How can commissioning and the London TB Plan provide practical solutions to Londons TB problem? Dr Bill Lynn Clinical Lead, TB project London Health Programmes.

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

http://www.londonhp.nhs.uk/services/tuberculosis

2Disclaimer: 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.

Figure 1: TB notification rates in a selection of countries and big cities of EU/EEA, in 2009.

43.0 / 43.2

31.9 / 62.1

81.0 / 108.2

31.9 / 38.3

17.8 / 21.6

Riga / Latvia

Vilnius / Lithuania

Warsaw / Poland

Bucharest / Romania

Sofia / Bulgaria

16.9 / 6.0Copenhagen / Denmark

21.3 / 7.0Rotterdam / Netherlands

23.4 / 8.2Paris / France

44.4 / 14.8London / United

Kingdom

24.3 / 16.6Barcelona / Spain

33.2 / 6.5Milan / Italy

< 20 cases per 100,000 population

≥ 20 cases per 100,000 population

Pattern of TB situation in big cities differs across the EU

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

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Vision

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

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http://www.londonhp.nhs.uk/services/tuberculosis

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

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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 ratioSide effects/complianceFunding

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’

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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

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Can case finding in London work?

Screening programme

Slide courtesy ofChris Griffiths, 2012

TB

Cas

es/1

00,0

00

• 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

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Financial considerations – costs

Financial considerations – savings

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15

20

25

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

Do Nothing is Not and Option

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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

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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

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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

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

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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

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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

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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

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TB London measure

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 and previous), d) alcohol, e) mental health issues. Green - ≥100% of notified TB patients

QuarterlyContinued breaches will mean lead service provision will be reviewed

TB London measure

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 requiring DOT to receive DOT. Green - 100% DOT, amber - 80 - 99.9% DOT, red - ≤79.9% DOT

QuarterlyContinued breaches will mean lead service provision will be reviewed

TB London measure

Cohort ReviewAdherence to cohort review guidance as detailed by HPA document November 2011

Six monthlyContinued breaches will mean lead service provision will be reviewed

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 Groups23

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Public Health EnglandPartner in service delivery not

commissioner

NHS Commissioning Board i.e. as a specialised service

TB not a specialist service

(despite much lobbying!)

Local AuthoritiesPartner in service delivery, not NHS

service provider

Clinical Commissioning Groups NHS CB is likely to recommend that TB is commissioned collaboratively

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

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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

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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

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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

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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

Implementation in North Central LondonAn 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

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

• 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%

Clinical impact of cohort review

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. Current service configuration

2. Limited resources

3. 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:

[email protected]

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

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• 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

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• 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’

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• 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??

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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

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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

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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

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