lifestyle factors can play a significant role in reducing the risk associated with these factors. The effectiveness of population interventions to address healthy eating, obesity and physical activity are addressed in NICE guidelines21 . Effective individual lifestyle support on diet and physical activity remains important in the management of the patients with diabetes and the prevention of complications such as retinopathy (NICE clinical guideline 43 (2006), NICE public health intervention guidance 2 (2006)). Although the association between smoking and DR is to reduce the incidence and prevalence of DR in those who smoke, the considerable morbidity and mortality associated with smoking in people with diabetes associated cardiovascular disease and neuropathic complications, means that the importance of giving effective advice and interventions to reduce smoking cannot be underestimated22 . 5.6 REDUCTION OF POPULATION RISK THROUGH SCREENING Screening is a population approach to reduce risk from a particular condition within an identified population. Its purpose is to identify those people who have early signs of disease but who do not yet exhibit symptoms and to provide an effective treatment which will lead to an overall reduction in the condition of interest. As screening invites individuals to participate in a process that may not benefit them as an individual and could harm them, it is important that screening programmes are well constructed and evaluated to ensure they deliver more benefit than harm and that they remain cost-effective. DR screening is a population screening programme; it is not a diagnosis and treatment service. Screening will not detect every individual with DR and it will not be possible to offer screening to all people with diabetes. However, the intention is to deliver an overall reduction in sight loss due to DR in the population at risk. The four nations offer screening through their national screening programmes. (England: NHS Diabetic Eye Screening Programme www.diabeticeye.screening.nhs.uk; Scotland: National Diabetic Retinopathy Screening Programme, www.ndrs.scot.nhs.uk; Wales: Diabetic Retinopathy Screening Service for Wales,www.cardiffandvaleuhb.wales.nhs.uk/drssw; Northern Ireland: Northern Ireland Diabetic Retinopathy Screening). To deliver effective screening, the test must be part of a well-organised system to ensure that appropriate interventions occur following screening and rigorous quality assurance of the whole process. It is generally accepted that screening for DR is clinically good practice and Jones (2010) suggested that, in terms of sight years preserved, systematic screening for DR is cost effective compared with no screening23. However, the changing epidemiology of the condition and the improvement in care of people with diabetes means that the UK National Screening 38 Committee must constantly review the population eligible for screening, the screening model and key policies such as screening intervals to ensure it remains a costeffective programme that reduces the risk of sight loss from DR in the population screened. Recommendations: · Policy-makers and commissioners must ensure that DR screening programmes are constructed to deliver cost-effective systematic screening that reflect emerging evidence, changing epidemiology of DR and advances in technological developments. (Level B) · Policymakers and commissioners of public health programmes should ensure that screening programmes are commissioned in the context of a broad approach to preventing sight loss from DR. This will include effective partnership working with primary care, diabetology and ophthalmology services. (Level B) 5.7 THE PUBLIC HEALTH ROLE OF THE OPHTHALMOLOGIST The ophthalmologist has two key public health roles: · Reducing the overall morbidity and mortality associated with diabetes by contributing to the effective management of eye problems in patients with diabetes · Contributing to the collection, analysis and dissemination of information which underpins patient management and the monitoring of quality and outcomes for an effective screening programme 5.7.1 Reducing morbidity and mortality associated with diabetes The ophthalmologist is a member of a team that cares for a patient with diabetes. Early signs of retinopathy or maculopathy may be the first signs of tissue damage from poor control of diabetes and/or blood pressure in a patient. The ophthalmologist should provide effective advice to patients on how they can change their behaviour to reduce the risks associated with unhealthy lifestyles and poor diabetic control. (ref section on medical management) Information on retinopathy and/or maculopathy should be fed back to the physician with a responsibility for overall diabetic care for a patient. Communication between physicians caring for patients with diabetes is essential to create clear messages for patients. Recommendation: Consultant ophthalmologists caring for patients with DR should develop strong links with local primary care and diabetology services to ensure that patients have effective integrated care plans for the management of their condition. (Level B) 39 5.7.2 Collection and analysis of data The ophthalmologist is in a unique position to collect information on sight loss. Without the collection and analysis of this kind of data it is not possible to understand the changing epidemiology of DR as well as other important conditions leading to sight loss and blindness. Collection of outcome data is essential for a screening programme to: · Undertake audit to ensure that systems are working effectively · Demonstrate cost-effectiveness of screening as an intervention · Understand inequalities in access to services and use the information to improve services for the future Recommendation: Ophthalmologists should ensure that they collect information on sight loss and severe sight loss and submit data to national collection systems. (Level B)