Tuberculosis

Baroness Jolly Excerpts

Thursday 11th December 2014 Grand Committee

[Baroness Jolly (LD)]

My Lords, I am grateful to my noble friend for securing this important debate, which has proved to be fascinating, and to all speakers for their informed and thoughtful contributions. I, too, commend the work of the APPG on TB and declare that a couple of years ago I, too, went courtesy of RESULTS UK to see TB in Zambia. I have many questions from noble Lords. Should I run out of time, I will write and post a letter in the Library.

There are considerable inequalities in the distribution of TB cases in England with respect to age, ethnicity, sex, location and socio-economic status. TB today is largely a disease of poverty and inequality. Underserved and marginalised members of our communities have the highest rates of TB and the greatest risk of onward transmission. The Chief Medical Officer has identified the inequalities associated with TB as an important priority for England and the Health and Social Care Act 2012 has placed a duty on local government, clinical commissioning groups, Public Health England and NHS England to reduce inequalities.

In response to the high rates of TB, Public Health England and NHS England will launch the Collaborative Tuberculosis Strategy for England 2015-2020 in January. The draft strategy was widely consulted on in the summer of 2014, with the active input and participation of a wide range of stakeholders and partners across the Department of Health, the NHS, local government, Public Health England and the third sector. It is jointly developed to improve national TB control, with the aim of achieving a year-on-year decrease in TB incidence and a reduction in health inequalities, with a particular emphasis on bringing improvements in the areas with the highest rates of TB. NHS England and Public Health England are committed to resourcing the implementation of the strategy, and precise funding mechanisms are currently being finalised. The strategy will establish clear lines of responsibility for TB control at a national and local level, and provide a framework for the commissioning of TB services that takes into account all aspects of the patient pathway.

Most cases of TB are found in large urban areas: London, West Yorkshire, the West Midlands, Greater Manchester, Leicester and Luton. The noble Lord, Lord Hunt, inquired about the situation in London. I have just asked my officials what role the London Assembly and the mayor have in all this, because that is the overarching body for all boroughs. Public Health England London advises the mayor on all health issues via the Public Health England London director, who also chairs the London TB control board, so there is someone who has a handle on all this.

To follow up on the issue of funding, there is no TB weighting in either the local authority or the NHS funding formulae, but there are special TB tariffs for TB care within the NHS tariff system. The majority of cases are in deprived areas. TB is more likely to occur among settled migrants, those with connections to high-incidence countries, ethnic minority groups, the elderly and those with social risk factors including homelessness, a history of imprisonment or drug or alcohol use. The lifestyles of those most at risk often mask the symptoms of TB, which can cause problems accessing and completing appropriate care. This in turn creates inequality in outcomes.

The noble Baroness, Lady Masham, inquired about providing accessible health services to the homeless. This particular group can face great inequalities in accessing health services, yet their health can often suffer just from being homeless or living in poor quality temporary accommodation. Poor health, whether physical, mental or both, can also cause a person to become homeless in the first place. Homeless people may often leave health problems untreated until they reach a crisis point, and then present inappropriately.

My noble friend Lady Suttie asked about the response from global health R&D and the licensing of newly approved TB drugs. In 2012 Ministers of Health called on the WHO to develop a post-2015 global TB strategy in order to have a world free of TB and zero deaths, disease and suffering caused by TB. This is in recognition of the need to address the disease globally; in 2013 it affected nine million people around the world. As my noble friend has already told us, it has killed 1.5 million. To achieve this reduction, the strategy sets out ambitious global targets for the reduction of TB incidence and mortality and the individual costs of illness, with targets and milestones up to 2030.

The collaborative TB strategy contains 10 areas of action which will underpin local prevention and control services. It makes provision for a whole-system, evidence-based approach across the whole health and care system. Implementation will be supported by a small team working with local and regional experts ensuring delivery through existing structures. This structure will provide accountability, reinforced by national oversight provided by NHS England and Public Health England. A formal monitoring framework will be put in place with effect from 1 April 2015. It will monitor performance at local and national levels. Public Health England will provide annual monitoring reports on a suite of indicators relevant to the control of TB at geographical and organisational levels.

My noble friend Lady Ludford was talking about comparisons with major cities across the world. The TB strategy will address this issue. It should bring organisational change and funding improvements, focusing on TB control. There is a focus on public health in England because incidence is more than four times as high as in the US.

The noble Baroness, Lady Masham, inquired about the incidence of multidrug-resistant TB in the UK and asked why it was lower in other European countries. The incidence of MDR TB in the UK is not higher than in the rest of Europe. However, the proportion of multidrug-resistant TB cases in the UK has increased from 0.9% to 1.6%.

My noble friend said that London is regarded as the TB capital of western Europe. London has 35% of the UK total, with 2,965 cases reported in 2013—a decrease from the 3,403 cases reported in 2012. This concern is being recognised and work is currently under way to draft the implementation plan for London that meets London’s needs. A number of CCGs and local authorities with the highest TB rates are already working with Public Health England and NHS England (London) to implement latent TB case finding, and with TB Alert, a third sector organisation, to raise awareness within their communities. London has a TB service specification with key performance indicators that are being used to ensure that TB service providers are able to meet local population need. London is also looking in depth at the mortality of TB patients, scoping BCG provision and accommodation for “no recourse to public funds” TB patients and those with chaotic lifestyles.

My noble friend Lady Suttie inquired about general prison awareness issues. Much is being done to raise awareness of TB in prisons in the UK and to help to educate prisoners. This awareness-raising is arranged locally by health protection teams.

My noble friend made reference to the work of Find & Treat. My honourable friend Jane Ellison MP, the Minister for Public Health, met representatives of the Find & Treat service when they visited Parliament in March this year. Dr Alistair Story, the service’s clinical lead, has been involved in the development of the TB strategy and its plans for the expansion of an outreach service, similar to Find & Treat, for the rest of England. I would be happy to join any noble Lords on a visit to Find & Treat and Olallo.

The vast majority of TB cases can be cured when the medicines are provided and taken properly. Active, drug-sensitive TB disease is treated with a standard six-month course of four antimicrobial drugs with the support of specialist healthcare staff and additional support, as required, from social care support staff. Without such supervision and support, treatment adherence can be difficult and the disease can spread or manifest in drug-resistant form.

With regard to the issue of delayed diagnosis and what is being done to tackle it, poor access and late diagnosis result in more advanced and complex disease, with greater morbidity, mortality and cost. The Royal College of General Practitioners has an e-learning programme—which is available to all primary care staff—to raise awareness of TB, especially the signs and symptoms of TB disease.

As to R&D, the UK Government support a range of research programmes to promote the development of new diagnostics, drugs and vaccines. The MRC is one of the main agencies through which the Government support medical and clinical research. It receives its grant in aid from the Department for Business, Innovation and Skills and supports a wide portfolio of research, including the current UK-based research into new TB drugs.

Through effective localised commissioning of TB treatment services, we are able to place patient safety at the forefront of the work in the UK. The collaborative TB strategy paves the way for this to happen. The measures contained in the strategy are comprehensive and far reaching. To ensure that they are brought to fruition, PHE and NHS England will oversee implementation, monitor progress and publish reports. The strategy will set out what needs to be done both at a national and local level. It will be aimed at a range of key partners, including in health and social care and the third sector at a local level, which will be empowered to ensure that the clinical priorities affecting their communities are effectively addressed.

Committee adjourned at 5.51 pm.