Hospital designs an outreach service to facilitate early diagnosis and interventions for preventing risk of tuberculosis and hepatitis C, delivering screening and healthcare to over 100,000 people

Outline:

UCLH Find&Treat is a unique, highly innovative health service designed to meet the needs of homeless and vulnerable people at high risk of tuberculosis (TB) and other serious health problems. This pan-London specialist outreach team takes state-of-the-art diagnostics and care to the streets to ensure early diagnosis, and supports patients to complete treatment and address the social problems that put them at risk in the first place.

As in many big cities, the TB and blood-borne virus epidemic in London is concentrated in vulnerable and socially excluded populations. Numbers of homeless people sleeping rough has increased by 134% in London and nationally since 2012 and the health needs of this population are acute and often unmet.

The Find&Treat team are highly multidisciplinary including former homeless patients, nurses, social and outreach workers, radiographers, and technicians. Engagement begins on a specially designed Mobile Health Unit (MHU) providing digital x-rays to over 8,000 patients every year, point of care testing for TB and Hepatitis C and immunisations against influenza, pneumococcal pneumonia and Hepatitis B.

Every patient benefits from accessing the screening service and those with onward care needs are supported by the outreach teams to engage with and complete treatment.

Challenges:

Find&Treat aims to address the extreme health harms of exclusion and inequity. Increased numbers of people are now facing social exclusion characterised by homelessness, drug and alcohol misuse, and destitution. These intersecting populations experience the greatest burden of undiagnosed and unmanaged infectious, mental and chronic diseases and the worst health outcomes.

The goals of the Find&Treat service are to promote early diagnosis, improve health outcomes and prevent serious public health consequences including onward transmission and the emergence of drug resistance. People facing extreme exclusion have problems using our NHS. Patients with multiple health issues, compounded by addiction and social problems, often get appointments with different teams, confused messages and commonly disengage with treatment.

This perpetuates exclusion and drives transmission of serious infections, reliance on emergency care, preventable morbidity and premature death. Find&Treat have pioneered an integrated model the works collaboratively with over 200 health and social care partners to address the underlying social determinants of disease and cement patients care into high quality mainstream services.

The service is recognised by WHO and NICE as a model of best practice and has been independently evaluated as highly cost-effective and potentially cost saving.

Outcomes:

What sets the service apart is a relentless drive to bring the best available diagnostics, preventive interventions and onward care directly to patients, tailor care directly to their needs and circumstances, and generate evidence of effectiveness. Since 2005, Find&Treat have outreached screening and health care to over 100,000 homeless and vulnerable people and provided intensive case management and social support to almost 4,000 patients with active TB and hepatitis C.

Treatment for TB requires a minimum of six months daily medication in order to achieve cure and prevent drug resistance. The MHU continues to detect very high rates of active TB (247 per 100,000 individuals screened) and 84% of cases found successfully completed treatment within 12 months; higher than the proportion of cases who complete TB treatment nationally.

Detection rates for Hepatitis C are even higher, with over one-third of persons tested requiring treatment. Almost 90% of homeless patients commencing Hepatitis C treatment achieve cure. Treatment is supported using direct observation either in person or using a bespoke secure Video Supported Care App.

Integrating both testing and treatment pathways leads to improved patients engagement, care outcomes and efficiency. The service is now potentially cost saving.

Spread:

Homelessness is a national problem and Find&Treat are regularly commissioned to screen in major towns and cities across the country. This is recommended by NICE as best practice to strengthen TB control among vulnerable populations. Many areas now routinely commission the service to screen local homeless hostels, day centres and drug treatment projects. In addition to screening high-risk groups in London, Find&Treat also support PHE to manage public health incidents and outbreaks nationally.

There is only one MHU in England equipped with digital radiology that can provide a onestop-shop TB screening service for people potentially exposed in congregational settings such as schools, factories and prisons.The team also work extensively with PHE Health and Justice Team and Home Office supporting screening initiatives in detention and migrant assessment centres. The Find&Treat model is internationally recognised by both ECDC and WHO.

The teamwork in close partnership with teams in Ireland and Romania, and have been instrumental in establishing MHU’s and specialist outreach teams in both these countries. Future work will extend the model into high burden settings where poverty and poor access to health services is fuelling the global TB, HIV and viral Hepatitis pandemic.

Value:

Understandably much emphasis is put on prevention to improve health care outcomes and to control ever increasing costs of medical care. The treatment of highly prevalent diseases such as tuberculosis, blood borne diseases and infections is expensive and can be prevented by early detection and appropriate interventions, which could also contain further spread of the infections.

In addition, appropriate treatment may prevent antibiotic resistance, which is a growing problem in TB. Homeless and socially weak people have difficulty in accessing NHS care for various reasons. The Find & Treat initiative is actively meeting this group in places where they come together for other reasons utilising a mobile van and offer preventive and therapeutic services for common health care problems.

The service is fully integrated across various health care providers, simple and highly cost-effective. An economic analysis a few years ago estimated that the service has a net cost of £1.4 million/year and, under conservative assumptions, gained 220 QALYs. The incremental cost-effectiveness ratio was £6400-£10 000/QALY gained (about €7300-€11 000).

The Find and Treat components were also cost-effective, even in unfavourable scenarios (mobile screening unit (for undiagnosed cases), £18 000-£26 000/QALY gained; case management support team, £4100- £6800/QALY gained).

Involvement:

Find&Treat is an exemplar of the importance of health service co-design. The service has continually adapted to meet the needs of the population served and maximise health opportunities and outcomes. The outreach team includes a high proportion of people with lived experience of homelessness and its health consequences. The team use this knowledge to ensure that the service is accessible, welcoming and flexible and to advocate effectively for homeless people, many of who have previous negative experiences of trying to use health services.

Partnership working is a key ingredient to our success. Forging relationships with over 200 third sector health, social care and NHS allied providers nationally has enabled us to work seamlessly across geographical and organisational boundaries and provide holistic individualised care to patients with multiple and complex needs. Training and educating our partners has enabled us to extend care and support into non-traditional health care settings including homeless hostels, emergency shelters day centres, drug treatment services, and custodial environments.

Find&Treat have an impressive track record of engagement with policy makers, charities and patient advocacy organisations. The team have contributed evidence and expertise to multiple national and international guidelines and service standards. The project continues to learn and improve.