Tackling TB in London's excluded groups

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Crossbench peer Baroness Masham of Ilton sets out the issues which have prompted her question to ministers in the Lords about London's mobile X-ray units for tuberculosis.

I visited the mobile X-ray unit (MXU) in June 2009 as it was screening clients of two hostels in Westminster. I was pleasantly surprised to find the MXU had access for a wheelchair by a lift which enables disabled people to use it. I found the unit and its team to be an excellent model of the NHS working in the interest of public health. There is a serious increase of drug resistant TB especially in London.

The MXU was launched on World TB Day 2005. It aims to actively find cases of TB amongst those at greater risk of contracting the disease.

These include: homeless people (including rough sleepers and people living in temporary or hostel accommodation); people from countries where TB is endemic; prison inmates; and hard drug users and street-drinkers.

It is part of a larger service for socially excluded groups called 'Find and Treat'.

Why is it needed?

TB has changed from being a disease of the general population to a health issue in certain sub-populations. London sees many TB patients who have complex social needs due to chaotic lifestyles.

These individuals are often socially excluded, disengaged with health services and are thus extremely hard to reach and treat. Normal TB services are not set up for treating patients with complex social needs. Outreach and community-based services are the best means of engagement.

The key to TB control is early diagnosis. To ensure early diagnoses to those individuals disengaged with health services, the MXU strives to "bring the health service to the individual".

How does the unit operate?

The unit consists of a mobile diagnostic vehicle, TB outreach workers, radiographers and admin staff. It has links with TB clinics and other key agencies across London.

Unlike the vans phased out in the 1970s, the current MXU utilises digital x-ray equipment and a capability of screening 50 people per hour. Crucially, the MXU offers on-the-spot evaluation of the patient and helps raise awareness of TB among risk groups and those who work with them.

The unit is funded by the Department of Health, and is hosted by University College London Hospitals NHS Foundation Trust on behalf of the NHS in London.

The project is managed by a multi-disciplinary steering group with representation from the Department of Health, London sectors, the voluntary sector and the Health Protection Agency.

An operational group supports the day-to-day management of the project with representatives from agencies working with the target groups, TB services and users of the service.

Evaluation of the MXU

In 2007, the Health Protection Agency led an independent evaluation of the Unit. The reports recommendations were:

1. Ensure screening is more effectively targeted to populations with highest rates of undetected active TB and poorest access to routine health services.

Progress: Done – the MXU now targets homeless people and problem drug users exclusively but are able to reach a fraction of these due to limited capacity as there is only one MXU for the whole of London.

2. Maximise uptake of screening through improved planning and organisation of support staff and use of incentives and peer educators.

Progress: Done – The unit has successfully implemented the TB peer-to-peer project initially through Homeless Link and now through Groundswell. There are currently five peer educators who work alongside the Find and Treat Team to promote awareness, uptake of screening and support Directly Observed Therapy (DOT). Uptake of the screening has increased in most areas by around 40 per cent. St Mungo's have now included 100 per cent uptake of screening as a performance management indicator for all their hostels across London.

3. Maximise follow-up care by offering same-day accompanied referrals to TB centres able to offer "one-stop-shop" for enhanced case management, including full clinical investigation and hospital admission where indicated.

Progress: The unit has reduced loss to follow up pre-diagnosis from around one in three to less than one in twenty. However, due to the extremely varied care provided by different TB clinics in London the treatment options and outcomes for MXU clients are still largely dependent on where they get treated. Many of the patients are still not getting access to DOT despite clear recommendations from Nice that this should be a treatment standard.

4. Implement and evaluate use of static digital X-rays in prisons serving high risk populations.

Progress: The Department of Health has invested in a teleradiology network to link the five adult male prisons in London to a central reporting hub and screen all new prisoners on arrival. This service should be operational across London by October/November 2009. The next objective is to try and link the other screening initiatives that are recommended in the prison setting into a one stop shop so that all prisoners get access to rapid testing and treatment pathways for TB, Hep B, Hep C, HIV and other STIs.

5. Increase capacity and epidemiological impact of MXU screening by providing two mobile units for use in London and for national outbreak response.

Progress: There is still only the one original unit. This unit is now quite old and will soon need to be replaced. The team actually need two new units that can be linked to the central reporting hub set up for the prison system. Unfortunately, the unit has been unable to respond to the last three requests from health protection units to support TB outbreak responses in schools and other settings due to lack of capacity.

6. Improve TB awareness among staff and clients in homeless and prison settings.

Progress: The Find and Treat Team have done an enormous amount of work to raise TB awareness among frontline staff and vulnerable groups across London. They have established excellent collaboration with the National Treatment Agency and the Department of Communities and Local Government to reach our target audience and develop better training packages.