Healthcare Screening Programme Report 2015-2016

Board Meeting 30.01.19 Agenda Item: 10.1 Purpose: For Information

1

Healthcare Screening

Programme Report

2015-2016

Author Christina Morrison, Health Protection and Screening Nurse Specialist

Date Version control Next review due date Reviewers/review team

03.03.2017 V 4 Annual PH Governance Group


2

Contents

Executive Summary ............................................................................................................ 4

1 Screening in Scotland ................................................................................................. 6

2 Antenatal Screening .................................................................................................... 7

2.1 Overview ................................................................................................................. 7

2.2 Delivery of NHS WI pregnancy screening programmes .......................................... 8

2.3 Ultrasound scanning ............................................................................................. 11

2.4 Future developments ............................................................................................ 12

3 Newborn Bloodspot Screening ................................................................................. 13

3.1 Overview ............................................................................................................... 13

3.2 Delivery of Bloodspot Screening in NHS WI .......................................................... 14


4 Hearing Screening ..................................................................................................... 19

4.1 Overview ............................................................................................................... 19

4.2 Service delivery .................................................................................................... 19


5 Abdominal Aortic Aneurysm Screening ................................................................... 22

5.1 Overview ............................................................................................................... 22

5.2 Background........................................................................................................... 22

5.3 Aim of screening ................................................................................................... 22

5.4 Eligible population for screening ........................................................................... 22

5.5 AAA screening test ............................................................................................... 23

5.6 Screening Key Performance Indicators (KPIs) and screening outcomes ............... 23


6 Diabetic Retinopathy Screening (DRS) ..................................................................... 30

6.1 Overview ............................................................................................................... 30

6.2 Background........................................................................................................... 30

6.3 Aims of screening programme .............................................................................. 30

6.4 Eligible population for screening ........................................................................... 30

6.5 The screening test ................................................................................................ 33

6.6 Screening outcomes ............................................................................................. 33

6.7 Grading ................................................................................................................. 35

6.8 Following a negative result .................................................................................... 36

6.9 Following a positive result ..................................................................................... 36



3

Figures & Tables

Figure 1: Uptake of newborn hearing screening by deprivation quintile in all of NHS

WI, financial period 2013/14 – 2015/16. ................................................................... 20

Figure 2: AAA Screening Pathway of care ............................................................... 27

Figure 3: Summary of DRS outcomes - period 2015-16 ........................................... 32

Table 1: NHS WI Cohort for antenatal screening by deprivation quintile .................... 8

Table 2: Total uptake of antenatal screening in NHS Western Isles by number and

percentage. ................................................................................................................ 9

Table 3: NHS WI Rubella screening uptake by deprivation quintile ........................ 10

Table 4: NHS WI HIV screening uptake by deprivation quintile ................................ 10

Table 5: NHS WI Hepatitis B screening uptake by deprivation quintile .................... 11

Table 6: NHS WI Syphilis screening uptake by deprivation quintile ......................... 11

Table 7: Eligible cohort for Newborn Screening, NHS WI by Deprivation quintile,

period 2014-15 and 2015-16 .................................................................................... 15

Table 8: Distribution of ancestry groups, NHS WI .................................................... 15

Table 9: Number and percentage of mothers born in the UK, NHS WI .................... 16

Table 10: Total specimens received by the lab for testing on NHS WI newborns .... 16

Table 11: Avoidable repeat samples ........................................................................ 17

Table 12: Number and percentage of babies tested vs specimen days in transit ..... 17

Table 13: NHS WI hearing screening uptake by deprivation quintile ........................ 20

Table 14: Number of men eligible, invited and uptake rates for NHS WI AAA

screening, period 1st April 2015 to 31st March 2016 ................................................. 24

Table 15: KPI 1.3 Uptake of AAA screening by SIMD quintile, NHS Western Isles &

Scotland ................................................................................................................... 25

Table 16: KPI 1.4a Percentage of annual surveillance appointments due where men

are tested within 6 weeks of due date ...................................................................... 26

Table 17: Number of self referral men and positive screen results by year and

cumulative number to end of period 31st March 2016. ............................................ 26

Table 18: NHS WI Cumulative number of men with initial screen positive results by

aneurysm size since introduction of the AAA programme in 2012 ........................... 28

Table 19: KPI 3.1: Percentage of men with AAA≥5.5cm seen by vascular specialist

within two weeks of screening .................................................................................. 28

Table 20: DRS uptake, DNA rate and successful screening rate ............................. 34

Table 21: DRS KPIs 8 and 9; written report result within 4 weeks ........................... 35

Table 22: Grading of Diabetic Retinopathy Screened images .................................. 36


4

Executive Summary

This report provides information relating to the non-cancer screening programmes in

place in NHS Western Isles. It encompasses the screening of pregnant women and

their newborn babies, screening of older men for abdominal aortic aneurysm, and of

all people aged 12 years and above with diabetes for retinopathies.

Each programme is Scotland wide and is supported by national training and

education and a national screening group, enabling those responsible for the

programmes to exchange information, make comparisons across geographies and

learn from each others’ experiences of activities around the programmes.

Healthcare Improvement Scotland is responsible for the development and monitoring

of key performance indicators, intended to ensure that programmes are operating to

best effect, and also to highlight areas where improvement would be beneficial. The

success of screening programmes, across the organisation as a whole, relies on

individuals working in a coordinated manner to deliver a safe, effective and quality

assured programme to our population.

Successful measurement of screening programmes requires robust information

management systems to be in place. Historically, this has been a weakness within

NHS Western Isles, however, systems are being adapted and established to provide

effective data collection. All programmes, with the exception of the universal national

hearing screening progamme, have established data collection systems.

Our geography offers a unique position for partnership working which can be seen

with diabetic retinopathy screening, where NHS Western Isles Public Health and

Health Strategy Division work closely with local Optometrists to provide a safe and

effective person-centred programme, enabling multicentre or domiciliary access to

the screening programme, throughout the islands.

This screening report aims to provide an overview of screening programmes in the

period 1st April 2015 to 31st March 2016. There are differences in timeframe reporting

in AAA screening as ISD data on uptake is cumulative, based on men who have

turned 65 years of age from 29th June 2012 to 31st March 2016.


5

In the pregnancy and newborn screening programme, figures are given for the

period 2013-14 - 2015-16 to enable comparisons of data and give deeper

understanding of our population. There are limitations to the data as a robust

information management system is required for the inter-island reporting of

pregnancy and newborn data and is not yet functional.


6

1 Screening in Scotland

Screening programmes are designed to detect early signs of disease in the healthy

population and then to provide a reliable method of referral for diagnostic testing and

further treatment. Early detection and management should result in better outcomes

for screen positive individuals.

In order for a screening programme to be considered for national designation, it must

be acceptably accurate and designed to test for a disease where earlier detection

and intervention would be of benefit to the patient. Introduction, modification or

withdrawal of a population screening programme is based on a set of internationally

recognised criteria and rigorous evidence review, weighing the ethical benefit versus

harm of a screening programme.

Screening policy is set by the Scottish Government Health Directorate on the advice

of the UK National Screening Committee (UK NSC) and others such as the Scottish

Screening Committee (SSC).

The UKNSC reviews the best quality evidence available worldwide to assess

whether a screening programme should be established for a new condition.

Evidence is used both to recommend the introduction of a new screening

programme and to monitor the effectiveness/need for existing programmes. The

evidence is usually sourced from peer reviewed journals, which means that it has

been subject to critical analysis by other experts.

Evidence is also important for explaining why screening is not recommended for

some conditions when people might believe it should be. In addition, some

conditions are routinely tested for in a person’s clinical care when attending their

General Practitioner. In these cases testing is not the responsibility of the UK NSC or

SSC.


7

2 Antenatal Screening

2.1 Overview

Antenatal screening in pregnancy is offered to all pregnant women at the first

booking visit. Women in NHS WI are encouraged to access an antenatal booking

appointment prior to 12 weeks gestation. Booking appointments can be accessed by

the woman from either direct contact to Maternity services or via their general

practitioner (GP). In the antenatal booking appointment, all women are offered

screening tests for:

a) Haemoglobinopathies: An antenatal blood test that screens for sickle cell and

thalassaemia which aims to identify couples at risk of having an affected child. This

identification allows the couple to have information on which to base reproductive

choices.

The pregnant woman is requested to complete a family origin questionnaire. The

information on the questionnaire and the blood test are assessed to identify the risk

of either parent being a carrier of sickle cell and other haemoglobin variants. Where

a mother is identified as a carrier, the baby’s father will also be offered testing to

identify risk to the baby.

b) Communicable diseases: An antenatal blood test that screens for HIV, Hepatitis

B (HBV), Syphilis and Rubella. This screening is carried out to identify infection and

allow for the management and treatment of affected individuals, their families and

their babies to be put in place at the earliest opportunity. Screening allows for the

treatment of the mother and to minimise the risk of mother to child transmission,

improve long term outcomes and enhanced care of the mother and baby.

c) Down Syndrome and Congenital anomalies screening: A blood test combined

with an ultrasound anomaly scan of the developing fetus and analysis of maternal

risk factors aims to detect the risk of Down Syndrome and other congenital

anomalies in the early antenatal period. A test called AFP is offered at 20 weeks if

the woman books for antenatal care after 12 weeks or has changed her original

decision not to be screened at the earlier offer. The decision for a pregnant woman

to accept screening for Down Syndrome and other congenital abnormalities raises


8

moral and ethical issues in pregnancy. Screening allows women and their partners to

have information on which to base management of pregnancy choices which can be

planned for in the antenatal period.

2.2 Delivery of NHS WI pregnancy screening programmes

There is a statutory requirement for NHS Boards to submit data on antenatal activity.

Key Performance indicators (KPIs) are set by Healthcare Improvement Scotland,

and incorporate HEAT targets, to measure outcomes which demonstrate

standardised service delivery of person-centered, safe and effective healthcare.

Pregnancy and Newborn KPIs and HEAT targets can be accessed from:

http://www.healthcareimprovementscotland.org/our_work/reproductive,_maternal__c

hild/programme_resources/pns_indicators.aspx and

http://www.gov.scot/About/Performance/scotPerforms/partnerstories/NHSScotlandpe

rformance/AntenatalAccess

There were 184 women booked to attend antenatal clinic care throughout the

Western Isles, recorded in the Scottish Birth Record (SBR), in the financial period of

1st April 2015 to 31st March 2016. Data can be further divided by Scottish Index of

Multiple Deprivation (SIMD) quintile.

Deprivation quintiles split data into 5 groups, each containing 20% of the data and

with each group described from group 1 (the most deprived) to group 5 (the most

affluent). Table 1 shows the total number of women booked by SIMD in NHS WI,

documented in the SBR.

Table 1: NHS WI Cohort for antenatal screening by deprivation quintile

Local Deprivation Quintile

Born in financial year 1 2 3 4 5

Total Cohort

2013-14 47 42 27 45 46 207

2014-15 39 29 16 46 42 172

2015-16 37 32 35 41 39 184

Source: Scottish Birth Record (SBR) Cohort for Antenatal screening. (This does not include records not recorded on SBR or those delivered in Western Isles where residence is elsewhere).

http://www.healthcareimprovementscotland.org/our_work/reproductive,_maternal__child/programme_resources/pns_indicators.aspx

http://www.healthcareimprovementscotland.org/our_work/reproductive,_maternal__child/programme_resources/pns_indicators.aspx

http://www.gov.scot/About/Performance/scotPerforms/partnerstories/NHSScotlandperformance/AntenatalAccess

http://www.gov.scot/About/Performance/scotPerforms/partnerstories/NHSScotlandperformance/AntenatalAccess


9

A quick glance table of the screening uptake by pregnant women in NHS Western

Isles is provided below (Table 2).

Table 2: Total uptake of antenatal screening in NHS Western Isles by number and percentage.

Number Uptake (%)

Eligible cohort 184*

Haemoglobinopathies** 18 9.7

Rubella 171 92.9

Hep B 163 88.5

Syphilis 165 89.6

HIV 160 86.9 Source: SBR. *Haemoglobinopathies % uptake is based on samples sent for testing not actual

consent for screening. **Anomaly screening shows above 100% uptake, this is due to some anomaly

scans requiring multiple visits to complete screening requirements.

The Scottish Morbidity Record - Maternity (SMR-02) provides data on when women

attend for antenatal booking with the midwife. Eighty two percent of antenatal

bookings occurred within 10 weeks gestation and 94% of women booked by 12

weeks gestation in the period 1st April 2015 to 31st March 2016. This highlights that

NHS WI Maternity Services in NHS Western Isles are achieving the HEAT target by

successfully booking over 94% of pregnant women before 12 weeks gestation.

KPI 4.2 is timeliness of screening for haemoglobinopathies, measuring this on the

screening sample being received by 10 weeks gestation. The screening is carried

out in two parts; a screening questionnaire, and processing of the blood sample to

identify the presence of haemoglobinopathies.

The laboratory risk-assesses women based on the questionnaire; into high and low

risk categories, with the blood samples of those in the high risk category being sent

for further screening.

Of all women booked in NHS WI for 2015-16, 18 samples were sent away for

screening of haemoglobinopathies, however data are not available to identify the

total of individuals consenting to being screened or when the screening took place.

All women are offered haemoglobinopathy screening in NHS WI. However, it is not

possible to identify the uptake and delivery of this screening within 10 weeks

gestation, as recommended by the KPI, since our recording system is set up for 12


10

weeks. It is anticipated that the Badger net IT system will enable this KPI to be

assessed.

Uptake for all four communicable diseases screening tests offered at initial booking

varied between 86.9% and 92.9% (Table 2), noting that data is incomplete in the

SBR system. Tables 3-6 show the uptake rates of each communicable disease

screened for in NHS WI and by deprivation quintile. The identified percentage uptake

of antenatal screening is lower in deprivation quintile 3 in period 2015-16; however, it

is too early to draw conclusions from this as more data would be required to

establish if this is a pattern unique to NHS WI.

Table 3: NHS WI Rubella screening uptake by deprivation quintile

Rubella WI Deprivation Quintile n (%)

Delivery in financial year 1 2 3 4 5 Grand Total

2013/14 46

(98) 41

(98) 25

(93) 43

(96) 45

(98) 200 (97)

2014/15 36

(92) 28

(97) 15

(94) 46

(100) 42

(100) 167 (97)

2015/16 35

(95) 31

(97) 29

(83) 40

(98) 36

(92) 171 (93)

Source: SBR

Table 4: NHS WI HIV screening uptake by deprivation quintile

HIV Deprivation Quintile n (%)


2013/14 44

(94) 39

(93) 25

(93) 42

(93) 42

(91) 192 (93)

2014/15 31

(80) 29

(100) 12

(75) 44

(96) 42

(100) 158 (92)

2015/16 34

(92) 30

(94) 25

(71) 36

(88) 35

(90) 160 (87)

Source: SBR


11

Table 5: NHS WI Hepatitis B screening uptake by deprivation quintile

Hep B Deprivation Quintile n (%)


2013/14 45

(96) 41

(98) 26

(96) 40

(89) 45

(98) 196 (95)

2014/15 35

(90) 29

(100) 15

(94) 46

(100) 41

(98) 166 (97)

2015/16 33

(89) 29

(91) 28

(80) 38

(93) 35

(90) 163 (89)

Source: SBR

Table 6: NHS WI Syphilis screening uptake by deprivation quintile

Syphilis Deprivation Quintile n (%)


2013/14 46

(98) 42

(100) 26

(96) 41

(91) 45

(98) 200 (97)

2014/15 36

(92) 28

(97) 15

(94) 46

(100) 42

(100) 167 (97)

2015/16 33

(89) 29

(91) 28

(80) 39

(95) 36

(92) 165 (90)

Source: SBR

2.3 Ultrasound scanning

Ultrasound scanning is carried out in pregnancy to assist with dating of pregnancy, to

confirm fetal growth and development and to identify specific anomalies. Three

hundred and six dating scans were carried out in the 2015-16 reporting period.

Numbers of dating scans are higher than the number of women booked as repeat

scans can be carried out for reasons such as:

unsure of dates

too early to scan for dating

poor visualisation

the need for a second opinion.

There were 220 women recorded in SMR-02 as pregnant in the reporting period, of

which 96% were reported to have received dating scans carried out in NHSWI.

Anomalies in numerator identification are apparent in pregnancy and newborn

screening due to a number of reasons; different recording systems, quality of data

recording, women may receive tertiary care in the perinatal period, or when patients


12

move residence. Thus identification of eligible cohorts is different from antenatal

communicable diseases to ultra sound scanning.

All pregnant women (100%) are offered screening for Down syndrome at booking.

Whilst 122 Nuchal dating scans were carried out, only 92 completed the CUBS

(combined ultrasound and biochemical screening) screening, therefore, uptake for

first trimester Down Syndrome screening from nuchal scans was 75% or 42% of total

women receiving local antenatal care. In the reporting period, no women in NHS WI

were tested in the second trimester of pregnancy.

It is important to note that not all CUBS samples have been recorded, as samples

from the Southern Isles have historically been sent directly to Glasgow. This system

has recently changed to ensure a more robust service and reduce possible errors or

omissions due to unrecorded information. All samples now go through NHS WI

Laboratory to Glasgow for processing.

There was a 96% uptake for anomaly scans in period 2015-16, with less than five

referrals to tertiary care.

2.4 Future developments

Gaps have been identified in the recording screening processes of antenatal care of

pregnant women. The future provision of a robust system has been identified as the

Badger net IT system and is due to be implemented in 2017-18. Badger net enables

the recording, viewing and auditing of data gathered on pregnant women in the

antenatal period, throughout NHS Western Isles. It allows women to access their

password protected information via an online portal, which can be downloaded to

their mobile phones, a positive development in woman centered care.


13

3 Newborn Bloodspot Screening

3.1 Overview

NHS WI offers all babies born in NHS WI Newborn Bloodspot on day 5 after birth. A

capillary blood sample is gained by the midwife from the baby’s heel and collected

on a specialised bloodspot card, which is sent for analysis to the Scottish Newborn

Screening Laboratory, Southern General Hospital, Glasgow. The screening aims to

identify those babies at risk of abnormalities that can lead to growth and

developmental problems later in life. The identification of disease allows for

appropriate and timely management of conditions, which can result in a normal and

healthy life. Screening is carried out for five markers:

i) Phenylketonuria (PKU): is a condition that affects 1 in 8,000 babies born in

Scotland. It means that the baby cannot digest the amino acid phenylalanine,

and the buildup of phenylalanine can cause damage to the brain. Symptoms

appear after 6 months of age and can manifest as developmental delay and

may lead to seizures, learning disabilities and behavioural difficulties.

Phenylalanine is a natural part of the protein within our body and is found in

most of our foods. PKU is treated with a special low-protein diet, which

reduces levels of phenylalanine in the body preventing brain damage.

ii) Congenital Hypothyroidism (CHT): is a condition that affects approximately 1

in every 3,500 babies born in Scotland. Congenital means that a baby is born

with the condition of Hypothyroidism meaning that the baby won’t produce

enough of the hormone thyroxine, which is needed for healthy mental and

physical development.

Although CHT cannot be cured it can be treated simply and successfully by

giving daily thyroxine, which will result in children being able to live a full and

active life.

iii) Cystic Fibrosis (CF): This condition affects 1 in every 2,500 babies born in

Scotland. It is an inherited condition that occurs when a baby inherits an altered

form of the CF gene from each of its parents, which together cause CF. Both

parents are healthy carriers of the altered gene and are unaffected by the

condition themselves. CF affects the lungs and the pancreas the most, causing


14

chest infections and problems with digesting food. One in 25 people in Scotland

is a CF gene carrier. Being a carrier has no effect on the baby's health,

however knowing that your baby is a carrier is valuable for when they grow up

and have children of their own.

Babies with cystic fibrosis may not gain weight well and frequently have chest

infections. Babies with the condition can be treated early with a high-energy

diet, medicines, and physiotherapy. Although children with cystic fibrosis may

still become very ill, early treatment can help them live longer, healthier lives.

iv) Sickle Cell Disorder (SCD): is an inherited condition affecting 1 in 2,500

babies born in the UK. It is a condition that affects the quality of the cells which

carry oxygen in the blood. The blood cells of someone with SCD change from a

round shape to a ‘sickle’ shape, and get stuck in the small blood vessels. This

can cause pain and damage to the baby’s body, sometimes leading to serious

infection and can be fatal. Once detected, treatment includes antibiotics and

immunisations to help prevent serious illness. Screening will also identify

carriers of SCD.

v) Medium Chain Acyl-CoA Dehydrogenase Deficiency (MCADD): affects

approximately 1 in 10,000 babies born in Scotland. Babies with this inherited

metabolic condition have problems breaking down certain fats in order to make

energy for their body. This is not a problem when a baby is well and feeding

normally but it can lead to serious illness and in some cases could be fatal

where a baby has an infection or goes for a long time without food.

3.2 Delivery of Bloodspot Screening in NHS WI

There were 232 babies eligible for newborn bloodspot screening in NHS WI during

2015-16 (Table 7), 229 (98.7%) of the total population were screened, a 4.7%

increase on season 2014/15.

Data were unable to be broken into different Island groups.


15

Table 7: Eligible cohort for Newborn Screening, NHS WI by Deprivation quintile, period 2014-15 and 2015-16

Deprivation Quintile (number)

Born in financial year 1 2 3 4 5 Total Cohort

2014-15 52 32 35 52 45 216

2015-16 39 39 60 51 43 232

Source: Child Health System (This will include babies born outwith Western Isles and transferred in and exclude babies that have transferred out since birth)

Ancestry is requested for screening purposes as some conditions may be inherited

through genetic changes such as sickle cell. Conditions such as congenital

hypothyroidism are based on TSH concentration and can also be affected by a

newborns ethnic background. Table 8 shows the breakdown of the ancestry for

babies tested in NHS WI. 88% had white UK ancestry. Southern and other European

(White) and South East Asian ancestry were both 2%, whilst for 5% the ancestry was

not stated. Table 9 shows that 95% of mothers were born in the UK.

Table 8: Distribution of ancestry groups, NHS WI

Health Board Western Isles

Number %

A African or African-Caribbean 0 0

B. South Asian (Asian) 1 0.5

C. South East Asian (Asian) 4 2

D. Other non-European (other) 0 0

E. Southern & other European (White) 3 1.5

F. United Kingdom (White) 203 88

G. North Europe (White) 3 1.5

H. Don’t Know 0 0

I. Declined to Answer 0 0

J. Any Mixed Background 3 1.5

Z. Not Stated 12 5

Total 229 100

Source: Scottish Newborn Screening Laboratory data report 2015-16


16

Table 9: Number and percentage of mothers born in the UK, NHS WI


There were a total of 250 cards received in the West of Scotland Laboratory for

newborn screening (Table 10).

Table 10: Total specimens received by the lab for testing on NHS WI newborns


*More than one outcome may apply.

Table 11 identifies that 14 avoidable repeat samples were carried out within this

period, 3.6% (9) were due to insufficient samples, 1.6% (4) due to no CHI being

reported and 0.4% (1) noted as other unsatisfactory, and some cards had multiple

errors resulting in repeat samples being required.

Mother born in UK

Yes

No.

(%)

No

No.

(%)

Unknown

No.

(%) Totals

Western Isles

217

(95%)

10

(4%)

2

(1%)

229

Specimen Test – Outcomes* NHS

WI Refused all tests 0

Partial refused 0

Insufficient blood to perform all

tests

9

Unsatisfactory >14 days in transit 1

Unsatisfactory Other 1

Updated info 2

IRT tested late (total) 2

IRT tested late (Born in Scotland) 2

<3 days post T/F 1

Normal result 227

Pre-TF 1

Sent for SCD DNA 0

Total Specimens received 250


17

Table 11: Avoidable repeat samples

Health

Board Insufficient

>14

days

transit

<4

days

old

No

CHI Expired

Other

unsat

Total

avoidable

repeats

Total

cards

received

Western

Isles 9 1 0 4 0 1 14* 250

Source: Scottish Newborn Screening Laboratory data report 2015-16. * Total avoidable repeats are

less than the sum of all columns because some cards are included in more thean one category.

Timeliness of samples is important to enable specialist treatment of conditions

identified by the newborn bloodspot screening process. KPI 16 identifies that

specimens should reach the Laboratory within four working days. This KPI was

achieved for 80.2% (n 183) as shown in Table 12. This is an improvement of 4% on

period 2014-15, where 76% of samples reached the Laboratory in four working days.

Key performance indicators identify that babies screened positive for

Phenylketonuria, congenital hypothyroidism and MCADD require early access to

specialist care by 14 days of age (KPI 19), to treat and reduce severity of conditions.

This would not be possible if delays occur in the transportation to labs or the

requirement for repeat samples. However, 98% (n 223) of NHS WI samples arrived

within 7 days; this allows for processing and timely referral to specialists. It is not

possible to identify if all delays were due to remote and rural location.

Table 12: Number and percentage of babies tested vs specimen days in transit

Health Board Western Isles

Days in Transit: No. %

≤4 183 80.2

5-7 40 17.5

8-10 4 2.0

over 10 1 0.5

Total excluding pre-

transfusion cards 228 100



18


A midwife has been identified to take the lead on implementation of Newborn blood

spot screening. Steps to raise awareness and provide further education on the taking

of a blood spot sample have been adopted aiming to reduce the number of avoidable

repeats.

The blood sample cards used in the screening process are changing in September

2016, reducing the amount of blood spots from five to four, similar to the sample

cards used across the rest of the rest of the UK. This will provide the opportunity to

increase awareness of the techniques required in the screening process.


19

4 Hearing Screening

4.1 Overview

The Universal Newborn Hearing Screening Programme (UNHS) in Scotland aims to

identify all children born with a moderate to profound permanent bilateral deafness

early and to promote the provision of ongoing high quality and appropriate

assessment and support for deaf or hearing impaired children and their families. One

or two babies in every 1,000 are born with a hearing loss in one or both ears. Most of

these babies are born into families with no experience or history of hearing loss. The

hearing screening test is a simple test carried out within the first few weeks after a

baby is born.

4.2 Service delivery

In November 2013, Healthcare Improvement Scotland set out a new set of quality

indicators (KPI), for hearing screening, identified as indicators 11 – 13:

Indicator 11: Newborn hearing screening - timely completion.

Indicator 12: Newborn hearing screening - timely assessment of screening

referrals

Indicator 13: Newborn hearing screening - outcome

In NHS WI, 100% of parents were offered UNHS within the first four weeks of life,

achieving the KPI. The Scottish Birth Records indicate that uptake of screening in

2015-16 was 96%, a decrease of 1% on period 2014-15. However, NHS Tayside

UNHS (the oversight group encompassing NHS WI) reports 100% (n184) of the

eligible cohort were successfully screened in period 2015-16. This difference may be

due to discrepancies in date of screening data recording.

Uptake can be broken down further by SIMD as set out in Figure 1 and Table 13; no

clear deprivation gradient can be seen in the local data.


20

Figure 1: Uptake of newborn hearing screening by deprivation quintile in all of NHS WI, financial period 2013/14 – 2015/16.

Source: Scottish Birth Record

Table 13: NHS WI hearing screening uptake by deprivation quintile

Hearing Screening Deprivation Quintile n (%)

Born in financial year 1 2 3 4 5 Grand Total

2013/14 39

(91) 41

(95) 25

(93) 42

(98) 46

(88) 193 (93)

2014/15 39

(98) 29

(100) 13

(87) 46

(100) 40

(95) 167 (97)

2015/16 36

(97) 31

(97) 31

(89) 40

(98) 36

(97) 174 (96)

Source: Scottish Birth Record

The Scottish Birth Record shows that two neonates were referred for follow up to

specialist audiology services, after failed or incomplete result of screening, in the

period 2013-14 with no instances noted in period 2014-15 and period 2015-16.

However, there is missing data within the SBR system and timing of the decision to

refer is not recorded.

80

82

84

86

88

90

92

94

96

98

100

2013/14 2014/15 2015/16

1

2

3

4

5

TOTAL UPTAKE


21

Audit base system records show that seven infants were referred to audiology in

NHS Western Isles, in the 2015-16 reporting period, due to a family history of

hearing loss. These children were followed up at eight months of age; all were

discharged from audiology as hearing was within normal limits.

Timeliness and final screening outcome data are not accessible from SBR,

Audiology systems or the National Hearing Screening Co-ordinator, thus KPIs 12

and 13 cannot be measured or commented on.

As planned for 2015, the Audit base system was implemented in the audiology

department NHS WI. This has provided a robust patient pathway tracking system

from screening to diagnostics.


Hearing screening equipment requires replacement in period 2016-17. The new

machines will have the added capability of carrying out both AABR (automated

auditory brainstem response) and OAE (otoacoustic automated emission) screening,

allowing increased accuracy and flexibility in the screening process.


22

5 Abdominal Aortic Aneurysm Screening

5.1 Overview

Abdominal Aortic Aneurysm (AAA) screening was implemented in NHS Western

Isles in June 2012. In the north west of Scotland AAA screening is carried out in

collaboration with NHS Highland. This report will inform on AAA screening in NHS

Western Isles only.

5.2 Background

An abdominal aortic aneurysm is described as the dilatation of the aorta within the

abdomen, where the aortic diameter is identified as being 3.0cm or more.

There are risk factors associated with the development of abdominal aneurysms,

including smoking, age, gender, family history of AAA, hypertension, atherosclerosis,

hyperlipidaemia, obesity and being Caucasian. Men from areas of higher deprivation

are more likely to have an abdominal aortic aneurysm than the least deprived. It is

unknown the effect that deprivation has on mortality rates. Research identified

Scotland as having a death rate of 42.7 per 100,000 men aged 65 to 74 years from

AAA in the year 2000, whilst a randomised controlled trial in England identified that

the mortality rates may be as high as 88 per 100,000 men aged 65 to 74 years.

Aneurysms are often asymptomatic and present a risk of rupture; the bigger the

aneurysm the greater the risk of rupture. Mortality following a ruptured aneurysm is

very high. When an aneurysm ruptures less than half of patients will reach hospital

alive and of those who receive surgery, only 60% can be expected to survive.

5.3 Aim of screening

The aim of AAA screening is to detect aneurysms in the male population early and to

monitor or treat by elective repair thus preventing spontaneous rupture.

5.4 Eligible population for screening

All men aged over 65 years of age who are resident in NHS Western Isles are

invited, by letter, to attend for an abdominal ultrasound scan. Men aged 66 years and

over can self refer to be included in the AAA screening programme.


23

5.5 AAA screening test

Screening for AAA is carried out at two areas in NHS WI – at the Western Isles

Hospital and at the Uist and Barra Hospital.

Measurement of the abdominal aorta is achieved by an ultrasound scan of the

abdomen; this scan is carried out by an experienced and accredited Sonographer.

Clinics are run on a monthly basis and are a mixture of new men invited to attend

and follow up or ‘surveillance’ scans. Results will be given to the participant at the

point of screening. The result will dictate the pathway of care to be followed.

5.6 Screening Key Performance Indicators (KPIs) and screening outcomes

The outcomes are categorised into four different groups:

Normal: Aorta measures less than 3.0 cm. Normal aorta, patient discharged

from screening.

Small: Aorta measures 3.0cm to 4.4cm. Patients are monitored on an annual

basis.

Medium: Aorta measures 4.5cm to 5.4cm. Patients are monitored on a

quarterly basis.

Large: Aorta measures 5.5cm and over. Patient is referred to vascular

services in NHS Highland for assessment.

All participants identified as having a large aneurysm are referred for vascular

assessment; however they may not all be suitable for treatment due to their

individual health status and/or personal choice not to have further treatment.

The KPIs for AAA screening are points of measurement that cover the patient’s

journey from invitation, delivery of the scan, referral to vascular services and

outcome. They provide information that can be analysed to ensure quality of the

programme and inform on performance at a local and national level. The KPIs are

expressed in two thresholds:

Essential: the minimum level of performance which the programme is

expected to attain


24

Desirable: the screening programme should aspire to attain and maintain this

level of performance.

KPIs for the AAA programme are available at http://www.isdscotland.org/Health-

Topics/Public-Health/AAA-Screening/2017-03-07-AAA-KPI-Definitions.pdf

KPIs for AAA screening are based on HIS 2011 AAA screening standards, available

at

http://www.healthcareimprovementscotland.org/our_work/cardiovascular_disease/scr

eening_for_aaa/aaa_screening_standards.aspx

KPI 1.1 measures the percentage of the eligible population who are sent an initial

invitation for screening before the age of 66 years. 100% (203) of the NHS Western

Isles eligible population was invited to be screened in the period from 1st April 2015

to 31st March 2016 (Table 14), achieving the desired threshold.

The uptake of screening is reported at the age of 66 and 3 months (KPI 1.2), this

allows for men to have a further 3 months to attend for screening following their 66 th

birthday. NHS Western Isles met the desirable threshold (≥85%), with an 85.2%

uptake of screening which is above the national average of 84%.

Table 14: Number of men eligible, invited and uptake rates for NHS WI AAA screening, period 1st April 2015 to 31st March 2016

NHS Board of residence

Number of men eligible

Offered screening Attended screening

(uptake)

N % N %

Western Isles4 203 203

100.0 173

85.2

Scotland 30,560 29,650 97.0 24,893 84.0

Source: ISD; Scottish AAA Call Recall System at 1 September 2016.

NHS Western Isles achieved the desirable threshold for KPI 1.3 with two out of three

SIMD identified deprivation quintiles, whilst achieving the essential threshold for the

third (Table 15). Uptake of screening is lower in the most deprived areas; this is

comparable with national findings.

http://www.isdscotland.org/Health-Topics/Public-Health/AAA-Screening/2017-03-07-AAA-KPI-Definitions.pdf

http://www.isdscotland.org/Health-Topics/Public-Health/AAA-Screening/2017-03-07-AAA-KPI-Definitions.pdf

http://www.healthcareimprovementscotland.org/our_work/cardiovascular_disease/screening_for_aaa/aaa_screening_standards.aspx

http://www.healthcareimprovementscotland.org/our_work/cardiovascular_disease/screening_for_aaa/aaa_screening_standards.aspx


25

NHS Western Isles achieved the essential threshold of ≥ 90% for surveillance screen

attendance within 6 weeks of invite (KPI 1.4a at 91.7%) and attendance within 4

weeks of invite (KPI 1.4b at 90%). Interestingly, had one more participant attended

for screening within 6 weeks of invite, then NHS Western Isles would have had

achieved the desirable threshold of 100% for KPI 1.4a (Table 16).

Table 15: KPI 1.3 Uptake of AAA screening by SIMD quintile, NHS WI & Scotland


National SIMD quintile

Turned 66 in year ending 31 March 2015

Turned 66 in year ending 31 March 2016

Offered screening

before the age of 66

Tested before age 66 and 3 months

Offered screening

before the age of 66

Tested before age 66 and 3

months

N N % N N %

Scotland

Total 25,659 21,622 84.3 29,650 24,893 84.0

1=most deprived

4,199 3,163 75.3 5,109 3,881 76.0

2 4,771 3,950 82.8 5,698 4,654 81.7

3 5,611 4,779 85.2 6,354 5,358 84.3

4 5,599 4,888 87.3 6,456 5,644 87.4

5=least deprived

5,427 4,801 88.5 5,987 5,317 88.8

Unknown 52 .. .. 46 .. ..

Western Isles

Total 231 191 82.7 203 173 85.2

1=most deprived

.. .. .. .. ..

2 56 47 83.9 50 41 82.0

3 153 126 82.4 141 120 85.1

4 19 17 89.5 10 10 100.0

5=least deprived

- .. .. - .. ..

Unknown 3 .. .. 2 .. ..

Source: ISD; Scottish AAA Call Recall System at 1 September 2016. Data is provided on known

SIMD


26

Table 16: KPI 1.4a Percentage of annual surveillence appointments due where men are tested within 6 weeks of due date


Due to attend annual surveillance in year ending 31

March 2015

Due to attend annual surveillance in year ending

31 March 2016

Appointments due Tested

Appointments

due Tested

N N % N N %

Scotland 557

535

96.1

1,008

971

96.3 Western Isles

11

9

81.8 12

11

91.7

Source: ISD; Scottish AAA Call Recall System at 1 September 2016

In the cumulative period from 29th June 2012 to 31st March 2016, 35 men self

referred to AAA screening, of whom 94.2% (33) were screened negative and 5.7%

(2) were screened positive .There were six self referrals in the financial period 2015-

16, none of whom had an abdominal aortic aneurysm identified (Table 17).

Table 17: Number of self referral men and positive screen results by year and cumulative number to end of period 31st March 2016.


Screened in year ending 31

March 2013


March 2014

Screened in year ending 31 March

2015


March 2016

Cumulative total to 31 March

2016

Men tested

Positive screen result

Men tested


Men tested


Men tested


Men tested


n n % n n % n n % n n % n n %

Western Isles

2 - - 13 - - 14 2 14.3 6 - - 35 2 5.7

Scotland 268 6 2.2 1,630 38 2.3 1,394 45 3.2 877 29 3.3 4169 118 2.8 Source ISD: Scottish AAA Call Recall System at 1 September 2016.


27

Figure 2: AAA Screening Pathway of care

Note:

1. When aortic measurement is less than 3.0cm at initial screen, a discharged participant can self-refer at a later

date.

2. Clinical decision to discharge from screening programme would be made only if the AAA is stable or following

surgery.

3. Non-attendees receive two invites for screening before being discharged from the programme. However, they

are advised to return as a self referral any time after the age of 66 years should they wish to be screened in

future.

Entry to programme

Aneurysm found Attend

screening

No aneurysm

found

4.5cm – 5.4cm

Discharge from

programme

Decline

screening

3.0cm – 4.4cm >5.5cm Discharge from

programme

Yearly scan 3 monthly scan Referral to

vascular service


28

From the positive screening results, aneurysms can be further identified by size (Table 18),

described earlier in screening outcomes.

Table 18: NHS WI Cumulative number of men with initial screen positive results by aneurysm size since introduction of the AAA programme in 2012


Number of men with

initial screen positive results

Number of men with positive results by aneurysm size grouping

Small (3.0 to 4.4cm)

Medium (4.5 to 5.4cm)

Large (≥5.5cm)

Western Isles 11 9 1 1

Scotland 1,308

1,059 160 89 Source: ISD; Scottish AAA Call Recall System at 1 September 2016

When a large aneurysm is found, measuring ≥5.5 cm, participants are referred for surgical

assessment and intervention. A total of six referrals have been made either from identification at

initial scan or from the surveillance programme to vascular services, NHS Highland at Raigmore

Hospital, from NHS Western Isles since the onset of the screening programme in June 2012.

Table 19: KPI 3.1: Percentage of men with AAA≥5.5cm seen by vascular specialist within two weeks of screening


Screened in year ending 31 March 2015

Screened in year ending 31 March 2016

Referrals

Seen within two weeks of screening Referrals

Seen within two weeks of screening

N N % N N %

Western Isles

2 2 100.0 3 2 66.7

Scotland 87 65 74.7 93 67 72.0

Source: ISD; Scottish AAA Call Recall System at 1 September 2016

For KPI 3.1, NHS Western Isles has met the desirable threshold of greater than or equal to 95%,

achieving 100% year ending 31st March 2015. Period ending 31st March 2016 saw NHS Western

Isles failing to meet the essential threshold of ≥ 75% for KPI 3.1, reflecting a 66.7% achievement

rate. However, data should be interpreted with caution due to small numbers as 2 out 3

participants were seen by vascular services within two weeks of referral (Table 19).


29

The AAA screening pathway of care (Figure 2), illustrates how men progress within the screening

programme and the interval period between surveillance screens, leading to referral to vascular

services.


In NHS WI all men that attend screening are offered advice on healthy lifestyle and given

information on how to access smoking cessation services.

If men are found to have an aneurysm, they are given the opportunity to access both smoking

cessation and dietetic services (as appropriate) by referral at the point of screening. If men wish to

access this service at a later date they can do so either through their GP or calling the AAA

screening assistant.

The development of KPIs for the AAA screening programme is ongoing and projected to be

completed by year end 2016. This will also be combined with the launch of data by ISD.


30

6 Diabetic Retinopathy Screening (DRS)

6.1 Overview

Diabetic Retinopathy screening has been offered to people aged 12 and over with

diabetes in NHS WI since 2006. It is a long standing programme and assessment of

screening is linked with NHS Tayside.

6.2 Background

Diabetic retinopathy is a condition that affects the retina at the back of the eye in

people with diabetes. Retinopathy can cause serious damage to the eyes which may

result in blindness. If retinopathy is detected early and treated appropriately, damage

can be minimised and early changes reversed.

In NHS Western Isles screening is carried out by local optometrists and is offered at

three sites, Stornoway, Balavanich and Castlebay. This allows for screening to be

easily accessible throughout the Western Isles. Domiciliary visits are also offered to

those who are unable to attend screening due to mobility problems.

6.3 Aims of screening programme

The aim of the screening programme is to reduce risk of sight loss due to diabetic

retinopathy.

The screening programme aims to identify pathological features associated with an

increased risk of sight loss. If retinopathy is detected, this will result in referral to

hospital ophthalmic and diabetic services, for monitoring, support, advice and/ or

treatment.

6.4 Eligible population for screening

Diabetic Retinopathy Screening is offered to all diabetic patients aged over 12 years

in NHS Western Isles. All those identified in this cohort are invited by letter to attend

screening.


31

There were 1267 people eligible for screening in NHS WI in the reporting period 1st

April 2015 to 31st March 2016 (Figure 3).


32

Figure 3: Summary of DRS outcomes - period 2015-16

Source: SOARIAN National DRS Co-ordinator for Scotland

Diabetic Retinopathy Screening

(DRS)

Total Population: 1503

Eligible for screening

1,267

84% of total population

Did not attend

(indicative)

24%

Screened

996

79% of eligible population

71.5% of total population

12 month recall

1045

82.5% of eligible population

6 month recall

10

1% of eligible population

Referral to Ophthalmology

37


Unsuccessful screen

36


2.5% of total population

Not eligible for screening

236

16% of total population

Permanently suspended

96

37% of not eligible population

Temporarily suspended

174

73% of not eligible population


33

6.5 The Screening test

The screening consists of a digital photograph of the participant’s retina. If this is

unobtainable under normal processes, the patient may be given an eye drop to dilate

the pupil. Dilatation of the pupil is to allow for the digital image to be taken. In some

cases this is unsuccessful and a slit lamp examination of the eye will be carried out.

6.6 Screening outcomes

The identified diabetic population is initially screened for suitability to take part in the

screening process. Those deemed unsuitable will be temporarily or permanently

excluded from the programme Key Performance indicators and screening standards

are set by Healthcare Improvement Scotland and can be accessed from:

http://www.ndrs-wp.scot.nhs.uk/wp-content/uploads/2013/04/KPI-definition-v1.5-.pdf

and

http://www.healthcareimprovementscotland.org/previous_resources/standards/diabet

ic_retinopathy_screening.aspx

Uptake of screening in NHS WI was 78.6%, above the national average of 77.9%.

The Did Not Attend (DNA) rate of 23.6% is above the national average of 20.4%

(Table 20).

NHS Western Isles successful screening rate is 75.8%, whilst comparable to the

national successful screening rate of 76%, NHS Western Isles did not achieve the

the KPI target of 80%.

http://www.ndrs-wp.scot.nhs.uk/wp-content/uploads/2013/04/KPI-definition-v1.5-.pdf

http://www.healthcareimprovementscotland.org/previous_resources/standards/diabetic_retinopathy_screening.aspx

http://www.healthcareimprovementscotland.org/previous_resources/standards/diabetic_retinopathy_screening.aspx


34

Table 20: DRS uptake, DNA rate and successful screening rate

KPI 2: Screening uptake rate

DNA rate

KPI 3: Annual

successful screening

rate

Target 80% KPI

Target for Q4

Indicative

DNA rate by %

80% KPI Target

Bo

ard

of

tre

atm

en

t

Peo

ple

att

end

ing a

t le

ast o

nce

(AT

T)

% (

100 *

AT

T / E

P)

% (

100 *

IN

V -

AT

T)

Peo

ple

successfu

lly s

cre

en

ed

in t

he p

rev y

ear

(SU

C1)

% (

100 *

SU

C1 /

EP

)

Ayrshire & Arran 16946 79.0% 24.2% 16839 78.5%

Borders 4515 77.8% 24.9% 4417 76.1%

Dumfries and Galloway 7678 91.2% 10.5% 7626 90.6%

Fife 15709 82.1% 23.2% 15458 80.8%

Forth Valley 12844 81.2% 18.8% 12428 78.5%

Grampian 20906 78.9% 20.4% 20099 75.9%

Greater Glasgow 45002 78.8% 20.0% 44227 77.4%

Highland 10744 69.2% 20.6% 10161 65.5%

Lanarkshire 24354 72.0% 18.3% 23993 70.9%

Lothian 28139 76.2% 23.3% 27629 74.8%

Orkney 955 91.2% 9.8% 943 90.1%

Shetland 898 85.0% N/A 860 81.4%

Tayside 15801 78.7% 17.5% 15058 75.0%

Western Isles 996 78.6% 23.6% 961 75.8%

Scotland 205487 77.9% 20.4% 200699 76.0%

Source: SOARIAN. Screening performance KPIs produced by National DRS Co-ordinator Scotland.

Once an image is taken it is sent digitally to NHS Tayside for grading. Each

participant’s subsequent care pathway is dictated by the results of the graded image.

Grading of images by NHS Tayside ensures rigorous quality assurance in the

assessment of the diabetic cohort screened.


35

NHS Western Isles’ timeliness of results being returned to individuals screened was

lower than those screened in NHS Tayside by 3.7% (Table 21). This issue has been

taken forward and although an initial improvement was noted in the first quarter of

2015, the final quarter showed a difference in KPI attainment of 3.7% between NHS

Tayside and NHS Western Isles, this continues to be addressed. However, it is

important to note that NHS Western Isles remains above the NHS QIS standard 3

target of 80% of individuals screened receiving their written results within 20 working

days.

Table 21: DRS KPIs 8 and 9 written report result within 4 weeks

KPI 8: Duration to written report

KPI 9: Written report success rate

Target

A minimum of 80% of people screened are sent the result in writing within 4 weeks (20 working days) of

the photograph being taken (STANDARD 3 ~ Screening Process).

QIS Standards

Bo

ard

of

tre

atm

en

t

Num

ber

of

epis

odes (

NE

)

Long

est re

cord

ed n

um

ber

of

days to w

ritt

en r

eport

(L

RD

)

Avera

ge

of th

e n

um

ber

of

days to w

ritt

en r

eport

(A

D)

Med

ian o

f th

e n

um

ber

of

da

ys

to w

ritt

en r

eport

(M

D)

Epis

odes w

ith <

= 2

0 w

ork

ing

days to w

ritt

en r

eport

(E

20

D)

% (

100 *

E20D

/ N

E)

Tayside 17267 79 7 7 16305 94.4%

Western Isles 1074 48 8 7 974 90.7%

Scotland 221835 249 6 5 212072 95.6%

Source: SOARIAN. Screening performance KPIs produced by National DRS Co-ordinator Scotland.

6.7 Grading

In accordance with the national grading protocol (Table 22), retinal images are

graded for retinopathy and maculopathy. Retinopathy grades of R3 or R4, and a

Maculopathy grade of M2 are all referable to ophthalmology care together with

retinal images graded as R1 or R2, also graded as M2. The M2 maculopathy grade

supersedes the retinopathy grade as changes have been identified in an area (the

macula) where the central vision could be affected.


36

Table 22: Grading of Diabetic Retinopathy Screened images

Retinopathy Description Outcome

R0 No diabetic Retinopathy anywhere Rescreen 12 months

R1 Background diabetic retinopathy (mild) Rescreen 12 months

R2 Background diabetic retinopathy - observable

Rescreen 6 months or refer to ophthalmology if rescreen not feasible

R3 Background diabetic retinopathy - referable Refer ophthalmology

R4 Proliferative diabetic retinopathy PDR Refer ophthalmology

M0 No maculopathy Rescreen in 12months

M1 Observable maculopathy

Rescreen 6 months or refer to ophthalmology if rescreen not feasible

M2 Referable maculopathy Refer to ophthalmology

R6 Inadequate: Not visuailised

Technical failure. Patient requires alternative screening method

Adapted from the Scottish Diabetic retinopathy grading scheme 2007 v1.1

6.8 Following a negative result

When a person with diabetes has successfully attended the screening programme

and been found to have no or mild retinal changes (R0, R1, M0), (s)he is returned to

the twelve month review pathway. No further referral is required.

6.9 Following a positive result

When an image returns a positive result, there are three possible pathways of care:

rescreen in 12 months, rescreen in 6 months or referral to ophthalmology. The

pathway followed is dependent on the severity of the retinal changes found.

NHS Western Isles’ 6 month recall rate is 1.0% (10) which is below the national rate

of 1.6%.

The current referral rate to ophthalmology from the DRS service NHS Western Isles

is 3.5% (37), which is comparable to the national average of 3.8%.

A summary of DRS outcomes can be seen at Figure 3.


37


In NHS Western Isles our participants receive a good standard of screening, through

the optometrist clinics, as the slit lamp examination can be carried out in the same

appointment if image capture fails in the first instance. In other areas this test would

require a second appointment to complete the screening process.

A new national computer system for DRS will be introduced in 2016 called VECTOR.

This system will replace SOARIAN, scheduled for change-over in winter of 2016. It

will be a complete screening system that can follow individual participants from initial

appointment to completion of the screening process and ophthalmic intervention if

required. It also provides a robust audit package and can link with MyDiabetes,

which will enable patient centered care. It is hoped that with the implementation of

VECTOR, coupled with improved information returns on retinopathy and

maculopathy results, we can gain greater understanding of the needs of our diabetic

population to maintain a proficient and effective service.

Healthcare Screening Programme Report 2015-2016

Documents

Transcript of Healthcare Screening Programme Report 2015-2016