Tuberculosis - RNOH/GIRFT review: national report

5 Background and Approach

Getting It Right First Time (GIRFT) is a national programme in England developed by the GIRFT national team under the chairmanship of Professor Tim Briggs. GIRFT has been designed to improve patient care, by reducing unwarranted variations in clinical practice. GIRFT helps identify clinical outliers and best practice amongst providers, highlights changes that will improve patient care and outcomes and delivers efficiencies (such as the reduction of unnecessary procedures) and cost savings.

Working to the principle that a patient should expect to receive equally timely and effective investigations, treatment and outcomes wherever care is delivered, irrespective of who delivers that care, GIRFT aims to identify approaches from across the NHS that improve outcomes and patient experience.

RNOH/GIRFT was asked by the Scottish Government to conduct a review of Tuberculosis (TB) services in Scotland. Dr Martin Allen, the GIRFT Respiratory Clinical Lead, led this review. (See biography in Annex B). Martin is a Respiratory consultant at University Hospitals of North Midlands NHS Trust and is the National Specialty Adviser for Physiological Science and Respiratory Medicine for NHS England.

Martin has also provided the Clinical Leadership for the TB review in England and is leading on the TB Implementation Framework for England, which has been commissioned by NHS England following the recent publication of the England National Report.

5.1 Objectives of the Review

The review had the following objectives:

• Identify how different services are providing TB care and reflect this back to each provider
• Help to reduce diagnostic and patient delays
• Gain a better understanding of TB workforce models
• Improve and future proof TB services through appropriate rationalisation and service transformation
• Review and comment on the TB infrastructure in Scotland.

5.2 Methodology

Our approach was based on the methodology developed by GIRFT which uses data to identify the impactful and high priority opportunities for transformation. This includes opportunities to generate re-investment savings, improve service quality and address unwarranted variation in practice and/or spending.

The scope of the review was to look at TB service providers and to look at the engagement within TB systems and Public Health Scotland.

5.3 Data Collection

The first phase of the review was the identification of available data sources and how to gain access to them for the key areas we wished to review. For many areas there were gaps in knowledge and information, especially around the process of care and workforce numbers in relation to levels of service activity.

To fill this information gap, we developed a questionnaire which had been used for the England workstream and which we further enhanced for the Scotland review. The initial England questions were based upon the key deliverables of the TB action plan and developed using the ‘Delphi’ methodology, involving key opinion leaders from medical and TB nursing backgrounds. These questions were shared with colleagues in Scotland, who further developed them to answer specific issues thought to be important in Scotland and filled in data gaps which had been identified during the England work. The aim was to give a more comprehensive overview of TB services in Scotland. The questions were structured into the following themes:

• Staffing/workforce
• Bacillus Calmette–Guérin Vaccine (BCG)
• Preventative Treatment
• Organisational Support and Infrastructure
• Screening Services
• Diagnostics
• Contact Tracing
• Inclusion Health
• Management of TB

There were 186 questions in the survey and these questions were shared with the following key stakeholders to gain agreement:

• Representatives of the Specialty Advisory Group (SAG) of the British Thoracic Society (BTS)
• The Scottish Health Protection TB Network (SHPN)
• Scottish Government Population Health and Protection Division
• Several TB providers
• TB specialist nursing leads

Once the survey questions were agreed, they were developed into a ‘webform’ which was shared with the main contact(s) within each TB service. To provide more information and to encourage participation, we held a webinar to launch the TB Survey on 17 September 2024.

We also set up a dedicated mailbox to ensure effective communication and engagement during the review.

The full set of survey questions can be found via the link in Annex E.

5.4 Results of the Returns

The duration of the review was from March 2024 through to April 2025. The review used the full dataset from 2022 for TB data returns, with the survey responses aligned to this period. Over this period there were 201 TB notifications in Scotland.

5.5 Data pack production

To develop information and intelligence to support the report and visits, data was identified from different sources. The national surveillance returns for each service ESMI (Enhanced Surveillance of Mycobacterial Infections) data was collated as were the admission data from SMR01 (Scottish Morbidity Records Inpatient Dataset) where tuberculosis was the main code on discharge.

The data was then collated by the RNOH/GIRFT analytics team and reviewed to ensure the correct fields were captured. Graphs were produced for each TB Service, and a further webinar held to explain to services how to interpret the data. To facilitate interpretation a ‘core’ set of 102 graphs was produced, with all the collected data and information in the data pack ‘Appendix’, totalling some 348 graphs including the repeated ‘core’ graphs.

Surveys were sent out to 16 TB services, with responses received from all 16. Of these we received complete data from 15 services, and 1 service only partially completing 4 out of 9 of the survey sections. From these 16 services, 4 services had no notifications and therefore there is limited information in ESMI, and another 4 services had zero admissions, producing some variability in aggregated results. However, data was used as if the survey was totally or partially completed, recognising in some services the lack of notifications (ESMI data) or no admissions. This provided a very comprehensive overview of TB services in Scotland at this point in time.

The table in Annex A shows the TB service providers who participated in the survey.

5.6 Clinical Lead ‘Virtual Deep Dive’ Meetings

To validate and explore the data, the RNOH/GIRFT clinical lead led 11 virtual ‘deep dive’ reviews with TB providers. These were selected based on the details in the data packs, including the geography of the provider (rural versus urban) and the number of TB notifications. We asked for a broad attendance at the virtual deep dive reviews by all staff delivering TB services including: the service lead consultant, the lead TB nurse, Infectious Disease (ID) leads, CYP (Children and Young People) consultants, microbiology staff, pharmacy staff, administrative staff, Public Health colleagues, acute provider managers and service leads.

MS Teams’ virtual deep dive meetings were conducted in 11 services, including one provider, as an example of a service with 0 notifications or admissions. Prior to each deep dive, the RNOH/GIRFT clinical lead reviewed the graphs and selected those most pertinent for discussion and explanation.

Each virtual deep dive meeting was of 3 to 4 hours’ duration and engagement was excellent. There was a set process for each meeting in which the service leads were invited to present ‘what worked well’ and’ what their issues were’ before exploring the data pack in detail. The clinical lead focused on any unwarranted variation, as well as identifying and recognising areas of good practice.

For each service reviewed a local report was produced highlighting areas of good practice, some of which fed into the national good practice, and we made recommendations to improve the service. We were unable to conduct a deep dive visit one service due to time constraints for the service and so we provided a verified paper-based review (so in fact 12 reviews were undertaken).

The schedule of deep dive meetings in Annex D and the link to the Key Lines of Enquiry (KLOEs) we used are found via the link in Annex E.

5.7 Communication and Engagement

We delivered a series of communication and engagement activities throughout the lifecycle of the review including:

• An information leaflet to all stakeholders providing information about the review
• A fortnightly Project Team Meeting which included colleagues from RNOH/GIRFT and the Scottish Government
• A national webinar on 24^th September 2024 to launch the survey
• Regular TB Review Updates which provided progress on the review at each key stage
• A second national webinar to explain and aid understanding of the data pack on 21^st November 2025
• A stakeholder workshop to develop and agree the content for this report
• A third and final webinar is being scheduled to outline the key findings from the review.