population registered with the programme comes from a wide variety of socio-demographic
backgrounds. One way of expressing this is to look at rankings of the Index of Multiple Deprivation
(IMD) - a deprivation index at a small area level known as Lower Super Output Areas (LSOAs). LSOAs
have between 1000 and 3000 people living in them with an average population of 1500 people. In most
cases, these are smaller than wards, thus allowing the identification of small pockets of deprivation. The
IMD combines a number of factors covering a range of health, economic, social and housing issues into a
single deprivation score for each small area in England. There are 32,482 LSOAs in England. The LSOA
ranked 1 by the IMD 2007 is the most deprived and that ranked 32,482 is the least deprived. A common
way to summarise IMD ranking is to divide the ranks into quintiles and deciles, in other words to describe
‘the most deprived 20% or 10%’ and ‘the least deprived 20% or 10%’.
Portsmouth City PCT rank of average Index of Multiple deprivation is 71stout of 152 PCTs (compared to
Southampton 70th and Hampshire 147th, where 1 is most deprived and 152 least deprived). Portsmouth
City has areas significant deprivation, particularly in Charles Dickens ward, which has one Super Output
Area which is among the most deprived 10% of SOAs in the South East, and in which 47% of the
population are classified as ‘income deprived’ 15. The chart below shows the number and gender of people
registered with the Portsmouth and South East Hampshire screening programme who live in each of the 10
national deciles of multiple deprivation (where 1 is most deprived and 10 is least deprived).
Figure P7. Index of Multiple Deprivation distribution for those registered with the Portsmouth and South
East Hampshire screening programme
Numbers of people registered with the Portsmouth DRS
Programme by gender and IMD deciles
2500
2000
1500
1000
500
0
1
2
3
4
5
6
7
8
9
10
IMD decile (1 = most deprived, 10 = least deprived)
Male
Female
This shows that a significant proportion of people registered with this screening programme live in more
deprived areas. 21% of those registered with the programme live in areas within IMD deciles 1, 2, and 3,
and 36% live in areas within IMD deciles 8, 9, and 10.
Ethnicity
Recording of ethnicity data is incomplete in many NHS contexts, and ethnicity definitions vary between
organisations and between different years of the national census. Despite these limitations, there is an
impression that ethnicity information is being more routinely collected, and ethnicity and language issues
may be important in terms of equity. The GP data requested therefore included a search for ethnicity
status. For practices referring to the Portsmouth and South East Hampshire programme, a summary of this
information for the main groups for which data was recorded is given below:
15.
Portsmouth City Council information from www.Portsmouth.gov.uk. Accessed July 2010
Dr Simon Fraser & Dr Laura Edwards
July 2010
52
Table P1. Ethnicity recording in Portsmouth and South East Hampshire GP practices
Ethic group
Not recorded
White British
White other
Indian
Other Asian
Black African
Black Caribbean
Number
10969
8444
965
85
182
41
19
Proportion of total
52.57%
40.47%
4.62%
0.41%
0.87%
0.20%
0.09%
It can be seen from this that, for the majority of people registered with the screening programme, ethnicity
information is not recorded. This makes it difficult to draw conclusions about equity between ethnic
groups in the analysis of the data in this audit.
Dr Simon Fraser & Dr Laura Edwards
July 2010
53
Provision
As stated above, screening in the Portsmouth and South East Hampshire programme is delivered via static
cameras in five locations:
• St Mary’s NHS Treatment Centre, Portsmouth
• Gosport War Memorial Hospital
• Emsworth Victoria Cottage Hospital
• Sylvan Clinic, Coldeast Hospital
• Petersfield Community Hospital
The maps below show the screening locations and the number of patients registered with the programme
in each area. Dark red areas are those with higher numbers of patients registered with the programme. It
can be seen that there are two distinct areas with a higher density of patients which are some way from the
location of the static cameras: Horndean and Cowplain, and Hayling Island. There are also areas of
Portsmouth city with higher numbers of diabetics, such as Somerstown and Portsea. In addition to this,
areas of Havant and Waterlooville appear to have high numbers of people with diabetes registered with the
programme.
Figure P8. Map of Screening locations and numbers of patients registered with the Portsmouth and South
East Hampshire screening programme
Dr Simon Fraser & Dr Laura Edwards
July 2010
54
Figure P9. Map of screening locations and numbers of patients in Portsmouth City registered with the
Portsmouth and South East Hampshire screening programme
Dr Simon Fraser & Dr Laura Edwards
July 2010
55
Figure P10. Map of Screening locations and numbers of patients in Havant and Hayling registered with
the Portsmouth and South East Hampshire screening programme
Dr Simon Fraser & Dr Laura Edwards
July 2010
56
Figure P11. Map of screening locations and numbers of patients in Fareham and Gosport registered with
the Portsmouth and South East Hampshire screening programme
Dr Simon Fraser & Dr Laura Edwards
July 2010
57
Figure P12. Map of Screening locations and numbers of patients in Petersfield and Bordon registered with
the Portsmouth and South East Hampshire screening programme
Access
Access to the screening service is determined by several factors including the geographical location of
services, the timing of service provision, and the mobility of the population served.
Due to software limitations, it is not possible to extract information on the numbers and proportions of
people screened at each of the screening locations. All screening sites operate in core hours except the St
Mary’s treatment centre which does have some Saturdays and a late session (till 8pm on Wednesdays). In
the past, the programme offered some appointments on Saturdays at Petersfield but the numbers using this
opportunity were small. The St Mary’s treatment centre opened in April 2007, is fully booked at all times
and sees 36 patients per day. The Bio Microscopy Clinic runs on Mondays and sees 27 patients per day,
led by a consultant ophthalmologist or a practicing fully qualified optometrist. Extra clinics are held on
Thursdays when capacity is required. The Gosport War Memorial Hospital clinic opened in June 2007. It
is operational four days per week; Monday, Wednesday, Thursday, Friday 8.30 – 4.30, and sees 36
patients per day. The site opening hours do not allow for Saturday clinics or late clinics. The Emsworth
Victoria Cottage Hospital opened in July 2007. It is Operational five days per week, reduced to four days
when there is a Petersfield clinic on a Tuesday. 8.50 – 4.30 The later starting time is due to the opening
hours of the unit. 34 patients are seen per day. The site opening hours do not allow for Saturday clinics or
late clinics. The Sylvan Clinic opened in May 2009 and is operational one day per week – Tuesday 8.40 –
4.30 – and books 36 patients per day Later starting time due to opening hours of the unit. The site opening
hours do not allow for Saturday clinics or late clinics. Petersfield Hospital site opened in July 2009 and
has been operational two days per month. It has experienced poor uptake in the past.
Grading screen for ophthalmologist to complete EQA and review images of bio microscopy patients.
One of the challenges for retinopathy screening in Portsmouth is the need for patients to travel to the
location of the static cameras. For Portsmouth city this means getting to St Mary’s NHS treatment centre.
Some patients in the survey component of this audit commented that the location of the service and
transport to it were challenging. It was perceived that this might be a particular problem for certain groups
of people. This is explored further below under ‘uptake’.
In order to assess the impact of location on access to the Portsmouth and South East Hampshire
programme, we mapped the area covered by the screening programme and superimposed rates of nonattendance to give an impression of ‘density of DNA’. The maps below show this for DNAs in a one year
Dr Simon Fraser & Dr Laura Edwards
July 2010
58
period by lower super output area. The dark red areas are those with the highest rate of DNA in this
period.
It is important for the programme to consider the reasons for higher numbers of DNAs in certain areas in
terms of camera locations, timing of service provision, and the characteristics of the population.
Figure P13. Map of rates of DNA among people in Portsmouth City registered with the Portsmouth and
South East Hampshire screening programme
Dr Simon Fraser & Dr Laura Edwards
July 2010
59
Figure P14. Map of rates of DNA among people in Havant and Hayling registered with the Portsmouth
and South East Hampshire screening programme
Dr Simon Fraser & Dr Laura Edwards
July 2010
60
Figure P15. Map of rates of DNA among people in Fareham and Gosport registered with the Portsmouth
and South East Hampshire screening programme
Figure P16. Map of rates of DNA among people in Petersfield and Bordon registered with the Portsmouth
and South East Hampshire screening programme
Dr Simon Fraser & Dr Laura Edwards
July 2010
61
Uptake
In 2007 – 2008, the Portsmouth and South East Hampshire screening programme screened 12154 people.
In 2009/10, the programme screened over 16,000 (exact figures not yet confirmed).
Uptake of screening is challenging to assess for an annual screening programme. Proxy measures, such as
did not attend (DNA) rates can be used to measure uptake. From this audit, this can be assessed from three
perspectives:
• Those recorded as ‘DNA with no subsequent attendance in the following year’ by the screening
programme
• Those recorded in GP records as not having attended retinopathy screening.
• Those people classified in the screening programme as ‘declined’ or ‘permanent opt out’ of the
service.
Each of these has limitations, such as uncertainty about the completeness of recording of screening at
practice level, and problems that may be encountered when interrogating the screening programme
database (such as changing patterns with time). However, examining the characteristics of those not
attending using these groups gives interesting insights into the diabetic population, which may be useful in
reshaping aspects of the service.
The chart below shows the age and gender distribution of people who did not attend screening in a one
year period (1st April 2009 to 31st March 2010). This shows that a greater number of men did not attend,
particularly in younger age groups, and that the DNAs appear to be in younger age groups generally than
the age distribution of the screening programme as a whole.
Figure P17. Age and gender distribution of people who did not attend screening in the Portsmouth and
South East Hampshire screening programme in a one-year period.
Age and gender distribution of people who DNA the Portsmouth/SE Hants DRs Programme in 1
year
180
160
140
120
Number
100
80
60
40
20
0
0 to
4
5 to 10 to 15 to 20 to 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to 75 to 80 to 85 to 90 to 95 to 100 105+
9
14
19
24
29
34
39
44
49
54
59
64
69
74
79
84
89
94
99
to
104
Male
Female
Not recorded
If these figures are expressed as the proportion of people in each age group who did not attend, then the
younger age groups are more noticeably represented. This has implications for the programme in terms of
targeting screening efforts to accommodate the needs of these age groups.
Dr Simon Fraser & Dr Laura Edwards
July 2010
62
Figure P18. Distribution of age and gender among those who DNA as a proportion of the number of
people in each age group in the Portsmouth and South East Hampshire screening programme
Proportion of people who DNA the Portsmouth / SE Hants DRS Programme by age group and gender
25.00%
20.00%
15.00%
Proportion who DNA
10.00%
5.00%
0.00%
0 to
4
5 to 10 to 15 to 20 to 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to 75 to 80 to 85 to 90 to 95 to 100 105+
9
14
19
24
29
34
39
44
49
54
59
64
69
74
79
84
89
94
99
to
104
Male
Female
The total proportion of males who did not attend is 8.47%; the proportion of women is 8.45%. The
difference between these proportions was not statistically significant (at the 5% level).
Deprivation is another variable with the potential to affect uptake of the screening service (and therefore
affect equity). It is therefore valuable to consider those who DNA in terms of the deprivation decile of
their home address. The chart below gives this distribution for a one-year period for the number of people.
Figure P19. Gender and deprivation distribution of people who DNA the Portsmouth and South East
Hampshire retinal screening programme in a one year period
Number of people who DNA the Portsmouth DRS Programme in a 1 year
period by IMD deciles
300
250
200
Number of people 150
100
50
0
1
2
3
4
5
6
7
8
9
10
IM D decile (1 = most deprived, 10 = least deprived)
Men
Women
Total
As for age, if this is represented in terms of the proportion of people in each IMD decile who did not
attend, the more deprived groups are much more noticeably represented.
Dr Simon Fraser & Dr Laura Edwards
July 2010
63
Figure P20. Gender and deprivation distribution of people who DNA the Portsmouth and South East
Hampshire retinal screening programme in a one year period as a proportion of people in each deprivation
decile
Proportion of people in the Portsmouth DRS Programme who
DNA in a 1 year period by deprivation deciles
14.00%
12.00%
10.00%
Proportion who 8.00%
DNA in 1 year
6.00%
4.00%
2.00%
0.00%
1
2
3
4
5
6
7
8
9
10
IMD decile (1 = most deprived, 10 = least deprived)
Proportion of men
Proportion of women
Proportion of total
The odds ratio for not attending if in the lower two deciles compared to the highest two deciles is 1.90
(p<0.0001). This implies that the odds of not attending in those who live in a more deprived area is nearly
twice the odds for those living in the least deprived area.
There is also a difference in the proportion of male and female DNAs, with more women from deprived
areas tending to DNA compared to men, while the reverse is true of the less deprived areas.
As stated above, the proportion of those people where the type of diabetes is recorded is 52%. For those in
whom this is known, in the year for which these figures were collected, the proportion of people with
Type 1 diabetes who did not attend was 12.45%. For type 2 diabetics, this figure was 8.93%. The odds
ratio for DNA if Type 1 compared to Type 2 is 1.45 (p<0.0001). In other words, in the sample of those
who did not attend, for whom type of diabetes is recorded, the odds of Type 1 diabetics not attending was
1.45 times that of Type 2 diabetics, and the difference in proportion attending was statistically significant.
However, it must be remembered that this only represents a proportion of all those who did not attend, and
the true value might be different if the data on type of diabetes were complete.
It is also worth considering those people who are not receiving screening, because, for a variety of
reasons, they decline or opt out of the programme. From the screening programme records, it is possible to
look at the age, gender, and type of diabetes of people in these groups. The numbers of people are as
follows:
Total ‘declined’ = 437 people
Total ‘permanent opt out = 225 people
The charts below show the age and gender distributions of those classified as ‘declined’ and ‘permanent
opt out’ in the programme in terms of absolute numbers and as proportions of people in each age group. It
can be seen that for both of these categories, older people form a higher proportion of those declining or
opting out of screening. This may not be very surprising, particularly for the very elderly. However, it may
be important to consider the access of elderly people to the screening programme as some may decline on
the basis of not being able to get to the cameras.
In addition to this, it may be very valuable to explore in more detail the small number of younger people
who decline or opt out, as there may be important implications for them in the long term for not being
screened.
Dr Simon Fraser & Dr Laura Edwards
July 2010
64
Figure P21. Age and gender distribution of people classified as ‘declined’ in the Portsmouth and South
East Hampshire screening programme
Age and gender distribution of people classified as 'declined' in
the PSEH DRS programme
40
Number declined
35
30
25
20
15
10
5
Male
105+
100 to 104
95 to 99
90 to 94
85 to 89
80 to 84
75 to 79
70 to 74
65 to 69
60 to 64
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
10 to 14
5 to 9
0 to 4
0
Female
This suggests that people who decline screening tend to be in the older age groups.
Figure P22. Age and gender distribution of people classified as ‘declined’ in the Portsmouth and South
East Hampshire screening programme as a proportion of people in the programme in each age group
Proportion of people 'declined' in each age group of the PSEH
DRS programme
14.00%
Proportion declined
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
Male
105+
100 to 104
95 to 99
90 to 94
85 to 89
80 to 84
75 to 79
70 to 74
65 to 69
60 to 64
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
10 to 14
5 to 9
0 to 4
0.00%
Female
This suggests that a greater proportion of people in older age groups decline screening.
Dr Simon Fraser & Dr Laura Edwards
July 2010
65
Figure P23. Age and gender distribution of people classified as ‘permanent opt out’ in the Portsmouth and
South East Hampshire screening programme
Age and gender distribution of 'permanent opt outs' from PSEH
DRS programme
Number of 'opt out'
25
20
15
10
5
Male
105+
100 to 104
95 to 99
90 to 94
85 to 89
80 to 84
75 to 79
70 to 74
65 to 69
60 to 64
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
5 to 9
10 to 14
0 to 4
0
Female
As for those classified as ‘declined’, this suggests that people who permanently opt out of screening tend
to be in the older age groups.
Figure P24. Age and gender distribution of people classified as ‘permanent opt out’ in the Portsmouth and
South East Hampshire screening programme as a proportion of people in the programme in each age
group
Proportion of people in each age group classified as
'permanent opt out' in PSEH DRS programme
Proportion 'opt out'
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
Male
105+
100 to 104
95 to 99
90 to 94
85 to 89
80 to 84
75 to 79
70 to 74
65 to 69
60 to 64
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
5 to 9
10 to 14
0 to 4
0.00%
Female
This suggests that a greater proportion of people in older age groups permanently opt out of screening.
Comparing gender differences in the screening programme, the odds ratio of being classified as ‘declined’
or ‘permanent opt out’ is 1.25 female: male (χ2 7.79, p<0.05)
In those for whom type of diabetes is recorded, the following charts show the proportion in each age group
who are classified as ‘declined’ or ‘permanent opt out’. These show a higher proportion of middle aged
people with type 1 diabetes and an older population of people with type 2 diabetes who fall into these
categories.
Dr Simon Fraser & Dr Laura Edwards
July 2010
66
Figure P25. Age and gender distribution of people with Type 1 diabetes classified as ‘declined’ or
‘permanent opt out’ in the Portsmouth and South East Hampshire screening programme as a proportion of
people in the programme in each age group
Proportion of people by age known to have Type 1 diabetes in the
Portsmouth DRS programme classified as 'declined' or 'permanent opt
out'
8.00%
7.00%
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
95 94
10 to 9
9
0
to
10
4
10
5+
89
to
84
90
85
80
75
to
79
to
74
to
69
65
70
to
to
60
Male
to
64
59
54
55
to
to
50
45
to
49
44
39
40
to
35
30
to
34
29
to
to
19
to
to
25
10
15
20
9
14
to
4
to
to
5
0
24
0.00%
Female
Figure P26. Age and gender distribution of people with Type 2 diabetes classified as ‘declined’ or
‘permanent opt out’ in the Portsmouth and South East Hampshire screening programme as a proportion of
people in the programme in each age group
Proportion of people by age known to have Type 2 diabetes in the
Portsmouth DRS programme classified as 'declined' or 'permanent opt
out'
9.00%
8.00%
7.00%
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
Male
95
10 to 9
9
0
to
10
4
10
5+
94
89
to
90
84
to
85
79
to
80
74
to
75
69
to
70
64
to
65
60
to
59
54
to
55
to
50
45
to
49
44
39
to
40
34
to
35
29
to
30
to
25
20
to
19
to
15
9
14
to
10
5
to
4
to
0
24
0.00%
Female
In terms of measures of deprivation, the charts below show the proportion of people in each index of
multiple deprivation decile who are classified as ‘declined and ‘permanent opt out’. This shows that
women from less deprived areas are the group most likely to decline or opt out of screening.
The total proportion of people classified as ‘declined’ and ‘permanent opt out’ in the lowest two
deprivation deciles is 1.87%. In the highest two deprivation deciles, this proportion is 3.78%, which gives
a difference in proportions of 1.91%. The odds ratio of being classified as ‘declined’ or ‘permanent opt
out’ for people who live in the two least deprived deciles compared to people who live in the two most
deprived deciles is 2.06 (χ2 = 28, p<0.0001).
Dr Simon Fraser & Dr Laura Edwards
July 2010
67
Figures P27 and 28. Gender and deprivation distribution of people classified as ‘declined’ and ‘permanent
opt out’ in the Portsmouth and South East Hampshire retinal screening programme as a proportion of
people in each deprivation decile
Proportion of people in each decile of deprivation classified as
'declined' in the PSEH DRS programme
3.50%
Proportion declined
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
1
2
3
4
5
6
7
8
9
10
IMD decile (1 = most deprived, 10 = least deprived)
Male
Female
Proportion of people in each deprivation decile who are
classified as 'permanent opt out' in the PSEH DRS programme
2.00%
Proporiton opting out
1.80%
1.60%
1.40%
1.20%
1.00%
0.80%
0.60%
0.40%
0.20%
0.00%
1
2
3
4
5
6
7
8
9
10
IMD decile (1 = most deprived, 10 = least deprived)
Male
Female
GP data
In order to better understand the population of people not being screened, analysis of GP records focused
on those people not recorded as having had retinal screening for two periods of time – in the last year and
in the last 3 years (since April 2009 and since April 2007 respectively).
Overall, for practices referring to the Portsmouth and South East Hampshire screening programme about
5,100 people with diabetes do not have a record of retinal screening in the last year, and about 2,200 have
no record in the last three years.
Dr Simon Fraser & Dr Laura Edwards
July 2010
68
Figure P29. Age and gender of people from GP practices referring to the Portsmouth and South East
Hampshire retinal screening programme with no record of screening in the last three years
If this data is presented as a proportion of people with diabetes who have no record of retinal screening in
the last 3 years, it appears that young and elderly age groups are more strongly represented.
Figure P30. Proportion of people in each age and gender group from GP practices referring to the
Portsmouth and South East Hampshire retinal screening programme with no record of screening in the last
three years
The chart below shows the proportion of people with different types of diabetes who have no record of
retinal screening in the last 3 years in their GP records. This shows that, in the practices referring to the
Portsmouth and South East Hampshire screening programme, a higher proportion of people with Type 1
diabetes have no record of screening compared to Type 2 diabetics, or those with a general code of
‘diabetes’ in their record (those aged under 15 are excluded from this comparison as they would not be
expected to have started screening until 12 years old).
Dr Simon Fraser & Dr Laura Edwards
July 2010
69
Figure P31. Proportion of people with specified type of diabetes from GP practices referring to the
Portsmouth and South East Hampshire retinal screening programme with no record of screening
(‘Diabetes mellitus’ refers to those in whom a general diabetes code was used rather than Type 1 or Type
2. ‘All types’ refers to the overall proportion when all are considered together)
Proportion with no
record of screening
Gender and type of diabetes distribution of proportion of
people w ith diabetes in GP practices referring to the PSEH DRS
program m e w ith no record of retinal screening in the last 3
years
20.00%
15.00%
10.00%
5.00%
0.00%
Diabetes
Type 1 diabetes Type 2 diabetes
mellitus
mellitus
Male
Female
All types
Total
Unfortunately, the current lack of Super Output Area and deprivation measure in the Hampshire Health
record means that the picture of deprivation among people with diabetes registered with GPs in this
programme is incomplete as shown below. The following chart shows the distribution of people who have
no record of screening in the last 3 years with the measure of deprivation using the Index of Multiple
Deprivation deciles. (For 576 of the 2212 people with no record of screening in the last 3 years, this data is
unavailable due to the source of data being the Hampshire Health record). However, the graph suggests
that a greater proportion of people who live in areas with the lowest deprivation scores have no record of
screening in the last 3 years.
Figure P32. Proportion of people in each decile of the Index of Multiple Deprivation from GP practices
referring to the Portsmouth and South East Hampshire retinal screening programme with no record of
screening in the last three years
10
ld
ec
ile
s
Al
9
8
7
6
5
4
3
2
No
t
1
18.00%
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
re
co
rd
ed
Proportion with no record of
screening
Proportion of people in each IMD decile with no record of retinal
screening in last 3 years in PSEH GP records
IMD decile (1 = most deprived, 10 = least deprived)
Male
Dr Simon Fraser & Dr Laura Edwards
July 2010
Female
Total
70
Outcomes
Measuring success and equity in terms of outcomes of screening are difficult for a number of reasons:
• The need for annual screening
• A changing population (people moving into and away from the area, new cases, deaths)
• The low incidence of blindness and visual impairment due to diabetes
• The need for accurate recording of outcomes
• The limitations in ability to query screening and hospital IT systems for outcome data
For these reasons, proxy outcomes are often used to monitor the screening programme. Examples are the
numbers of referrals from the programme for ophthalmology opinion.
Some information for the Portsmouth and South East Hampshire programme is given here. However, for
IT reasons, accessing this information at patient level to assess some of the dimensions of equity is
problematic.
:
Table P2. Outcomes from the Portsmouth and South East Hampshire retinal screening programme for
2007 / 2008
Outcome: R1M0 Number of patients, with a final grading outcome of ‘R1
Background retinopathy, M0 No maculopathy’.
Outcome: R1M1 Number of patients with a final grading outcome of ‘R1
Background retinopathy, M1 Maculopathy’.
Outcome: R2M0 Number of patients, with a final grading outcome of ‘R2 Preproliferative retinopathy, M0 No maculopathy’.
Outcome: R2M1 Number of patients with a final grading outcome of ‘R2 Preproliferative retinopathy, M1 Maculopathy’.
Outcome: R3M0 Number of patients with a final grading outcome of ‘R3
Proliferative retinopathy, M0 No maculopathy’.
Outcome: R3M1 Number of patients with a final grading outcome of ‘R3
Proliferative retinopathy, M1 maculopathy’.
2565
319
129
104
91
99
In view of these challenges, an alternative approach was adopted in conducting this equity audit. In order
to compare people having screening with those who appear not to be having screening, the data obtained
from GP databases was analysed for two distinct groups of people:
• Those with a record in their electronic GP notes of having had retinal screening in the last year
(since April 2009)
• Those with no record of retinal screening in their electronic GP notes for the last three years (since
April 2007).
In doing this, it is recognised that there may be many reasons why there is no GP record of screening,
including those excluded from screening because of blindness or other reasons, lack of recording by GP
practices, or true lack of registration with the programme or non-attendance by the patient. However, this
approach was considered reasonable on the basis that recording of retinopathy screening is required as one
of the targets in the GP Quality and Outcomes Framework, and recording is therefore likely to be
optimized by practices. It was also considered reasonable as those identified are likely to include those
people who are either not registered with the screening programme at all, or are not attending. As there is
a possible correlation between attendance at retinal screening and other measures of good diabetes
management, this group are therefore also potentially at greater risk of other diabetic complications.
Identifying their characteristics may therefore be helpful to everyone involved in their diabetes care.
The results of this comparison for the Portsmouth and South East Hampshire programme are shown in the
table below. From comparison of this data with the numbers given above, it can be seen that there is likely
to be incompleteness in the recording of outcomes such as maculopathy and retinopathy in GP records.
Dr Simon Fraser & Dr Laura Edwards
July 2010
71
Table P 3. Comparison of characteristics between people with a record of retinal screening in the last year
and people with no record of screening in 3 years in their GP records.
Number
Gender
Male
Female
Diabetes type
General 'diabetes' code used
Type 1
Type 2
Deprivation
Percentage in lowest IMD quintile
Ethnicity
White British
Other
No record
Language of choice
English
Other
No record
Retinal screening
Recorded as seeing optician /
optometrist
Retinopathy recorded
Background
Proliferative or pre-proliferative
Maculopathy
Laser treatment recorded
Visual impairment
Blind
Partial sight
Hypertension
PSEH screened
within last year
PSEH 3-year
no screening
recorded
13388
2212
Number
%
Number
%
7512
5876
56.11%
43.89%
1247
965
56.35%
43.65%
2257
1998
9133
16.86%
14.92%
68.22%
268
488
1456
12.12%
22.06%
65.82%
1804
13.47%
349
15.78%
5306
383
6559
39.63%
2.86%
48.99%
677
170
1365
30.61%
7.69%
61.71%
5596
138
7559
41.80%
1.03%
56.46%
639
37
1536
28.89%
1.67%
69.44%
717
5.36%
143
6.46%
66
15
7
74
0.49%
0.11%
0.05%
0.55%
3
0
0
13
0.14%
0.00%
0.00%
0.59%
34
120
6742
0.25%
0.90%
50.36%
15
28
870
0.68%
1.27%
39.33%
This comparison suggests that a higher proportion of people in the ‘3-year non-attendance’ population
lived in more deprived areas compared to the ‘screened in the last year’ population. There may be
differences in the type of diabetes between the groups (such as a higher proportion of Type 1 diabetics in
the unscreened group), but given the high proportion of those in which a general code for diabetes was
used, it is not possible to comment on this with any certainty. Similarly, for ethnicity and language groups,
there appear to be differences between the groups with a higher proportion of people in the unscreened
group not being white British and having a language other than English as their preferred language, but
these differences are obscured by lack of completeness of recording. A slightly higher proportion in the
non-screened group appears to opt for optometrist attendance. A lower proportion in the unscreened group
had a record of retinopathy and laser treatment recorded, but a higher proportion of blindness. The high
prevalence of hypertension in both groups is a particular concern for the unscreened group as high blood
pressure is associated with an increased risk of developing retinopathy.
Dr Simon Fraser & Dr Laura Edwards
July 2010
72
North Hampshire
Diabetic Retinopathy Screening Programme
Dr Simon Fraser & Dr Laura Edwards
July 2010
73
Description of the population
There are 18,967 patients currently registered to the North Hampshire service (July 10). The active
programme size as at July 10 was 15,192 (80%). The archived population on the system, (those not
currently being screened by the programme) at July 10 was 3775 (20%). Patients may be classed as
archived if they are currently under 12 yrs of age, have moved out of area, have been deemed physically
or mentally incapacitated, returned mail received marked ‘wrong address’ or are currently receiving
screening as part of their care from an ophthalmologist.
Background of service
The North Hampshire Diabetic Retinopathy Screening programme was initially established as part of the
South Wiltshire retinal screening service via the Medical Photography department at Salisbury. The initial
screening population was approximately 5000 patients and the service operated via screeners using mobile
equipment in GP surgeries. The service screened the complete diabetic population for a single practice
before moving on to the next surgery. Guidance from the National Retinopathy Screening Programme in
2007 stipulated a minimum programme size of 12,000 patients, and so the programme expanded to
provide screening for North Hampshire. It was not feasible for the same model of screening to be applied
in North Hampshire General Practices and so a different model was instigated using fixed cameras. The
service now covers the North of Hampshire and some practices in the West of Hampshire (where it
continues to deliver screening at GP surgeries).
Patient list and care pathway
The list of patients to be screened is drawn from the programme database and the list of all active and
archived patients (excluding deceased patients) is sent to the GP surgery for confirmation 12 weeks prior
to patient invitation. This is done to update records and check whether any archived patients should be reactivated.
Key screening standards include:
2
To invite all eligible persons with known diabetes to attend for the DR screening test.
3
To ensure database is accurate
4
To maximise the number of people taking the test
15
To ensure timely re-screening
Invitations are then sent out to patients approximately four weeks later. If there is no response then two
further invitations are sent out including an opt-out form and the GP is informed that there has been no
patient response.
Immediately after retinal imaging, the screener performs a ‘disease/ no-disease’ check (with the patient
present). If the status is defined as ‘disease’ then the patient is informed and given an impression of
severity and likely need for further clinical review. Two graders review the images and the result is sent to
the patient and GP and a referral generated to Ophthalmology if necessary. Screeners identifying an
‘urgent’ finding inform the secondary grader of the need for more urgent review. Current care under
ophthalmology is elicited by reference to the GP (this is recognised as a potential area of weakness of the
system. The service has made a business case for a ‘Failsafe Officer’ who would check these patients as
part of their remit). Current guidelines state that 10% of those screened as ‘no disease’ should also be
audited by the graders.
Key screening standards include:
6
To ensure grading is accurate.
7
To ensure optimum workload for graders, to maintain expertise.
8
To ensure timely referral of patients with R3 (fast-track) screening results (e-mailed or faxed).
9
To ensure GP and patient are informed of all test results.
Staff:
There are currently eight screeners working for the service, (6.5 whole time equivalents). All screeners are
registered for, and taking modules of, the City and Guilds diploma in retinal screening (the expected
standard), and two have completed the six mandatory modules (though are yet to be fully certified). The
service currently has two screeners operating as ‘graders’. These are the Programme Manager and Deputy
Programme Manager. All graders complete a test grading set once a month and have a monthly training
day.
Dr Simon Fraser & Dr Laura Edwards
July 2010
74
Figures N1 & N2. Care pathways in the North Hampshire Diabetic Retinopathy Screening programme
Age, gender, type of diabetes, measures of deprivation
The age, gender and type of diabetes distributions of those registered with the programme and their
referring GP practices are shown in the charts below. They show that there are more men than women
registered with the programme, that largest proportion of men are between 60 and 75, and the largest
proportion of women are between 65 and 80. ‘Active’ and ‘archived refer to the individuals’ status within
the programme (see above). The second chart is from the GP data. (It should be remembered that the
numbers are less in the GP data because of the lack of completeness of data from the Hampshire Health
record).
Dr Simon Fraser & Dr Laura Edwards
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Figure N3. Age and gender distribution using data from the North Hampshire Diabetic Retinopathy
Screening programme
Age gender distribution of 'active' and 'archived' people in the North
Hants DRS programme
1400
1200
Number
1000
800
600
400
200
Male 'active'
Female 'active'
Male archived
105+
95 to 99
100 to 104
90 to 94
85 to 89
80 to 84
75 to 79
70 to 74
65 to 69
60 to 64
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
5 to 9
10 to 14
0 to 4
0
Female archived
Figure N4. Age and gender distribution using data from GP practices referring to the North Hampshire
Diabetic Retinopathy Screening programme
This shows that, despite the lack of completeness of GP data available, the population distributions are
very similar.
Dr Simon Fraser & Dr Laura Edwards
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Figure N5. Population pyramid showing proportions of each age group and gender registered with the
North Hampshire Diabetic Retinopathy Screening programme
Population pyramid of people registered with the North Hants
Diabetic Retinopathy Screening Programme
105+
100 to 104
95 to 99
90 to 94
85 to 89
80 to 84
75 to 79
70 to 74
65 to 69
age group
60 to 64
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
10 to 14
5 to 9
0 to 4
10.00% 8.00%
6.00%
4.00%
2.00%
0.00%
2.00%
4.00%
6.00%
8.00%
Percentage of people
Male
Female
Figure N6. Age and type of diabetes distribution using data from GP practices referring to the North
Hampshire Diabetic Retinopathy Screening programme
Dr Simon Fraser & Dr Laura Edwards
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It is noticeable that by far the majority of the burden of diabetes in the population is from Type 2 diabetes.
The population registered with the programme comes from a variety of socio-demographic backgrounds.
One way of expressing this is to look at rankings of the Index of Multiple Deprivation (IMD) - a
deprivation index at a small area level known as Lower Super Output Areas (LSOAs). LSOAs have
between 1000 and 3000 people living in them with an average population of 1500 people. In most cases,
these are smaller than wards, thus allowing the identification of small pockets of deprivation. The IMD
combines a number of factors covering a range of health, economic, social and housing issues into a single
deprivation score for each small area in England. There are 32,482 LSOAs in England. The LSOA ranked
1 by the IMD 2007 is the most deprived and that ranked 32,482 is the least deprived. A common way to
summarise IMD ranking is to divide the ranks into quintiles and deciles, in other words to describe ‘the
most deprived 20% or 10%’ and ‘the least deprived 20% or 10%’. Hampshire PCT rank of average Index
of Multiple deprivation is 147th out of 152 PCTs (compared to Southampton City 70th and Portsmouth City
71st, where 1 is most deprived, and 152 least deprived). Hampshire’s most deprived Lower Super Output
Area is in Rushmoor.
The chart below shows the number and gender of people registered with the North Hampshire screening
programme who live in each of the 10 national deciles of multiple deprivation (where 1 is most deprived
and 10 is least deprived).
Figure N7. Index of Multiple Deprivation distribution for those registered with the North Hampshire
Diabetic Retinopathy Screening programme
Numbers of people registered with the North Hants DRS
Programme by deprivation deciles
7000
6000
Number
5000
4000
3000
2000
1000
10
9
8
7
6
5
4
3
2
1
No
t
re
co
rd
ed
0
IMD decile (1 = most deprived, 10 = least deprived)
Male
Female
Total
This shows that the majority of people registered with the North Hampshire retinopathy screening
programme live in areas that are relatively less deprived by national comparison. 2% of those registered
with the programme live in areas within IMD deciles 1, 2, and 3, and 65% live in areas within IMD
deciles 8, 9, and 10.
Ethnicity
Recording of ethnicity data is incomplete in many NHS contexts, and ethnicity definitions vary between
organisations and between different years of the national census. Despite these limitations, there is an
impression that ethnicity information is being more routinely collected, and ethnicity and language issues
may be important in terms of equity. The GP data requested therefore included a search for ethnicity
status. For practices referring to the North Hampshire programme, a summary of this information for the
main groups for which data was recorded is given below:
Dr Simon Fraser & Dr Laura Edwards
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Table N1. Ethnicity recording in North and West Hampshire GP practices
Ethnic group
Not recorded
White British
White other
Indian
Other Asian
Black African
Black Caribbean
Number
8934
3686
982
88
223
44
27
Proportion of total
63.58%
26.23%
6.99%
0.63%
1.59%
0.31%
0.19%
It can be seen from this that, for the majority of people registered with the screening programme, ethnicity
information is not recorded. This makes it difficult to draw conclusions about equity between ethnic
groups in the analysis of the data in this audit. There are important specific areas in North Hampshire with
prominent ethnic minority groups, most notably the Nepali communities in Rushmoor and Basingstoke (an
estimate of approximately 9000 people). They may be at particular risk of diabetes and it’s complications
and may be less likely, for a variety of reasons, to engage with screening. It is estimated that there are
significant language and literacy difficulties in this population.
Provision
The North Hampshire retinopathy screening programme is delivered via static cameras in the following
locations
• Rooksdown Surgery (Park Prewett Medical Centre, Basingstoke),
• Aldershot Centre for Health.
• Proposal for an additional camera, which would be used at Bordon and Alton.
Historically, the service considered using mobile cameras but decided on a fixed location model except for
the part of the service in the west of Hampshire where GP practices are visited by a screener (an extension
of the South Wiltshire service).
In previous years the service has moved one of the cameras to Chase Community Hospital for
approximately 4 months of the year. Due to increase in patient numbers at the main screening sites, this
has not continued this year. New referrals to the service are offered screening at Park Prewett or
Aldershot.
The three maps below show the screening locations and the number of patients registered with the
programme in each area. Dark red areas are those with higher numbers of patients registered with the
programme. It can be seen that there are three distinct areas with a higher density of patients which are
some way from the location of the static cameras: North West of Basingstoke towards Kingsclere, the area
around Fleet and Hartley Wintney, and around Alton and Bordon.
Dr Simon Fraser & Dr Laura Edwards
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Figure N8. Map of Screening locations and numbers of patients registered with the North Hampshire
Diabetic Retinopathy Screening programme
Dr Simon Fraser & Dr Laura Edwards
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Figure N9. Map of Screening locations and numbers of patients in North East Hampshire registered with
the North Hampshire Diabetic Retinopathy Screening programme
Figure N10. Map of Screening locations and numbers of patients in West Hampshire registered with the
North Hampshire Diabetic Retinopathy Screening programme
Dr Simon Fraser & Dr Laura Edwards
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Dr Simon Fraser & Dr Laura Edwards
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Access
Access to the screening service is determined by several factors including the geographical location of
services, the timing of service provision, and the mobility of the population served.
The Rooksdown Practice is based in Park Village, an area of regeneration on the Park Prewett site. The
practice is currently housed in temporary accommodation with a new housing development being
constructed opposite the site (135 residential units are now occupied on the Harness House site (a Housing
Association scheme) and 50 units opposite the existing surgery are also now occupied). Positioned behind
a metal fence the site is not visually welcoming. There are two possible routes to access Rooksdown
practice. There were no signs noted for the Diabetic Retinopathy screening service at either road leading
to Rooksdown practice. It was also noted that the nearest bus stop was approximately 250m walk.
Wheelchair access was available. Appointments in the North Hampshire programme are between 9.30am
and 16.15, 5 days a week. The service closes for one hour at lunchtime. Appointments are at 15-minute
intervals and patients are expected to be at the site for around 45 minutes. The service sees 24 patients per
day with 2 screeners tending to each clinic.
Access for those patients in the West of Hampshire is easier, with screening taking place in their own GP
surgery.
Uptake
Uptake of screening is challenging to assess for an annual screening programme. Proxy measures, such as
did not attend (DNA) rates can be used to measure uptake. From this audit, this can be assessed from three
perspectives:
• Those recorded as offered screening who were actually screened
• Those recorded as ‘DNA with no subsequent attendance in the following year’ by the screening
programme
• Those recorded in GP records as not having attended retinopathy screening.
Each of these has limitations, such as uncertainty about the completeness of recording of screening at
practice level, and the problems encountered with accurately interrogating the screening programme
database. However, examining the characteristics of those not attending using these groups gives
interesting insights into the diabetic population, which may be useful in reshaping aspects of the service
Offered, screened and DNA
For the year April 2009 to March 2010, the programme screened 9622 patients, which is 84% of its
‘active’ registered population, and 63% of the total population of people registered with the programme.
The proportion of people with diabetes who DNA screening varies widely between different practices in
the North Hants programme (range 0% to 37%). This is an important variation, which may reflect
differences in the demography of patients registered, their awareness of the programme, or their ability to
access the screening locations. This may warrant further exploration in order to better understand the
differences and identify potential causes.
GP records
In order to understand the population of people not being screened, analysis of GP records focused on
those people not recorded as having had retinal screening for the last 3 years (since April 2007).
Overall for practices referring to the North Hampshire screening programme, about 4,900 people with
diabetes do not have a record of retinal screening in the last year, and about 1,500 have no record of
screening in the last three years.
The charts below show that younger people and the very elderly are those more likely to have no record of
screening. More men have no record of screening, but, for some age groups, the proportion of women with
no record of screening is higher.
Dr Simon Fraser & Dr Laura Edwards
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Figure N11. Age and gender of people from GP practices referring to the North Hampshire Diabetic
Retinopathy Screening programme with no record of screening in the last three years
Figure N12. Proportion of people in each age and gender group from GP practices referring to the North
Hampshire Diabetic Retinopathy Screening programme with no record of screening in the last three years
Dr Simon Fraser & Dr Laura Edwards
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Figure N13. Proportion of people with type of diabetes from GP practices referring to the North
Hampshire Diabetic Retinopathy Screening programme with no record of screening (‘Diabetes mellitus’
refers to those in whom a general diabetes code was used rather than Type 1 or Type 2. ‘All types refers to
the overall proportion when all are considered together)
There does not appear to be a clear association between types of diabetes and non-attendance at screening.
Figure N14. Proportion of people in each Index of Multiple deprivation decile with no record of retinal
screening in the last three years in their GP records
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
10
ld
ec
ile
s
Al
9
8
7
6
5
4
3
No
2
2.00%
0.00%
re
co
rd
Proportion with no record of
screening
Proportion of people residing in each deprivation decile who
have no record of retinal screening in their GP record in the last
3 years
IMD decile (1 = most deprived, 10 = least deprived)
Male
Female
Total
The lack of completeness of deprivation data means that it is difficult to draw firm conclusions about this
dimension of equity with respect to those with no record of screening.
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Outcomes
Measuring success and equity in terms of outcomes of screening are difficult for a number of reasons:
• The need for annual screening
• A changing population (people moving into and away from the area, new cases, deaths)
• The low incidence of blindness and visual impairment due to diabetes
• The need for accurate recording of outcomes
• The limitations in ability to query screening and hospital IT systems for outcome data
For these reasons, proxy outcomes are often used to monitor the screening programme. Examples are the
numbers of referrals from the programme for ophthalmology opinion. However, for IT reasons, accessing
this information at patient level to assess some of the dimensions of equity is problematic.
In view of these challenges, an alternative approach was adopted in conducting this equity audit. In order
to compare people having screening with those who appear not to be having screening, the data obtained
from GP databases was analysed for two distinct groups of people:
• Those with a record in their electronic GP notes of having had retinal screening in the last year
(since April 2009)
• Those with no record of retinal screening in their electronic GP notes for the last three years (since
April 2007).
In doing this, it is recognised that there may be many reasons why there is no GP record of screening,
including those excluded from screening because of blindness or other reasons, lack of recording by GP
practices, or true lack of registration with the programme or non-attendance by the patient. However, this
approach was considered reasonable on the basis that recording of retinopathy screening is required as one
of the targets in the GP Quality and Outcomes Framework, and recording is therefore likely to be
optimized by practices. It was also considered reasonable as those identified are likely to include those
people who are either not registered with the screening programme at all, or are not attending. As there is
a possible correlation between attendance at retinal screening and other measures of good diabetes
management, this group are therefore also potentially at greater risk of other diabetic complications.
Identifying their characteristics may therefore be helpful to everyone involved in their diabetes care.
The results of this comparison for the North Hampshire programme are shown in the table below.
Dr Simon Fraser & Dr Laura Edwards
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Table N2. Comparison of characteristics between people with a record of retinal screening in the last year
and people with no record of screening in 3 years in their GP records.
Number
Gender
Male
Female
Diabetes type
General 'diabetes' code used
Type 1
Type 2
Deprivation
Percentage in lowest IMD quintile
Ethnicity
White British
Other
No record
Language of choice
English
Other
No record
Retinal screening
Recorded as seeing optician /
optometrist
Retinopathy recorded
Background
Proliferative or pre-proliferative
Maculopathy
Laser treatment recorded
Visual impairment
Blind
Partial sight
Hypertension
NH screened
within last year
NH 3-year no
screening
recorded
10359
1552
Number
%
Number
%
5906
4453
57.01%
42.99%
877
675
56.51%
43.49%
612
1596
8151
5.91%
15.41%
78.69%
116
244
1192
7.47%
15.72%
76.80%
154
1.49%
11
0.71%
3122
1198
6039
30.14%
11.56%
58.30%
289
202
1080
18.62%
13.02%
69.59%
1894
64
8401
18.28%
0.62%
81.10%
238
16
1292
15.34%
1.03%
83.25%
990
9.56%
263
16.95%
18
9
21
101
0.17%
0.09%
0.20%
0.97%
1
0
1
8
0.06%
0.00%
0.06%
0.52%
37
72
5173
0.36%
0.70%
49.94%
18
15
632
1.16%
0.97%
40.72%
This comparison suggests that a lower proportion of people in the ‘3-year non-attendance’ population
lived in more deprived areas compared to the ‘screened in the last year’ population. Distribution of type of
diabetes appears to be very similar between the groups. For ethnicity and language groups, there appears
to be differences between the groups with a higher proportion of people in the unscreened group not being
white British and having a language other than English as their preferred language, but these differences
are obscured by lack of completeness of recording making firm conclusions difficult. A higher proportion
in the non-screened group appears to opt for optometrist attendance. A lower proportion in the unscreened
group had a record of retinopathy and laser treatment recorded, but a higher proportion of blindness and
visual impairment. The high prevalence of hypertension in both groups is a particular concern for the
unscreened group as high blood pressure is associated with an increased risk of developing retinopathy.
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Patient Experience
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Patient experience
110 questionnaires were distributed at two events; a diabetes awareness day conference in Southampton,
and the Southampton Mela festival. 47 responses were received (a response rate of 42.7%). The results are
summarised in the table below:
Table 1. Results of patient experience survey
Gender
M
F
Age group
<20
21 to 40
41 to 60
61 to 80
Over 80
Ethnicity
British
Indian
Other white
Other Asian
Length of time with diabetes
0 to 5 years
6 to 10 years
11 to 15 years
>15 years
Type of diabetes
Diet controlled alone
Tablet controlled alone
Insulin controlled alone
Tablet + insulin controlled
Had yearly eye screening
Screening location
Optician
Eye screening van
Diabetic resource centre
Hospital
NHS treatment centre
Knowledge of reason for
screening
Receive letter of invitation
Appointment easy to attend
Difficulties with aspects of the
service
None
Appointment date / time
Changing appointment
Number
% of total
15
33
31%
69%
0
3
8
34
3
0%
6%
17%
71%
6%
44
2
1
1
92%
4%
2%
2%
12
14
13
9
25%
29%
27%
19%
5
20
15
7
46
10%
42%
31%
15%
96%
5
30
1
13
2
10%
63%
2%
27%
4%
46
46
46
96%
96%
96%
40
2
3
83%
4%
6%
Comments
Screening centre location
Transport to / from
2
3
4% Treatment Centre Portsmouth
6% Treatment Centre Portsmouth
Other
Problems with facilities
Treatment for eye problems
related to diabetes
1
1
2% Results sound frightening in the letter
2% Van claustrophobic, prefers RSH
4
8% Various
Dr Simon Fraser & Dr Laura Edwards
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These results show the following:
• The majority of people completing the questionnaire were female (which is not representative
of the predominant diabetic population)
• The majority of respondents were aged between 60 and 80, and described their ethnicity as
British.
• There was good representation of different groups people in terms of length of time with
diabetes and type of diabetes.
• The majority of respondents had had yearly eye screening, and most accessed the eye
screening van. A small proportion used their optician as the screening location of choice.
• The large majority knew why eye screening is done, received invitation for screening, found
appointments easy to attend, and had no other difficulties with the service.
• A small number found the screening location in Portsmouth difficult to travel to, and one
person found the eye screening van claustrophobic.
Given the nature of the sampling method used, it is important to recognise that this survey is subject to
selection bias (as it collected opinion only from those who attended the events at which the
questionnaire was distributed who were willing to complete a questionnaire). This needs to be born in
mind in the interpretation of these results.
It may be useful for the screening services to consider establishing patient user groups to further
explore aspects of the screening programmes.
Dr Simon Fraser & Dr Laura Edwards
July 2010
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Limitations of this audit
This audit was conducted using data from several sources – the screening services, GP practices, the
Hampshire Health Record, and survey data. A strength of the audit is therefore the ability to look at
the problem from these different perspectives. However, the inability to link across datasets reduces
the power of this study to identify specific groups of people at risk of not being screened. As with any
cross sectional study, it is not possible to attribute causality between exposures and outcomes, but only
to make observations and develop hypotheses. Another weakness was the unexpected lack of
deprivation measure within the Hampshire Health Record. It is hoped that this will be rectified soon,
which may facilitate and improve future such audits.
It was recognised that there are many existing pressures on GP practices to conduct Miquest searches
for other reasons, and the lack of response from some surgeries probably reflects this.
As described already, the convenience sampling method used for the survey could lead to selection
bias. In addition to this, there were no additional resources to conduct the survey in other locations
that might more accurately reflect the opinions of people in Portsmouth, South East Hampshire, and
North Hampshire.
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Conclusions
This health equity audit has identified patient factors (such as the groups of people at most risk of
retinopathy, those less able to access and take up the opportunity for retinal screening), provider factors
(such as the need to reconsider the location and timing services to improve accessibility, and the need for
recording of important dimensions of equity), and system factors (such as the weaknesses of the current IT
systems, and geographical overlap between individual screening programmes). We therefore make the
following recommendations for the screening programmes
Recommendations for all programmes
•
•
•
•
•
•
•
IT issues – recommendation to lobby national programme for improvements in IT system in order
to be able to query the database and more easily obtain information on people at each stage of the
system.
Need to improve recording of important dimensions of potential inequity in order to be able to re
audit, for example improving type of diabetes and ethnicity recording.
Need to improve the facility and uptake of recording of outcomes in the eye units, and seek IT
solutions to be able to link data from the screening service to the eye units and vice versa.
Linkage with GP systems has been demonstrated by the Hampshire Health Record, who may
therefore be well placed to be involved in this process.
Consideration should be given to timing of appointments to make screening more accessible to
those in employment.
Consideration should be given to location of services – particularly in Portsmouth and North
Hampshire, where the static cameras limit screening locations and potentially reduce accessibility.
Consideration should be given to methods for targeting particular groups who have been shown to
have a higher chance of not being screened – particularly men, the young and the very elderly, and
those from more deprived areas
Consideration should be given to awareness raising among GP practices of those with no record of
retinal screening in order to combat an ‘inverse care law’ effect in this population.
This audit has shown that there are examples of good practice in each of the three screening
programmes in Hampshire and the Isle of Wight. There is therefore potential to learn from one another
and for consideration to be given for a more coordinated, centralised, screening programme across
SHIP with adequate funding for IT and admin support.
Dr Simon Fraser & Dr Laura Edwards
July 2010
92
References
1. National Screening Programme for Diabetic Retinopathy.
http://www.retinalscreening.nhs.uk/pages/default.asp?id=2
2. Health Equity Audit – a guide for the NHS. Department of Health. Dec 2003.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
DH_4084138
3. Health Equity Audit made simple. A briefing for Primary Care Trusts and Local Strategic
Partnerships. Health Development Agency. Working document January 2003. Available at:
http://www.nice.org.uk/aboutnice/whoweare/aboutthehda/hdapublications/health_equity_audit_m
ade_simple.jsp
4. What is diabetes? Information from Diabetes UK. http://www.diabetes.org.uk/Guide-todiabetes/Introduction-to-diabetes/What_is_diabetes/
5. A Needs Assessment of Diabetic retinopathy screening in Southampton City Primary Care Trust
(SCPCT) area. Dr D Chase, January 2008.
6. Pardhan S, Mahomed I. The clinical characteristics of Asian and Caucasian patients on Bradford’s
Low Vision Register. Eye 2002; 16: 572-576.
7. Spijkerman AMW, Dekker JM, Nijpels G, Adriaanse MC, Kostense PJ, Ruwaard D, Stehouwer
CDA, Bouter LM, Heine RJ. Microvascular Complications at Time of Diagnosis of Type 2
Diabetes Are Similar Among Diabetic Patients Detected by Targeted Screening and Patients
Newly Diagnosed in General Practice. The Hoorn Screening Study. Diabetes Care 2003; 26(9):
2604-2608
8. Millett, C, Dodhia H. Diabetes retinopathy screening: audit of equity in participation and selected
outcomes in South East London. Journal of Medical Screening 2006; 13(3): 152-5.
9. Nsiah-Kumi P, Ortmeier SR, Brown AE. Disparities in Diabetic Retinopathy Screening and
Disease for Racial and Ethnic Minority Populations – A Literature Review. Journal of the
National Medical Association 2009; 101(5): 430-437
10. Farrington E. Wirral Digital Diabetic Retinopathy Screening Programme Health Equity Audit.
Aug 209.
http://info.wirral.nhs.uk/document_uploads/Publications/DigitalDiabeticRetinopScreenEquitAudit
_d37e6.pdf . Accessed March 2010
11. Improving Access to Derbyshire Diabetic Retinopathy Screening Services
http://www.retinalscreening.nhs.uk/userFiles/File/DERBYSHIREStaff%20Celebration%20Event
%202007%20Poster%20final%20.pdf Accessed March 2010
12. Litwin AS, Clover A, Hodgkins PR, Luff AJ. Affluence is not related to delay in diagnosis of
Type 2 diabetes as judged by the development of diabetic retinopathy. Diabetic Medicine 2002;
19(10): 843-846
13. Scanlon PH, Carter SC, Foy C, Husband RFA, Abbas J, Bachmann MO. Diabetic retinopathy and
socioeconomic deprivation in Gloucestershire. J Med Screen 2008;15:118-121
14. Cockings S, Martin D, Leung S, Population24/7: space–time specific population surface
modelling. http://www.southampton.ac.uk/geography/research/phew/pop247/index.html
15. Portsmouth City Council information from www.Portsmouth.gov.uk. Accessed July 2010
Dr Simon Fraser & Dr Laura Edwards
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Appendices
Dr Simon Fraser & Dr Laura Edwards
July 2010
94
Appendix 1 – GP Practices referring patients to each of the retinopathy screening programmes
Southampton, South West Hampshire and Isle of Wight Screening Programme
PCT
Practice
Isle of Wight PCT
Isle of Wight PCT
Isle of Wight PCT
Isle of Wight PCT
Isle of Wight PCT
Isle of Wight PCT
Isle of Wight PCT
Isle of Wight PCT
Isle of Wight PCT
Isle of Wight PCT
Isle of Wight PCT
Isle of Wight PCT
Isle of Wight PCT
Isle of Wight PCT
Isle of Wight PCT
Isle of Wight PCT
Isle of Wight PCT
Hampshire PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Pyle Street Surgery
Carisbrooke Health Centre
Brighstone Surgery (South Wight)
Cowes Medical Centre
East Cowes Health Centre
Tower House Surgery
St Helens Medical Centre
Esplanade Surgery
Garfield Road Surgery
Argyll House Surgery
Medina Healthcare - Wootton
Beech Grove Surgery - BRADING
Sandown Health Centre
Shanklin Medical Centre
Grove House Surgery
Ventnor Medical Centre
Brookside Health Centre
Whitchurch Surgery
Homeless Healthcare Team
Nichols Town Surgery
St Marys Surgery (Southampton)
Bargate Medical Centre
Alma Road Surgery (Portswood)
Newtown Health Clinic (branch of Alma Rd)
Walnut Tree Surgery
Atherley House Surgery
The Grove Medical Practice
Raymond Road Surgery
Hill Lane Surgery
Shirley Avenue Surgery
Victor Street Surgery
Stoneham Lane Surgery
Burgess Road Surgery
Brook House Surgery
Cheviot Road Surgery
Regents Park Surgery
Aldermoor Health Centre
Lordshill Health Centre
Highfield Health
University Health Service
Mulberry House Surgery
Linfield Surgery
St Denys Surgery
Portswood Road Surgery
Bitterne Park Surgery
Midanbury Surgery
Townhill Surgery
Dr Simon Fraser & Dr Laura Edwards
July 2010
Practice
code
J84014
J84011
J84016
J84015
J84004
J84012
J84007
J84005
J84602
J84008
J84017
J84020
J84013
J84010
J84018
J84003
J84019
J82214
J82662
J82024
J82081
J82631
J82122
J82122
J82605
J82115
J82088
J82126
J82207
J82062
J82022
J82087
J82001
J82213
J82062
J82203
J82092
J82002
J82663
J82080
J82183
J82619
J82612
J82607
J82171
J82622
J82180
Postcode
PO30 1JW
PO30 1NR
PO30 4BB
PO31 7ER
PO32 6RR
PO33 1LP
PO33 1UG
PO33 2EH
PO33 2PT
PO33 2QG
PO33 4PR
PO36 0DE
PO36 9GA
PO37 7HR
PO38 1EU
PO38 1EZ
PO40 9DT
RG28 7AE
SO14 0LT
SO14 0YG
SO14 1LT
SO14 2EG
SO14 6UX
SO14 0WX
SO15 2HQ
SO15 3FH
SO15 3UA
SO15 5AL
SO15 5DD
SO15 5RP
SO15 5SY
SO16 2AB
SO16 3BD
SO16 4 NZ
SO16 4AH
SO16 4RJ
SO16 5ST
SO16 8HY
SO17 1BJ
SO17 1BJ
SO17 1PJ
SO17 2GD
SO17 2GN
SO17 2NJ
SO18 1HZ
SO18 2PA
SO18 3RA
95
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Southampton City PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Harefield Surgery
Thornhill Park Surgery
Bath Lodge Practice
Bitterne Surgery
Chessel Surgery - Sholing
Spitfire Court Surgery
Canute Surgery
Woolston Lodge Surgery
The Old Fire Station Surgery
Weston Lane Surgery
St Peters Surgery
Twin Oaks Medical Centre
The Arnewood Practice
New Milton Health Centre
Barton Surgery
West Meon Surgery
Mansfield Park Surgery
Wickham Surgery
Stockbridge Surgery
Twyford Surgery
Gratton Surgery
Badger Farm Surgery
St Paul's Practice
St Clements Partnership
Alresford Surgery
St Lukes Surgery
Hedge End Medical Centre
West End Surgery
Blackthorn Health Centre
Bursledon Surgery
Bishops Waltham Surgery
Totton Health Centre
Testvale Surgery
Forest Gate Surgery
Milford Medical Centre
Brockenhurst Surgery
Sway Surgery
The Wistaria Practice
Chawton House Surgery
Lyndhurst Surgery
Forestside Medical Practice - Dibden Purlieu
Hythe Medical Centre
Waterside Health Centre - Green Practice
Waterside Health Centre - Red Practice
Waterfront Garden Surgery
Boyatt Wood Surgery
St Andrews Surgery
The Old Anchor Inn Surgery
Stokewood Surgery
Eastleigh Health Centre (Dr Drabu)
Pineview Practice
Nightingale Surgery
Alma Road Surgery (Romsey)
Dr Simon Fraser & Dr Laura Edwards
July 2010
J82187
J82622
J82141
J82040
J82101
J82651
J82182
J82076
J82128
J82187
J82208
J82151
J82007
J82029
J82166
J82036
J82059
J82034
J82016
J82116
J82106
J82130
J82050
J82035
J82124
J82192
J82089
J82008
J82051
J82188
J82064
J82097
J82132
J82112
J82139
J82129
J82129
J82139
J82075
J82146
J82072
J82645
J82057
J82057
J82156
J82169
J82071
J82634
J82018
J82620
J82020
J82186
J82074
SO18 5JL
SO18 5TS
SO18 6BT
SO19 4AA
SO19 4AA
SO19 7TN
SO19 9AL
SO19 9AL
SO19 9AN
SO19 9GH
SO19 9RL
BH238AD
BH25 5JP
BH25 6EN
BH25 7EN
GU32 1LR
GU34 5EW
PO17 5JL
SO20 6HG
SO21 1QY
SO21 3LE
SO22 4QB
SO22 5DD
SO23 8AD
SO24 9JL
SO30 2US
SO30 4FQ
SO303PY
SO31 4NQ
SO31 8DQ
SO32 1GR
SO40 3ZN
SO40 7GL
SO40 8WU
SO41 0PG
SO41 6BA
SO41 6BA
SO41 9GJ
SO41 9ND
SO43 7EW
SO45 4JA
SO45 4ZD
SO45 5WX
SO45 5WX
SO45 6AW
SO50 4QP
SO50 5PT
SO50 6LQ
SO50 8AU
SO50 9AG
SO50 9AG
SO51 7QN
SO51 8ED
96
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Abbey Mead Surgery
North Baddesley Health Centre
The Fryern Surgery
The Brownhill Surgery
Parkside Family Practice
St Francis Surgery
St Marys Surgery (Andover)
Adelaide Medical Centre
Charlton Hill Surgery
Andover Health Centre
Shepherds Spring Medical Centre
Derry Down Clinic
Dr Simon Fraser & Dr Laura Edwards
July 2010
J82145
J82121
J82019
J82190
J82063
J82143
J82103
J82053
J82025
J82017
J82082
J82629
SO51 8EN
SO52 9EP
SO53 2LH
SO53 2ZB
SO53 4SD
SO53 4ST
SP10 1DP
SP10 1HA
SP10 3JY
SP10 3LD
SP10 5DE
SP11 6BS
97
Portsmouth and South East Hampshire screening programme
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Portsmouth City PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Queens Road Surgery
The Osbourne Practice
Somers Town Health Centre
The Health House
Waverley Road Surgery
Southsea Medical Centre
Kirklands, Copnor Rd
Lake Road Health Centre
Northern Road Surgery
Sunnyside Medical Centre
The Baffins Surgery
Drayton Surgery
Cosham Health Centre
Hanway Road Surgery
Derby Road Group Practice
Portsdown Group Practice
Campbell Road Surgery
The Devonshire Practice
Ramilies, Victoria Road surgery
Victory Surgery
Salisbury Road Surgery
John Pounds Surgery
Heyward Road Surgery
Milton Park Practice
University Surgery
Eastney Surgery
Somerstown Health Centre
Guildhall Walk Health Centre
Rowlands Castle Surgery
Emsworth Practice
Bosmere Medical Practice
Havant Surgery, Suite D, Havant Health Centre
Waterside Medical Practice, Hayling Island
The Curlew Practice, Suite E, Havant Health Centre
Waterbrook Medical Practice
The Staunton Surgery, Havant Health Centre
Stakes Lodge Surgery
The Swan Surgery
Denmead Doctors Surgery
Forest End Surgery
The Clanfield Surgery
Cowplain Family Practice
Hillbrow & Newtown Practice
The Homewell Practice, Suite B Havant Health Centre
The Grange Surgery
The Elms Practice
Queenswood Surgery
Riverside Partnership
Horndean Practice
Park Lane Medical Centre
Middle Park Medical Centre
Dr Simon Fraser & Dr Laura Edwards
July 2010
J82004
J82028
J82031
J82038
J82055
J82060
J82073
J82085
J82086
J82090
J82091
J82102
J82114
J82117
J82149
J82155
J82159
J82165
J82168
J82170
J82175
J82177
J82191
J82194
J82199
J82212
J82665
Y02526
J82005
J82009
J82010
J82014
J82021
J82032
J82037
J82041
J82093
J82098
J82119
J82134
J82147
J82163
J82164
J82196
J82201
J82210
J82609
J82167
J82640
J82646
J82650
PO2 7NX
PO5 3ND
PO5 4NJ
PO6 3AP
PO5 2PW
PO5 1AT
PO3 5AF
PO1 4JT
PO6 3DS
PO4 8TA
PO3 6BH
PO6 1PA
PO6 3AW
PO1 4ND
PO2 8HW
PO7 5XP
PO5 1RN
PO4 9EH
PO5 2DB
PO2 8AL
PO4 9QX
PO1 3DU
PO4 ODY
PO4 8QZ
PO1 2BH
PO4 9HU
PO5 4NJ
PO1 2DD
PO9 6BN
PO10 7DD
PO9 1DQ
PO9 2AZ
PO11 9AP
PO9 2AZ
PO7 6AJ
PO9 2AZ
PO7 8NS
GU32 3AB
PO7 6NR
PO7 7AH
PO8 0QL
PO8 8DZ
GU30 7DR
PO9 2AZ
GU31 4JR
PO11 9AP
PO8 8DA
GU33 7AD
PO8 0AA
PO9 3HN
PO9 4AB
98
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Greywells Surgery
The Village Practice, Cowplain
Gosport Medical Centre
Portchester Health Centre
Locks Road Surgery
The Centre Practice
Gudge Heath Lane Surgery
Jubilee Surgery
Stoke Road Medical Practice
Bury Road Surgery
Forton Medical Centre
Stubbington Medical Practice
Waterside Medical Centre
Brune Medical Centre
Brockhurst Medical Centre
Bridgemary Medical Centre
Fareham Health Centre
Westlands Medical Centre
Lockswood Surgery
The Lee-On-The-Solent Medical Practice
Brook Lane Surgery
Manor Way Surgery
Rowner Health Centre
Dr Simon Fraser & Dr Laura Edwards
July 2010
J82657
Y01281
J82006
J82012
J82023
J82026
J82033
J82044
J82083
J82084
J82100
J82104
J82113
J82127
J82133
J82152
J82154
J82161
J82174
J82215
J82216
J82648
J82669
PO9 5AA
PO8 8XL
PO12 2JX
PO16 9TU
SO31 7ZL
PO16 7ER
PO15 6QA
PO14 4EH
PO12 1PA
PO12 3PR
PO12 3JP
PO14 2JP
PO12 1BA
PO13 0EW
PO12 3AX
PO13 0HR
PO16 7ER
PO16 9AE
SO31 6DX
PO13 9JG
SO31 7DQ
PO13 9JG
PO13 9SP
99
North Hampshire screening programme
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Hampshire PCT
Giffard Drive Surgery
Liphook Surgery
Victoria Practice (Aldershot CFH)
Ringwood Medical Centre
Badgerswood Surgery
Oakley & Overton Surgery
Hartley Corner Surgery
Oaklands Medical Centre
Bramblys Grange Medical Practice
Odiham Health Centre
South Ham Surgery
Southlea Surgery
Milestone Surgery
Gillies Health Centre
Bermuda Practice
Clift Surgery
Holmwood Health Centre
Marlowe Partnership (Shakespeare)
Richmond Surgery
Fleet Medical Centre
Alexander House Surgery
Hackwood Partnership
Jenner House Surgery
Fordingbridge Surgery
Fleet Surgery (Branksomewood)
Chawton Park Surgery
Hook & Hartly Wintney Surgery
The Border Practice
Church Grange (Crown Heights)
Cornerways Medical Centre
The Wilson Practice
Riverside Surgery
Alexandra Surgery
Mayfield Medical Centre
Pinehill Surgery
Southwood Practive
Bentley Village Surgery
Monteagle Surgery
Chineham Medical Practice
Highview Surgery
The Rooksdown Practice
Boundaries Surgery
New Crondall Surgery
North Camp Surgery
Kingsclere Medical Practice
East Barn Surgery
The Beggarwood Surgery
Wellington Practice (Aldershot CFH) Rahman
Dr Simon Fraser & Dr Laura Edwards
July 2010
J82015
J82027
J82030
J82039
J82042
J82046
J82049
J82052
J82058
J82061
J82065
J82066
J82067
J82069
J82077
J82079
J82094
J82096
J82099
J82110
J82120
J82123
J82125
J82131
J82135
J82136
J82138
J82142
J82144
J82150
J82157
J82167
J82178
J82181
J82184
J82195
J82197
J82206
J82218
J82219
J82220
J82625
J82628
J82630
J82639
J82647
J82688
J82198
GU14 8QB
GU30 7AQ
GU11 1AY
BH24 1JY
GU35 8LH
RG25 3DU
GU17 0DB
GU46 7LS
GU34 5EW
RG29 1JY
RG22 6RL
GU11 3RB
GU14 7JN
RG22 4EH
RG24 9DT
RG26 5BH
RG26 4ER
RG24 9DS
GU52 7US
GU51 4PE
GU14 7AW
RG21 8SU
GU14 0HQ
SP6 1RS
GU51 4JX
GU34 1RJ
RG27 8QJ
GU12 4DN
RG21 7AN
BH24 1SD
GU34 2QX
GU33 7AD
GU11 1SD
GU14 8UE
GU35 0BS
GU14 0NA
GU10 5LP
GU46 6FE
RG24 8ND
GU35 0AX
RG24 9RG
GU34 5HG
GU10 5RF
GU14 6DH
RG20 5QX
RG24 8TF
RG22 4AQ
GU11 1AY
100
Appendix 2 - Data requested
Practice data
At practice level:
Total registered practice population
Numbers of diabetics
Type of diabetes – I or II
Proportion achieving QOF HbA1c target
Then, of those diabetics:
DOB or Age
Gender
Ethnicity
Preferred language (Completeness unlikely)
Postcode
First diagnosis date
Last retinal screening date
Presence of diabetic retinopathy (and whether background/proliferative) and date of diagnosis
of that retinopathy
Whether had laser treatment for retinopathy
Whether registered blind/partially sighted
Measure of diabetes control (e.g. achieved QOF HbA1C target)
Likelihood of attending screening by:
• gender
• ethnic group
• language preference
• postcode
• last retinal screening date and presence of retinopathy
Of those blind/partially sighted:
Including discrimination of which came first, diabetes or visual impairment
Hampshire Health Record data
GP practice code
PBC group name
PCT name
DOB
Age (or age category)
Gender
Ethnicity
Type of diabetes – I or II
First diagnosis date
Total retinal screenings, first and last ret screening dates
Presence of diabetic retinopathy
Whether had laser treatment
Whether registered blind/partially sighted
Measure of diabetes control (e.g. QOF HbA1C target)
Lower super output area
Deprivation quintile
Language preference (where available)
DRS Programme Data
Dr Simon Fraser & Dr Laura Edwards
July 2010
101
General
Demography
Access
Uptake
Outcomes
Dr Simon Fraser & Dr Laura Edwards
July 2010
Numbers of patients registered
System issues e.g. Care pathway mapping,
Communication issues
Identifier
Postcode
GP Practice
PCT name
DOB/Age
Gender
Ethnicity
Practices visited by vans
Locations of cameras
Facilities e.g. disabled access
Language / literacy issues
Type of diabetes – 1 or 2
Numbers of retinal screenings – esp first and
last
Non response / DNA
Presence of retinopathy or maculopathy
Stage of retinopathy + date of first diagnosis
Referral for further assessment
Laser treatment
Visual impairment
Under ophthalmology care
Referrals for assessment – targets etc
102
Appendix 3 – questionnaire
Diabetic Retinopathy Screening Questionnaire
The purpose of this questionnaire is to help us find out what people think about
the Diabetic Retinopathy Screening Service, which tests for eye problems in
people with diabetes. We are trying to improve the service, so finding out about
your experience is very helpful.
This questionnaire is anonymous; please do not give name or address, thank you
To answer questions please tick boxes that apply.
How long have you had diabetes? (please tick)
0-5 years … 6-10 years
11-15 years
Since birth
20-25 years
What kind of diabetes do you have?
Diet controlled
Tablet controlled
Insulin controlled
Have you had yearly eye screening / testing?
Yes
No
If Yes, where:
Optician
Eye screening van
Diabetic Resource Centre
Hospital
Other: (please specify) ……………………………………………………………….
……………………………………………………………………………………………...
Do you know why eye tests are done in diabetes?
Yes
No
Do you receive a letter once a year letter inviting you for diabetic retinal screening (eye
testing for diabetes)?
Yes
No
Did you find your appointment easy to attend?
Yes
No (if no, please explain) …………………………………………………………….
……………………………………………………………………………………………...
……………………………………………………………………………………………...
Dr Simon Fraser & Dr Laura Edwards
July 2010
103
Did you experience any difficulties with any aspect of the service? E.g. (please tick all
that apply)
Appointment date / time
Changing your appointment
Screening centre location
Transport to / from
Other
Please explain: …………………………………………………………………………...
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
Were there any problems with the screening facilities (e.g. ease of access etc)?
Yes … No
If Yes, what was the problem?
……………………………………………………………………………………………...
……………………………………………………………………………………………...
……………………………………………………………………………………………...
Have you had treatment for eye problems related to diabetes care?
Yes … No
If so, where did you go for this and were there any problems?
……………………………………………………………………………………………...
……………………………………………………………………………………………...
……………………………………………………………………………………………...
……………………………………………………………………………………………...
……………………………………………………………………………………………...
……………………………………………………………………………………………...
Are you:
Male
Female
Age:
Up to 20 … 21 – 40 … 41 - 60
61 – 80 … 80 +
Tick which one of the following categories best describes your ethnic origin:
British
Indian
Caribbean
Bangladeshi
African
Other White
Pakistani
Other Black
White & Black Caribbean
Other Asian
Chinese
White & Black African
White & Asian
Other Mixed
Irish
Other … (please explain) ……………………………………………………………..
Thank you very much for taking the time to complete this
Dr Simon Fraser & Dr Laura Edwards
July 2010
104
Diabetic Retinopathy Health Equity Audit
Descriptive summary of process
Total time of project: 6 months (based on 4 days per week) – Feb to July 2010
Scoping
Understanding the screening process
Book: Screening evidence and practice: Angela Raffle and Muir Gray
National retinopathy screening programme website: www.retinalscreening.nhs.uk
Other sources of information – discussion with screening leads, ophthalmologists, managers of screening
programmes, screeners, diabetologists.
Understanding the QA process
Documents relating to outcome of 2009 QA process which defined need for HEA
Literature review
Reading around Health Equity Audit methods, process, examples.
Review of local work to date
Understanding diabetes, retinopathy and risk factors
Previous HEAs of diabetic retinopathy
Dimensions of equity
Consideration of need to look at data by age, gender, location, ethnicity, language, deprivation, type of
diabetes
Involving others
Screening programmes
Meetings with programme managers for each programme, discussion with screeners
Involvement of PH screening leads
Establishing a steering group – monthly meetings to follow progress of audit and make recommendations
One to one with trainer to report progress on weekly basis
GP involvement
Laura Edwards (GP Leadership Fellow)
LMC involvement to request data from practices. Met with LMC team to discuss.
Diabetologists and ophthalmologists
Early discussion with both hospital and community-based diabetes specialists to identify issues
Discussion with clinical lead of SHIOW screening programme to set priorities
Discussion with other ophthalmologists to gain their perspectives
Information specialists
Information specialists advising on identification of data sources, extraction of data from practices, HHR
and QMAS
Collation of data and assistance with analysis and mapping
PPI
Involving PPI experts in PCT to devise questionnaire
Involvement of service users to refine and distribute questionnaire
Discussion with individual patients in GP context and at events
Identifying data sources
Screening programmes
Southampton, Hampshire and Isle of Wight Programme
Portsmouth and South East Hampshire Programme
North Hampshire Programme (based in Salisbury)
Obtaining data via the programme managers
Hampshire Health Record
This involved identifying the variables to be considered, discussion with Hugh Sanderson to discuss
feasibility, and formal application process to extract data for those practices submitting to the HHR
Practices
Data was needed at practice and patient levels to properly understand equity issues.
Dr Simon Fraser & Dr Laura Edwards
July 2010
105
This was achieved through MiQuest searches for Southampton, Isle of Wight and Portsmouth practices. It
was agreed that Hampshire practices’ data would be requested if the practice did not contribute to the
HHR.
QMAS/QOF data
Obtained from PCTs and from the NHS information centre on line.
Service user opinion
A questionnaire was designed and piloted to garner patient opinion on retinopathy screening services and
given out at appropriate events.
Hospital data
The possibility of extracting data on outcomes for those people referred from the screening programme
was explored
Extracting data
The process for arranging to extract data from practices was the most time consuming and complex. It
involved meetings with the Primary Care data managers in each locality to agree Miquests search terms,
Read codes and acceptability / timing of requesting data. It also involved meeting and negotiation with the
LMC to agree the process and acceptability of requesting patient – level data.
One key issue was the extraction of postcode data to enable a deprivation ranking to be attributed to each
patient. This required particular discussion because of the potential for patient identifiability. It was agreed
that postcodes would be transferred to LSOA in order to preserve non-identifiability of data.
A letter was drafted to GP practices that outlined the need for the data, the support of the LMC and the
screening programmes and gave information about information governance issues. Practices returned the
spreadsheets containing practice data via nhs.net. The data was then converted to a useable Excel format
and stored on a secure server at the PCT. Assistance from the data analysts allowed transfer to larger
spreadsheets for analysis. Data extraction from the screening programmes was also problematic due to the
poor search function of the screening programme software (a problem recognised at a national level). This
meant that data was slow to be sent, in varying formats, and containing different definitions from each
screening programme, making comparisons difficult. These data extraction issues caused significant
delays for the project and should form the first thing to be done if the process were to be repeated.
Data analysis
Data analysis was done by the dimensions of equity approved by the steering group.
Grouped according to Provision, Access, Uptake and Outcomes. Methods – used Access and Excel for
analysis and chart design. Mapping conducted by information specialists on postcode data.
Feedback
Written reports were provided for the project as a whole and for each screening programme
Presentations made at screening board meetings
Recommendations made to the screening programmes
Dr Simon Fraser
StR Public Health
NHS Southampton City
Dr Simon Fraser & Dr Laura Edwards
July 2010
106