PROPOSAL FOR NEW LATENT TUBERCULOSIS (TB) SCREENING SERVICE TO BE FUNDED BY NHSE/PHE PROJECT TITLE NHSE/PHE TB Funding Request Proposal for LTBI Testing PROPOSED BY Christine Falzon (Project Manager) EMAIL christine.falzon@nhs.net PHONE NO Tel: 01895203038 DATE SUBMITTED Hillingdon CCG has a TB incidence rate of 36 per 100,000 population with the South of the Borough being a very high prevalence area ( 150 per 100,000). This is probably due to the higher proportion of foreign-born immigrants from high prevalence countries like India, Pakistan and Sub-Saharan Africa in this area. PURPOSE & BACKGROUND Based on 2011 2013 average numbers of TB notifications (123 annually), it is estimated that 1,206 Hillingdon residents (prospective, new GP registrations) should be offered a LTBI test over the next 5 years. Of these 20 25% are expected to be positive and require treatment for LTBI infection. Retrospective screening for patients meeting the criteria who have registered with a GP over the last 5 years will screen approximately the same number of patients per year. A proposal will need to be submitted to NHSE for funding. The LMC will need to approve the proposal as well. A BHH plan has been submitted (but not approved) by the LMC which has requested further detail on GP workload. This document will provide the detail for Hillingdon. 1
Commissioning Guidelines recommend that patients who meet the following criteria are screened for latent TB: - Aged 16-35 years - Entered the UK from a high incidence country ( 150/100,000 or SSA) within the last five years and been previously living in that high incidence country for six months or longer. The Hillingdon Service will consist of two phases as proposed by NHSE and the LTBI Commissioning Guidelines; Phase 1: Offering LTBI screening of all prospective new registrants from high risk countries. This will run for the first year and enable the services to become established before moving on to Phase 2. Identification will be done at registration with the GP practice by adding two questions to the existing registration form asking: PROPOSED SERVICE MODEL How long it has been since they lived in the high prevalence country? How long they lived in the high prevalence country? Those that meet the above criteria will be called by practice staff and offered an IGRA test (ordered using the existing blood test forms) through services delivered centrally in two (existing) LTBI testing clinics in Hillingdon the Community TB clinic and Hillingdon Hospital Microbiology Laboratory. Patients found to have latent or active TB will have to be referred to secondary care TB clinics, although some of the treatment may be delivered in the community. Prospective screening will be expected to continue GP funding is for set-up in the first year. Phase 2: Offer LTBI screening to patients that have registered over the last 5 years who have previously lived in high risk countries. The retrospective component (Phase 2) will be delivered using an EMIS search developed by the CCG. Patients identified will be sent a letter by practice staff and offered an IGRA test. Patients with latent TB may also need to have HIV and Hepatitis B & C tests as per pathway. The following costs were used to develop the request for funding as indicated in the commissioning guide and determined through liaison with NHSE TB lead. FUNDING REQUIRED AND RATIONALE GP PAYMENTS: GP incentive for each patient that has an LTBI screen GP payment for each positive LTBI test (20%) GP payment for each active TB identified (3) TESTING COSTS: IGRA testing cost 5 per patient 20 per patient 100 per patient 32 per patient TREATMENT COSTS: TB Clinic Payment for each positive LTBI test Active TB 460 per patient* Not funded 2
HIV/Hep B & C Not funded - approx. 8 per test *Refers to cost of one first and two FU outpatient respiratory medicine tariff plus MFF. This would include nurse/doctor time/drugs/x-ray and basic blood tests i.e. LFTs. Total Costs requested from NHSE based on the above costs relating to projected Hillingdon figures are as follows: For Phase 1, set-up of prospective screening for new registrants, GPs will be incentivised to set up the process as detailed above. This is however expected to continue and become business as usual after the first year. For Phase 2, retrospective screening of patients from high prevalence countries that have registered with a GP practice within Hillingdon since 2010 shows 13,366 new patients in total (Source: EMIS ) 2673 per year. However at this stage it is difficult to understand how many of these were born abroad and meet eligibility criteria. A phone call will be made by practices to each patient identified where it is not clear to the practice whether they are new immigrants that meet criteria or not. Those that meet criteria will be sent a letter as per NHSE pathway and invited for screening at the two central locations. The same figures provided by PHE for prospective screening were used as a estimate for patients who will be eligible for LTBI retrospective testing (as advised by PHE). This equates to 45% of new patients registered from high prevalence countries per year. Phase 1 (prospective) Phase 2 - over 4 years (retrospective) Projected no. of patients that will require screening 1207 4828 GP incentive for screening 1207 pts (@ 5 per pt) 6,035 24,140 Projected no. of patients with positive latent TB test (20%) 241.4 965.6 3
GP payment for positive latent TB test ( 20 each) 4,828 19,312 IGRA Test Costs ( 32 each) 38,624 154,496 Active TB (3% of +ve cases @ 100 each) - GP cost 300 1,200 Positive latent TB - Treatment cost (2 0 Care) @ 460 per case 111,044 444,176 TOTAL 160,831 643,324 TOTAL FUNDING REQUEST = 643,324 + 160,831 = 804,155 The first 3 months of funding from NHSE will be determined by the above projection figures. Following this, data returns will be expected by NHSE and funding will be amended depending on actual figures and paid on a monthly basis. DATA COLLECTION & KPIs PROPOSED CRO PROPOSED SRO The following activity and Quality Outcomes will be collected: - Number of GP requests for LTBI screening - Number of patients screened (attendance to community TB clinic and THH pathology) - Number of positive LTBI screens - Number of patients given treatment for Latent TB - Number of active TB cases identified - Patient satisfaction scores (TB clinics) Christine Falzon (Project Manager) Helen Delaitre The pilot will not negatively impact any patients based on: EQUALITY IMPACT Gender Sexual Orientation Religious Beliefs Ethnicity The NHSE funding for the service is limited to patients between the ages of 16-35, however other patients identified to need testing and treatment will be treated along existing pathways. CARERS IMPACT No negative impact on carers has been identified. Positive LTBI tests may require HIV, Hep B and C tests creating a cost pressure of 5,784 per year if all positive patients had to have all 3 tests. In reality test numbers will be lower than this. SYSTEM IMPACTS Approximately 3-5 patients could have active TB creating a cost pressure of approx. 13k per year. The total cost pressure for services not funded by NHSE may amount to a maximum of approximately 18k per year. This does not include additional screening and contact tracing that may be required outside the 16-35 age range which is likely to be minimal and is difficult to quantify. 4
This programme will have a positive impact on quality of services for TB patients by: Clinical Quality and Safety Patients with latent TB will be identified preventing the likelihood of them developing active TB in future. This will also reduce the likelihood of spreading TB to family members. QUALITY IMPACT Operational Effectiveness The central testing will ensure quality of the tests and minimise re-testing as agreed (unanimously) by local TB specialists. This will also ensure operational efficiency using existing services. Trust and/or CCG Reputation This is a national program and Hillingdon CCG is expected to make a viable proposal to NHSE to obtain funding. 5
APPENDIX 1: List of Countries with high incidence of TB. 6