1. Dr Bill Lynn Clinical Lead, TB project London Health Programmes 2012
How can commissioning and the London TB Plan provide practical solutions to London’s TB problem?
Dr Bill Lynn
Clinical Lead, TB project
London Health Programmes 2012
Lynn Altass,
London Health Programmes
Jacqui White, North Central London TB team

2. Pattern of TB situation in big cities differs across the EU
Figure 1: TB notification rates in a selection of countries and big cities of EU/EEA, in 2009.
< 20 cases per 100,000 population
≥ 20 cases per 100,000 population
Riga / Latvia
16.9 / 6.0
Copenhagen / Denmark
43.0 / 43.2
21.3 / 7.0
Rotterdam / Netherlands
Vilnius / Lithuania
31.9 / 62.1
44.4 / 14.8
London / United Kingdom
Warsaw / Poland
17.8 / 21.6
23.4 / 8.2
Paris / France
Bucharest / Romania
81.0 / 108.2
33.2 / 6.5
Milan / Italy
Sofia / Bulgaria
31.9 / 38.3
24.3 / 16.6
Barcelona / Spain
Disclaimer: Survey performed by the Metropolitan TB network, Please note that ECDC does not collect city-level TB surveillance data and take no responsibility for accuracy of data collected for this survey.

3. TB rates in London,

4. 2011 Data 3588 cases 46 per 100,000 population (nationally 13.6)
Not evenly distributed
85% cases non-UK born
High proportion reactivation of latent disease
TB Epidemiology in London

6. How was the plan developed ?
By the TB community involving nurses, consultants, GPs, HPA and TB networks
Project board and clinical working group with strong public health expertise and service user representation
Stakeholder events along with meetings, national and public media, 1:1 interviews
Over 200 individuals provided feedback including GPs, patients, voluntary and community organisations, public health and government committees
There was widespread support for the plans

7. Reduce TB cases in London by 50% over the next 10 years
Vision
Reduce TB cases in London by 50% over the next 10 years

8. Model of Care
Recommendations in the model are targeted at three aspects of the patient pathway:
Improving detection and diagnosis of the disease
Both active and latent infection
Better coordinated commissioning
Addressing variability of provision

9. Key issues for TB control in London
Latent TB
Active transmission
80% of active cases are from latent TB, activated years after the patient has become infected
More prevalent in social risk groups including drug and alcohol users, homelessness, prisoners and people with mental health issues
No systematic screening – majority identified only when disease reactivates
Poor treatment completion rates lead to high rates of drug resistant TB in some patient groups
Prophylactic treatment has not been consistently applied
Benefit/risk ratio
Side effects/compliance
Funding
Patients from high risk groups often present late, resulting in complications and onward transmission of the disease to others

10. Improving detection and diagnosis
Raise awareness in communities with higher rates of TB disease
Raise awareness and knowledge of TB among wider groups of health and social care workers
Explore the potential of active and latent TB case finding
New registrations in primary care
? How to access ‘hidden populations’

11. Active and latent TB case finding
Through higher awareness earlier referral of patients with possible active TB
Improved contact tracing once infective cases identified
Targeted screening and prophylaxis offered to individuals in risk groups
Based on use of IGRA testing in primary care

12. Can case finding in London work?
TB Cases/100,000
Screening programme
Slide courtesy of
Chris Griffiths, 2012

13. Financial considerations – costs
Annual NHS spend on healthcare in London
£13.9billion
Annual TB healthcare spend in London
At least £18-20 million
Wider cost – financial and social
Unknown
Annual costs of the TB plan
£7.2 million
Including additional diagnostic and treatment costs from active case finding

14. Financial considerations – savings
Cost of TB Treatment
Case Finding vs. Do Nothing

15. Do Nothing is Not and Option

16. Current commissioning of TB
TB services predominantly provided by acute trusts
Not all activity is recorded correctly or completely
Provider income doesn’t link to service provision
Only 1 cluster has a commissioning manager (covering only 13% London’s TB cases)
Sectors with the highest proportion of spend on staff (including the MDT approach ) have seen a reduction in TB numbers
Metrics based on the 2004 National TB Action Plan – used as a tool to measure progress rather than performance
Lack of specialist knowledge to manage the relationship between commissioning and provision
Variability of provision means best use is not made of the resources i.e. staff mix, DOT, contact tracing .
No systematic approach across London – the 5 local TB networks support local service planning, development and protocols but not through proactive commissioning – organic
- with some TB teams employed by community trusts with the service in an acute trust
- so we don’t accurately know what the TB workload is and this potentially impacts on TB services resources
providers of care, health protection, social care and housing and fail to take note of the extensive guidance (NICE, DH etc) including performance management and which fail to take account of the London TB metrics and TB control
Linking TB rates to staff ratios shows wide variation across and within sectors i.e. 2 adjacent services provide very different TB support 16

17. Proposed London Model of Care approach
Establish a London TB commissioning board to coordinate TB control and provide proactive, robust commissioning of TB services
Ensure the treatment of medically complex and multi-drug resistant TB is managed along agreed pathways by clinical teams at specialist TB centres
Pan-London Find and Treat service to work with local delivery boards to reduce the number of individuals failing to complete treatment
Establish a central fund, managed by the TB commissioning board, to provide temporary accommodation for people with TB whose homelessness is a risk to completing treatment 17

18. 18

19. Proposed objectives of the new London TB commissioning board
Ensure all relevant agencies are engaged in the control of TB in London
Achieve a year on year reduction in the incidence of TB in London
Hold providers of TB services accountable for their performance against agreed standards of care and control
To ensure a coordinated, multi-agency approach to the control of TB in London
To ensure robust commissioning of TB services, including sound planning and strong performance management
To improve the quality and productivity of services
To ensure capacity of services is related to need
To exploit opportunities for cost reduction
Strengthen and redevelop the London TB Commissioning Board to address current system fragmentation by coordinating provision and strengthening the perfomance management of servcies.
The board would bring together the functions of health care commissioning, health protection and public health to ensure a co-ordinated, multi-agency approach to TB control incl continuing to comission F&T with more robust mgt to ensure its activities are aligned with the moc
Hold a cemntral budget to fund temp accom for those with nrpf
Commisison tb servcies with appropriate level of expertise and access to specialist facilities - 3 levels of servcie are proposed formally acknowledging the informal provision already in place
Robust commissioning of TB services will include sound planning, standard setting and strong performance management 19

20. The new London TB commissioning board would achieve these objectives by:
Commissioning all TB services in London
Developing standards in relation to clinical care, investigation and prevention
Maintaining an overview of developments in research, clinical practice, diagnostics and treatment and recommending appropriate action 20

21. Addressing variability of provision
Local delivery boards established to act as a single providers of TB services - mirror current networks to maintain strong clinical relationships and referral patterns
Delivery boards will ensure standardised pathways and protocols are developed to promote consistent, high quality care for patients
Workforce development group will ensure appropriate skill mix and best value for money is achieved 21

22. What are we doing in 2012/13? London’s commissioning intentions for 2012/13 included this statement: Tuberculosis (TB) Pan-London TB protocols have been agreed for the use of directly observed therapy and implementation of cohort review. All providers will be expected to adhere to these protocols and to use the risk assessment tool available through the London TB Register, to identify patients at risk of non-compliance with treatment. And in 2012/13 contracts - 'Quality Requirements' for TB 22

23. NHS Commissioning Board i.e. as a specialised service
In the new NHS architecture the four options for commissioning of TB services are:
Public Health England
NHS Commissioning Board i.e. as a specialised service
Local Authorities
Clinical Commissioning Groups 23

24. Partner in service delivery not commissioner
Public Health England
Partner in service delivery not commissioner
NHS Commissioning Board i.e. as a specialised service
TB not a specialist service
(despite much lobbying!)
Local Authorities
Partner in service delivery, not NHS service provider
Clinical Commissioning Groups
NHS CB is likely to recommend that TB is commissioned collaboratively 24

25. So where does TB fit into CCGs/CSSs commissioning?
From April 2013, Clinical Commissioning Groups (CCGs) will have the statutory responsibility for commissioning health services
Local commissioning support services (CSS) are being set up to offer an efficient, locally-sensitive and customer-focused service to CCGs (based around the current PCTs/clusters)
CCGs are likely to need support in leading change and service redesign, procurement, contract negotiation and monitoring, information analysis, communications and corporate services such as finance
Around 24 commissioning support services being established across the country 25

26. CCGs
Potential negative effect on TB control – insufficient budgetary flexibility to work across boundaries for outbreaks, drug resistant TB, NRPFs, F&T
Fragmentation with responsibility for public health devolved across at least 3 very different organisations and impair the response to TB across London reducing joint working and co-ordination
Further fragmentation in services leading to poor and varied quality of care for patients, increased rates of active, latent and drug resistant TB
Financial considerations - simple, complex, greater cost to the system for TB services and treatment for patients 26

27. CCGs – potential positive
Closer local working in partnership with GPs
Local health and well being Boards
Partnership working at local level with opportunities for innovative working and focussed funding

28. What can we do? During 2012/13 business as usual
Work in 2012/13 to demonstrate complexity of TB service delivery requires a single matrix approach to improve patient outcomes i.e. accommodation, complex TB care, Find and Treat, LTBI case finding
Towards middle 2012/13 expect 1 Commissioning Support Organisation / Commissioning Support Services to emerge as London lead commissioner on behalf of London’s CCGs (collaborative commissioning)
Based on smart evidence looking at geography, epidemiology, demography and service provision 28

29. Addressing variability in service provision through Cohort Review
Jacqui White – Lead Nurse
North Central London TB Service

30. Outline What is cohort review? Origins of cohort review?
Implementation in North Central London
Evaluation
Impact
Does cohort review address variability in service provision?

31. What is Cohort Review ? (1)
Quality assurance tool to track and improve patient outcomes.
Systematic review of patients with tuberculosis (TB) disease and their contacts to enhance the prevention and control of TB
A “cohort” is a group of TB cases identified over a specific period of time, usually 3 months
Cases are reviewed 6 months after they are notified.

32. What is Cohort Review? (2)
TB cases are reviewed in a group setting with the following information presented on each case by the case manager:
Patient’s demographic information
Patient’s status: clinical, lab, radiology
Adherence to treatment, completion
Results of contact investigation
Individual outcomes are assessed

33. What is Cohort Review? (3)
Group outcomes are also assessed
Indicators track progress towards national, regional and local service objectives.
Everyone leaves the meeting knowing the results

34. Origins of Cohort Review?
Tanzania – 1970’s
New York – 1990’s
Piloted in NC London

35. Implementation in North Central London
An opportunity to review practice across 5 NCL sites
Gain insight into our service – identify strengths and weaknesses
Standardise practice/documentation
Assess our contact tracing activities
Identify gaps in service provision
Assess our efforts compared to local / national TB control targets
Review and improve data quality
Encourage greater accountability

36. Evaluation of cohort review
Evaluation 1 yr after implementation with the following aims:
Assess impact on outcomes relating to case management and contact tracing:
- Treatment completion
- Offer of, and uptake of HIV testing of TB cases
- Effectiveness of contact tracing
Identify service issues raised
Review the experience of staff and partners
Assess the impact on data completeness
Make recommendations

37. Clinical impact of cohort review
Improved treatment outcomes from 82% to 90%, including among those with a social risk factor.
Proportion of sputum smear +ve PTB with one or more risk factors receiving DOT increased from 42% to 67%.
Reduction in proportion of lost to follow up at 12 months from 2.5% to 0%.
Proportion of TB cases with sputum smear +ve PTB who had one or more contact identified from 79% to 100%
Proportion of TB cases with sputum smear +ve PTB who had 5 or more contacts identified increased from 50% to 69%

38. Service impact of cohort review
Collated and summarised under 5 headings. Assessed for potential public health risk and potential harm to the patient if issue remains unresolved.
Treatment
Delay in diagnosis - ? Patient, primary care or TB service
Paediatric HIV testing – variable practice
Standardised treatment protocols required.
Case Management
Increased provision of DOT needed for infectious cases with social risk factors. Current service configuration inflexible (9-5)
Clinic v Community service e.g. Home visits as standard for every case, DOT workers, active case finding.

39. Service impact of cohort review
Management of contacts
Improved strategy needed to identify, engage, follow up and report on contacts.
Incident management inconsistent and insufficiently resourced.
Data
Incomplete data on LTBR – improved data quality
Education and training issues
Externally eg A+E, primary care
Internally - standardisation of nursing practice, IV drug administration for MDRTB, phlebotomy skills

40. Has Cohort Review addressed service variability in NCL ?
Brings 5 sites together every 3 months to reflect on the clinical management of every case of TB and their contacts.
Promotes standardisation via documentation, protocols and peer review
Drives up quality and highlights service inequalities
Forum to share good practice and reveals key areas of practice that require attention.
Promotes collaboration on all levels internally and externally.
Informs the future direction of our service based on evidence gathered in Cohort Review

41. Has Cohort Review addressed service variability in NCL ?
…..there are a number of service issues which cannot be resolved due to:
Current service configuration
Limited resources
Fragmented nature of the structure of TB services across London. .

42. To conclude:
Cohort Review is a framework which underpins the entire case management and contact investigation process. It is a tool which enables us to address variability in service provision and ensures accountability for patient care on all levels.

43. For all cohort review enquiries: Jacquiwhite@nhs.net
Thank you for listening.

44. Why this is really important
37 male born in India resident UK 10 years
Employed, married with 2 children at school
Presents - 4 months of fever, cough, weight loss.
Several courses antibiotics
Extensive pulmonary disease, admitted
Smear positive – in hospital for almost 3 weeks
Discharged on standard therapy

45. Attends first clinic visit– all seems well
Then defaults
Culture – INH resistance
TB nurses visit at home
Lost his job because of his time off work, started drinking, moved out of the marital home sleeping on various friends sofas
5 week re-admission – reconcilliation with wife
Sent home with DOT
Multidrug regimen including injectable agent

46. DOT seems to be going well for first 3 months
Revealing fax from GP
Readmitted – further 6 week admission
Home with DOT
Wife throws him out for good
Homeless
Various admissions over next 2 years to different acute hospitals around London,
Finally developed MDR-TB
Spent 6 months as inpatient elsewhere and eventually ‘cured’

47. How many other people did he infect? What was the cost
Direct healthcare and treatment costs
Indirect social care costs
Family harm, impact on children etc
Could this have been different??

48. What could have been different
Offered screening for latent TB long before he developed active disease?
Earlier diagnosis of first presentation could have avoided prolonged admission and he may have kept his job?
More effective and co-ordinated care after initial diagnosis

49. What could have been different
Co-ordinated approach at second admission
Multidisciplinary
Deal with social, substance use and accommodation issues
Specialist help available to support local centre
Better tracking and delivery of care rather than ‘loosing’ him across boroughs

50. Summary
There is a plan
Full and rapid implementation will be challenging in time of change, uncertainty and less cash
Much has already been accomplished and substantial momentum to improve the detection and treatment of TB in London