Retinal Screener

Taking a Look Behind the Screens

I've always said that retinal screeners and failsafe are a lot like teenagers and sex: we all talk about it; no one really knows how to do it; but we think everyone else is doing it all the time, so we say we’re doing it too. And until BARS holds another Failsafe Discussion Day (or sex education class) that's likely to remain the case.

But one area where I always assumed the National Diabetic Eye Screening Programme differed from the average teenage boy was in the overwhelming compulsion to draw penises. Frankly I didn't think we had any (compulsion, not penises). Admittedly, I've been known to explain retinal images to patients with the words "If it looks like Mars, it's normal; if it looks like Venus, it's ischaemic; and if it looks like Uranus, it could be a macula hole", but I've never had the balls to mention male genitalia, and the only thing I've drawn on is my experience.

That all looks set to change, however, following the arrival of last month's Test & Training set.

Back in 2013, the journal Psychological Science published a study entitled The Invisible Gorilla Strikes Again, which was based on the phenomenon of 'Inattentional Blindness', whereby observers miss unexpected, but salient, events while engaged in other tasks. It had previously been demonstrated by videos such as this one:

With the exception of Dian Fossey and the Harlem Globetrotters, however, most people viewing that video weren't specialists on the subject matter, so researchers at Harvard Medical School and Brigham & Women's Hospital in Boston decided to examine whether inattentional blindness also affects expert observers. They asked 24 radiologists to examine five CT scans of lungs for cancer nodules, a specialised task highly familiar to all of them. The last of those five scans looked like this...

Gorillas in the Midst

Despite being highly skilled observers, 20 of those 24 radiologists, or 83%, failed to spot the gorilla in the top right hand corner. The other 4 went ape when they saw it.

The results indicate not that the radiologists weren't looking carefully enough, but rather that their brains were so focused on spotting cancer nodules, they were blind to anything else.

The resulting press coverage of this study prompted a lot of discussion in my screening programme about whether or not we would notice such a thing when grading a retinal image. Most graders found it hard to believe they could ever miss anything so out of place. But then the radiologists probably would have said the same thing too. And let's face it, you could hide Lord Lucan in a nasal left view being graded after four-thirty on a Friday afternoon, and we'd all be none the wiser.

My conclusion was that there could be no better environment to further test this phenomenon than a diabetic eye screening programme. Not only would we be reducing the risk of blindness, we'd be assessing the risk of inattentional blindness. Once you include the blind luck required to get 100% on the TAT, we'd be on the verge of designing a triple threat study of high quality sight-impaired research, straddling Diabetes Care, The British Journal of Ophthalmology and Psychobabble Weekly.

And if I was thinking that way, I felt sure the national team were too. For the past two years I've been quietly confident that somewhere in Gloucester, behind closed doors, in a dimly lit room, and possibly in the dead of night, someone was green-lighting a top-secret research project to test the inattentional blindness of screeners, and that one day I would open an apparently innocuous image on the TAT, only to be confronted with a picture of Steve Aldington, the silverbacked godfather of grading, beating his chest as he swings through the temporaral arcade, grabbing veins like vines and shaking his fist at the camera.

Sadly it hasn't happened. Although if it had, 83% of us wouldn't know.

The thing about blind faith, however, is that it's eventually rewarded with a sight worth savouring. The April Test & Training set contained an unusual error in screen 005, which was assigned a ground-truthed grade of R0M0, despite the clear presence of retinopathy. My assertion is that this was a deliberate and subtle clue to the following month's invisible gorilla warfare...

Screen 035 in May's Test & Training set was this temporal left image, graded as R2M1:


It's clearly M1. But in this case the M stands for Member...

Maculopathy With Knobs On

So there you have it. The April set featured a cock-up. The May set featured a cock. And I'm standing proud amongst the 17% who saw it.

An official definition, courtesy of

R3 Stable

Thank god it's only for a short period of time.

R3 Stable

Merry Christmas everyone!

I was in a room with the National Programme Manager earlier this month. It wasn't a hotel room or a police cell, but it was both relaxing and arresting, and gave rise to some interesting questions. Not all of which have answers. Amongst these was the issue of whether or not we should consider using a single field of view for screening, rather than the two we currently employ, and having posed that question, Lynne Lacey stated that the HTA have reported very similar sensitivity and specificity for the detection of sight-threatening diabetic retinopathy (STDR) with just one 45º view.

When she said HTA, I'm assuming Lynne meant the Health Technology Assessment Programme and not the Horticultural Trades Association, although as we're talking about fields, I could be wrong. The former is part of the National Institute of Health Research, and "produces independent research information about the effectiveness, costs and broader impact of healthcare treatments and tests for those who plan, provide or receive care in the NHS". Which covers virtually all of us, and makes their views well worth a listen.

The NHS Diabetic Eye Screening Programme in England has always employed two 45º fields of view, one centred on the macula and the other on the optic disc, and to anyone familiar with this method, the suggestion of reducing our field of vision to a single photograph of each eye seems entirely counter-intuitive. Two images must be better than one. The more of the retina we can see, the more chance we have of spotting STDR, the more accurate our grading will be, and the less likely we are to miss something serious. We've all come across examples like this...

Background Retinopathy

Background Retinopathy

The temporal view shows, at worst, mild R2, but the nasal view reveals active new vessels. Relying on the first image alone would result in a routine referral, when an urgent one is clearly needed. With a bit of digging, I could probably find a macula-centred view which looks like a minor case of R1, complete with a disc-centred shot of R3. So it's case closed, surely? We need that second field.

Well, I'm not so certain. Back in 2004, the British Journal of Ophthalmology published this study from a team in Scotland which aimed to assess the effects of single versus three (rather than just two) field photography on screening for diabetic eye disease, and the results were somewhat startling. They concluded that using mydriasis and three field photography does not increase the sensitivity or specificity of detecting diabetic retinopathy. In other words, taking one photo without eye drops produces results which are just as accurate as those you'd get if you dilated the patient and took three photos of each eye. It might seem counter-intuitive, but it's peer-reviewed and in print.

Following on from this study, the Scottish Diabetic Retinopathy Screening Programme opted to go with single field photography, which it still employs to this day. In England we've always used two-field photography, but by putting this issue firmly on the agenda, Lynne Lacey has (quite rightly, in my opinion) started a debate which could have far-reaching consequences for the national programme. Put simply, this is a potential game-changer.

I spoke recently to a retinal screener from another programme who was telling me about the steady increase in her workload, and said that in order to meet the rising demand for screening without any increase in budget, she's being asked to screen almost forty patients a day. That includes measuring the visual acuity, dilating the pupils, recording any notes and taking the photographs. And she's not alone. Every screening programme in England is seeing its patient cohort grow year upon year, but I don't know of any with a rising budget to match. Programmes are consistently being asked to do more for less, and with that situation likely to continue, it's inevitable that the number of patients seen by each screener in clinic will have to go up.

As a retinal screener, that gives me concerns for my colleagues across the country, but equally I fear for the patients. The more people we see in each clinic, the less of a service they get. As patient numbers grow and appointment times shrink, the educational nature of the job will all but vanish, as the time to talk to patients becomes a luxury that no one can afford. Patients will end up being herded in and out of clinics by stressed, over-worked screeners who barely have the time to check a date of birth, never mind discuss a patient's condition. Photographs will be captured, but the quality of patient care will be diminished beyond recognition. All those added extras - the education, information and friendly, personal service that can transform a simple screening appointment into something far more valuable for the patient and just as rewarding for the screener - well, all of that will be lost.

Adopting a single field strategy would change that overnight. Taking only one photograph of each eye would dramatically reduce the need for drops, and with tropicamide priced at around 50p an ampoule, that would instantly slash costs. Removing the need for dilation, and halving the number of photos taken, would speed up the practicalities of the screening process and give the screener more time for patient education and feedback, while the likelihood of not having drops would encourage patients to attend, and reduce DNA rates. Meanwhile, back in the office, graders would have half the number of images to assess, and could potentially grade twice as many patients. Capacity would increase, as would patient uptake, and yet costs would realistically go down.

But what about the patient above? How do we manage the risk of an R3 patient masquerading as an R1 in a single temporal view?

Well, it's quite simple. We adopt a halfway house between single field and two-field photography. A few months ago, I mentioned that our national number-cruncher, Strat the Stat, had come to the conclusion that annual screening for patients with no retinopathy might be a waste of our resources. Well, so is two-field photography. And probably mydriasis too. I would implement a very simple new rule: all patients are subjected to single field retinal photography until such time as they have background retinopathy in both eyes. At that point, they're put on an annual rescreen and given two-field photography at future visits.

Adopting this rule would result in the overwhelming majority of patients being effectively screened with just a single photograph of each eye, whilst simultaneously ensuring that anyone at any risk of STDR gets a two-field screening. As technology advances, and cameras improve, more and more of those single field screenings will be possible without drops, and by limiting this method to those patients at lower risk, we can rest assured we're not missing anything, whilst successfully reducing costs.

Put it this way: in front of you is a patient with type 2 diabetes. They're diet-controlled, and received a grade of R0 at their last screening, twelve months ago. With your budget increasingly tight and your workload rising, do you really need to spend significant time and money dilating their pupils with tropicamide and capturing four distinct views in an unlikely search for sight-threatening diabetic retinopathy, or would one undilated photo of each eye suffice? I'd suggest that's one question which does have an answer.

One of the trickier challenges for any diabetic eye screening programme is getting the wording right on the patient letters. Communicating the potential seriousness of diabetic retinopathy without terrifying the patient in the process is a balancing act that would challenge the skills of Charles Blondin, and when you add in the need to be clear and concise enough to earn a crystal mark, the feat becomes nigh on impossible.

Where I come from, Crystal Mark is the rough-looking bloke down the road who's addicted to methamphetamine, but in other parts of the country it's a highly prized award from the Plain English Campaign, which can be earned by any document with the clarity of a freshly fitted lens implant. The Derbyshire Diabetic Eye Screening Service won an even more prestigious award earlier this year, which was somewhat surprising as most of their letters begin with the words "Ey-up, duck", and they use the phrase "dunna wittle" in their R1 results.

But for the rest of us, finding the right words can be a constant struggle. A number of years ago, we started getting phone calls from patients who'd been told they had background retinopathy and were worried they were going blind. So we added a line to the results letter stating "This does not mean you are going blind". At which point we started getting calls from people who'd never even thought about losing their sight, and were suddenly terrified by the word 'blind'.

To this day, about 50% of newly diagnosed R1 patients tell me how reassured they were by the wording of our results letter. The other 50% tell me how panicked they were. The concept of Ironic Process Theory states that if you tell people not to think of an elephant, they automatically do. Except that in this case, half of them think of Dumbo, while the others think of the killer elephant attacks they've watched on YouTube.

To my mind, one of the main aims of patient letters should be the avoidance of telephone calls. Any letter which prompts either a question or a fear is going to result in a call to the office to have those questions answered and those fears allayed. An imperfect letter template could mean an entire admin team being tied up indefinitely. And yet getting it right seems extraordinarily difficult. When a patient moves into our area from another screening programme, they often bring their last results letter with them, and I'm constantly amazed by the variations in wording. A recent example informed the patient that whilst his eyes were clear of diabetic retinopathy, they'd noted an unspecified "non diabetes related issue" which might require treatment, and urged him to contact his GP. As far as the patient was concerned, it could have been anything from cancer to a brain tumour. It turned out to be a cataract.

Unfortunately, when it comes to clear communication, the national programme fares no better. The 'Guide to Diabetic Eye Screening' that we're all handing out to the patients, lists the concepts of 'bringing your glasses' and 'not driving after the appointment' under "hints and tips" rather than vital information. Which is a bit like putting the appointment time as a P.S..

And as for the national letter templates, they're an object lesson in the difficulty of getting it right. Logging on to the DESP extranet provides you with access to twenty-one standard letter templates, covering almost every eventuality bar alien invasion and tsunami, and yet still the perfect wording proves elusive. Take the R0M0 results letter. This is the one that all patients dream of getting, sent to those with no retinopathy, who have nothing to worry about and no problems to fear. It's the medical equivalent of a missive from the Reader's Digest prize draw manager. And here's how it breaks the good news:

You are at very little risk of sight-threatening diabetic retinopathy at this time.

Hurrah! A small risk of blindness! At the moment! It goes on...

Screening detects nearly all early signs of diabetic eye disease. However, very occasionally it can miss changes that could threaten your sight.

So we've probably missed something terrible. But we'll see you again in a year. Although whether you'll have enough vision left to see us is another matter.

That letter should fill people with happiness, relief and positivity, not fear, dread and paranoia. Unfortunately, the only people benefiting from that particular wording are the opticians with fundus cameras who can charge our worried R0M0 patients for an unneeded extra test.

Of course, the results letters are always going to be a minefield. But the appointment letters should be plain sailing. And plainly worded. Or so you might think. The standard DESP invitation letter template, which can be downloaded from the extranet, suggests using the following text:

The aim of diabetic eye screening is to detect any changes caused by diabetes that could damage your sight. You may be completely unaware of these changes but they are usually very treatable.

I like that wording a lot. The second sentence in particular sums up the most important, and most reassuring, aspect of screening: that if we find problems, we can treat them. It's something we need to repeat ad infinitum, in appointment letters, results letters and in clinics. It's the one fact that can stop patients worrying, and - despite its apparent obviousness - it's not widely enough known. This time last year, we added that text to our appointment letters, and it seems to have worked well.

Until now, that is.

I screened a Middle Eastern gentleman this week, whose knowledge of English was limited, but probably better than the average EDL member. Despite having to speak a little slower, we understood each other perfectly, and his affable nature meant that by the end of the appointment we were firm friends. I concluded by showing him the retinal photographs, talking him through what I could see, and reassuring him about the likely outcome, before standing up to show him to the door.

At which point he looked very confused. I repeated the information, briefly, in simpler words, but he still looked decidedly puzzled. So I asked him if he had any questions. His response succeeded only in transferring that look of confusion from his face to mine.

As unlikely as it may sound, he asked me why the appointment letter had told him to bring a change of clothes. I replied that it had merely asked him to bring a pair of glasses, but he was adamant that he'd been expecting to take all his clothes off, and wondered why I'd let him keep them on, suggesting that maybe I hadn't done my job properly. I politely argued my point again, and he responded by producing his letter and directing me to the section concerned.

It transpired that he'd taken the phrase "You may be completely unaware of these changes" to mean "You may need a complete change of underwear". He then held up a bag containing a pair of pants and a vest. And he wasn't even joking.

I'm not sure which is more surprising: the fact that he'd misinterpreted our letter so spectacularly, or the fact that he was quite happy to go along with it. Let's face it, if anyone has a good excuse for a DNA, it's the man who thinks the screening process involves getting naked, and may very well soil your underwear.

I can't wait to hear what he thinks of our results letter. He'll probably read 'background' as 'backside' and complain that I refused to look at his bottom.

With 2013 now upon us, and the Mayas looking sheepish, perhaps the biggest threat to the future of the NHS Diabetic Eye Screening Programme is our failure to restructure our screening intervals. Back at the dawn of civilisation (circa 2003), it was decided that diabetic retinopathy screening in the UK should adopt a 'one size fits all' approach, which is unfortunate, as it's a phrase which strikes fear into the hearts of a lot of type 2 diabetics with body image issues. As a result, patients found to have sight-threatening DR are referred to the hospital eye service, while everyone else is screened annually, regardless of potential risk.

As patient numbers increase, and budgets are squeezed, the need to look again at this policy has become ever more important. On the one hand we have those diet-controlled octogenarians who claim they were only diagnosed with diabetes because they ate a Chocolate Hob-nob ten minutes before having a blood test - and then prove it by coming back year after year with no retinopathy - and on the other, we have the young type 1s with bad control and a bit of background, who can go downhill faster than Rik Waller on a log flume. Yet we continue to screen them all annually as if there were no distinction.

The less money we have, the more crucial it is that those scarce resources are targeted appropriately, and it's long been suggested that to screen patients with no retinopathy on an annual basis is a waste of our time and money. Conversely, we need to ensure that those patients who have the potential to progress on to sight-threatening DR are not left too long between screenings.

The solution, it would seem, is to identify those patients at low risk, screen them less frequently, and channel those extra resources into more frequent screening for those at higher risk. It's a simple and sensible solution, makes sound financial sense, and seems a lot better for all concerned. Assuming you know who they are.

The problem is identifying which patients fall into which group. And that was the aim of a recent study carried out by Irene M Stratton (the M is for Maculopathy), senior statistician of the Gloucestershire Diabetic Retinopathy Research Group. I've a lot of respect for Irene. She's a vastly experienced number-cruncher with some head-turning vital statistics, and she's produced more funnel plots than a conspiracy theorist. I also like the way she seems to be turning the word 'Stratification' into an eponym.

The important thing is that Irene has a very attractive figure. And that figure is 14,554. It's the number of patient outcomes she's studied in order to develop a simple algorithm to assess the risk of a patient screened annually for diabetic retinopathy developing sight-threatening DR within that twelve month period. You can read more about Irene's stratifications by clicking here, but it's the conclusions which are interesting, and more than a little surprising.

The aim was to estimate a patient's future risk by looking at the results of two consecutive eye screenings. And here's what she found:

Of 7,246 with no DR at either screening, 120 progressed to sight-threatening diabetic retinopathy (STDR), equivalent to an annual rate of 0.7%.

Of 1,778 with no DR in either eye at first screening and in one eye at second screening, 80 progressed to STDR, equivalent to an annual rate of 1.9%

Of 1,159 with background DR in both eyes at both screenings, 299 progressed to STDR, equivalent to an annual rate of 11%.

A lot of attention has been focused on that final statistic, but I find the first one just as shocking. I'd like to know what went on in the lives of those 120 people who had R0 for two years running, and then went straight to M1 (or possibly R2?). And more to the point, who was responsible for their care? Or lack thereof.

The implication is that patients who have no retinopathy for two consecutive screenings can probably be left for a couple of years, although I wouldn't like to be the one who has to explain that policy to an anxious individual who reads the figures above, and points out that one such patient in every 150 will go blind before their next visit.

That aside, it would appear that anyone found to have background retinopathy in both eyes on two consecutive screenings has a better than 1 in 10 chance of developing STDR within twelve months, and therefore needs to be screened more often. But is that the full picture?

My suggestion is no. I think this is:

Background Retinopathy

That eye has received an official, undisputed, and quality assured grade of R1M0, meaning it has background retinopathy with no maculopathy.

And so has this one:

Background Retinopathy

That's not a doctored photo, it's a genuine case of R1. There's a faint microaneurysm less than two disc diameters from the fovea, on the temporal side.

Does it seem likely that the first patient could progress on to sight-threatening DR within the next twelve months? Absolutely. But what about the second?

The problem is that just as the current system makes no distinction between a low risk type 2 with no retinopathy, and a high risk type 1 with background, a system based purely on consecutive grades of R1 would make no distinction between the two patients above. If the second patient came back a year later with the same microaneurysm, they'd be classed as high risk, and called back in six months. Which, on an instinctive level at least, doesn't seem like the best use of our resources.

I'm all for simplicity, but perhaps screening grades alone are unreliable. Perhaps we need to include factors such as whether the patient is type 1 or type 2, whether they're diet controlled or on medication, and how long they've been diabetic. Maybe we even include their latest HbA1c and take their blood pressure.

Or maybe we just redefine R1. A grade which covers both the patients above, and everyone in between, seems far too wide to be meaningful. Especially if we're considering using it to judge future screening intervals. But in these times of austerity and increasing workloads, there's no doubt the system needs reform. Perhaps desperate times call for DESP E-Rate measures.

A festive message from four very special people...

Merry Christmas everyone!

As a retinal screener, one of the most common complaints I hear from my older patients is that their eyes are watering too much. Particularly when I've had onion soup for lunch, and I'm leaning in close for the eye drops. As a general rule, however, excessive watering in older age is often a sign of dry eye, a revelation which can lead to arguments with certain patients, who insist their eyes are too wet, not too dry. In those cases I tell them it could be keratoconjunctivitis sicca instead.

If I had a pound for every time I've sent a patient to the nearest pharmacy for some lubricating eye drops, I could probably afford to do the MSc in Retinal Screening, but sadly the drops are so cheap, I'd barely make my fortune even if I worked on commission. The fact remains, however, that as retinal screeners, we're probably responsible for the production of more artificial tears than the finalists on The X Factor.

But that could all be about to end. I was taking an eye history from a new patient this week, and he told me that until a couple of years ago he suffered from the most terrible dry eyes, which watered constantly and were frequently sore. But that all changed one day in 2010 when he found an overnight cure.

I'm naturally skeptical of anything patients tell me, including their date of birth and GP, but I took the bait, and asked him what the cure was. He said "Honey". I said "On toast?". He said "No, in my eyes".

My first thought was to consider the possible implications of a patient with diabetes ingesting neat glucose through their eyes. My second thought was to ask "What's next - marmalade for earache?". But having pondered the idea for a moment, I replied that the antibacterial properties of Manuka honey are well established, so I suppose it's not impossible it could have benefits in other areas. The patient shrugged and said "Well I don't use that. I use Tesco's."

Apparently he first heard of the cure in some far-flung land (I think it was the Isle of Wight), and since starting to smear supermarket honey on his eyes two years ago, he's never looked back. Mainly because his eyelids are stuck shut. But his dry eye has completely cleared up, and he now swears by the stuff. Like a trooper.

At the time, I gave his story about as much credence as the lady who once told me her retinal haemorrhages were due to a nurse over-tightening the cuff on her blood pressure monitor, but having done a little research of my own, it appears there could be something in it. The internet is awash with anecdotal (and highly questionable) evidence of the effects of honey on dry eyes, but if you dig around, there are one or two slightly more credible sources.

One comes from the Journal of Apicultural Research, which is the bee all and end all in honey studies, and published a paper in 2007 entitled Using 20% Honey Solution Eye Drops in Patients with Dry Eye Syndrome. Their sample was small at only 36 patients, 19 of whom were given the eye drops, but they reported significant improvement compared with those given artificial tears, and even suggested a positive effect on the state of the cornea in those using honey eye drops.

Another comes from the home of Manuka honey, Australia, and the Institute of Health and Biomedical Innovation at the Queensland University of Technology in Brisbane. They published a study in 2006 which looked at the Effect of Antibacterial Honey on the Ocular Flora in Tear Deficiency and Meibomian Gland Disease. They were cautious not to overstate their results, but the authors' findings were positive enough for them to conclude that "there is sufficient preliminary data to warrant further study of the effects of antibacterial honey in chronic ocular surface diseases".

Fortunately, that 'further study' has been carried out by a bloke from Glasgow, whose findings were published in the indisputable Bible of modern medicine and cutting edge health advice, The Daily Mail. They reported earlier this year that a retired soul DJ who knows a lot about ocular health due to having been shot in the eye with a bow & arrow (I expect there's a tapestry depicting the event in his local pub), had cured his chronic blepharitis with a 99p jar of honey.

Medical proof doesn't get much more watertight than The Daily Mail, so by this point I'm thinking "Ok... so honey cures dry eye and blepharitis. If it can do anything for cataracts, I can solve all our pensioners' problems". I wasn't serious, obviously. But maybe I should have been. After a bit of digging, I found a brief report of a study carried out in Russia in the 1980s, and published in a Russian ophthalmology journal twenty-two years ago, which is entitled Use of Honey in Conservative Treatment of Senile Cataracts. Patients with cataracts were followed for an average of seven years, and whilst 65% of those in the control group got progressively worse, the same was true of only 44% of those given honey eye drops.

That study suggested that honey could halt or slow the progression of cataracts, but another carried out jointly by the University of The Andes in Venezuela and Cardiff University in the UK, goes even further. Published in the Journal of Health Science in 2008, and entitled Putative Anticataract Properties of Honey Studied by the Action of Flavonoids on a Lens Culture Model, the paper suggests that honey could actually reverse the growth of cataracts and produce a reduction in lens opacification.

So that's dry eye, blepharitis and cataracts. At this rate, my patients will have nothing left to complain about. Forget financial backing from Big Pharma, I need to do a sponsorship deal with Gale's.

Back in the good old days, when British Rail were getting there, British Leyland weren't, and the only Diabetic Eye Screening Programme was the moment the star wore sunglasses on The Mary Tyler Moore Show, the thought of having a National Health Service run by private companies seemed about as likely as Gary Glitter being a paedophile.

Obviously a lot has changed since then. Hospitals no longer give out keys to Radio 1 DJs, and numerous NHS services are now delivered by potentially profit-making businesses. Not all services, of course. The complex, high-risk cases that no capitalist would touch with a bargepole are still happily run by the NHS, but the attractive, low-risk services with a good chance of turning a profit, have been kindly taken over by private companies in a benevolent act that gives the British taxpayer greater value for money, whilst maintaining the high standards of care that Nye Bevan dreamt of.

At least that's the theory. I should state immediately that I work for the NHS. But a lot of retinal screeners don't. The National Diabetic Eye Screening Programme includes the likes of Virgin Care in Surrey, Clinicenta in Hertfordshire, Health Intelligence in Suffolk, 1st Retinal Screen in London and Yorkshire, and Medical Imaging UK in Worcestershire, Essex and beyond. As an NHS employee, it's easy to feel like a T-Rex in the last days before the asteroid hit, but is the spread of privatisation in the world of diabetic eye screening necessarily a bad thing?

Well that depends. At the time of writing, entering the word 'Clinicenta' into Google returns seven results on page 1, four of which are negative news stories, including the headline "Patients 'Lost Sight' at NHS Hospital Private Clinic" . So if they're making a profit, they need to spend some of it on PR. But that doesn't make all privatisation (or indeed all Clinicenta services) bad. Assuming that all NHS programmes are run by hard-working, selfless angels, and all private services by ruthless, money-grubbing profiteers is clearly ridiculous.

My only concern would be whether profits are being put before patients. And that might be a common accusation levelled at a private company by supporters of the NHS. What's more worrying is when those private companies themselves accuse the government of awarding contracts based on price rather than standards of care.

Channel 4 broadcast an edition of 'Dispatches' this week entitled 'Getting Rich on the NHS'. Here's a two-minute clip...

Should we shed any tears when one private company is replaced by another? Well, in this case, maybe. 1st Retinal Screen have been providing diabetic eye screening in Swindon and North Wiltshire since the early days of the national programme. And if Mike Nelson is to be believed, they've only recently made any money. The 'sour grapes' accusation is one that's easy to level at Mr Nelson, and to some degree there's probably an element of truth in it. Is it really so outrageous for a new provider to enquire about buying some cameras? One could argue that if you're taking over an existing service and (presumably) employing a lot of the old staff, then making use of their (now redundant) equipment is a logical and sensible step.

But that doesn't make Mike's arguments invalid. When the PCT began the tendering process in February, there were reportedly fourteen expressions of interest from both NHS hospitals and private sector providers. One would assume that 1st Retinal Screen held all the cards in that bidding war, possessing top trumps in experience, knowledge and quality of care. But they lost out on price, which appears to be the one card that consistently trumps all the others. And that has to be a concern.

Virgin Care might end up providing a first rate service, but the initial impact on patients can only be negative. The handover from one company to another inevitably results in a gap in service, which means delays to patients' screening, and a potential for serious consequences. And in the longer term, how can Virgin Care provide a service of similar quality at a price that's 14% lower than 1st Retinal Screen say they need to charge to break even?

Only time will tell. But as a retinal screener, it's a question which worries me. The biggest overhead for any diabetic eye screening programme is its staff, and those staff will inevitably become the focus for any cost-cutting exercise. If losing screeners is not an option, then getting more out of them is the only alternative.

There seems to be a commonly held misconception amongst some NHS screeners that if their programmes are taken over by the likes of Virgin Care, it will mean the replacement of their chronically underfunded facilities with privately-owned state-of-the-art equipment. Clapped-out laptops will be replaced with cutting-edge iPads, stylish new uniforms will be issued, and Richard Branson will be popping in once a week to hand out £50 notes and free air miles. The perception is that NHS poverty will be replaced by Virgin wealth, and we'll all be riding the gravy train to an easy life.

The reality is likely to be the complete opposite. Any company that wins a contract at a rock-bottom price will be looking to squeeze every last penny of value from each of its assets. And that means making staff do a lot more for a lot less. I have no personal experience of working for a private screening company, but common sense tells me that my professional life can only get worse. By definition, my new employer would have outbid my current one on price, and the programme's budget would therefore be even tighter than it is now.

As I understand it, private companies taking over NHS contracts are not allowed to make current staff redundant, meaning that their only option is to get greater value from them. Which means working them harder, with fewer benefits, and less job satisfaction. That might maintain standards of service at first, but how long before an over-worked and dissatisfied screening team begins to impact on patient care?

As taxpayers, we all want value for money from the NHS, but as patients, we want good care too. And as a screener, I'd like to see fairness for staff in the mix also. Undoubtedly there are private companies who can achieve a balance of all three, but for how long? With prices being driven down all the time, something's got to give, and probably already has. It only takes one company to win a contract by lowering standards, and the rest will inevitably follow suit. In the world of business, how else can they compete?

1st Retinal Screen lost the Swindon contract because they couldn't provide a good quality service for a price that low. So what do they do the next time a contract comes up for tender? Lower their standards, or go out of business? It's a choice no company providing NHS services should be forced to make. And the only way to avoid it, is for the government to place less emphasis on price, and more on the quality of patient care. I don't want shareholders getting rich from my NHS care, but I want that care to be decent. And if it's not, then it's time to renationalise.

***UPDATE 7/12/12***
In the above article, I posed the question "Is it really so outrageous for a new provider to enquire about buying some cameras?". Well, I bumped into a chap from 1st Retinal Screen this week, and it seems the answer's yes. Apparently the equipment you own forms a key part of your bid, so if Virgin Care had the cameras they required, why were they keen to buy more? And if they didn't have the necessary equipment, how did they win the contract? Those are questions I'll be asking when I bump into a chap from Virgin Care.

Looking forward to it, Mr Branson...

There have been times over the past few months when I've felt that 'Year 3 of TAT' is so called because some of the images are so poor, they look like they were taken by a class of 7-year-olds. I'm still convinced that one or two were captured by candlelight with the patient's glasses still on, using a pinhole camera knocked up from an old occluder and a box of tropicamide.

I know we're meant to be saving sight, but at times I've been more worried about the vision of the photographer who felt they were acceptable images. We live in an age of digital photography, where the only cost of a bad photo is a few seconds of the operative's time, so surely we should be wiping those smudges off the lens, removing the dust from the microchip, and then bumping up the flash and having another go.

Of course, the whole point of Test and Training is to perform an EQA function, and it's definitely succeeding there. I've identified a few outliers myself, just from looking at the photos. Now we just need to find out which programmes they work for, and teach them how to use a camera.

Personally I think each Test & Training image should be coded to identify the photographer, and come with a scorecard, allowing us all to rate them on a scale of one to ten. Thus every image set would not only give an insight into the skill of the grader, but also provide quality assurance for the photographers. Screeners whose photos receive consistently low marks could be flagged up for more training, in the same way that graders are.

If anything, this is an even more vital aspect of EQA. It's all very well checking that your graders are up to the job, but if the images they're presented with are sub-standard, no amount of grading skill is going to compensate for that, and disease will undoubtedly be missed. The photos are the foundation on which the whole screening process is based, and if programmes make do with poor quality images, that house of cards will soon come crashing down around us.

On the plus side, of course, grading the occasional dodgy photo does give us a bit of practice with the more unusual and challenging images we all face from time to time. So have a go at this one...

Retina Display
Suffice it to say, there's a lot going on there. Fragments of the temporal arcade are still visible, particularly the superior artery, but the optic disc appears to have faded into the background, possibly as a result of papilloedema. The macula is ill-defined, with some haemorrhaging at the fovea, and some lighter patches which could be AMD, hard exudates or clumps of drusen. Overall, the picture looks so ischaemic that virtually the entire retinal blood supply has been shut down, with obvious implications for vision.

It's clearly not a well eye. In fact it's not an eye at all. It's actually a photo of the sun. But I think I'd go for R1M1 and a routine referral.

About this blog

I'm a Retinal Screener and Grader currently working for the NHS as part of a Diabetic Retinopathy Screening Programme somewhere in England.
Click here for more.

Technical Issue

If this sidebar is appearing at the very bottom of the page, you're probably using Internet Explorer 6.
Click here to enter the 21st century and update your browser.