Skip to main content

Breaking down barriers to diabetic eye screening attendance

Posted by: and , Posted on: - Categories: NHS Diabetic Eye Screening Programme

Diabetic eye screening is one of the 15 essential regular healthcare checks identified by Diabetes UK that everyone with diabetes can access to help reduce the risk of serious diabetes complications.

Screening helps reduce the risk of sight loss but screening is a choice. Some people with diabetes choose to decline screening while others do not attend (DNA) for a variety of reasons.

Today is World Diabetes Day. In this blog article, North Central London Diabetic Eye Screening Programme team leader Iveta Olejkova and administration manager Agnes Bourke explain how their team addresses the causes of the DNA issue.

Head and shoulders photo of Agnes Bourke
Agnes Bourke

Screening works

Screening is extremely effective at detecting diabetic retinopathy.

Since 2012, nearly 11 million diabetic eye screening tests have been carried out.

Between 1 April 2017 and 31 March 2018:

  • 2,700,774 people with diabetes were offered diabetic eye screening
  • 2,232,797 people were screened
  • 63,675 people were referred for follow-up tests or treatment

Every year, around 7,000 people with sight-threatening diabetic retinopathy are referred to hospital eye services for urgent treatment.

Why do people DNA?

People who DNA their appointment are at greater risk of sight loss.

DNAs are also costly if the person fails to inform their local service they will not be attending.

To understand and reduce DNAs, we started by asking the following questions:

  1. What defines a ‘hard to reach’ patient?
  2. What local factors, such as communication, can we address?
  3. What are the next steps we need to take to improve the situation?

Barriers to attendance include lack of time and conflicting priorities, such as having multiple appointments and difficulty taking time off work. This is where a more integrated care approach would work.

There is also a need for education. Some patients still believe other hospital eye appointments or regular optician appointments include a test for diabetic retinopathy.

Some will be anxious about their results or possible treatment, while others believe everything is fine because their vision is OK. There are also patients who simply feel embarrassed about their poor glycemic control and fail to engage with all diabetes interventions.

Hard to reach patients include:

  • young adults
  • rural dwellers
  • single parents
  • black and minority ethnic groups
  • older people, particularly those with mobility issues
  • deprived inner city dwellers
  • young middle class workers
  • white British working age men

The term hard to reach covers anyone who simply does not engage with diabetic eye screening. Should we say they are hard to reach or are we not trying hard enough to reach them?

We identified a number of programme-level factors influencing DNA rates, including:

  • clinic locations
  • clinic availability
  • walk-in slots
  • text message reminders
  • software restrictions
  • mobile screening units
  • staff perceptions of non-attenders

Research suggests that adjusting the wording in text message reminders to focus on the cost involved in a missed appointment would result in 5,800 fewer missed appointments per year for just one NHS provider – Barts Health NHS Trust – at no additional expense.

Newly diagnosed patients are not always given enough information about having diabetes, so phoning them and explaining the reasons for screening can help them understand its importance.

How can we support patients more?

In North Central London, we helped improve uptake by fine-tuning text message reminders and calling people a few days before their appointments. This was the result of a study with Imperial College London that used the awareness-raising message ‘Diabetes harms eyes before you notice. Screening can save sight’.

Results of this study showed that people receiving this message were much less likely to DNA.

Staff attitudes

We also need to look at staff attitudes, making sure we use a friendly manner when explaining what can happen if too many appointments are missed and advising on the benefits of attending. It can also help to show people with diabetes their retinal images at their screening appointment in order to demonstrate the importance of regular attendance, good control of blood sugar, blood pressure and cholesterol, and smoking cessation.

This can empower them to take ownership of their health.

Working together

Diabetes is a long-term condition and it is extremely important that people move towards taking control and managing their condition. Engaging with local community and faith leaders can help improve understanding, as can making sure screening is represented at local cultural and religious events and festivals.

By working together we can minimise the complications caused by diabetes.

See Diabetes Update, Diabetes UK’s quarterly publication for professionals, for a longer version of this article including a patient case study.

PHE Screening blogs

PHE Screening blog articles provide up to date news from all NHS screening programmes. You can register to receive updates direct to your inbox, so there’s no need to keep checking for new blogs.

Sharing and comments

Share this page


  1. Comment by Irene Stratton posted on

    It would be so useful if you could writie this up and submit to a peer reviewed journal such as Diabetic Medicine or the Journal of Medical Screening. Let me know if you would like me to help with the stats or data presentation.
    Irene Stratton
    Senior Medical Statistician
    Gloucestershire Retinal Research Group.

  2. Comment by Katy Welsh posted on

    In South Devon, we are very fortunate to have a good pathway in place to support people with learning disabilities (who are often hard to reach). By working in partnership with the screening team and Primary Care Liaison Team (Learning Disability services), we increased uptake from around 40% to over 90% of those patients identified.

    • Replies to Katy Welsh>

      Comment by Mike Harris posted on

      Thank you Katy,
      We would love to share the learning from your work in South Devon on the blog.