Organising a TB service the results of BTS Surveys

1. Organising a TB service – the results of BTS Surveys Marc Lipman Royal Free Hospital London

2. However, when we look in more detail at the situation in the EU and West European region we see that trends in notification rates between 2000 and 2004 varied widely between countries. The reasons explaining these changes vary as well. Of course, such trends should be interpreted with caution and one should take into account: possible artefact i.e. changes in surveillance system, changes in TB control, or in the health system. For instance, the increase in TB rates in Greece is most likely due to improved reporting. The increases in the UK and Norway, on the other hand, appear to be real and related, in part, to migration from high prevalence countries. However, when we look in more detail at the situation in the EU and West European region we see that trends in notification rates between 2000 and 2004 varied widely between countries. The reasons explaining these changes vary as well. Of course, such trends should be interpreted with caution and one should take into account: possible artefact i.e. changes in surveillance system, changes in TB control, or in the health system. For instance, the increase in TB rates in Greece is most likely due to improved reporting. The increases in the UK and Norway, on the other hand, appear to be real and related, in part, to migration from high prevalence countries.

3. Tuberculosis now affects specific subgroups of the population However, even looking at the regional level data masks variations between small geographic areas as this map of TB rates by local authority shows. Most TB occurs in cities. And even within cities there is much variation as shown here for London. However, even looking at the regional level data masks variations between small geographic areas as this map of TB rates by local authority shows. Most TB occurs in cities. And even within cities there is much variation as shown here for London.

4. New York & London

5. Policy and public health measures initiated Reduce the risk of people being newly infected with TB in England Provide high quality treatment and care for all people with TB Maintain low levels of drug resistance, particularly MDRTB Following the publication of the CMO’s action plan, expert working groups have produced a planning and commissioning toolkit as well as evidence based guidelines for the prevention and control of tuberculosis. National BCG vaccination policy has been changed to better reflect the epidemiology of tuberculosis and other specific measures have been implemented to support local control. Further monitoring of tuberculosis trends is necessary to assess progress towards the goals of the action plan.Following the publication of the CMO’s action plan, expert working groups have produced a planning and commissioning toolkit as well as evidence based guidelines for the prevention and control of tuberculosis. National BCG vaccination policy has been changed to better reflect the epidemiology of tuberculosis and other specific measures have been implemented to support local control. Further monitoring of tuberculosis trends is necessary to assess progress towards the goals of the action plan.

6. TB control in UK: main elements Case finding passive - clinical presentation active - contact tracing (source)  & screening (high risk groups) Prompt treatment of cases Successful treatment of cases Chemoprophylaxis (for latent TB) BCG It is time to think outside the box – stabilisation of rates – work towards elimination – effectiveness of more widespread identification and treatment of latent infectionIt is time to think outside the box – stabilisation of rates – work towards elimination – effectiveness of more widespread identification and treatment of latent infection

7. What does this look like in practice?

8. BTS/APPG surveys 2007 TB leads in England, Wales & N Ireland PCTs in England Compare observed with expected

9. TB leads survey 40 questions, on-line survey Sent to 184 medical TB leads Explored TB team/workforce/facilities Service organisation Number of TB cases Lab services Screening & contact tracing Case management Issues now & in the future

10. TB leads survey Response rate 33% (even spread across country) Low priority service Trusts: 75% more needed PCT: 85% more needed DH: 70% poor/very poor role in TB prevention 78% no change in resources since Action Plan published (8% decline) 71% predicted no future increase (15% decline)

11. TB leads survey Result of financial pressure on specialist nursing 35% reported TB nurse role under threat/review Laboratory services 44% TB leads had access to designated micro Screening & contact tracing 69% no awareness raising programmes 49% no active case finding in high risk groups

12. TB leads survey Chest physicians predominant TB lead Multi-disciplinary working 54% services had some form of MDT 25% paediatric cases were shared care 65% TB/HIV co-infection were shared care

13. BTS/APPWG on TB PCT survey Determine the degree to which key elements of TB toolkit were being implemented Survey questions Incidence & popn changes PCT TB lead Testing & screening Priority setting Awareness raising Collaborative working Sent to 152 PCTs. 101 (66%) responses.

14. BTS/APPWG on TB PCT survey Who is the person in your organisation who deals with TB? What is his/her name and position: Only 50% could provide a name

15. BTS/APPWG on TB PCT survey Has specific agreement been reached with providers on arrangements for provision of community and secondary care TB services? 30% = Yes

16. Treatment completion remains below the 85% WHO target

17. What to do? Implement change Meeting with CMO Parliamentary questions DH initiatives Repeat survey in 2009 (APPG, BTS, RCN & TB Alert) TB leads TB nurses PCTs

18. Implement change – joined up working Department of Health funding received Feb 2008 Overseen by BTS Tuberculosis Specialist Advisory Group (TB SAG) 2 strands to the project: Support and development of pilot MDTs Development of a Clinical Advice Network

19. Project assumptions Professional decision making about TB management should not be made by isolated clinicians All professionals working in TB management should have access to quality, up-to-date information on best practice Education for junior clinical staff should be facilitated to ensure there is a “next generation” of experts Communication between professionals to be encouraged

20. What is an MDT for TB? A meeting of a range of professionals, not just one TB clinician and a nurse, to discuss the management of TB cases Value placed on innovation: the aim is to be flexible to meet the needs of individual services Not like a cancer MDT! No formal rules on membership No formal funding structure

21. First steps Global email sent to BTS TB leads asking for volunteers for the project 34 expressions of interest received for the MDT pilot scheme (both high and low incidence areas) Baseline data collection started with the 34 sites

22. Where are the pilot sites?

23. How do current MDTs work? From the expressions of interest, we have information from 18 sites with existing MDTs 12 colleagues working to set up a new TB MDT Information from these groups, and any subsequent volunteers is being gathered and summarised

24. Who is part of the MDT? From our pilot sites, the following colleagues are most commonly part of the MDT: 2 or more physicians (both respiratory and ID) TB lead nurse Public health representative Microbiologist / scientist SpRs Paediatricians, HIV experts, GPs and PCT involved as needed

25. Model of working Groups are working with MDTs within their own departments and also wider “strategy” groups Internal group tend to meet weekly as part of a ward round, or monthly

27. Improving the quality of TB care A national MDRTB group: Collects and pools clinical and microbiological information on all cases. Discussion by experienced individuals. Advice offered on management.

28. Improving the quality of TB care Extend the concept of an “advice network” to all aspects of TB.

31. What can BTS offer MDTs? Developing a strong network of MDTs that link with neighbouring units and regional experts eg link low incidence areas to provide a “critical mass” of expertise Possibility of providing support with expenses / facilities for meetings, database development Comprehensive website offering: Information on and sharing of best practice Access to the Clinical Advice Network

32. Project website http://www.brit-thoracic.org.uk/ClinicalInformation/Tuberculosis/tabid/115/Default.aspx Louise Preston, BTS project manager tb@brit-thoracic.org.uk Project overview providing up-to-date information on the status of the project Opportunity to join the project How to establish an MDT Information about who is involved in the project in each locality

33. Project website Good practice area What constitutes an effective MDT Practical examples from the pilot sites – what works and what does not! Submit good practice from your area Discussion forum Quarterly survey tool for pilot sites

34. What is the future for TB? Commissioned service Needs based on local epidemiology MDT as part of routine TB care Access to local CAN & specialist CAN Simple channels of communication for complex patients/ social needs Focus on active case finding Training of new TB specialists Fostering of UK TB R & D