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.

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 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:

• How long it has been since they lived in the high prevalence country?
PROPOSED • How long they lived in the high prevalence country?
SERVICE MODEL
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.

GP PAYMENTS:
GP incentive for each patient that has an LTBI screen £5 per patient
GP payment for each positive LTBI test (20%) £20 per patient
FUNDING
GP payment for each active TB identified (3) £100 per patient
REQUIRED AND
RATIONALE
TESTING COSTS:
IGRA testing cost £32 per patient

TREATMENT COSTS:
TB Clinic Payment for each positive LTBI test £460 per patient*
Active TB Not funded
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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 2 - over 4
Phase 1 years
(prospective) (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

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 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 (20Care) @ £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.

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
DATA COLLECTION pathology)
& KPIs - Number of positive LTBI screens
- Number of patients given treatment for Latent TB
- Number of active TB cases identified
- Patient satisfaction scores (TB clinics)

PROPOSED CRO Christine Falzon (Project Manager)

PROPOSED SRO Helen Delaitre
The pilot will not negatively impact any patients based on:

 Gender
 Sexual Orientation
 Religious Beliefs
EQUALITY IMPACT  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.

Approximately 3-5 patients could have active TB creating a cost pressure of approx. £13k
SYSTEM IMPACTS 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.
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 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.

 Operational Effectiveness
QUALITY IMPACT 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.

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APPENDIX 1: List of Countries with high incidence of TB.