TB and commissioning

William Roberts

TB Network Manager

There are some certainties in life

What are we all moaning about?

• TB is under funded

• Revenue from TB services rarely heads back into the TB service

• TB services work very hard for very little money

• TB is incredibly cost effective to treat using any measurement

“We have seen an unprecedented level of investment in the NHS” Tony Blair 2006

So where has the money gone?

• Increase in managers in the NHS• Consultant contract• GP contract • Agenda for Change• A&E 4 hour wait• 2 week cancer target • 13 week outpatient target• Not to mention we all like new technology, IT,

Drugs, scanners

Health should not be limited by money but…

• Health is a limited commodity

• When demand outstrips supply, there is a need for rationing

• How do you decide what services to deliver?

• What is your biggest priority?

• What do you need to do to deliver the most appropriate care to your population?

How much does anything cost?

• 1 TB nurse• £45,000 based on

mid point band 7 with on costs

What else can you buy for £45,000

• 900,000 sheets of computer print outs

• 375,000 syringes• 90 days of ITU care• 0.5 of a Consultant post• 625 monthly courses of TB

treatment

30,000 BCG vaccine doses

1.5 courses of Herceptin

3 hip replacements

2/3 liver transplant

1/2000 tank

What is commissioning?

What is commissioning?

• Strategic Planning

• Contracting and Procurement

• Payment Settlement & reporting

• Strategic Commissioning and market management

What does this really mean?

• Ensuring the right care to the right people in the right place within the resources available

How will commissioning work in the future?

• Services will be split into purchasers (the PCTs) and providers (organisations who provide care)

• Primary care services will be commissioned through Practice Based Commissioning (PBC)

• Other services will be commissioned as a service and funded through Payment By Results (PBR)

How will commissioning work in the future?

• Payment by results will mean your trust is paid every time the activity is recorded

• Practice based commissioning will mean that any work undertaken by primary care based services will be paid tp the organisation hosting them

Person (assume adult) with signs and symptoms of active pulmonary TB

Patient attends GP. Referred to hospital Admitted to hospital to a negative pressure room

Diagnostic tests for TB. Diagnosis of fully sensitive Pulmonary TB confirmed

(B) Pathology outside and radiography

Seen in outpatient clinic for follow up appointmentwith consultant and TB nurse

(C) 2nd Outpatient appointment

Home visit from TB nurse

Follow up clinic appointmentat 2,3 4,5 and 6 months

(D) No tariff for community services.

2 home visits during treatment from TB nurse(F) No tariff for community services.

99

PbR £

Local £Pathway and payments for patients, with active Pulmonary TB

(A) 1st Outpatients appointment (Thoracic medicine 340)Non-elective spell tariff (up to 34 d - 4 weeks)

(A) (+ 17% specialised service tariff top up) or short stay emergency tariff

675

A

(A) 1. Does specific service top-up apply (p10 – appears to apply 17% to respiratory)

2. Short stay emergency tariff v. non-elective spell. TB patient would normally stay in –ve pressure

for 2 weeks . Which applies and what is the incentive intention? (Difference ./.emergency and non-

elective).

3. Does pass - through flexibility for ID isolation apply?

B

C

D

E

F

196

495(E) Follow up appointments 5 x 99

Isolation facility local flexibility

Total £1464

Person with signs and symptoms of active pulmonary TB

Patient attends A&E. Admitted to hospital to a negative pressure room

Diagnostic tests for TB. Diagnosis of TB confirmed

Patient fails to attend follow up clinic

Seen in outpatient clinic for follow up appointment with consultant and TB nurse. Commenced

on directly observed therapy (DOT)

Patient fails to attend for DOT

Patient fails to attend follow up clinic

PbR £ Local £Pathway and payments for poorly compliant patients, with active Pulmonary TB

A

B

C

D

E

F

Home visit from TB nurse

G Home visit from TB nurse

Readmitted to hospital with worsening symptoms

Home visit from TB nurse

Patient started on DOT in the community by TB nurse

Patient fails therapy and is lost to follow up

H

K

L

J

I

(A) Standard attendance at A&E

(A) Short stay emergency tariff

(B) No tariff

(C)

(E) ? 1st Outpatients appointment

(F) No tariff, but other costs?

(I) No tariff, but other costs?

(D) No tariff

(G) No tariff

(H) Short stay emergency tariff

(J) No tariff

(K) No tariff

(L)

71

196

675

675

(A) ? 17% specialised service top up and ? Pass through flexibility for ID unit stay?

(C) ? Does PbR tariff apply for DNAs

Total £1617

Person with signs and symptoms of active pulmonary TB

Patient attends A&E. Admitted to hospital to a negative pressure room

Diagnostic tests for TB.Diagnosis of MDR-TB confirmed

(B) No tariff for pathology/radiology

Remains inpatient for period of infectivityUsually 4-12 weeks

(C) If 12 week stay

Seen in outpatient clinic for follow upAppointment with consultant and TB nurse

Commenced on directly observed therapy (DOT)

Home visit from TB nurse (E) No tariff for community services.

Attends hospital 3 times a week to receive medication

(F) If this counts as outpatients appointment,Then (3 x 99) /week

11,875

196

PbR £

Local £Pathway and payments for patients, with active Multi Drug Resistant

Pulmonary TB

(A) Standard attendance at A&E

(A) Non-elective spell tariff (up to 34 d- 4 weeks) 3,375

A

(F) May be nurse-supervised medication. Does this count as outpatient appointment?

(G) Is there a limit on number of outpatient appointments under PbR tariff?

B

C

D

E

F

(D) 1st Outpatient appointment

71

Follow up clinic appointment at every month for 2 years until curedG

6 home visits during treatment from TB nurseH

(G) Outpatient appointment

(H) No tariff for community services.

297

99

Either

Or

/week

/month

Total £37792

Pathway and payments for patient with active Lymph node TB

Person with signs and symptoms of Lymph node TB

Patient referred to consultantDiagnostic tests for TB

Diagnostic tests for TB.Diagnosis confirmed

(C) No tariff for community services.

Home visit from TB nurse

PbR £ Local £

495

(A) 1st Outpatients referral (Thoracic medicine?) 196

(B) No PbR tariff for diagnostics (pathology/radiology)

Follow up appointment at 2,3,4,5 and 6 months (D) Follow up appointments 5 x 99

2 home visits during treatment from TB nurse(E) No tariff for community services.

A

B

C

D

E

(A) Would GP suspect Lymph node TB? If so, would s/he refer to specialism other than respiratory

(e.g. ? general medicine) and would internal re-referral be necessary? Does it affect additional tariff?

Total £691

Pathway and payments for paediatric patients, with active Lymph node TB

Child with Lymph node TB identified by TB nurseduring contact tracing

Seen in paediatric outpatient clinic for follow up.Appointment with consultant and TB nurse

Diagnostic tests for TB.Diagnosis confirmed

(C) No tariff Home visit from TB nurse

PbR £ Local £

600

(A) 1st Outpatients appointment (paed) 205

(B) No tariff

Follow up appointment at 2,3,4, 5 and 6 months (D) Follow up appointments 5 x 120 (paed)

Repeated phone support from TB nurse during care (E) No tariff

A

B

C

D

E

Total £805

Pathway and payments for patients requiring chemoprophylaxis

Patient with latent TB infection identified by TB nurse during contact tracing

Seen in outpatient clinic for follow upappointment with consultant and TB nurse

Follow up clinic appointment at 2, 3 months

(C) No tariffRepeated phone support from TB nurse

during care

PbR £ Local £

(A) 1st Outpatients appointment 196

(B) Follow up appointments 2 x 99

A

B 198

C

No tariff for contact tracing

Total £394

So will there be more money?

• Service will be paid based on their activity. The more patients you see the more money you generate, up to a point

• The trick will be to ensure that the money generated by TB patients will be used for TB services

How will commissioning work in the future?

• Aspects of TB services will be commissioned through different routes in a tiered model

Nowhere PCT TB rates 50:100000

• 90 TB cases per year (steady increase year on year of 5%)

• Large contact tracing workload• Large ethnic minority and new entrant population• Bordered by high incidence areas• Urban setting• Large Teaching Hospital locally• Mixture of poor and affluent areas• No local prison• Low HIV rates

Considerations

• TB rates increasing• Is a specialist service justified?• Need for Universal neonatal BCG programme• Large ethnic mix, how will population change?• Some areas may require targeting for prevention and

screening• No need for prison TB services• Where is the critical mass to support outbreak and incident

screening?• Can the local hospital provide the services required?• What needs to be specified in the Service Level Agreement

(SLA)?

Somewhere PCT TB rates 4:100000

• 10 cases per year• Largely UK born, White population• Bordered by low incidence areas• Semi-rural setting• No local hospital• Has local prison• Soon to receive new entrants as a dispersal town• Growing intravenous drug population with medium levels

of HIV

Considerations

• Will population change with time?• How can the risk to the HIV positive and drug using

populations be managed?• Where is the best place to provide hospital based services?• How will the prison population effect TB rates?• What services need to be available to the prison?• Where is the critical mass to support outbreak and incident

screening?• How can the PCT ensure patients have access to expert

knowledge?• What needs to be specified in the Service Level Agreement

(SLA)?

Measure performance against standardsPerformance management competencies for Tuberculosis commissioning PCT commissioning standard Performance measure Reported to TB services are provided through an

agreed service level agreement (SLA) A discrete service level agreement is in place governing TB control and prevention

services Provider has fulfilled contractual obligations

SHA

The PCT has ensured TB services appropriate to the local population are in place

A local specification of TB services has been agreed A local needs and risk assessment has been performed against the commissioning

framework Universal neonatal BCG is applied in all areas where TB rates are >40:100000 Selective neonatal BCG is in applied in all areas where TB rates are <40:100000 A system is in place to capture patient feedback TB is given appropriate place within annual public health report and Local Delivery

Plan

SHA

The PCT has a strategy for TB control Strategy in place

SHA

Services achieve the performance criteria identified in the TB action Plan

There has been a progressive decline (of at least two per cent per year) in rates of TB in population groups born in England

65% of Pulmonary TB diagnosed by Laboratory culture Suspected pulmonary TB cases to be seen by TB service within 2 weeks of

presentation to primary care PCT and Acute trust have achieved 85% treatment completion rates A reduction in the number of human cases of bovine (cattle) TB in people under the

age of 35 years and born in the UK No more than seven per cent of new cases resistant to the anti-TB drug Isoniazid and

two per cent Multi-drug resistant A clinical network is in place to ensure effective cross border working

SHA

Performance to Healthcare commission standards

Each PCT has a named individual responsible for TB Information is available to patients and the public about local TB services Patients are provided with suitable and accessible information on the care and

treatment they receive and, where appropriate, inform patients on what to expect during treatment, care and after-care

A local plan is in place to demonstrate the ability to provide services in the event of an incident or emergency situation which could affect the provision of normal TB services

Healthcare commission

What can TB nurses do?

• Record the activity you undertake• Act as an advocate for the service• Don’t be afraid to talk the service up• Make sure everyone knows how good value for

money you are• Share your good practice• Ensure that if there is a better way of delivering

your service you explore it• Lead the changes needed, don’t wait for

someone to lead you• Get on with the job in hand

Thank you for not sleeping