Mary Wallace (Meath East, Fianna Fail)

I welcome the opportunity to speak on the HSE document, Framework for the Development of a Diabetic Retinopathy Screening Programme for Ireland, which was published in November 2008.

Diabetes is a chronic and progressive metabolic disease. There are two types of diabetes. Type 1 diabetes, or insulin dependent diabetes, accounts for approximately 10% of all cases of diabetes. It affects mainly children, adolescents and young adults and requires lifelong treatment with insulin. Type 2 diabetes, or non-insulin dependent diabetes, accounts for 90% of all cases diagnosed in Ireland. It affects mainly middle aged and older people. Its prevalence is increasing rapidly due to a number of factors, including the ageing of the population and lifestyle factors such as obesity. Diabetes is a common condition. An Institute of Public Health report, Making Diabetes Count — What Does the Future Hold?, provides the best available estimate of the prevalence of diagnosed and undiagnosed diabetes in the Ireland. Just over 140,000 adults in this jurisdiction are estimated to have type 1 or type 2 diabetes. The report predicts that this figure will increase by approximately 37% — to at least 194,000 people, or 5.6% of the population — by 2015. It estimates that this will largely result from an increase in the incidence of type 2 diabetes, as a consequence of the increase in childhood and adolescent obesity.

The diabetes policy of the Department of Health and Children, Diabetes: Prevention & Model for Patient Care, was published in 2006. It sets out a model of care, based on shared care between primary care and acute services, which will deliver quality diabetes care at an appropriate level. It identifies retinopathy screening for eye disease, patient education and empowerment and the development of podiatry services as key areas for further development. The Health Service Executive has established an expert advisory group under Dr. Colm Costigan to develop and implement the various policy recommendations. The group's report, which was published on 14 November 2008, represents a blueprint for the development of services for patients with diabetes over the coming years. It is practical and focuses on the patient. It places a strong emphasis on prevention, service integration and community based management supported by specialist services.

The expert advisory group emphasises that real savings in health care costs can be achieved if complications of diabetes, such as eye disease, or retinopathy, kidney disease and cardiovascular disease can be prevented. Retinopathy has been identified as one of the most common serious complications of diabetes. Diabetic retinopathy, which is a disease of the small blood vessels of the retina, is a common cause of blindness in people between the ages of 60 and 65. Approximately 5% or 10% of people with diabetes have sight-threatening retinopathy that requires ophthalmic follow-up and treatment. Of the estimated 140,000 people with diabetes in Ireland, between 14,000 and 16,000 will develop sight-threatening retinopathy. Screening for, and subsequent treatment of, retinopathy is effective in preventing blindness. International evidence shows that 6% of those who screened and treated for retinopathy are prevented from going blind within a year. This figure increases to 34% within ten years. The expert advisory group has recommended the introduction of a diabetic retinopathy screening programme to prevent eye disease. A subgroup of the group, the diabetic retinopathy screening sub-committee, was established to develop a framework for the development, implementation and monitoring of the national diabetic retinopathy screening programme. The sub-committee's report, which was published in November of last year, is being discussed in the House today.

In December 2007, before the expert advisory group published its report, it delivered its interim recommendations to the HSE leadership team for the development of diabetic services. The group decided to prioritise the roll-out of the national diabetic retinopathy screening programme. The targets recommended by the group at that time were that funding for the development of a national diabetic retinopathy screening programme be prioritised; that funding be made available incrementally over the next four years to implement the programme in each of the four Health Service Executive areas, with the programme being commenced in a new area each year; that the HSE immediately prioritise funding and commence procurement for an eye-specific information technology system to support a national diabetic retinopathy screening programme; that the HSE set up a formal governance structure for a national diabetic retinopathy screening programme; that 95% of registered people with diabetes be invited for screening within five years of full national implementation of the programme; and that 70% of registered people with diabetes attend such screening within five years.

In November 2008, the diabetic retinopathy screening sub-committee produced the document we are debating today, Framework for the Development of a Diabetic Retinopathy Screening Programme for Ireland. The framework sets out the aims and principles that should underpin the development of a screening programme. The aims of the national diabetic retinopathy screening programme are to detect diabetic retinopathy that is threatening sight but is treatable, to detect any diabetic retinopathy that may be detected with digital retinal photography, to provide screening on a call and recall basis according to best practice guidelines and to refer patients in a timely way for ophthalmic assessment and treatment, as required.

I will list the principles of the national diabetic retinopathy screening programme that have been adopted by the HSE's diabetes expert advisory group. A population-based call and recall programme should be delivered on an annual basis. Eligible patients should include all those with diagnosed diabetes aged 12 years and over who are medically fit to attend. It should be accessible to all eligible patients. It should be free, wheelchair accessible and delivered locally. Provision should be made for the screening of prisoners and people in nursing or residential homes who are fit to receive treatment. Screening should be carried out using digital retinal photography. Screening should be delivered in four area programmes, based on a population of approximately 1 million in each area, and in a geographic area corresponding to each HSE area. A register of people with diagnosed diabetes should be established for each area and collated nationally. A grading service should be developed on the basis of the population of each HSE area. These centres should grade images taken by all photographers in the programme for that area. The screening model should be mixed — it should feature a combination of fixed and mobile clinics, and possibly photography by optometrists, depending on the geographical distribution of the population, public transport links and economies of scale.

HSE areas should propose their preferred service model to the national screening committee and national executive office for approval. Screening should be carried out in co-operation with general practitioners, hospital diabetes service staff, optometrists, ophthalmic physicians and surgeons. There should be timely referral, assessment and treatment of any abnormalities discovered. There should be timely feedback to the screening programme of the result of screening events and of referrals. There should be a robust system of clinical governance and quality assurance.

It was decided to continue the roll-out of the programme across the HSE west, as a population-based screening programme had previously been established in the former North-Western Health Board. The funding was made available to the HSE west primary community and continuing care budget. This would allow for screening services to be offered to all people with diabetes — approximately 30,000 people over the age of 12 years — registered with the programme between west Limerick and north Donegal. Due to resource constraints, the diabetic retinopathy screening programme did not commence in 2008. The HSE is moving into the implementation phase for the roll-out of the screening programme to the rest of the western region, based on the national framework document. Funding of €750,000 is available in 2009 for this purpose.

One of the key parts of the implementation phase is the development of the governance and committee structures, and this process is under way. Job descriptions and recruitment forms for the eight agreed staff is with the relevant local health office, and it is expected that these posts will be advertised shortly. The formal procurement process for the ICT requirements of the programme is to begin in the coming months.

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