Bristol, North Somerset, South Gloucestershire (BNSSG) TB Network: An Update Report For Bristol Clinical Commissioning Group

Transcription

1 Bristol, North Somerset, South Gloucestershire (BNSSG) TB Network: An Update Report For Bristol Clinical Commissioning Group 1. Introduction 1.1 This paper provides an update to strategic partners on the background / context for the current TB strategic control arrangements for the BNSSG Network. 1.2 An update on the delivery of the Latent TB Infection (LTBI) Screening Programme for Bristol is outlined including objectives for the year ahead. 1.3 A summary of the key findings from a TB Health Needs Assessment recently completed for the network area and outline of strategic direction of the Network is provided. 1.4 This paper is for information and to encourage partner organisations to consider their role in further supporting the Network to deliver its priorities over the year ahead. 2. Background / Context 2.1 UK TB incidence is higher than most other Western European countries and the US. For example in 2013, TB incidence in the UK of 14.0 per 100,000 population was much higher than in France (8.8 per 100,000), Germany (5.8 per 100,000) or USA (3.0 per 100,000). England has not seen the consistent reductions that have been achieved in some comparable countries and if current trends are not reversed then within two years England could expect to have more TB cases than the whole of the US. 2.2 The Collaborative Tuberculosis Strategy for England 2015 to 2020 was published in January 2015 following extensive consultation. The strategy was jointly launched by PHE and NHS England in response to concerns that overall rates of the disease have not shown a sustained reduction in recent years. 2.3 The overarching aim of the strategy is to achieve a year-on-year decrease in incidence, a reduction in health inequalities and ultimately the elimination of TB as a public health problem in England. 2.4 TB infection is a significant public health concern in the BNSSG area, mainly due to the notifications occurring in the City of Bristol. There were 321 cases of TB notified in the South West in 2014, of which 31% (99) were among Bristol

2 residents and 40% (129) among BNSSG residents. Despite a relatively low TB rate in the South West in 2014 (5.9 per 100,000), the City of Bristol with its high rate of 22.4 per 100,000 population significantly exceeded the England figure (12.0 per 100,000)7. TB Control Boards 2.5 As outlined in the strategy, a significant step to achieving success is the establishment of TB Control Boards. The TB Control Board that this Network reports to is the TB Control Board for the South of England which has been operational since September The Board s intent is to concentrate effort on high incidence areas (more than 20 cases per 100, 000 population) whilst liaising, guiding and sharing work and expertise with low incidence areas. Bristol is the only high incidence area in the South West of England. 2.6 TB Control Boards require a lead Clinical Commissioning Group (CCG) and it was agreed that the TB Control Board for the South of England should have a lead CCG for each of the South East and South West PHE Centre footprints. As Bristol is the only high incidence area in the South West and was therefore the only eligible area to receive additional funding to establish a Latent TB Infection Screening Programme in this region, Bristol CCG has agreed to take on the role of lead CCG with support from PHE South West. Although the lead CCG is Bristol, strong representation from North Somerset and South Gloucestershire CCGs at the Network is important in order that they can influence strategic development at a local level and inform any future commissioning / re-commissioning arrangements. TB Networks 2.7 The Bristol, North Somerset and South Gloucestershire (BNSSG) Tuberculosis Strategic Group is responsible for: providing clinical leadership to inform the commissioning of TB services for adults and children across the BNSSG area in line with national guidelines; overseeing implementation of the National Collaborative Strategy for TB through a local BNSSG TB Strategy and annually revised Action Plan; ensuring commissioning managers are providing adequate assurance regarding the provision of TB-related services and highlighting any significant performance issues. 2.8 The Network has representation at the TB Control Board and its work is informed by a quarterly TB Cohort Review of patients being treated within their geographic boundaries. 2.9 Cohort reviews aim to strengthen the prevention and control of TB through a review of case management and assessment of outcomes compared to local and national TB targets. They provide an opportunity to identify unmet health and social care

3 needs of cases and highlight system-issues in the TB control pathway at case-level. Additionally, they provide oversight of the reliability of data on the national Enhanced TB Surveillance System and local TB registers as well as providing an opportunity to share best practice between practitioners and consultants in attendance. 3. Health Needs Assessment and Strategic Priorities 3.1 The aim of the Health Needs Assessment was to help the Network to understand the epidemiology of TB for its geographic catchment and identify unmet health needs of the affected population including barriers of access to community services. The report will inform and support the development of a local TB strategy and Action Plan in line with the Collaborative TB Strategy for England 2015 to 2020, national clinical guidelines and best practice. 3.2 From the full report, the following areas are important to highlight: TB screening and pro-active case finding is limited amongst vulnerable population groups and other migrants who are not captured by the eligibility criteria of the current prospective LTBI service and is considered a gap in current TB service provision. In BNSSG, 10.5% of the population are non-uk born, but account for more than half (65.9%) of notified TB cases and these cases are likely to be attributable to reactivation of latent TB which mostly occurs within ten years of entry % of TB cases in BNSSG experienced a delay from symptom onset to treatment commencement of more than 4 months and therefore more work is required to improve early diagnosis. The proportion of cases with a delay of more than 4 months was higher among UK born cases compared with non- UK born, which may be explained by a lower awareness that UK-born patients with no risk factors can also present with TB Despite a low number of paediatric cases compared to adult cases, TB in children is increasing in BNSSG. Consultant paediatricians at Bristol Hospital for Children receive no specific funding for TB care and have limited capacity to provide this service. There is no dedicated TB nurse to undertake outreach concerning paediatric cases The new Bristol pathway model for providing BCG vaccination has got several disadvantages such as patient waiting lists, delays to vaccination, travel required to access vaccination. These difficulties may discourage patients to take up the vaccination.

4 3.3 The Network is now formulating its strategy and action plan. The following priority areas are being considered for focused action: Work with service users / at risk communities to identify barriers of access to treatment services Early diagnosis to reduce the time from symptom onset to treatment commencement (e.g. extensive education campaign across primary care and voluntary sector organisations) LTBI Screening Programme expansion to identify resources from commissioning organisations to roll-out a retrospective screening programme for those who have entered the UK from high incidence countries in the last 10-years Develop outreach services to support active case-finding in at risk groups (e.g. explore feasibility of sputum screening in homeless community). These services should look at opportunities to improve health in other areas (e.g. Blood Born Virus Screening) Work with NHS England and the Screening and Immunisations Teams to maximise BCG uptake in eligible new-borns; Review TB services in paediatric services and identify opportunities for service improvement / re-specification against national spec.

5 4. Latent TB Infection Screening Programme in Bristol - Update 4.1 In January 2015, the Collaborative Tuberculosis Strategy for England identified 10 million of funding to establish new migrant LTBI testing and treatment services in areas with high incidence (>20 per 100,000) in order to prevent active TB disease in the future thus reducing incidence of the disease. 4.2 In Bristol, the programme once fully rolled-out will offer all new patients registering with a GP practice (or identified through The Haven 1 ) who meet the eligibility criteria a latent TB screening test. This is a single blood sample resulting in a referral to TB secondary care providers for follow up if a positive result is received. 4.3 Individuals are eligible for screening if they are aged years, entered England from a high incidence country ( 150/100,00 or Sub Saharan Africa) within the last five years and been previously living in that high incidence country for six months or longer. 4.4 The service is being delivered in three phases and phase 1 began in January 2016 across five GP practices with the highest need and The Haven; phases 2 and 3 will see the service delivered across the remaining GP practices in Bristol. 4.5 Significant internal resource has been assigned to planning and implementing the pilot. The initial funding received was allocated to our internal project management arrangements (lead executive director, lead senior manager and a project manager who are working intensively on the pilot start up). Additionally, the project has received excellent support from PHE and other colleagues from within the CSU to ensure support, reporting and monitoring are in place. 4.6 To date, 3 practices and the Haven have begun testing eligible patients. At the end of April 2016, 37 tests had been performed and 10 patients found positive with LTBI. Next Steps 1 The Haven offers asylum seekers and refugees across Bristol a comprehensive health assessment

6 5.0 The Deputy Director of Health Protection will present priority areas of action to relevant strategic forums in the BNSSG Network for discussion and adoption. 5.1 BNSSG Network to finalise its TB strategy and oversee the delivery of its action plan and maintain a risk register concerning delivery. 5.2 BNSSG Network will continue to support the TB Board and identify further opportunities to deliver its plan alongside other Network pla

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