Roxanne Crosby-Nwaobi

At the beginning of my fellowship...

The board and executive team of Moorfields Eye Hospital have been trailblazers in supporting and equipping staff for the purpose of developing digital health solutions in response to both the Topol Review and NHS Long Term Plan. This is embodied by their recent appointment of Ophthalmology Consultants as Director of Digital Innovation (Peter Thomas) and Director of Telemedicine (Dawn Sim), the latter of whom is sponsoring this project. In addition to these appointments, there is a clear agenda to prepare our nursing, optometry, and technician staff to be a digitally ready workforce; with curricula, training programmes, and governance and research teams in place.

From an organisational perspective, we further recognise that patients’ expectations are changing in that they expect service providers to be responsive, and they seek to be more active participants in their healthcare. Therefore, our ambition is to seek to understand the digital healthcare adoption behaviours of our patients and employ advances in digital technology to enhance our interaction with our patients, each other and with organisations.

Personal goals:

1. To improve the rates of diabetic eye screening in a non-attending populations (as demonstrated in the project proposal below)
2. To increase my experience in digital health – particularly from a nursing, research, and governance perspective
3. To support staff (especially the research nursing team under my supervision) and patients to deliver and utilise a future ‘digital first’ NHS.

During my fellowship...

Topol project – To improve the rates of diabetic eye screening in a non-attending populations

It is well established that a delay in diabetic eye screening is associated with an increased risk of sight-threatening diabetic retinopathy. Diabetic retinopathy accounts for 4% of an estimated 1.93 million people living with sight loss and blindness in the UK, 10% of an estimated £2.99 billion direct healthcare system costs expenditure and 8% of total burden of disease (years of healthy life lost). Visual impairment due to diabetes is treatable and preventable through screening. Whilst the Public Health England screening key performance indicator data summary shows that although the overwhelming majority of people with diabetes attend screening, it is the minority group of non-attenders that are most at risk for visual loss. The result of this health inequality is evidenced by a late diagnosis of diabetes, poor diabetes outcomes (including sight loss) and continued poor access to health services.

Several reports have highlighted a number of patient-level and system level factors associated with repeat non-attendance to Diabetic Eye Screening (DES). These include social deprivation, language and culture in ethnic minority populations, disengagement with diabetes care, invitation to screening and recall and patient dislike of dilating eye drops. There is an unmet need to improve uptake of DES to prevent visual impairment by improving access to the service. With the increasing prevalence of diabetes, it is of public health importance to address DES non-attendance in a manner that is both feasible and acceptable to the patient, healthcare professional and the healthcare system.

The proposed project aimed to:

1. utilise a cloud-based solution (Big Picture Eye Health) that will enable a specialist-level clinical history delivered by community nurses;
2. test the feasibility and acceptability of opportunistic DES in non-attenders at the GP surgery, with asynchronous transfer of retinal images to a specialist centre (Moorfields Eye Hospital) for grading and reporting.

The project was conducted as follows:

1. The local DES sent a list of patients who had not attended screening in the last 3 years to the GP surgery.
2. The GP surgery administrative staff compared the DES list to their registered patient list and called patients to invite them to screening at the GP practice.
3. If the patient consented, the trained practice nurse acquired the retinal image and used a tablet to capture the relevant clinical data.
4. The retinal image and clinical data were reviewed by a clinician to advise as to whether the patient’s condition required monitoring or referral to the hospital eye service. The results were given to the patient, the GP surgery and the local DES. Face-to-face education about the effect of metabolic factors on diabetic retinopathy was also provided by the trained nurse at the appointment.
5. A questionnaire on the patient’s experience of the intervention was administered locally as part of the study assessments.
6. At the end of the pilot, a focus group was held with the GP Surgery staff to determine their experience and acceptability of the intervention.

Outcomes

1. I was able to conduct a pilot of the project proposed prior to the start of the pandemic (Dec 2019 – Jan 2020). OPTOS Plc provided an ophthalmic imaging device (free of charge) to support this innovative project. I also received support from Big Picture Medical Teleophthalmology service to adapt and integrate an Electronic Medical Records system for this pilot.
2. Thirty-three patients were identified as non-attenders by the DES. Approximately 25% of patients agreed to attend the pilot programme. 25% were not eligible for or were no longer registered with the GP surgery. We were unable to contact the remainder or they had declined to participate (50%).
3. Three patients with potentially sight-threatening disease were referred to secondary care. Overall, patients deemed the intervention as highly acceptable. The staff focus group provided insight into how to improve aspects of the intervention. Staff appreciated the opportunity to be upskilled in eye health and requested further education for other ophthalmic conditions.

Other activities

1. Yale Nursing school invited speaker and observership (02/2020)
2. HEE-NIHR Integrated Clinical Academic Programme Clinical Lectureship (08/2020 – 07/2025)
   – Improving diabetic retinopathy screening attendance in non-attenders
   – Development of intervention based on behaviour change theory and feasibility trial.
3. Led on the development of a patient and public facing database to be hosted on the Moorfields website which allows interested parties to register for contact about Research Opportunities At Moorfields (ROAM) (open studies, future studies, PPIE, patient ambassador etc). Launched in September 2020. We have been able to continue research activity which has maintained and improved patients vision-related quality of life.
4. Involved in NHSx processes to develop a digitally-enabled ophthalmology service.
5. Had discussions with BUMP technology to pilot the use of their software/equipment in my Trust. However, I was unable to get leadership buy-in as to the importance of this initiative within a specialist Trust.
6. Supervised 2 applications for the 2nd cohort of Topol Digital Fellows; 1 successful.
7. Received research funding to evaluate the acceptability of the RetinaRisk digital application amongst patients and clinicians. The RetinaRisk application is designed to give patients a real-time risk assessment of the likelihood of developing sight-threatening diabetic eye disease in one year and advice on how to reduce this risk.

Lessons learned:

1. Whilst we recognise that a digitally-ready workforce is required to facilitate current and future healthcare-related changes, we need to invest in front-line/grass-roots staff to propagate these changes. In some areas, opportunities/support are still not afforded to front-line/grass-roots staff.
2. Networking – A skill to be developed and mastered.
3. Having protected time was essential to allow me the breathing space and head space to plan, do, study and act within the digital landscape.