The aim of this project is to reduce the number of appointments that those on the diabetes register need to attend by offering a “one stop shop” for both retinal screening and diabetic review. The surgery I work in is demographically situated in one of the most deprived areas in the UK and typically the patients attending are those who make poor lifestyle choices and fail to attend appointments, they may be classed as hard to reach, homeless and vulnerable patients with complex needs.
Aims and Objectives
My intention was to improve on the number of diabetic patients attending their appointment for retinal screening and for their annual diabetic review in order to capture them and integrate them into local services for diabetes care. Objectives involved improving communication with the diabetic retinal screening service, an audit and inspection of available rooms at the GP surgery to allow for retinal screening to be performed at the surgery, and the development of a patient letter and protocol to promote a consistent approach for patients to be recalled and reviewed. This change in practice would enable the surgery’s hard to reach and vulnerable patients to attend for one appointment where they could receive their retinal screening and their diabetic review at the same appointment.
The most serious complication affecting the eye for people with diabetes is the development of diabetic retinopathy. A delicate network of blood vessels supplies the retina with blood. Diabetes affects these tiny blood vessels of the eye and if they become blocked or leak then the retina, and possibly the vision can be affected. The Royal National Institute of Blind People (RNIB) estimate that forty percent of people with type 1 diabetes and 20 per cent with type 2 diabetes will develop some sort of diabetic retinopathy.
Diabetic retinopathy progresses with time but may not cause symptoms until it is quite advanced and close to affecting the person’s sight. The duration of diabetes is the most important factor that predicts whether a person develops diabetic retinopathy as well as poor glycaemic control. The United Kingdom Prospective Diabetes Study (UKPDS 1998) and the Diabetes Control and Complications Trial (DCCT 1993) showed that improved glycaemic control reduced the development and progression of retinopathy.
This demonstrates that glycaemic control is significant in reducing a person’s risk of developing diabetic retinopathy and by combining the retinal screening with the diabetic review, it was anticipated that improved glycaemic control could be discussed at an appropriate time as most people would consider maintaining their eyesight as significant.
A study by Jones, Hepburn, Man, Ridout and Gable (2011) demonstrated that diabetes care in the community is not always flexible enough to accommodate the needs of vulnerable people with complex needs however, type 2 diabetes mellitus (T2DM) complications are often avoidable through adequate care and therefore there has been an increase in programmes to improve the quality of routine care received by people with T2DM (Stribbling 2013).
The importance of targeting non-attenders is significant in order to attempt to reduce complications. Diabetes is associated cardiac and cerebrovascular disease, as well as small vessel disease that can result in blindness and renal failure (Fowler 2008). Good glycaemic management reduces the risks of complications, why is why it is important to make every effort to reach the non-attenders (Thomas 2012).
Socio-economic deprivation is one of the main reasons people are unable to attend appointments for health care. Deprivation is strongly associated with the development of diabetes and the complications associated with it. People on a low income may not be able to access public transport, they may not class their own health as priority and those who have substance misuse issues may use their money to buy illicit drugs instead of using the money to buy healthier food or for getting to and from appointments.
Research by Mitchell, Malone and Doebbeling (2009) demonstrated that individuals with substance misuse disorders and mental health problems were significantly less likely to receive retinal screening or foot sensory examination even though those with a mental disorder had significantly more out-patient visits. This researched concluded that there was strong evidence to support inequalities in medical care for those people with a mental health problem or a substance misuse disorder even though the nature of these diagnoses increased the risk of them developing T2DM and complications from it.
In consideration of the practice population where I work, there are a high proportion of people with mental health issues, drug misusers and a few homeless people. I also work in a deprived area which alerts me to acknowledging the problems these people face on a day to day basis and realising that health is not top of their daily agenda. It has highlighted that the evidence is present to facilitate a change in practice to allow for improved access to health care and to perform as many health assessments as possible in one session.
Overview of audit
The audit undertaken earlier in the year was performed by analysing the number of people with diabetes attending appointments for annual retinal screening (see appendix 1). I then divided the results down further to encompass age groups and gender. The middle age range had the highest number of non-attenders and more males than females failed to attend their appointment. The number of people attending for retinal screening was considerably higher than anticipated, and in comparison to those attending for other areas of their diabetes care, which identified an opportunity in modifying appointments.
The audit highlighted that patient’s rank their eyesight as very important compared to other aspects of their diabetes review and I considered how I could change this behaviour and allow for the patients diabetic review to be performed at the same time as retinal screening. This recognised that there needs to be a more robust system in place as this type of complication can only be detected by a detailed examination of the eye at attendance of the retinal screening programme. Attendance issues may be improved upon by combining appointments and therefore, in conclusion, communication between departments needs to be more effective ensuring that diabetic patients can be recalled for both review and screening and a protocol for patients who do not attend needs implementing.
My initial action was to ensure that the diabetes register at the practice was up to date and that all patients over the age of twelve years had been referred to the screening service. I performed this audit by reviewing the diabetic register on Systmone including any new patients and systematically checking through the patients computerised notes to establish whether referrals had indeed been made and read coded onto the computer. For patients who had not been referred for retinal screening, a referral form was completed and faxed over to the screening service. Local diabetic eye screening services need to be informed of everyone who is newly diagnosed as well as those people with diabetes who have moved into the area or changed GP practice.
Once this was complete, I contacted the retinal screening service via email to ask whether it would be a feasible option for them to batch appoint several of the surgeries patients together on the same morning or afternoon to allow for sufficient patients to make it cost effective for a full session. The retinal screening took place at a different GP surgery and I therefore needed to contact the practice manager to request permission for the use of a room in order to be able to review the patients at the same time as the retinal screening appointment. This would mean I would have to travel and see patients at the other surgery and it was recognised that both cost effectiveness and productiveness would be improved by consulting with several patients within one session.
Unfortunately, rooms were very limited at the other surgery and therefore this option was taken out of the equation as it was not possible to agree a solution.
I reconsidered the idea and emailed the screening service again to ask the standards and measurements needed for a room for retinal screening. I was informed that the room needed to be at least three metres in length with a desk and two chairs, a computer, and access to an electricity supply to extend to the car park where the screening van would be located.
My surgery often hires vacant rooms out to other services and therefore, I discussed this with the centre manager who approved an inspection by the retinal screening service to establish whether the surgery had a suitable room. This was arranged for the screening service to attend the surgery and review all of the available rooms.
Two gentlemen from the screening service attended the surgery together with the screening vehicle to inspect the rooms available and to establish whether it would be feasible to park, connect to an electrical supply and be allocated a suitable room for screening purposes. They were shown around the majority of the rooms within the surgery and decided that one of the rooms at the front of the building was suitable; the screening van could be parked at the front of the building allowing suitable access to an electrical point. We therefore had an agreement with the retinal screening service for them to perform the screening procedure within the patient’s own surgery.
It was agreed that a nominated person from the retinal screening service would send, via email, a list of patients whom they were inviting for screening, directly to the practice, six weeks in advance of the appointment. This would allow time for the practice to invite the patients to attend for any blood tests needed prior to their diabetic review. The surgery would then send a letter to each patient informing them that their diabetic review would be performed immediately after their retinal screening.
For the appointment system to be robust, an educational session was delivered to other nurses and reception staff to inform them of the change in practice and the reasons behind this change. This was to attempt to engage all staff to work effectively in this process and to discuss any problems or ideas. Appointment length for the diabetes review was agreed to be thirty minute duration. There was a discussion featuring the implication for the Quality and Outcomes Framework (QoF) figures, and consequently monetary reward for the practice, and that retinal screening is an annual procedure. Patients are sent a leaflet regarding screening with their retinopathy screening appointment.
Following this, a prototype patient letter was devised for the practice to allow for consistency in appointing patients. The letter included the patient’s appointment time and date for their retinal screening and their diabetic review. The letter also advised patients of the risks of complications from diabetes and the importance of attendance. The letter was produced (see appendix 2) and this was evaluated and discussed at the next patient participation group which is only small but includes one person with diabetes.
Following approval of the appointment letter, a protocol (see appendix 3) was formulated to encompass all stages of the appointment process and ensure consistency.
The educational session took place and was attended by the practice nurses, reception and administration staff within the surgery. This was performed by discussion to allow for interaction of all staff members. The GP was unable to attend and this was discussed with her at another time. Feedback was positive and it was judged by the staff members to facilitate an improvement in patient care and improvement in appointment attendance. No problems were foreseen although it was recognised that if a patient failed to attend, it was mean a large portion of clinic time had been wasted. This time could be used to attempt to contact the patient by telephone to discuss diabetes care if necessary via a telephone consultation.
The “one stop shop” was perceived as a significant initiative in improving appointment attendance by the patient participation group. It was seen as something that would benefit patients rather than benefitting the surgery. As a representative group of patients, they highly recommended the implementation of the change in practice. This was seen as a successful challenge within the practice considering our patient population.
At the time of writing, I am awaiting the initial list of patients from the retinal screening service in order to be able to appoint people into this new project.
Equality of access should be a priority for all NHS services (DoH 2008). Vulnerable people with complex needs should still be entitled to quality health care as it is these patients who may lack the knowledge, skills and support to manage their condition (Thomas (2012).
Reflecting on the patients I care for, there is a high incidence of vulnerable people, substance misusers, and homeless, those on a low income or out of work, mental health and learning disability issues. These are often hard to target patients who repeatedly fail to attend appointments. The Quality and Outcomes Framework (QoF) rewards surgeries for achieving set outcomes for diabetes however surgeries such as the one where I am employed, often miss out on vital funds. This is not through the absence of working extremely hard to reach the targets but through patients not attending their appointments. Deprivation is strongly associated with the risk of developing diabetes and its complications. Diabetes UK (2006) reported that people living in derived areas were two and a half times more likely to develop type two diabetes. This was further reported by Diabetes UK (2009) who added that people in the most deprived areas are twice as likely to develop complications of diabetes compared to those in the least deprived areas.
Around 500 people a year experience loss of vision due to diabetic retinopathy and maculopathy at a level where it could be registered as a disability (Health and Social Care Information Centre (HSCIC) 2014). Diabetic patients are also at risk of developing cataracts or glaucoma. Diabetes UK (2013) in their mission statement declare the key points are
Diabetic retinopathy is the most common cause of sight loss in the working age population
All people with any type of diabetes are at risk of developing retinopathy. Those most at risk are those who have had diabetes for a long time and/or who have poorly controlled diabetes and hypertension
The NHS Diabetic Eye Screening Programme aims to reduce the risk of sight loss among people with diabetes by the early detection and treatment
Screening is offered annually to all people with diabetes aged 12 and over
A study by Waqar, Bullen, Chant, Salman, Vaidya and Ling (2009) into the cost implications of non-attendance at a retinal screening programme demonstrated an association between non-attendance and socioeconomic deprivation. The study divided the results down further into first and second did not attend (DNA) appointments. They discovered that sending out repeat reminders to patients resulted in a significant reduction in non-attendance rates. In the area where the study was performed on a total of 22,651 people, they declared the total cost by lost earnings from missed appointments to be almost eighty thousand pounds. Therefore failure of attendance at retinal screening appointments impacts enormously on Trust budgets.
Having the knowledge that DNA rates increase within areas of deprivation indicates that people in these areas need different ways of encouraging them to attend appointments. This group of patients needs targeting more aggressively and may need further reminders of their appointments. My vision for the patients that are registered with my practice is one that will encourage attendance by providing a service that will encompass the majority of components needed for a full diabetic review within one session. My feelings are that this will improve patient attendance as the patients will not have to attend multiple appointments or visit another surgery for their retinal screening. This will reduce time constraints and patients expenses should they need to use public or private transport. People leading chaotic lives tend to focus their day very differently to others and by generating one appointment instead of two may support these people to make an effort to attend one session.
I consider the strength of this change in practice focuses on the idea of only one appointment. This appears to be confirmed by the reaction of other members of staff and the patient participation group. I remain optimistic that this will improve patient attendance and therefore patient care and improved health outcomes with a reduction in complication rates. The ability for retinal screening to be performed at my practice was paramount to this change in practice and continuing effective communication between the surgery and the retinal screening service must be maintained.
I do not feel there is a particular weakness with the method, however the only drawback I can foresee is that if patients continue to DNA the new appointment then it will lead to a large amount of wasted appointment time.
I anticipate that the audit next year will highlight an increase in uptake of appointments. If attendance for retinal screening remains at the level that occurred during the audit, this should reflect upon the attendance for diabetic reviews also.
If successful, this may be a model of care that other practices may wish to replicate should they have available facilities at their surgery to accommodate the retinal screening service.
Student number DDNL04004