Presentation on theme: "Dr Bill Lynn Clinical Lead, TB project London Health Programmes 2012"— Presentation transcript:
1Dr 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 LynnClinical Lead, TB projectLondon Health Programmes 2012Lynn Altass,London Health ProgrammesJacqui White, North Central London TB team
2Pattern 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 populationRiga / Latvia16.9 / 6.0Copenhagen / Denmark43.0 / 43.221.3 / 7.0Rotterdam / NetherlandsVilnius / Lithuania31.9 / 62.144.4 / 14.8London / United KingdomWarsaw / Poland17.8 / 21.623.4 / 8.2Paris / FranceBucharest / Romania81.0 / 108.233.2 / 6.5Milan / ItalySofia / Bulgaria31.9 / 38.324.3 / 16.6Barcelona / SpainDisclaimer: 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.
6How was the plan developed ? By the TB community involving nurses, consultants, GPs, HPA and TB networksProject board and clinical working group with strong public health expertise and service user representationStakeholder events along with meetings, national and public media, 1:1 interviewsOver 200 individuals provided feedback including GPs, patients, voluntary and community organisations, public health and government committeesThere was widespread support for the plans
7Reduce TB cases in London by 50% over the next 10 years VisionReduce TB cases in London by 50% over the next 10 years
8Model of CareRecommendations in the model are targeted at three aspects of the patient pathway:Improving detection and diagnosis of the diseaseBoth active and latent infectionBetter coordinated commissioningAddressing variability of provision
9Key issues for TB control in London Latent TBActive transmission80% of active cases are from latent TB, activated years after the patient has become infectedMore prevalent in social risk groups including drug and alcohol users, homelessness, prisoners and people with mental health issuesNo systematic screening – majority identified only when disease reactivatesPoor treatment completion rates lead to high rates of drug resistant TB in some patient groupsProphylactic treatment has not been consistently appliedBenefit/risk ratioSide effects/complianceFundingPatients from high risk groups often present late, resulting in complications and onward transmission of the disease to others
10Improving detection and diagnosis Raise awareness in communities with higher rates of TB diseaseRaise awareness and knowledge of TB among wider groups of health and social care workersExplore the potential of active and latent TB case findingNew registrations in primary care? How to access ‘hidden populations’
11Active and latent TB case finding Through higher awareness earlier referral of patients with possible active TBImproved contact tracing once infective cases identifiedTargeted screening and prophylaxis offered to individuals in risk groupsBased on use of IGRA testing in primary care
12Can case finding in London work? TB Cases/100,000Screening programmeSlide courtesy ofChris Griffiths, 2012
13Financial considerations – costs Annual NHS spend on healthcare in London£13.9billionAnnual TB healthcare spend in LondonAt least £18-20 millionWider cost – financial and socialUnknownAnnual costs of the TB plan£7.2 millionIncluding additional diagnostic and treatment costs from active case finding
14Financial considerations – savings Cost of TB TreatmentCase Finding vs. Do Nothing
16Current commissioning of TB TB services predominantly provided by acute trustsNot all activity is recorded correctly or completelyProvider income doesn’t link to service provisionOnly 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 numbersMetrics based on the 2004 National TB Action Plan – used as a tool to measure progress rather than performanceLack of specialist knowledge to manage the relationship between commissioning and provisionVariability 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 resourcesproviders 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 controlLinking TB rates to staff ratios shows wide variation across and within sectors i.e. 2 adjacent services provide very different TB support16
17Proposed London Model of Care approach Establish a London TB commissioning board to coordinate TB control and provide proactive, robust commissioning of TB servicesEnsure the treatment of medically complex and multi-drug resistant TB is managed along agreed pathways by clinical teams at specialist TB centresPan-London Find and Treat service to work with local delivery boards to reduce the number of individuals failing to complete treatmentEstablish a central fund, managed by the TB commissioning board, to provide temporary accommodation for people with TB whose homelessness is a risk to completing treatment17
19Proposed objectives of the new London TB commissioning board Ensure all relevant agencies are engaged in the control of TB in LondonAchieve a year on year reduction in the incidence of TB in LondonHold providers of TB services accountable for their performance against agreed standards of care and controlTo ensure a coordinated, multi-agency approach to the control of TB in LondonTo ensure robust commissioning of TB services, including sound planning and strong performance managementTo improve the quality and productivity of servicesTo ensure capacity of services is related to needTo exploit opportunities for cost reductionStrengthen 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 mocHold a cemntral budget to fund temp accom for those with nrpfCommisison 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 placeRobust commissioning of TB services will include sound planning, standard setting and strong performance management19
20The new London TB commissioning board would achieve these objectives by: Commissioning all TB services in LondonDeveloping standards in relation to clinical care, investigation and preventionMaintaining an overview of developments in research, clinical practice, diagnostics and treatment and recommending appropriate action20
21Addressing 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 patternsDelivery boards will ensure standardised pathways and protocols are developed to promote consistent, high quality care for patientsWorkforce development group will ensure appropriate skill mix and best value for money is achieved21
22What 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 TB22
23NHS Commissioning Board i.e. as a specialised service In the new NHS architecture the four options for commissioning of TB services are:Public Health EnglandNHS Commissioning Board i.e. as a specialised serviceLocal AuthoritiesClinical Commissioning Groups23
24Partner in service delivery not commissioner Public Health EnglandPartner in service delivery not commissionerNHS Commissioning Board i.e. as a specialised serviceTB not a specialist service(despite much lobbying!)Local AuthoritiesPartner in service delivery, not NHS service providerClinical Commissioning GroupsNHS CB is likely to recommend that TB is commissioned collaboratively24
25So where does TB fit into CCGs/CSSs commissioning? From April 2013, Clinical Commissioning Groups (CCGs) will have the statutory responsibility for commissioning health servicesLocal 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 financeAround 24 commissioning support services being established across the country25
26CCGsPotential negative effect on TB control – insufficient budgetary flexibility to work across boundaries for outbreaks, drug resistant TB, NRPFs, F&TFragmentation 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-ordinationFurther fragmentation in services leading to poor and varied quality of care for patients, increased rates of active, latent and drug resistant TBFinancial considerations - simple, complex, greater cost to the system for TB services and treatment for patients26
27CCGs – potential positive Closer local working in partnership with GPsLocal health and well being BoardsPartnership working at local level with opportunities for innovative working and focussed funding
28What 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 findingTowards 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 provision28
29Addressing variability in service provision through Cohort Review Jacqui White – Lead NurseNorth Central London TB Service
30Outline What is cohort review? Origins of cohort review? Implementation in North Central LondonEvaluationImpactDoes cohort review address variability in service provision?
31What 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 TBA “cohort” is a group of TB cases identified over a specific period of time, usually 3 monthsCases are reviewed 6 months after they are notified.
32What 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 informationPatient’s status: clinical, lab, radiologyAdherence to treatment, completionResults of contact investigationIndividual outcomes are assessed
33What is Cohort Review? (3) Group outcomes are also assessedIndicators track progress towards national, regional and local service objectives.Everyone leaves the meeting knowing the results
34Origins of Cohort Review? Tanzania – 1970’sNew York – 1990’sPiloted in NC London
35Implementation in North Central London An opportunity to review practice across 5 NCL sitesGain insight into our service – identify strengths and weaknessesStandardise practice/documentationAssess our contact tracing activitiesIdentify gaps in service provisionAssess our efforts compared to local / national TB control targetsReview and improve data qualityEncourage greater accountability
36Evaluation 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 tracingIdentify service issues raisedReview the experience of staff and partnersAssess the impact on data completenessMake recommendations
37Clinical 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%
38Service 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.TreatmentDelay in diagnosis - ? Patient, primary care or TB servicePaediatric HIV testing – variable practiceStandardised treatment protocols required.Case ManagementIncreased 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.
39Service impact of cohort review Management of contactsImproved strategy needed to identify, engage, follow up and report on contacts.Incident management inconsistent and insufficiently resourced.DataIncomplete data on LTBR – improved data qualityEducation and training issuesExternally eg A+E, primary careInternally - standardisation of nursing practice, IV drug administration for MDRTB, phlebotomy skills
40Has 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 reviewDrives up quality and highlights service inequalitiesForum 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
41Has Cohort Review addressed service variability in NCL ? …..there are a number of service issues which cannot be resolved due to:Current service configurationLimited resourcesFragmented nature of the structure of TB services across London..
42To 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.
43For all cohort review enquiries: Jacquiwhite@nhs.net Thank you for listening.
44Why this is really important 37 male born in India resident UK 10 yearsEmployed, married with 2 children at schoolPresents - 4 months of fever, cough, weight loss.Several courses antibioticsExtensive pulmonary disease, admittedSmear positive – in hospital for almost 3 weeksDischarged on standard therapy
45Attends first clinic visit– all seems well Then defaultsCulture – INH resistanceTB nurses visit at homeLost his job because of his time off work, started drinking, moved out of the marital home sleeping on various friends sofas5 week re-admission – reconcilliation with wifeSent home with DOTMultidrug regimen including injectable agent
46DOT seems to be going well for first 3 months Revealing fax from GPReadmitted – further 6 week admissionHome with DOTWife throws him out for goodHomelessVarious admissions over next 2 years to different acute hospitals around London,Finally developed MDR-TBSpent 6 months as inpatient elsewhere and eventually ‘cured’
47How many other people did he infect? What was the cost Direct healthcare and treatment costsIndirect social care costsFamily harm, impact on children etcCould this have been different??
48What 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
49What could have been different Co-ordinated approach at second admissionMultidisciplinaryDeal with social, substance use and accommodation issuesSpecialist help available to support local centreBetter tracking and delivery of care rather than ‘loosing’ him across boroughs
50SummaryThere is a planFull and rapid implementation will be challenging in time of change, uncertainty and less cashMuch has already been accomplished and substantial momentum to improve the detection and treatment of TB in London