Tuberculosis

Baroness Ludford Excerpts

Thursday 11th December 2014 Grand Committee

[Baroness Ludford (LD)]

My Lords, I thank my noble friend Lady Suttie most sincerely for giving us the opportunity to debate this important subject. I acknowledge an interest in that my husband is chairman of the board of the Whittington Hospital, which is one of the hubs for the innovative TB Service North Central London, which I will mention later. I thank Dr Helen Booth, a consultant thoracic physician and TB clinical lead for that hub at the Whittington, for briefing material. I also appreciate the briefing from Results UK, the NGO that my noble friend mentioned. I also draw on evidence from the London TB clinical leadership advisory group.

I have no health background or expertise except some involvement in diabetes, but the more that I briefed myself on this subject, the more interested and alarmed I became. Having formerly had the privilege of being the elected representative for London in the European Parliament for 15 years, I was naturally very impressed with the fact that London, as has been mentioned, has the highest rates of TB of any capital city in western Europe—indeed, I believe, in the developed world—that the London Borough of Newham has rates equivalent to Nigeria, and that England is set to have a higher rate than the United States in 2015. These statistics are all very impressive. Unlike other major cities such as New York, Barcelona and Paris, London has not seen a reduction in TB rates, and accounts for almost half of the approximately 8,000 cases nationally. As a Londoner, I find this topic very important, and I am grateful to my noble friend for drawing attention to it.

The evidence suggests that in London the majority of new cases, around 75% or 80%, are due to the reactivation of latent infections after TB has been acquired in a high-risk country outside the UK, but of course if that latent infection is reactivated it acts as a source of infection for those in close contact with that person, including their family and children.

I mentioned the North Central London TB service, the NCL, which is an innovative service providing holistic care to TB patients. It has seen reductions in TB rates. It includes the outreach service, mentioned by the noble Baroness, Lady Masham, of the mobile X-ray and Find and Treat team based at University College Hospital, as well as a TB link project, which demonstrates the importance of an integrated social care team. It has introduced a cohort review into London and the UK, based on a New York model of TB control, and since 2007 it has had a united nursing, social care, outreach and administrative team. Lastly, it has concentrated non-in-patient services to two hubs in north central London—that is, the Whittington and the North Middlesex—instead of previously having had five sites. So this is a concentrated focus with consistent nurse leadership, avoiding the fragmentation of the nursing team and better able to tackle inequalities in the provision of care.

It has been mentioned that the national TB strategy is in preparation and I am advised that this needs to result in changes to the current model of fragmented care. However, as other noble Lords have said, it is important to acknowledge that success in TB control must involve agencies other than the health service and must address the social factors involved, which have also been mentioned. Homelessness is probably top of the list. It increases the likelihood of exposure to TB and also makes managing the care and treatment of patients very difficult. Treatment is quite arduous and requires a sustained commitment from the patient, which may be difficult in adverse social circumstances, particularly homelessness. It is a good illustration of why a co-ordinated approach between health and social care is vital.

Other factors include overcrowding, poor housing, poverty, poor access to health care, drug or alcohol dependency, HIV/AIDS and the social stigma which exists in certain individuals, cultural groups and society in general. This can lead to people having great difficulties with treatment compliance.

The rates of TB among the homeless community in certain parts of London have been recorded as up to 35 times higher than the national average. As the disease attacks people with reduced immune systems, the impact of rough sleeping, poor nutrition and chaotic lifestyles increases the chances of developing TB in the first place. Members of the homeless community are less likely to present to primary healthcare when experiencing symptoms. It is a vicious spiral because they are likely to remain infectious and transmit the disease to others, develop more severe and difficult-to-treat symptoms and increase the likelihood of developing drug resistant strains. Again, this is an illustration of the importance of taking a holistic view.

As I understand it, once a person is admitted, hospitals cannot discharge people without a home address, and a patient who cannot be discharged might cost the NHS more than £100,000 in bed fees alone. Not only is this expensive but it blocks access to in-patient treatment for other patients. One estimate that I have been given is that the cost of providing a hospital bed for a week would provide secure accommodation for all patients without housing for a year. So provision of housing can help break the cycle.

My noble friend mentioned the Olallo project in Euston, which is able to provide, on a more cost-effective basis, food, room, training, language skills and social support for TB treatment which helps the patient to recover. I am invited to invite the Minister to visit this project if she has not had the chance to see the positive impact of specialist accommodation.

Not only do we need a focused approach in the health service but a multiagency approach between the health service, housing authorities, the health and well-being boards of local authorities and other agencies. This approach goes a long way to account for the success in New York, Barcelona and Paris, which have achieved impressive and sustained reductions in infection rates. Not only do these cities recognise the problem but they have a unified, city-wide strategy to identify, treat and prevent transmission of TB.

That is the challenge in London, which is starting to be met. Significant progress has been made and now that the NHS and social care changes are bedding down there is a good prospect of success. A London TB control board has been established—I believe it has been suggested that control boards should be established nationally—which has on it all representative stakeholders. It is important that London, as the highest prevalence area in the UK, is an integral part of the national TB strategy.

Finally, I quote from Dr William Lynn, who is the clinical lead for TB and chair of the London TB Clinical Advisory Group, he said,

“health and social care (including housing) must work towards common, agreed London Wide service delivery and make the resources available to establish the detection and treatment of latent TB as the benchmark standard of care. Without this we fear that we will continue to fail the population of our Capital City and TB rates will not fall”.