How can commissioning and the London
TB Plan provide practical solutions to
London’s TB problem?
Dr Bill Lynn
Clinical Lead, TB project
Lynn Altass,
London Health Programmes
London Health Programmes 2012
Jacqui White, North Central
London TB team
http://www.londonhp.nhs.uk/services/tuberculosis
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
Copenhagen / Denmark
16.9 / 6.0
43.0 / 43.2
Rotterdam / Netherlands
Vilnius / Lithuania
21.3 / 7.0
31.9 / 62.1
London / United Kingdom
44.4 / 14.8
Warsaw / Poland
17.8 / 21.6
Paris / France
23.4 / 8.2
Milan / Italy
Bucharest / Romania
81.0 / 108.2
33.2 / 6.5
Sofia / Bulgaria
Barcelona / Spain
31.9 / 38.3
24.3 / 16.6
2
Disclaimer: Survey performed by the Metropolitan TB network, www.metropolitantb.org Please note that ECDC does not collect city-level
TB surveillance data and take no responsibility for accuracy of data collected for this survey.
TB rates in London, 1982-2010
TB rates in London, 1982-2010
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
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
6
Vision
Reduce TB cases in London by
50% over the next 10 years
http://www.londonhp.nhs.uk/services/tuberculosis
7
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
8
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
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’
10
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
11
Can case finding in London work?
140
TB Cases/100,000
120
100
80
Hackney
Tower Hamlets
60
Newham
40
20
Screening programme
0
2005
2006
2007
2008
2009
2010
Slide courtesy of
Chris Griffiths, 2012
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
13
Financial considerations – savings
Cost of TB Treatment
Case Finding vs. Do Nothing
£ Millions
25
20
15
2012
2013
2014
2015
2016
Net TB costs - with case finding
2017
2018
2019
2020
2021
Net TB costs - do nothing
14
Do Nothing is Not and Option
15
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
16
commissioning – organic
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
Improving detection and
diagnosis
Person has TB symptoms
Increased awareness of TB
in high-risk communities
(section 4.1)
Person enters UK from
high-incidence country
Port Health service
screens high-risk
person and identifies
potential TB infection
Patient identified by
other service - Find &
Treat, prison health and
other clinical specialists
Person presents at GP
surgery, A&E department or
other urgent care centre
TB suspected and patient
referred to TB service
Increased awareness and
knowledge of TB among
healthcare professionals
(section 4.2)
TB screening programme to
detect active and latent TB
(section 4.3)
Named Case Manager
allocated
Diagnostic investigations
by TB service
Improving commissioning
London Commissioning
Board ensures the
proactive, robust
commissioning of services
(section 5.1)
Patient diagnosed
with TB
Contact
tracing &
screening
Medically complex TB is
commissioned from
specialist TB centres
(section 5.2)
Find and Treat support
treatment completion
(section 5.3)
Central accommodation
fund for homeless TB
patients
(section 5.4)
HPU referral
where
appropriate
Treatment
Patient followed up and
reviewed
Treatment completed
Patient discharged
Improving services
Delivery Boards ensure a
coordinated, seamless
approach
(section 6.1)
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)
18
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
19
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
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
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 noncompliance with treatment.
And in 2012/13 contracts - 'Quality Requirements' for TB
TB
TB
TB
TB patients - risk assessment and
identification of complex needs
Percentage of notified TB patients assessed on a
quarterly and annual basis for all the following: a) use of
drugs, b) homelessness, c) detention in prison (current Quarterly
and previous), d) alcohol, e) mental health issues. Green ≥100% of notified TB patients
Continued breaches will mean lead
service provision will be reviewed
Directly observed therapy (DOT)
The preferred care support system for patients assessed
as requiring DOT is DOT delivered according to the
London TB DOT standard where 100% TB patients
Quarterly
requiring DOT to receive DOT. Green - 100% DOT,
amber - 80 - 99.9% DOT, red - ≤79.9% DOT
Continued breaches will mean lead
service provision will be reviewed
Cohort Review
Adherence to cohort review guidance as detailed by HPA
Six monthly
document November 2011
Continued breaches will mean lead
service provision will be reviewed
London measure
London measure
London measure
22
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
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
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
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
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
27
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
Addressing variability in service provision through
Cohort Review
Jacqui White – Lead Nurse
North Central London TB Service
Outline
•
•
•
•
•
•
What is cohort review?
Origins of cohort review?
Implementation in North Central London
Evaluation
Impact
Does cohort review address variability in service
provision?
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.
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
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
Origins of Cohort Review?
• Tanzania – 1970’s
• New York – 1990’s
• Piloted in NC London - 2010
An opportunity to review practice across 5 NCL sites
Implementation in North Central London






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
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
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%
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.
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
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
Has Cohort Review addressed service variability
in NCL ?
…..there are a number of service issues which cannot be
resolved due to:
1.
2.
3.
.
Current service configuration
Limited resources
Fragmented nature of the structure of TB services
across London.
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.
For all cohort review enquiries:
Jacquiwhite@nhs.net
Thank you for listening.
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
44
• 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
45
• 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’
46
• 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??
47
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
48
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
49
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
50