Guidance

Diabetic eye screening: Diploma for health screeners rules of combination

Updated 5 April 2022

1. Overview

The Level 3 Diploma for health screeners is the recommended national training programme for new screening staff in the NHS Diabetic Eye Screening (DES) Programme.

It provides screening staff with a nationally recognised qualification to ensure they have the knowledge and skills required to work in a healthcare setting and in the screening programme. They can use the qualification to support career progression and their own personal development.

The qualification is designed to reflect work-based learning. Learners need to provide evidence of achieving the learning outcomes for a number of generic units that are based on the provision of quality care in a healthcare setting.

There are a number of training pathways for different staff groups working within diabetic eye screening. This guidance provides local DES providers with additional information about the appropriate units that must be undertaken by those groups.

Only new clinical staff need to undertake the Level 3 Diploma for Health Screeners. The previous City & Guilds qualifications are still valid for existing staff.

However, staff who have completed individual units from the previous qualification but not obtained a City & Guilds qualification need to complete the appropriate Level 3 Diploma units if they want to undertake additional roles. This applies, for example, for staff moving from assistant to screener or screener to screener grader. They would also need to apply for recognition of prior learning for their existing units.

The qualification has a number of generic and screening programme role-specific units that must be undertaken by the different staff roles. Learners progress through the different units required with support from their local screening service.

2. Generic units

Generic units provide screening staff with the basic understanding and core knowledge and skills for working in a healthcare setting.

These units cover:

• engagement in personal development in health, social care or children’s and young people’s settings
• communication in health, social care or children’s and young people’s settings
• equality and inclusion in health, social care or children’s and young people’s settings
• promotion and implementation of health and safety in health and social care
• principles of safeguarding and protection in health and social care
• person-centred approaches in health and social care
• the role of the health and social care worker
• good practice in handling information in health and social care settings
• the principles of infection prevention and control
• causes and spread of infection
• cleaning, decontamination and waste management
• principles for implementing duty of care in health, social care or children’s and young people’s settings
• health screening principles

3. Role-specific units

There are 6 role-specific units for DES staff. These are:

• anatomy, physiology and pathology of the eye
• understanding diabetes and diabetic retinopathy
• preparing for diabetic retinopathy screening
• undertaking diabetic retinopathy imaging
• detection of retinal disease and classification of diabetic retinopathy
• understanding how to safeguard the wellbeing of children and young people

3.1 Screener

The screener prepares the person for their screening test by:

• recording their consent to be screened
• undertaking visual acuity test
• instilling mydriatic drops
• preparing and using the retinal camera and screening equipment for obtaining images of the eye
• assessing the quality of images
• determining the appropriate grading queue for the screening subject

Screeners must complete the generic units and the role-specific units.

Trainee screeners and unsupervised screening requirements

Trainee screeners can only screen independently if they have completed and passed the following units of the HSD:

• Anatomy and physiology of the eye
• Understanding diabetes and diabetic retinopathy
• Prepare for diabetic retinopathy screening
• Undertake diabetic retinopathy imaging

Each local screening service should have a process in place to record when their manager is satisfied a trainee screener is safe to screen unsupervised.

This process, to be agreed by the clinical lead of the service, should include:

• evidence of confirmation from the awarding centre that the 4 HSD units have been completed and passed
• evidence of completion of local mandatory training required for the role
• timescales and plans for completion of the 13 generic units and the Safeguarding the wellbeing of children and young people unit of the HSD within the 2-year time frame

Services should retain documented evidence of this process.

3.2 Grader

Graders use the feature-based grading technique to identify features in the retina. The screening software then assigns the correct grade (up to arbitration level) according to those features.

Graders must complete the generic units and the role-specific units.

Trainee graders and unsupervised grading requirements

Trainee graders are those learning to grade who have not passed the diploma unit Detect Retinal Disease and Classify Diabetic Retinopathy. All new graders must complete and pass this unit before they undertake unsupervised grading. They must also complete the diploma for health screeners within 2 years of initial registration.

Trainee graders can only grade ‘live’ on DES software in a supervised capacity. To gain the appropriate grading experience required for the unit they should be overseen by a senior grader in their learning environment. Trainee graders must not complete any live grading within DES software for a ‘live’ patient until this unit is completed and the clinical lead is satisfied that the trainee is fully competent.

A learning outcome for the grading unit requires learners to evidence that they have assessed 200 image grades to a satisfactory standard and achieved satisfactory scores (minimum of 80% specificity and sensitivity) in 3 live monthly test sets as a trainee grader or fully observed and supervised training sets. This is to ensure trainee graders have been given the appropriate level of supervision, oversight and training essential to complete the learning outcome.

DES providers should determine the best way to enable access to the appropriate number of supervised grades using existing educational resources, image libraries, test and training and grading software. Local services can determine if an image set constitutes 1 or 2 grades depending on each individual learner and training resources. An inter-grader agreement or Cohen’s Kappa is not required as assessment evidence.

Learners should develop a logbook locally to record their training grades. They should use this logbook to provide evidence of successful completion of the minimum 200 grades requirement.

The logbook should include as a minimum:

• identification number for reference (non-patient identifiable)
• trainee grader grade RXMX
• trainee grader outcome: RDS or DS or Referral (urgent or non-urgent) or U or SLB
• assessor or senior grader grade RXMX
• assessor or senior grader outcome RDS or DS or Referral (urgent or non-urgent) or U or SLB
• agreement in grade Y or N
• any additional comments the learner feels are relevant

This is the minimum requirement and local DES services may have additional competencies and procedures in place before unsupervised grading can occur. Completion of the 200 supervised grading and 3 live monthly test sets does not provide confirmation of competence in grading. This should be determined for each individual learner by the clinical lead.

3.3 Non-clinical grading staff

There may occasionally be non-clinical grading staff working within a local DES service. They may not be able to complete some of the clinical observations associated with the qualification. In these cases, learners should complete the appropriate units for their roles, including:

• principles of health screening
• anatomy and physiology of the eye
• understanding diabetes and diabetic retinopathy
• detection of retinal disease and classification of diabetic retinopathy
• engaging in personal development
• communication in health and social care
• equality and inclusion in health and social care
• good handling of information in health and social care settings

Learners receive unit certification upon completion of each unit. If learners change to a clinical role that requires completion of the diploma for health screeners they must complete the full qualification within the required timescale.

3.4 Screener grader

This is a combination of the screener and grader roles.

Screener graders must complete the generic units and role-specific units.

3.5 Optometrist

Optometrists must maintain the appropriate professional registration and act within their scope of practice. Optometrists do not need to undertake the generic units except the Principles of Health Screening unit. They must also undertake the appropriate role-specific units for their position within the DES service.

Following a competency mapping exercise from March 2022, optometrists no longer have to undertake the Prepare for Diabetic Retinopathy Screening unit.

The learning outcomes for the professional certificate in medical retina cover all the requirements for the Level 3 Diploma for Health Screeners (Diabetic Eye) with the exception of the Undertake Diabetic Retinopathy Imaging unit and the assessment element of 3.1 of the Detect Retinal Disease and Classify Diabetic Retinopathy unit. This is only for those optometrists undertaking the professional certificate from October 2017.

Optometrists who gained the certificate in medical retina before October 2017 can apply for recognition of prior learning for some or all of the role-specific units. This should be done via their local DES service.

3.6 Assistant and support workers

The role of assistant and support workers can be used across the screening programme to support services in the provision of DES. It can involve undertaking initial patient verification, consent, visual acuity test, the instillation of mydriatic eye drops, decontamination of equipment and associated infection control measures.

Trainee assistant and support workers must not undertake photography, triage or grading of images.

Individuals undertaking this role must always be under the supervision of an appropriately qualified clinical member of staff. This can include qualified screeners, optometrists and ophthalmologists.

Assistant and support workers are required to undertake the role-specific units outlined in this guidance. On successful completion they will receive unit completion certificates.

Trainee assistant and support workers must receive support from a qualified assessor while completing these required units.

Individuals will also be required to complete any local mandatory and clinical training requirements for this level of working and their role.

They should not start working under the auspices of a local DES service until these units and local training are completed.

4. Rules of combination table

Units	Screener	Grader	Screener grader	Optometrist	Optometrist with prof cert in medical retina	Assistant
13 generic units	Y	Y	Y	Principles of health screening unit only	-	-
Anatomy and physiology of the eye	Y	Y	Y	-	-	-
Understanding diabetes and diabetic retinopathy	Y	Y	Y	Y	-	Y
Prepare for diabetic retinopathy screening	Y	-	Y	-	-	Y
Undertake diabetic retinopathy imaging	Y	-	Y	role-specific	role-specific	-
Detect retinal disease and classify diabetic retinopathy	-	Y	Y	role-specific	-	-
Understand how to safeguard the wellbeing of children and young people	Y	Y	Y	-	-	-

Additional requirements for optometrists holding the professional certificate in medical retina are to:

• have 200 supervised grades to satisfactory standard
• achieve satisfactory scores in 3 tests and training sets