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

TB rates in Western European capital cities,

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

7 TB rates by Primary Care Trust of residence, 2010 Hillingdon Barnet Redbridge Harrow Havering Barking & Dagenham Bexley Newham Hammersmith & Fulham Haringey Brent Ealing Greenwich Bromley Lewisham Tower Hamlets City & Hackney Islington Camden Westminster Kensington & Chelsea Richmond & Twickenham Waltham Forest Southwark Lambeth Wandsworth Croydon Sutton & Merton Kingston Hounslow Enfield Hillingdon Barnet Redbridge Harrow Havering Barking & Dagenham Bexley Newham Hammersmith & Fulham Haringey Brent Ealing Greenwich Bromley Lewisham Tower Hamlets City & Hackney Islington Camden Westminster Kensington & Chelsea Richmond & Twickenham Waltham Forest Southwark Lambeth Wandsworth Croydon Sutton & Merton Kingston Hounslow Enfield TB rate /100,000 population ? <20 TB rate /100,000 population ? <20 Source: London Regional Epidemiologist, HPA

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Key issues for TB Latent TBActive 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

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Finance Estimated total spend on TB c.£25m 12 CategoryDefinitionCost UncomplicatedPatient 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) ComplexTreatment not complete - patient has increased risk of developing drug resistant TB and a lengthy hospital inpatient stay £10,000 (usually exceeds) ExceptionalExtensive 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 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 “multi- stranded 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

16 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 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 21 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 22

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) 23

Costs by cluster from 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. 25

Financial considerations – savings 26 Cost of TB Treatment Case 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 27

Further information Full versions of the case for change and model of care documents (not yet in the public domain) are available from Additional information (published) is available from 28