Áine Brady (Kildare North, Fianna Fail)

I thank the Leas-Chathaoirleach and Members for their welcome and welcome this opportunity on my first day in office as Minister of State to speak to the Seanad on the subject of the framework for the development of a diabetic retinopathy screening programme for Ireland, which was published in November 2008.

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

My Department's policy on diabetes, Diabetes: Prevention and A Model for Patient Care, was published in 2006. This set out a model of care based on shared care between primary care and acute services which would deliver quality diabetes care at the appropriate level. It also identified retinopathy screening for eye disease as well as patient education and empowerment, and the development of podiatry services as key areas for further development.

The Health Service Executive established an expert advisory group under Dr. Colm Costigan to take forward and implement the policy recommendations. The group published its report on 14 November 2008. The report is a blueprint for the development of services for patients with diabetes over the coming years. It is practical and patient focused, with strong emphasis on prevention, service integration and community based management, supported by specialist services. The group emphasises that real savings could be achieved in health care costs by preventing the complications of diabetes such as eye disease, specifically diabetic retinopathy, kidney disease and cardiovascular disease.

Retinopathy was identified as one of the most common serious complications of diabetes. Diabetic retinopathy is a disease of small blood vessels of the retina and is the most common cause of blindness in people aged 60 to 65. Approximately 5% to 10% of people with diabetes have a sight threatening retinopathy which requires ophthalmic follow-up and treatment. Of the estimated 140,000 people with diabetes in Ireland, approximately 14,000 will develop a sight threatening retinopathy. Screening, followed by treatment of retinopathy, is very effective in preventing blindness. International evidence shows that in a population of those screened and treated, 6% are prevented from going blind within a year and that this rate rises to 34% within ten years. Among the group's key recommendations was the introduction of a diabetic retinopathy screening programme to prevent eye disease. The expert advisory group formed a sub-group, the diabetic retinopathy screening sub-committee, to develop a framework for the development, implementation and monitoring of a national diabetic retinopathy screening programme which we are discussing in the House today.

In December 2007, and in advance of its report, the advisory group made interim recommendations to the HSE leadership team for the development of diabetic services. It prioritised the roll-out of the national diabetic retinopathy screening programme. It recommended the following targets: 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 HSE areas, commencing the programme in a new area each year; that the HSE immediately prioritise funding and commence procurement for an eye specific IT 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 by year five of full national implementation, and that 70% of registered people with diabetes attend screening by year five of full national implementation.

In November 2008 the diabetic retinopathy screening sub-committee produced a national framework for diabetic retinopathy screening in Ireland. This framework set out the aims and principles which should underpin the development of a screening programme. The aims of a national diabetic retinopathy screening programme are to detect sight threatening diabetic retinopathy which is treatable, detect any diabetic retinopathy that it is possible to detect with digital retinal photography, provide screening on a call/recall basis according to best practice guidelines and refer patients in a timely way for ophthalmic assessment and treatment as required.

The following principles of the national diabetic retinopathy screening programme have been adopted by the HSE diabetes expert advisory group. It should be a population based call-recall programme, delivered on an annual basis. Eligible patients should include all those with diagnosed diabetes, aged 12 years and over and medically fit to attend. It will be accessible to all eligible patients, by which I mean it will be free, wheelchair accessible, delivered locally, and that provision will be made for the screening of prisoners and persons in nursing and 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 and 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 each HSE area population. These centres will grade images taken by all photographers in the programme for that area. The screening model should be mixed, that is, it will 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 or national executive office for approval. Screening should be carried out in cooperation with general practitioners, hospital diabetes service staff, optometrists, ophthalmic physicians and surgeons. There should be timely referral, assessment and treatment of 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 Health Service Executive, western region, as a population-based screening programme had previously been established in the former North Western Health Board. The funding was, therefore, made available to the HSE western region 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.

Owing to resource constraints, the diabetic retinopathy screening programme did not commence in 2008. At present 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 are with the relevant local health offices. Currently all recruitment activity and recruitment competitions are placed on immediate hold pending further clarification regarding the filling of posts. Should approval be granted to fill the posts, it will then be possible to proceed to the various stages required for recruitment. The formal procurement process for the information and communications technology requirements of the programme is to commence in the coming months.

A quality assured diabetic retinopathy programme of highest international standard is being rolled out this year in the west. We hope to continue the roll-out of the programme in other areas as resources permit.