A TB Action Plan For Scotland: ANNUAL REPORT / 2013

2. Performance against A TB Action Plan for Scotland

2.1 In April 2013, a questionnaire was sent to all NHS Board TB teams. The questionnaire requested teams to assess their own progress against the 42 recommendations in the Action Plan and to provide written comments. Actions were assessed as 'implemented' (green), 'partially implemented' (amber) and 'not implemented' (red). The recommendations are often couched in general terms and can be complex. They are not presented as SMART (Specific, Measurable, Attainable, Reproducible, Timed) indicators. This means that the information collected is subject to interpretation of implementation status at local level. Furthermore, the settings in which programmes are delivered vary considerably in terms of case load, geography, available capacity, infrastructure and expertise. Responses need to be interpreted taking the above into account.

2.2 All Boards and agencies responded to the survey. The main strengths are that excellent clinical and laboratory services are available across all responding Boards - either directly or through collaboration with neighbouring boards. The main gaps in progress are multidisciplinary team approaches for new entrant screening, problem alcohol drinkers, neonatal BCG, and auditing of services such as contact tracing.

2.3 The following section provides a summary of progress. For further details on territorial Boards' progress see Annex A. For further details on HPS progress see Annex B.

2.4 Laboratory Services and Diagnostic Tools

• Many laboratories refer specimens to the Scottish Mycobacteria Reference Laboratory (SMRL).
• Laboratories within 11 of 14 Boards report that they culture specimens in liquid culture.
• 13 out of 14 Boards report that their laboratories are Clinical Pathology Accreditation (CPA) accredited and undertake appropriate quality assurance.
• The Health Protection Network (HPN) guidance on Interferon Gamma Release Assay (IGRA) tests has been reviewed and the revised guidance will be published by early 2014.
• A national group has developed and disseminated proposals for use of MIRU to detect and investigate clusters of TB cases. A final protocol will be available in 2014. In the meantime the approach is being used in practice to help boards manage clusters of TB cases.
• The TB Action plan Monitoring Group, HPN, HPS, SMVN and SMRL monitor developments to ensure that the most appropriate up-to-date diagnostic tools are available.

2.5 Clinical Services

• All Boards have identified TB as a strategic priority.
• All Boards report that they have multidisciplinary team (MDT) arrangements in place although the strength of implementation varies across Boards.
• 13 out of 14 Boards report that they have representation from primary care or GPs in the MDT and ensure case review by the MDT, although the strength of implementation varies.
• 11 out of 14 Boards report that they have arrangements in place to access negative pressure facilities when required, including for multi-drug resistant (MDR/XDR) TB. In three Boards interim measures are in place and work is ongoing to achieve full implementation.
• All Boards report that they are aware of existing guidance on HIV screening of TB patients and it is in force. 13 out of 14 Boards report that they score green for the recommendation that co-infected patients are managed by an expert in both conditions (with two of those Boards transferring patients elsewhere).
• HPS have completed an initial analysis of a data linkage based study to improve Scotland's evidence base around dual infection with TB and HIV.
• A TB study day on 12 June 2013 attracted over 130 participants from various disciplines. Over 76% of the respondents to the evaluation questionnaire indicated that the day was either excellent or good. There was support to continue the annual study day plus one annual thematic workshop to discuss clinical and operational issues in greater depth.
• The Scottish Government is fully supportive of the national TB Nurse network. In addition, a survey of Boards was carried out to determine attitudes to a national multi-disciplinary TB network. 10 of the 14 Boards responded, and of those respondents seven wanted a network, two did not, and one was unclear, although was mostly positive.

2.6 Surveillance

• All Boards report that they have at least partially implemented the recommendation to collect ESMI scheme data and conduct audits on the completeness and timeliness of the return of the ESMI data (10 of those Boards score green).
• HPS produce annual reports based on this ESMI data.
• Seven out of 14 Board MDTs report annually on TB activities.
• Following discussion with the Scottish Government Public Health Portfolio Management Group, and subsequent developments with the Scottish Health Protection Information Management System (SHPIMS - expected to be available by mid-2014) and Public Health England's plans for their surveillance system (a new system expected to be available in 2015), the surveillance group will meet again in autumn 2013 to scope the requirements for and costs of a replacement to the current paper-based surveillance system.

2.7 Public Health Services

• 13 out of 14 Boards report that they are confident that the national guidelines on contact tracing are being followed. However, not all Boards conduct formal audits and there is no standard audit tool to do this.
• Board level TB multidisciplinary teams are recommended to liaise with statutory and voluntary groups, educational institutions and primary care to implement case finding and follow up for latent TB in new entrants.
  - five out of 14 Boards report implementation of case finding for new entrants with a further eight reporting that systems are under development.
  - four out of 14 Boards report active engagement with voluntary groups.
  - seven out of 14 Boards report some active referral of cases from primary care.
  - 13 out of 14 Boards report provision of language translation services to facilitate case finding.

• There are a range of approaches to case finding for latent TB in new entrants including follow up of new entrants when notified by their port of arrival, dedicated clinics at universities, development of hospital based screening clinics, facilitation of referral and testing by primary care and new employee screening. There are no national standards available for new entrant screening and follow up in Scotland.
• Eight Boards score green, three score amber and three score red for engagement of MDTs and local services with primary care to highlight the alcohol misuse at-risk group.
• Nine Boards score green, one scores amber, and four score red for engagement of MDTs and local services with Alcohol and Drug Partnerships to highlight the problem drinker at-risk group, yet implementation is inconsistent.
• Six out of 14 Boards score green on being aware of and planning to better connect with hard-to-reach groups.
• 13 out of 14 Boards report that they have reviewed or are reviewing their BCG operational plans.
• A working group was established by HPS and the Scottish Government which developed a business case to improve SIRS for neonatal BCG, and work is to be scheduled for the first quarter of 2014 at the earliest, due to other priorities. In the meantime, HPS have collected mapping information on current Board practice and this will be developed further to produce recommendations on best practice and a standard audit tool for Boards.
• HPS have developed a paper summarising the appropriateness of the Child Health Systems Programme (CHSP) school system BCG screening questionnaire, but action is yet to be taken to review Board BCG audit activities.
• A review of the TB elements of the 2008 Health Clearance Guidance is yet to be undertaken.

2.8 Monitoring and Ensuring Progress

• An Action Plan Monitoring Group (APMG) was established, and it meets twice a year. It last met on 25 April 2013.
• The APMG will develop a number of key performance indicators (KPIs) in line with ECDC targets and the recommendations of the Action Plan in order to manage and track progress.