Newham has been described as “the TB capital of the West” in the national press. To address this challenge NHS Newham Clinical Commissioning Group (NCCG), working with local health and social care partners, has created an innovative latent tuberculosis infection (LTBI) screening and treatment programme.
Launched in July 2014, the programme targets people aged 16-35 from a defined list of high risk countries and who have been in the UK for five years or less. The programme draws on best practice but, uniquely, screening, treatment and follow-up are all based in primary care.
This innovative approach gives patients greater choice in treatment, significantly reduces cost and has boosted the numbers of patients being screened and treated. This cost effective model also reduces the impact on hospital TB services, reducing waiting times for other high risk TB patients.
As well as identifying patients with latent TB, the LBTI screening has also been successful in uncovering active TB patients that are asymptomatic and who may have otherwise presented late to the TB team. We project that over the medium to long term, the programme will significantly reduce the rates of active TB in Newham and in London overall.
For many years, the London Borough of Newham has seen high incidences of TB – higher than anywhere else in London and the UK and even greater than rates in some developing nations. One third of Newham’s young, ethnically diverse population was born overseas, many from countries with high levels of TB, and there is a low level of understanding about the condition, even among those most likely to be affected.
Another challenge is raising awareness of latent TB. Around 10% of people with latent TB will develop active TB in the future. Once active, TB is contagious and can be spread to others if it is not caught and treated. Engaging with a diverse, seldom heard audience to develop an approach that would work for them was another challenge.
A focus group showed that this audience predominantly saw TB as affecting older people in poor health, not younger people, and demonstrated that there is a huge stigma attached to TB, making people worried to talk about it openly. Once screened positive, it is also a challenge to encourage patients to have three months of treatment for an asymptomatic condition, when there is only a 10% chance of it becoming active.
Since the LBTI programme launched, rates of TB in Newham have been steadily falling - from 78.0 per 100,000 in 2014 to 48.1 in 2017, demonstrating the effectiveness of the programme. All 51 GP practices in Newham now actively screen patients and 16 community pharmacies are trained and commissioned to counsel and treat patients. Between April 2016 and March 2018, 5,616 eligible patients were screened and 969 identified as having latent TB.
As a result, 375 patients have started LTBI treatment. Under the new service, patients fitting the criteria who register at any GP practice are screened for LTBI. Healthcare professionals talk to them about active and latent TB, and at their introductory health check they are offered an interferon gamma release assays (IGRA) blood test.
Patients with positive results have a consultation with their GP, are given information about latent TB and can choose treatment in one of the 16 CCG-accredited pharmacies. The GP sends an electronic prescription to the chosen pharmacy for a three-month treatment programme.
The pharmacist dispenses the treatment monthly, monitors the patient at each visit (based on an agreed protocol) and reports on progress to the GP and, if necessary, the acute trust TB consultant.
The learning from NCCG’s programme has played an integral role in the development of NHS England’s national screening specification. NCCG is acknowledged on this screening specification and the Newham new patient registration LTBI clinical template has been replicated nationally.
NCCG’s programme was also scrutinised before the Department of Health’s decision to invest £11m for CCGs nationally to mobilise LTBI services in Newham’s experience and innovation in LTBI screening has become an example of best practice for tackling TB early, and NCCG has actively supported other CCGs in implementing their programmes, including the CCGs in north east London.
Because of its experience in LBTI screening, Newham is represented on the London TB Control Board, is also the lead commissioner for the London Laboratory IGRA contracts and administers the London CCG accommodation funding process for homeless active TB patients with no recourse to public funding.
Newham’s approach to LTBI is now the subject of a National Institute for Health Research approved trial. Designed to identify whether a primary care model for LTBI screening and treatment in migrants is more effective than secondary care, the trial results could then be used as clinical evidence to adopt the model both nationally and internationally.
Treating a person with LTBI in primary care is at least 3.6 times less expensive than treating them in hospital. On average (not including prescription medicine) it costs £598 for three months treatment at hospital, compared to NCCG’s primary care-based LTBI treatment which costs £165 from diagnosis to completion with a pharmacist.
Treating 375 patients in primary care rather than in hospital has saved the NHS more than £162,000. Furthermore, it has saved against the even higher costs to individuals, families, communities and the NHS threatened by a fraction of these 375 patients developing active TB.
The programme has improved chest X-Ray coverage for positive LTBI (a key KPI) from 26% in the early days of our implementation to 79% in 2016/17. We have also improved the use of the Electronic Prescription Service (EPS) for this service by 25% from 60% to 85%.
The scale of the programme in Newham is reflected in the most recent Public Health England report “Tuberculosis in England”. The report explains that 19 CCGs now screen migrants for latent TB, and that between 2014 and 2017 Newham’s programme accounted for 42% of all tests performed nationwide.
Following NICE guidance on targeted LTBI treatment Newham CCG, the borough public health team and Barts Health NHS Trust undertook detailed analysis to develop the criteria for who should be screened. A targeted focus group was then held to better understand how to engage with this audience. The results showed a lack of awareness about TB and a stigma around talking openly about the disease.
Because of this, and the diverse backgrounds and languages of the target group, a mass marketing approach was not recommended. Instead trusted medical professionals (e.g. practice nurse, GP and or pharmacist) talked to patients one-to-one, explaining the condition at point of contact.
An information leaflet was developed with the support of TB Alert, the national TB charity. A LTBI working group (consisting of a GP clinical lead, hospital TB consultant and nurse, community provider, council health official, NHS England adviser, medicines optimisation adviser, community pharmacist and the head of Public Health England LTBI screening) developed screening and treatment guidelines including advice on adverse effects of TB medication.
These guidelines and advice were disseminated to GPs, pharmacists and allied primary care professionals and training was provided on the protocols and pathways to delivering the new service.