On that note, I thank all noble Lords. I will reply in writing if there are any points I have not addressed. It would be great if we could have a cross-party approach on this.


Question for Short Debate

5.01 pm

Asked by Baroness Suttie

To ask Her Majesty’s Government what plans they have to reduce the rate of tuberculosis in the United Kingdom over the next 10 years.

Baroness Suttie (LD): My Lords, I am very grateful to have the opportunity this afternoon to raise the extremely important subject of tuberculosis in the United Kingdom, and I am very grateful to colleagues for agreeing to take part in this debate.

Like all 13 and 14 year-olds of my generation in the UK, I had my BCG vaccination while I was at high school. I remember that we all compared our scars for

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months afterwards. We believed at that time that TB, like smallpox, could be eradicated from our society. TB, or consumption, was supposed to be an illness of poverty of times gone by. In Victorian Britain it was known as the “silent killer” and as many as one in four deaths were attributable to it. So high was the death rate, in fact, that TB has been estimated to have killed more people than any other infectious disease in human history.

Shortly after I was appointed to this House, I became involved with the APPG on TB. Much to my surprise, I quickly had many of my preconceptions shattered, as I learnt that TB has not, in fact, disappeared and remains a very real problem. While great progress has been made against the disease in the West, globally TB is as deadly as ever. The latest estimates from the World Health Organization are that the disease kills 1.5 million people every year. The Lancet estimates that TB kills more people than any other single infectious agent worldwide. To put it in context, TB kills nearly as many people every single day as have died from Ebola since March.

TB today is not the same disease it was 100 years ago. Our failure to develop new drugs or to properly apply the ones we have has given TB bacteria the chance to evolve new, drug-resistant strains. The issue of drug-resistant TB is particularly pertinent today, following the first report from Jim O’Neill’s AMR commission. The report estimates that antimicrobial resistance could cost the world economy $100 trillion over the next 35 years, and it cites TB as a major driver of that cost. In this context, it is no overstatement to say that MDR TB is a threat to social and economic well-being across the world.

A growing percentage of global cases are resistant to our best drugs. Patients diagnosed with multidrug-resistant or MDR TB face two years of treatment, taking 14,000 pills, which are often associated with permanent and debilitating side-effects and which have only a 50% chance of cure.

In June this year, I took part in a delegation to Romania looking into the Romanian experience of the treatment and prevention of TB. Romania has the highest incidence of TB in the EU. At one clinic, I spoke to a young mother of two children who had been diagnosed with MDR TB. She had already had half of one lung removed and was expecting an operation imminently to remove a section of her other lung. She was struggling with the harsh regimen of drugs for her disease and constantly felt unwell and nauseous. She was also deeply worried for her two young children, who were in the process of being tested to see whether they, too, had MDR TB.

Of course, this debate today is not about global TB; it is about TB in the UK. London is regarded as the TB capital of western Europe. Some parts of the capital have rates equal to those in sub-Saharan Africa. The BCG vaccination with which we are all so familiar provides far less protection than many think and offers no protection at all to adults.

I would like to focus briefly on three key areas: education and awareness; testing and diagnosis; and tackling the problem at source—namely, developing

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new and better medication and a vaccine that works. TB is infectious and airborne. When patients start treatment, they become less infectious. If there is a delay in diagnosis, they remain infectious for longer, allowing the disease to progress, and develop more severe symptoms, thus exposing others to the risk of transmission, so the first thing we must tackle is delayed diagnosis.

I am pleased that Public Health England and NHS England have, together with a number of other stakeholders, drawn up a collaborative TB strategy for England. I also note that this strategy acknowledges:

“An additional factor that frequently delays diagnosis is the lack of TB awareness among health professionals and appropriate training among social care staff”.

In short, it is a problem that high-risk populations as well as many healthcare professionals are currently insufficiently well informed about TB. Earlier this year when I visited Romania with RESULTS UK, we went to a prison outside Bucharest which had an impressive TB education programme that far surpasses anything I have encountered in this country. Will the Minister outline our existing TB awareness programmes, particularly in prisons? We are not going to reduce delays in diagnosis unless we make people aware that TB is a genuine threat to public health across the UK.

Of course, there are other ways to reduce delays between the onset of symptoms and the diagnosis of the disease. Find & Treat screens up to 10,000 people a year in the UK. It works with some of the hardest-to-reach people and yet has a treatment success rate higher than the national average. In fact, the service is of such sufficiently high quality that the clinical lead, Dr Alistair Story, who I met a few months ago, has been asked by the World Health Organization to participate in a working group exploring how to eliminate TB in low-burden countries. Yet the Find & Treat service is on an uncertain financial footing and, although seeking to expand, is unable to do so. Will the Minister commit to seeing the work of Find & Treat first-hand and support it in its efforts to scale up?

Find & Treat is also behind a project that I visited in North London known as Olallo. Olallo offers accommodation and social support for homeless patients receiving drug-resistant TB treatments. Patients receive free lodging, food, education and skills training to support them in finding permanent employment. The project is an exemplary demonstration of how we can support those with chaotic lifestyles. As a model it could also save us money. The average cost of treating a TB patient in a hospital is £500 a day, and even more in a negative-pressure isolation room, whereas hostel accommodation with all the additional social support can cost between £60 and £80 a night. Will the Minister detail what the Government are doing to support and expand projects like Olallo?

Finally, I would like to speak briefly about TB treatment. Every time I have spoken to a TB patient or a healthcare professional, the conversation has turned to the terrible treatment burden and the awful side effects. Patients have told me of the risk of hearing loss, blindness, liver damage and suicidal urges. Healthcare experts have explained the very real dilemma of having to put an MDR TB patient on treatment, knowing the

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misery that the drugs can bring. In the 21st century it is simply unacceptable that a patient should face the choice between a disease that could kill them and a treatment that could leave them permanently disabled.

I am proud that the UK Government are the second biggest public funder in global health research and development in the world. Investments and product development partnerships, such as Aeras and TB Alliance, are life-saving. The concordat between DfID and the Medical Research Council is practically unique in the developed world and yet there is much more that can and should be done. At the root of our global failure to develop TB drugs and vaccines is a simple truth: people who suffer from TB are usually poor and do not offer a market of sufficient scale to incentivise pharmaceutical companies to invest in research and development. To put it more crudely, the commercial market has failed TB patients. In the face of this market failure, Governments must act. The UK Government could do even more than they currently do. We need to reclaim that thought-leadership and work with leading donors around the world to drive a new global consensus on overcoming the market failure in R&D for global health.

The response to the global HIV epidemic has been one of the greatest examples of the world responding to a global health threat, and HIV has lots of advocates and celebrity supporters. Ebola, too, has gripped the attention of the world’s media, and rightly so.

I mentioned at the beginning of my remarks that TB was once known as the silent killer. If politicians, the media and Governments continue to be largely silent as the disease kills millions every year we will never be rid of the disease, not in the UK and certainly not around the world. I very much hope that the Government will lead the way to reverse this situation.

5.10 pm

Baroness Masham of Ilton (CB): My Lords, I thank the noble Baroness, Lady Suttie, for this important debate.

Many people think TB is a thing of the past. However, here in London, Newham has been named the capital of tuberculosis in Europe. With modern travel, the world is very small. I will mention a few points on the international scene before concentrating on the UK.

I was very impressed and moved recently by a film on drug-resistant TB, shot in Africa. The 2014 WHO report also states that the problem of drug-resistant TB is worsening, with an estimated 480,000 new cases of MDR-TB in 2013. This, too, may be an underestimate, since estimates of the true burden of drug-resistant TB across sub-Saharan Africa, Asia and eastern Europe are impaired by the fact that drug-resistant testing and treatment services are broadly unavailable at the majority of healthcare facilities.

Of greater concern was that of the estimated half a million cases of multi-drug-resistant TB around the world only 136,000 were officially diagnosed. It is perhaps more dire to note that 9% of those with MDR are estimated to have extensively drug-resistant TB or, in other words, that close to 50,000 people worldwide have a form of the disease that we do not currently have the necessary tools to treat.

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TB is caused by bacteria. It is airborne and infectious, transmitted when a sick patient coughs or sneezes. TB has been estimated by the Lancet to be the deadliest disease in the world. The World Health Organization estimates that TB kills 1.5 million people every year. Like many other bacteria, TB is increasingly resistant to our best drugs.

We must not be complacent here in the UK. We have many demands on our NHS, but infections need controlling and preventing whenever possible. It is much easier to treat an infection in the early stages. Here in the UK, there were 7,982 cases of TB in 2013. This is a reduction of 10.6% over the previous two years. London, however, has the highest rate of any capital city in western Europe. Birmingham’s rate is even higher. Both are near the World Health Organization’s definition of a high-risk area. Before 2012, rates of TB in the UK rose steadily from the year 2000. Only 15% of TB cases in the UK occurred in people who had entered the UK in the previous two years. TB remains concentrated among the most deprived populations. In 2013, 70% of cases were resistant in the 40% most deprived areas. Nearly half of cases were among the unemployed, while 10% had social risk factors, including a history of alcohol and drug misuse, homelessness and imprisonment. More than a quarter of patients with TB in their lungs started treatment more than four months after the onset of symptoms. On average, patients in the UK wait 72 days between the onset of symptoms and diagnosis with TB. This increases the severity of symptoms and increases the likelihood that patients will transmit the disease.

There are two main reasons for this problem. Healthcare professionals in the UK often do not consider TB in the first instance. Thus, patients can be misdiagnosed. Patients can be reluctant to come forward due to stigma, lack of awareness of the disease and reluctance to access healthcare. In London, the Find and Treat service has overcome some of the challenges on the patient side. Find and Treat is a service based around a mobile X-ray unit in the back of a van which travels to hostels and other homeless places across the capital to screen marginalised and high-risk groups. I have visited this unit at work and I can tell your Lordships that it is run by enthusiastic, dedicated people. I assure your Lordships that if you had time you would find a visit most interesting. The unit even has access for a wheelchair, which is unusual. Most units for screening breast cancer do not have this facility.

The service frequently employs previous service users to offer mentoring to current patients, offering all-important social care and helping previous service users develop employable skill and experience. Find and Treat accordingly has a higher treatment completion rate than the UK national average, despite working with hard-to-reach, marginalised populations. The draft collaborative TB strategy for England recommended the scale-up of Find and Treat to become a national outreach service. This is welcome, but it must be done correctly.

TB is just one of several interlinked conditions across the UK that suffer from delayed and incomplete diagnosis. Some 30,000 people in the UK with HIV do

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not know their status. Half of all those with hepatitis C do not know their status. Some 630,000 people with type 2 diabetes do not know their condition and 11.5 million people are considered to be at high risk of developing type 2 diabetes. These conditions are linked. People with HIV are 20 to 30 times more likely to develop TB. People with diabetes are three times more likely to develop TB. Hepatitis C and HIV infection are connected by similar methods of transmission. All these conditions are found predominately in areas of high health inequalities. Many of these people are unaware of their status and are not accessing healthcare. HIV, hepatitis C, diabetes and TB can all be screened for in less than 15 minutes.

I must declare an interest, as among the all-party health groups I serve on, I am a member of the All-Party Parliamentary Group on HIV and AIDS, the All-Party Parliamentary Group on Global Tuberculosis, the All-Party Parliamentary Hepatology Group and the All-Party Parliamentary Group for Diabetes. Therefore, I agree with scaling-up Find and Treat to include these conditions. This would maximise the efficiency of the outreach service, making the most of a single contact with an individual to screen for multiple conditions. It would reduce stigma related to any single disease by making such tests part of routine health screening. It would target areas of high health inequalities, adapt a preventative approach to health and, most importantly, save money. The Find and Treat budget is under £1 million a year. The lifetime cost of HIV treatment in the UK has been estimated at over £300,000 per person, so an outreach service would need to help prevent only three cases of HIV to break even. Most importantly, an outreach programme such as this would save life.

We must do more to prevent these infections. I hope that in the next 10 years there will be a vaccine and more new drugs for TB, but I also hope that the Minister will commission her department to explore the possibilities of an integrated national outreach service for HIV, hepatitis C, diabetes and TB across the country. I look forward to the Minister’s reply.

5.20 pm

Baroness Ludford (LD): My Lords, I thank my noble friend Lady Suttie most sincerely for giving us the opportunity to debate this important subject. I acknowledge an interest in that my husband is chairman of the board of the Whittington Hospital, which is one of the hubs for the innovative TB Service North Central London, which I will mention later. I thank Dr Helen Booth, a consultant thoracic physician and TB clinical lead for that hub at the Whittington, for briefing material. I also appreciate the briefing from Results UK, the NGO that my noble friend mentioned. I also draw on evidence from the London TB clinical leadership advisory group.

I have no health background or expertise except some involvement in diabetes, but the more that I briefed myself on this subject, the more interested and alarmed I became. Having formerly had the privilege of being the elected representative for London in the European Parliament for 15 years, I was naturally very impressed with the fact that London, as has been

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mentioned, has the highest rates of TB of any capital city in western Europe—indeed, I believe, in the developed world—that the London Borough of Newham has rates equivalent to Nigeria, and that England is set to have a higher rate than the United States in 2015. These statistics are all very impressive. Unlike other major cities such as New York, Barcelona and Paris, London has not seen a reduction in TB rates, and accounts for almost half of the approximately 8,000 cases nationally. As a Londoner, I find this topic very important, and I am grateful to my noble friend for drawing attention to it.

The evidence suggests that in London the majority of new cases, around 75% or 80%, are due to the reactivation of latent infections after TB has been acquired in a high-risk country outside the UK, but of course if that latent infection is reactivated it acts as a source of infection for those in close contact with that person, including their family and children.

I mentioned the North Central London TB service, the NCL, which is an innovative service providing holistic care to TB patients. It has seen reductions in TB rates. It includes the outreach service, mentioned by the noble Baroness, Lady Masham, of the mobile X-ray and Find and Treat team based at University College Hospital, as well as a TB link project, which demonstrates the importance of an integrated social care team. It has introduced a cohort review into London and the UK, based on a New York model of TB control, and since 2007 it has had a united nursing, social care, outreach and administrative team. Lastly, it has concentrated non-in-patient services to two hubs in north central London—that is, the Whittington and the North Middlesex—instead of previously having had five sites. So this is a concentrated focus with consistent nurse leadership, avoiding the fragmentation of the nursing team and better able to tackle inequalities in the provision of care.

It has been mentioned that the national TB strategy is in preparation and I am advised that this needs to result in changes to the current model of fragmented care. However, as other noble Lords have said, it is important to acknowledge that success in TB control must involve agencies other than the health service and must address the social factors involved, which have also been mentioned. Homelessness is probably top of the list. It increases the likelihood of exposure to TB and also makes managing the care and treatment of patients very difficult. Treatment is quite arduous and requires a sustained commitment from the patient, which may be difficult in adverse social circumstances, particularly homelessness. It is a good illustration of why a co-ordinated approach between health and social care is vital.

Other factors include overcrowding, poor housing, poverty, poor access to health care, drug or alcohol dependency, HIV/AIDS and the social stigma which exists in certain individuals, cultural groups and society in general. This can lead to people having great difficulties with treatment compliance.

The rates of TB among the homeless community in certain parts of London have been recorded as up to 35 times higher than the national average. As the disease attacks people with reduced immune systems,

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the impact of rough sleeping, poor nutrition and chaotic lifestyles increases the chances of developing TB in the first place. Members of the homeless community are less likely to present to primary healthcare when experiencing symptoms. It is a vicious spiral because they are likely to remain infectious and transmit the disease to others, develop more severe and difficult-to-treat symptoms and increase the likelihood of developing drug resistant strains. Again, this is an illustration of the importance of taking a holistic view.

As I understand it, once a person is admitted, hospitals cannot discharge people without a home address, and a patient who cannot be discharged might cost the NHS more than £100,000 in bed fees alone. Not only is this expensive but it blocks access to in-patient treatment for other patients. One estimate that I have been given is that the cost of providing a hospital bed for a week would provide secure accommodation for all patients without housing for a year. So provision of housing can help break the cycle.

My noble friend mentioned the Olallo project in Euston, which is able to provide, on a more cost-effective basis, food, room, training, language skills and social support for TB treatment which helps the patient to recover. I am invited to invite the Minister to visit this project if she has not had the chance to see the positive impact of specialist accommodation.

Not only do we need a focused approach in the health service but a multiagency approach between the health service, housing authorities, the health and well-being boards of local authorities and other agencies. This approach goes a long way to account for the success in New York, Barcelona and Paris, which have achieved impressive and sustained reductions in infection rates. Not only do these cities recognise the problem but they have a unified, city-wide strategy to identify, treat and prevent transmission of TB.

That is the challenge in London, which is starting to be met. Significant progress has been made and now that the NHS and social care changes are bedding down there is a good prospect of success. A London TB control board has been established—I believe it has been suggested that control boards should be established nationally—which has on it all representative stakeholders. It is important that London, as the highest prevalence area in the UK, is an integral part of the national TB strategy.

Finally, I quote from Dr William Lynn, who is the clinical lead for TB and chair of the London TB Clinical Advisory Group, he said,

“health and social care (including housing) must work towards common, agreed London Wide service delivery and make the resources available to establish the detection and treatment of latent TB as the benchmark standard of care. Without this we fear that we will continue to fail the population of our Capital City and TB rates will not fall”.

5.30 pm

Lord Hunt of Kings Heath (Lab): My Lords, I, too, congratulate the noble Baroness, Lady Suttie, on securing the debate and on her comments. I associate myself with her remarks about praising the work of the all-party group on TB, which does excellent work. I am grateful to it for a specific briefing on issues in Birmingham, which I am particularly interested in.

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We have always had excellent briefs from Public Health England and the Local Government Association and it is credible that so many experts are now thinking about how we are going to address what are clearly very important problems.

Like the noble Baroness, I thought that TB had been virtually eradicated. It clearly has not been and we need to do something about it. Noble Lords have mentioned that the UK has one of the highest incidences in western Europe but if your Lordships look at the local authorities most affected, including my own Birmingham, there is a strong correlation between TB and general poor health. For instance, if you look at the list of the 20 local authorities with the highest rates of TB per 100,000 population, which I think gives a safer comparator, many of them have other very real health issues as well.

I say to the noble Baroness, Lady Jolly, that there is also an uncanny correlation between that list and the local authorities that have been affected worst by the funding formula switch. I ask her to reflect on this. It is rather ironic that if you read down this list of local authorities, which includes Manchester, Birmingham, Southwark and Hackney, many of them have taken huge hits in the changes to the local government funding formula. I know that some of this resource will obviously come from the Department of Health and that it has been ring-fenced, although health experts tell me they think that not all the money has actually reached public health. We can begin to see why; because of the squeeze on other resources in local government. The substantive point I put to the noble Baroness is given that, how can we ensure that the public health resources being allocated to local authorities are going to be spent on important issues such as TB?

The LGA and PHE produced a report called Tackling Tuberculosis—Local Governments Public Health Role. It is an excellent piece of work and I endorse the fact that it should be the local authority that leads this work. The report has a lot of very good recommendations, such as that the scrutiny work of local government could address TB issues. There are also substantive recommendations, such as driving improvement through the overview and scrutiny committees and health and well-being boards. The report then says that:

“Local health service commissioners should prioritise the delivery of appropriate clinical and public health services for TB”,

and that local leadership should be promoted at all levels, with a senior co-ordinator being appointed,

“perhaps from the public health team”,

to take responsibility for TB. It recommends that local authorities:

“Encourage and empower the voice of people affected by TB”.

and use,

“‘TB cohort review’ and other methods to collect data to inform local needs assessment”.

It also says that they should:

“Facilitate appropriate access to information and services for underserved populations, such as homeless populations … Assist with supporting an individual’s social needs … Review how third sector organisations can help improve access to services and patient support”,

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“Ensure information about TB is cascaded into key teams—for example Children’s Services, Adult Services, Housing and Benefits, Citizen’s Advice”.

These are great recommendations.

At the heart of this is a recognition that if we are going to tackle TB effectively—to pick up the point the noble Baroness, Lady Ludford, made about London—you have to have one plan, an integrated programme and one body accountable for delivering it. Can the noble Baroness, Lady Jolly, see a way through to getting that single point of accountability through the local authority where it is absolutely clear who is responsible for reducing TB rates in the area?

This is very relevant to Birmingham. Unlike London, we have only one local authority, so it ought to be easier to get that kind of integration. None the less, we have three clinical commissioning groups, at least three NHS acute trusts which collectively provide a lot of clinical and preventive services, many GP practices and, because education plays such an important role in this, a lot of schools, academies and free schools as well as the local education authority. It is clear—the all-party group has also commented on this—that although the director of public health is taking this very seriously and giving leadership, at the moment it has not been pulled together into one plan with a commitment from everyone to sign up to it. That is really what is missing. There is a lot of good work with lots of outreach programmes. Working with sex workers in the city is one example. TB professionals have also conducted screening and health education in English as a second or other language, and through this route they have screened high numbers of people quickly and raised awareness of the disease among high-risk populations. So lots of good work is being done, but it does not quite hang together at the moment.

I want to put two other questions to the noble Baroness, Lady Jolly. The noble Baroness, Lady Suttie, mentioned the report published this morning on dealing with antimicrobial resistance. Of course, this is very relevant to TB. I have just glimpsed the report. Can the Minister say a little bit about any steps that the department is now going to take to find new treatments to tackle multidrug-resistant TB? Finally, the Collaborative Tuberculosis Strategy for England 2014 to 2019 was launched in March at a meeting organised by the all-party group. The strategy aims to learn from successful TB programmes internationally and adapt the learning to our specific circumstances in the UK. Will she give noble Lords a report on progress with the strategy and how she thinks it will be implemented?

5.38 pm

Baroness Jolly (LD): My Lords, I am grateful to my noble friend for securing this important debate, which has proved to be fascinating, and to all speakers for their informed and thoughtful contributions. I, too, commend the work of the APPG on TB and declare that a couple of years ago I, too, went courtesy of RESULTS UK to see TB in Zambia. I have many questions from noble Lords. Should I run out of time, I will write and post a letter in the Library.

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There are considerable inequalities in the distribution of TB cases in England with respect to age, ethnicity, sex, location and socio-economic status. TB today is largely a disease of poverty and inequality. Underserved and marginalised members of our communities have the highest rates of TB and the greatest risk of onward transmission. The Chief Medical Officer has identified the inequalities associated with TB as an important priority for England and the Health and Social Care Act 2012 has placed a duty on local government, clinical commissioning groups, Public Health England and NHS England to reduce inequalities.

In response to the high rates of TB, Public Health England and NHS England will launch the Collaborative Tuberculosis Strategy for England 2015-2020 in January. The draft strategy was widely consulted on in the summer of 2014, with the active input and participation of a wide range of stakeholders and partners across the Department of Health, the NHS, local government, Public Health England and the third sector. It is jointly developed to improve national TB control, with the aim of achieving a year-on-year decrease in TB incidence and a reduction in health inequalities, with a particular emphasis on bringing improvements in the areas with the highest rates of TB. NHS England and Public Health England are committed to resourcing the implementation of the strategy, and precise funding mechanisms are currently being finalised. The strategy will establish clear lines of responsibility for TB control at a national and local level, and provide a framework for the commissioning of TB services that takes into account all aspects of the patient pathway.

Most cases of TB are found in large urban areas: London, West Yorkshire, the West Midlands, Greater Manchester, Leicester and Luton. The noble Lord, Lord Hunt, inquired about the situation in London. I have just asked my officials what role the London Assembly and the mayor have in all this, because that is the overarching body for all boroughs. Public Health England London advises the mayor on all health issues via the Public Health England London director, who also chairs the London TB control board, so there is someone who has a handle on all this.

To follow up on the issue of funding, there is no TB weighting in either the local authority or the NHS funding formulae, but there are special TB tariffs for TB care within the NHS tariff system. The majority of cases are in deprived areas. TB is more likely to occur among settled migrants, those with connections to high-incidence countries, ethnic minority groups, the elderly and those with social risk factors including homelessness, a history of imprisonment or drug or alcohol use. The lifestyles of those most at risk often mask the symptoms of TB, which can cause problems accessing and completing appropriate care. This in turn creates inequality in outcomes.

The noble Baroness, Lady Masham, inquired about providing accessible health services to the homeless. This particular group can face great inequalities in accessing health services, yet their health can often suffer just from being homeless or living in poor quality temporary accommodation. Poor health, whether physical, mental or both, can also cause a person to become homeless in the first place. Homeless people

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may often leave health problems untreated until they reach a crisis point, and then present inappropriately.

My noble friend Lady Suttie asked about the response from global health R&D and the licensing of newly approved TB drugs. In 2012 Ministers of Health called on the WHO to develop a post-2015 global TB strategy in order to have a world free of TB and zero deaths, disease and suffering caused by TB. This is in recognition of the need to address the disease globally; in 2013 it affected nine million people around the world. As my noble friend has already told us, it has killed 1.5 million. To achieve this reduction, the strategy sets out ambitious global targets for the reduction of TB incidence and mortality and the individual costs of illness, with targets and milestones up to 2030.

The collaborative TB strategy contains 10 areas of action which will underpin local prevention and control services. It makes provision for a whole-system, evidence-based approach across the whole health and care system. Implementation will be supported by a small team working with local and regional experts ensuring delivery through existing structures. This structure will provide accountability, reinforced by national oversight provided by NHS England and Public Health England. A formal monitoring framework will be put in place with effect from 1 April 2015. It will monitor performance at local and national levels. Public Health England will provide annual monitoring reports on a suite of indicators relevant to the control of TB at geographical and organisational levels.

My noble friend Lady Ludford was talking about comparisons with major cities across the world. The TB strategy will address this issue. It should bring organisational change and funding improvements, focusing on TB control. There is a focus on public health in England because incidence is more than four times as high as in the US.

The noble Baroness, Lady Masham, inquired about the incidence of multidrug-resistant TB in the UK and asked why it was lower in other European countries. The incidence of MDR TB in the UK is not higher than in the rest of Europe. However, the proportion of multidrug-resistant TB cases in the UK has increased from 0.9% to 1.6%.

My noble friend said that London is regarded as the TB capital of western Europe. London has 35% of the UK total, with 2,965 cases reported in 2013—a decrease from the 3,403 cases reported in 2012. This concern is being recognised and work is currently under way to draft the implementation plan for London that meets London’s needs. A number of CCGs and local authorities with the highest TB rates are already working with Public Health England and NHS England (London) to implement latent TB case finding, and with TB Alert, a third sector organisation, to raise awareness within their communities. London has a TB service specification with key performance indicators that are being used to ensure that TB service providers are able to meet local population need. London is also looking in depth at the mortality of TB patients,

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scoping BCG provision and accommodation for “no recourse to public funds” TB patients and those with chaotic lifestyles.

My noble friend Lady Suttie inquired about general prison awareness issues. Much is being done to raise awareness of TB in prisons in the UK and to help to educate prisoners. This awareness-raising is arranged locally by health protection teams.

My noble friend made reference to the work of Find & Treat. My honourable friend Jane Ellison MP, the Minister for Public Health, met representatives of the Find & Treat service when they visited Parliament in March this year. Dr Alistair Story, the service’s clinical lead, has been involved in the development of the TB strategy and its plans for the expansion of an outreach service, similar to Find & Treat, for the rest of England. I would be happy to join any noble Lords on a visit to Find & Treat and Olallo.

The vast majority of TB cases can be cured when the medicines are provided and taken properly. Active, drug-sensitive TB disease is treated with a standard six-month course of four antimicrobial drugs with the support of specialist healthcare staff and additional support, as required, from social care support staff. Without such supervision and support, treatment adherence can be difficult and the disease can spread or manifest in drug-resistant form.

With regard to the issue of delayed diagnosis and what is being done to tackle it, poor access and late diagnosis result in more advanced and complex disease, with greater morbidity, mortality and cost. The Royal College of General Practitioners has an e-learning programme—which is available to all primary care staff—to raise awareness of TB, especially the signs and symptoms of TB disease.

As to R&D, the UK Government support a range of research programmes to promote the development of new diagnostics, drugs and vaccines. The MRC is one of the main agencies through which the Government support medical and clinical research. It receives its grant in aid from the Department for Business, Innovation and Skills and supports a wide portfolio of research, including the current UK-based research into new TB drugs.

Through effective localised commissioning of TB treatment services, we are able to place patient safety at the forefront of the work in the UK. The collaborative TB strategy paves the way for this to happen. The measures contained in the strategy are comprehensive and far reaching. To ensure that they are brought to fruition, PHE and NHS England will oversee implementation, monitor progress and publish reports. The strategy will set out what needs to be done both at a national and local level. It will be aimed at a range of key partners, including in health and social care and the third sector at a local level, which will be empowered to ensure that the clinical priorities affecting their communities are effectively addressed.

Committee adjourned at 5.51 pm.