The London TB Plan
Dr William Lynn
Clinical 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
2
TB rates in Western European capital cities, 2009
3
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
4
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
5
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
6
TB rates by Primary Care Trust of residence, 2010
Enfield
Barnet
Harrow
Waltham
Forest
Haringey
Redbridge
Havering
Hillingdon
Brent
City &
Hackney
Camden
Barking &
Dagenham
Islington
Tower
Hamlets
Westminster
Ealing
Kensington &
Chelsea
Southwark
Greenwich
Hammersmith
& Fulham
Hounslow
Newham
Lambeth
Richmond &
Twickenham
Bexley
Wandsworth
Lewisham
TB rate /100,000
population
Kingston
Sutton &
Merton
Bromley
Croydon
? 80
60 -79
40 -59
20 -39
<20
Source: London Regional Epidemiologist, HPA
7
TB rates in London, 1982-2010
8
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
9
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
10
Treatment completion rates by PCT, 2010
95%
90%
85%
80%
75%
70%
North Central
North East
North West
South East
South West
11
Finance
• Estimated total spend on TB c.£25m
Category
Definition
Cost
Uncomplicated Patient identified early with prompt diagnosis, drug £1,100
sensitive TB requiring a six month course of
(lowest
treatment. May include brief inpatient spell or self amount)
managed isolation
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)
12
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
13
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 “multistranded solution to a multi-faceted problem”
14
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
15
Improving detection and
diagnosis
Person has TB symptoms
Model of
Care
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
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)
Patient discharged
16
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
17
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
18
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
19
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.
20
Finance Considerations – cost
Year one (pan-London)
Awareness raising programme
Establish London Commissioning Board
£150,000
£250,000
(Redeploy existing LHP resource)
Find and Treat
£816,000
(already agreed for 12/13)
Central accommodation budget
Total
£100,000
£1.32m
Of which £250K is not already in system
21
Finance Considerations – cost
Year one – NW London only
Costs of IGRA tests for case finding programme
Cost of LES or equivalent for case finding programme
Additional treatment costs (prophylactic and active)
Total
£253,000
£51,000
£1.4m
£1.704m
Of which £304K would be up-front investment and £1.4m would be
additional activity in acute contracts
22
Finance Considerations – cost
Annual costs from year two (pan-London)
Awareness raising programme
Costs of IGRA tests for case finding programme
Cost of LES or equivalent for case finding programme
Support to London Commissioning Board
Find and Treat
Central accommodation budget
Sub-total
£150,000
£890,000
£177,000
£250,000
£816,000
£100,000
£2,383,000
Additional treatment costs (prophylactic and active)
£5,089,000
(Decreasing year on year)
23
Costs by cluster from 2013
Total cost
Already in
system
New
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.
24
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.
25
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
26
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
27
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 from
http://www.londonhp.nhs.uk/publications/tuberculosis/
28