Organising a TB service the results of BTS Surveys

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Organising a TB service the results of BTS
Surveys

• Marc Lipman
• Royal Free Hospital
• London

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The incidence of tuberculosis has increased over
the last two decades
Mean annual percentage change in TB notification
rates, EU West, 2000-2004
EuroTB
3
Tuberculosis now affects specific subgroups of
the population
Enhanced TB Surveillance, ONS mid-year population
estimates
4
New York London
Moore-Gillon, 2008
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Policy and public health measures initiated

• Reduce the risk of people being newly infected wit
  h TB in England
• Provide high quality treatment and care for all pe
  ople with TB
• Maintain low levels of drug resistance, particular
  ly MDRTB

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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

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What does this look like in practice?
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BTS/APPG surveys 2007

• TB leads in England, Wales N Ireland
• PCTs in England
• Compare observed with expected

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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

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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)

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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

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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

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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.

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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

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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

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Treatment completion remains below the 85 WHO
target
Enhanced Tuberculosis Surveillance (ETS)
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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

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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

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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

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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

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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

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Where are the pilot sites?
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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

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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

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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

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DGH
DGH
DGH
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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.

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Improving the quality of TB care

• Extend the concept of an advice network to all
  aspects of TB.

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REGIONAL/NATIONAL ADVICE NETWORK
DGH
DGH
DGH
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3 monthly Regional TB Meeting
HPA
PCT
North City ID Unit 50 new cases/yr 1 TB Nurse
shared with Central
South City 10 new cases/yr
6 monthly steering group meeting Respiratory
Chair
Microbiology Lab
Central City TB Unit 3 Respiratory Consultants 3
TB Nurses 1 TB Admin asst 1 Pharmacist 140 new
cases/year monthly TB clinic weekly screening
clinic contact tracing/ new entrants
Microbiology Lab
Microbiology Lab IGRAs
Mycobact Reference Laboratory Molecular tests
Paediatrics 2 Respiratory Consultants 15 cases /
yr Monthly TB clinic Share TB nurses
HIV 900 cases 10 TB/yr Shared care
Weekly MDT
X-ray MDT
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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

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Project website

• http//www.brit-thoracic.org.uk/ClinicalInformatio
  n/Tuberculosis/tabid/115/Default.aspx
• Louise Preston, BTS project manager
• tb_at_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

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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

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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