The London TB Plan

Dr William LynnClinical Lead, TB project

London Health Programmes 2012

Overview

• In 2010 there were 3,302 new cases of TB in the capital, the highest of any major city in Western Europe

• London Health Programmes and the TB community have developed both a case for change and a model of care; a compelling set of arguments for the need improve the care for people with TB in London and a plan to reduce the number of new cases

• The cluster Chief Executives are currently reviewing this model, which aims to begin implementation from April 2012

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TB rates in Western European capital cities, 2009

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Development of the plan

• The case for change and model of care has been developed by the TB community including nurses, consultants, GPs, the Health Protection Agency and TB networks

• Overseen by both a clinical working group and project board with strong public health expertise and service user representation

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Engagement

• Extensive eight week engagement period on both the draft case for change and model of care

• 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

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Case for Change - TB in London

• TB is an infectious disease that is treatable and curable however remains a major public health issue

• The number of TB cases has increased by 50% over the last ten years and more than doubled over the last 20 years

• In 2010 there were more cases of new TB cases diagnosed in the capital than HIV cases

• TB rates vary widely across the capital

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TB rates by Primary Care Trust of residence, 2010

Hillingdon

Barnet

RedbridgeHarrow

Havering

Barking &Dagenham

Bexley

Newham

Hammersmith & Fulham

Haringey

Brent

Ealing

Greenwich

Bromley

Lewisham

TowerHamlets

City & Hackney

IslingtonCamden

Westminster

Kensington &Chelsea

Richmond &Twickenham

WalthamForest

Southwark

Lambeth

Wandsworth

Croydon

Sutton &Merton

Kingston

Hounslow

Enfield

Hillingdon

Barnet

RedbridgeHarrow

Havering

Barking &Dagenham

Bexley

Newham

Hammersmith & Fulham

Haringey

Brent

Ealing

Greenwich

Bromley

Lewisham

TowerHamlets

City & Hackney

IslingtonCamden

Westminster

Kensington &Chelsea

Richmond &Twickenham

WalthamForest

Southwark

Lambeth

Wandsworth

Croydon

Sutton &Merton

Kingston

Hounslow

Enfield

TB rate /100,000 population

? 80

60- 79

40- 59

20- 39

<20

TB rate /100,000 population

? 80

60- 79

40- 59

20- 39

<20

Source: London Regional Epidemiologist, HPA

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TB rates in London, 1982-2010

Key issues for TB

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 which is costly and time consuming for the patient and NHS

Prophylactic treatment can be unpleasant and lengthy.

Patients from high risk groups often present late, resulting in complications and onward transmission of the disease to others

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Treatment

• Treatment comprises anti-TB drugs for at least six months

• Treatment carries risk of unpleasant side effects

• Treatment completion essential - but often not finished

• Development of drug resistant TB means using more specialist anti-TB drugs with more side effects and worse outcome

• Greater cost to the system

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Treatment completion rates by PCT, 2010

70%

75%

80%

85%

90%

95%

North Central North East North West South East South West

Finance

• Estimated total spend on TB c.£25m

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Category Definition Cost

Uncomplicated Patient identified early with prompt diagnosis, drug sensitive TB requiring a six month course of treatment. May include brief inpatient spell or self managed isolation

£1,100 (lowest amount)

Complex Treatment not complete - patient has increased risk of developing drug resistant TB and a lengthy hospital inpatient stay

£10,000 (usually exceeds)

Exceptional Extensive inpatient stay, treatment and follow up care – mortality is high and may require lifelong care and support. A handful of these cases present each year

£100,000 (often exceeds)

Current service provision

• 5 TB networks across London with variability in commissioning, service planning, protocols and education

• Service resources, capacity and delivery does not align with TB rates

• Poor awareness of TB among health professionals

• Uptake and administration of neonatal vaccination is variable

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Case for Change

• The case for change highlights the risks for London if these problems are not addressed:

– Further fragmentation in services – Poor and varied quality of care for patients– Increased rates of active, latent and drug resistant TB – Greater cost to the system for TB services and

treatment for patients

A model of care was therefore developed that sets out how to address the TB problem in London using a “multi-stranded solution to a multi-faceted problem”

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Model of Care

• Recommendations in the model are targeted at three aspects of the patient pathway:

– Early detection and diagnosis of the disease – Better coordinated commissioning– Addressing variability of provision

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Improving commissioning

Improving detection and diagnosis

Increased awareness and knowledge of TB among healthcare professionals

(section 4.2)

TB screening programme to detect active and latent TB

(section 4.3)

Improving services

London risk assessment, DOT and cohort review

protocols are mandated in NHS contracts (section 6.2)

Workforce Development Group reviews capacity and capability of teams to deliver

the model of care(section 6.3)

Increased awareness of TB in high-risk communities

(section 4.1)

Delivery Boards ensure a coordinated, seamless

approach (section 6.1)

Find and Treat support treatment completion

(section 5.3)

London Commissioning Board ensures the proactive, robust

commissioning of services(section 5.1)

Medically complex TB is commissioned from

specialist TB centres (section 5.2)

Central accommodation fund for homeless TB

patients(section 5.4)

Person presents at GP surgery, A&E department or

other urgent care centre

Person has TB symptoms

TB suspected and patient referred to TB service

Diagnostic investigations by TB service

Patient diagnosedwith TB

Treatment

Contact tracing & screening

Patient followed up and reviewed

Patient discharged

Patient identified by other service - Find &

Treat, prison health and other clinical specialists

Person enters UK from high-incidence country

Port Health service screens high-risk

person and identifies potential TB infection

HPU referral where

appropriate

Named Case Manager allocated

Treatment completed

Model of Care

Improving detection and diagnosis

• Raise awareness in communities with higher rates of TB disease

• Raise awareness in health and social care workers

• Pan-London active and latent TB case finding focusing on new registrations in primary care

- piloted in NW London for first year

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Improving the commissioning of TB services

• Develop a London TB Commissioning Board to address current system fragmentation

• 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

• Robust commissioning of TB services will include sound planning, standard setting and strong performance management

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Improving the commissioning of TB services

• Continue to commission the Find and Treat service to work with hard to reach groups in the community

• Establish a central accommodation fund for patients with no recourse to public funds

• Ensure three levels of service provision

• Level 1 - Generic primary and community care

• Level 2 - Recognised TB services

• Level 3 - Specialist TB services

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Variability of service provision

• Five 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.

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Finance Considerations – cost

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Year one (pan-London)

Awareness raising programme £150,000

Establish London Commissioning Board £250,000(Redeploy existing LHP resource)

Find and Treat £816,000(already agreed for 12/13)

Central accommodation budget £100,000

Total £1.32m Of which £250K is not already in system

Finance Considerations – cost

Year one – NW London only

Costs of IGRA tests for case finding programme £253,000

Cost of LES or equivalent for case finding programme £51,000

Additional treatment costs (prophylactic and active) £1.4m

Total £1.704m

Of which £304K would be up-front investment and £1.4m would be additional activity in acute contracts

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Finance Considerations – cost

Annual costs from year two (pan-London)

Awareness raising programme £150,000

Costs of IGRA tests for case finding programme £890,000

Cost of LES or equivalent for case finding programme £177,000

Support to London Commissioning Board £250,000

Find and Treat £816,000

Central accommodation budget £100,000

Sub-total £2,383,000

Additional treatment costs (prophylactic and active) £5,089,000(Decreasing year on year)

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Costs by cluster from 2013

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Total costAlready in

systemNew

investment

NCL £1,206,901 £175,247 £1,031,653

NEL £1,806,733 £225,375 £1,581,358

NWL £2,069,476 £257,943 £1,811,533

SEL £1,400,585 £220,680 £1,179,905

SWL £988,435 £186,755 £801,680

Total £7,472,130 £1,066,000 £6,406,130

Note – additional treatment costs will reduce year on year. Savings will exceed new investment from 2016/17.

Financial considerations – savings

• Without intervention, costs of treatment are expected to rise over the next 10 years – savings resulting from the case finding programme alone will exceed the cost of the do nothing approach by 2016/17.

• The majority of savings are achieved through avoided treatment costs both as a result of a reduction in onward infection and an overall reduction in TB incidence.

• Further savings will be achieved through awareness raising programmes and pan-London protocol implementation.

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Financial considerations – savings

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2012 2013 2014 2015 2016 2017 2018 2019 2020 2021

£ M

illio

ns

Net TB costs - with case finding Net TB costs - do nothing

Cost of TB TreatmentCase Finding vs. Do Nothing

Next steps

The GP Council is asked to:

• Endorse the case for change

• Support the recommendation to cluster chief executives that implementation of the model begins in 2012/13

• Consider a progress report later in 2012 to inform future decision-making

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Further information

• Full versions of the case for change and model of care documents (not yet in the public domain) are available from

http://www.londonhp.nhs.uk/publications/tuberculosis/working/

• Additional information (published) is available fromhttp://www.londonhp.nhs.uk/publications/tuberculosis/

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