Health Service Focus

01.04.15

Twenty-first century infectious disease screening

Source: NHE March/ April 15

Dr Al Story, clinical lead and manager for Find&Treat at University College Hospitals NHS Foundation Trust, tells NHE about how a new mobile health van will help thousands of patients access testing for a variety of infections. David Stevenson reports.

The well-known Find&Treat Service, operated across London by University College Hospitals NHS Foundation Trust (UCLH), has expanded from a mobile TB diagnosis and treatment service into a mobile health unit capable of testing and vaccinating for a range of infections. 

Giving a brief history of the now permanent service, Dr Al Story, clinical lead for Find&Treat at UCLH, told NHE that the programme started off as a pilot back in 2002, with a borrowed Dutch screening unit. 

“We brought it over and within a day-and-a-half we found three cases of TB,” he said. “That woke people up to the issue that there are plenty of undiagnosed TB cases in hostels and prisons. 

“The NHS leapt into action and in 2005 we took delivery of our own unit. That same unit has been screening, and is still screening. The new one is being phased in and the old one is being phased out. But the old unit, since 2005, has screened over 100,000 people and covered nearly 300,000 miles. We’ve had our money’s worth out of that one.” 

The old unit will be retained as a back-up service and will continue to support Public Health England (PHE) in controlling outbreaks nationally. Figures have revealed that London has the highest TB rate in western Europe. And more than 9,000 patients are diagnosed in UK each year – 40% in London. 

Modern screening methods 

UCLH has designed and built a new van for just under £450,000. The unit has been equipped with state-of-the-art diagnostic and information technologies, which will provide thousands of patients with access to testing for TB, HIV, Hepatitis B and C and other priority infections. 

The van also includes a private consultation/examination area and disabled access. Dr Story told us: “Unlike the old unit, this van has actually got a private consultation area that can be used at the back. 

“We’ll be able to use it as a full-specification clinical space to provide an on-the-spot phlebotomy service. TB diagnostics are still a bit 20th century, but as we start to look outside the TB ‘box’ and look at what is available for on-the-spot diagnostics for Hep C, HIV etc, these are truly 21st-century technologies. 

“The point of care testing we are doing is able to just use saliva, as an antibody test, to triage into a full bleed that can be done on the unit. Within the space of a few minutes people can have a TB, Hep C, Hep B, HIV check and can be vaccinated. Also any need for onward care can be identified and arranged there and then.” 

Clockwork 

The van’s schedule is designed to ensure the team can reach the biggest public health projects across London twice a year: once every six months. “So, in essence, we do a kind of autumn/winter tour and a spring/summer tour, doing a clockwise circuit of the capital for all the big boroughs,” said Dr Story. 

“But a number of the projects we work with have much higher turnover, so we go back there quite regularly. We also regularly support PHE to go in and respond to cases in congregate settings such as factories, schools, prisons etc.” 

The new van was unveiled on the same day that PHE announced an £11.5m investment to drastically reduce the number of TB cases in England over the next five years. 

Dr Story told NHE: “The strategy is certainly outlining the right areas. For me it is quite clear that 21st-century control has to move beyond sitting in a hospital and waiting for people to come to you. 

“The reality is that a lot of people don’t know that they’ve got TB and, as the strategy outlines, there are many opportunities that are missed, unfortunately, to prevent cases by targeting preventative treatment of people. It is certainly a sensible step forward because it is a strategy that encompasses TB control in the community and all aspects of control, rather than just treating cases that make it to hospital.” 

Multidisciplinary team 

The Find&Treat team are multidisciplinary and include former TB patients who work as peer advocates, TB nurse specialists, social and outreach workers, radiographers and expert technicians. 

Dr Story said a key reason for the service’s success has been developing working relationships with the third sector. 

“They really are our allies. In London alone we have more than 220 partners across the capital,” he added. “When we think of the skills and engagement necessary to work effectively with the client group, we genuinely do need to form close working partnerships with drug and alcohol services, homeless services and offender health services and so on. 

“Increasingly, as a component of our research, we are demonstrating that it is extremely effective to try to recruit and train people from the affected populations themselves. The peer support element of our work has been extremely useful.” 

The peer support scheme tries to be as inclusive as possible, with relatively low entry requirements. So far, more than 40 peers who have been through the service have worked alongside the team. 

“It is certainly well into the double figures of those that have gone into paid work, including a couple who are fully paid-up members of the NHS,” said Dr Story. 

Van edit

The future 

Since its inception, the Find&Treat service has lived under a bright light, attracting a lot of interest due to its unique and innovative way of working. 

“One of the consequences of that is the need to be meticulous and robust in evaluating our effectiveness,” NHE was told. 

“We’ve been quite fortunate to have two independent evaluations of our effectiveness over the years: one by the Health Protection Agency (now PHE) and one by NICE themselves. 

“Both those evaluations demonstrated we were not only extremely cost-effective, we were potentially cost-saving. Effectiveness was on our side there, but dovetailing into the frontline clinical work is a major research investment for the National Institute for Health Research, and one of the components of that research is to look specifically at testing people who were accessing our service with a full blood test for HIV, Hep C, Hep B, and latent TB infection. 

“It really is this research that has underpinned our awareness of the need to design a service around multiple morbidities of the client group that we serve rather than looking just specifically at TB.” 

As well as expanding the range of testing on offer, PHE used its new collaborative strategy for England to recommend that the service is expanded geographically. 

“We are in the process of planning another return visit with the van to Birmingham in the very near future,” said Dr Story, “which is a repeat of a successful pilot we did last year.” 

During the pilot in 2014, the Find&Treat team were in Birmingham for five days and screened almost 700 people. The team also found a very high prevalence of TB in the population, which is “indicative of the fact that there are a lot of active cases out there”. 

“We still don’t have the full data from that evaluation as it is going to be combined with this new pilot,” explained Dr Story. “Some of the startling stats, as we’d found in London, was that there was a very high likelihood of a lot of undetected blood-borne virus in the population, particularly Hep C. There is an urgent need to get vaccine for the population, particular Hep B, Influenza and Meningococcal vaccine.” 

He added that the team’s ‘long-term vision’ is to add another unit to the ‘fleet’. He noted that the kit itself is quite expensive and consequently there are economies of scale to be had. 

“You wouldn’t want a unit for every city, but there is great opportunity for establishing a northern hub – as I like to call it – and having a unit dedicated to providing a service to the major conurbations in the north and Midlands,” said Dr Story.

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