My Lords, we know that the problem of TB is limited to particular localities these days. In these areas, PCTs are able to set their own targets and standards as part of a local delivery plan agreed with their strategic health authority. In respect of standards of treatment, there are clear recommended guidelines from the National Institute for Clinical Excellence.
In response to the second question: indeed they are. Our data show that around 70 per cent of the TB cases in England are among people born abroad, but who show no signs of the illness until they have lived here for many years. At the moment, as the noble Baroness will be aware, we have no test to predict who will develop TB in later life.
My Lords, there is an understandable tendency to think of tuberculosis as an entirely pulmonary disorder. Could the noble Baroness tell us something about the ratio of pulmonary to non-pulmonary tuberculosis, and whether the ratio has changed over the past 10 or 15 years? That would help us to understand a little about the relevance of the question of whether people have come from outside the UK.
I do not have the figures in front of me, but the noble Lord is indeed right that people think of tuberculosis as being something that affects only the lungs, which is not the case. My understanding is that you can get TB in virtually any part of your body: that is what we know to happen. In the UK, about 14 in every 100,000 people carry it. In parts of the world where TB is more prevalent, the number is 400 to 600 per 100,000. There is a large difference in the problem around the world.
We have funded the UK charity TB Alert to work with PCTs on a long-term basis to develop a range of strategies and approaches to suit their local area. For example, in my home town of Bradford, TB Alert presented to 170 local GPs in a continuing education seminar, with important messages alerting them to the symptoms of TB. In London, we have a partnership with the Homeless Link concerning finding and treating, which we have discussed in your Lordships' House before. We are developing training in those areas with homeless communities where we know there is enormous vulnerability to TB.
The noble Baroness and I are completely at one on the importance of the mobile X-ray unit. It has, for example, identified 400 cases of TB, and works in prisons, homeless units and places across London. It is a very important part of the Find & Treat TB exercise in London. I regret to say that at this moment the PCTs in London have yet to co-operate to find the relatively small amount of money—somewhere in the region of £20,000 to £30,000 per year each—to keep the mobile units going. The noble Baroness and I need to join together in campaigning to ensure that the units can continue this very important work.
Following on from that answer, and considering the irregular distribution of TB throughout London and other parts of the country, what does the Minister think of the suggestion that the Government should fund TB services over wider areas than single PCTs?
The funding of TB services is organised by the strategic health authorities; but the PCTs deliver the services, so it is done across wider areas than PCTs. Indeed, the SHAs are monitored by the CQC to ensure that they are delivering. So it is not a matter of there being no national targets; indeed we are looking carefully to ensure that they are delivering on the TB programme targets which they have set for themselves.
The number of drug-resistant TB cases in this country—as the noble Lord will be aware, because he has raised this issue and I know he is interested in it—is very small and, I am happy to say, is not increasing. As in the rest of the world, we have drug-resistant TB because people do not complete their treatment because they live itinerant lives or for whatever reason. It is exactly the same across the world. Where there is a greater incidence of TB, there will be a greater incidence of drug-resistant TB.
As the noble Baroness and those of us who still bear the scars of having had a BCG vaccination will know, we do not do 100 per cent vaccination for schoolchildren because TB is so localised that we need to deal with it in local areas. My children had the BCG because they grew up in Hackney. That is the point. It is not that we are not offering these vaccinations but that we are offering them where there are TB hotspots in particular parts of the country.
The key issue in those communities is about raising awareness of TB and ensuring that the doctors there know how to recognise it. Quite often in migrant communities in this country it may be two or three years after someone has settled here before they develop TB. The key point is to ensure that those communities and community leaders are aware of the need to ensure that the doctors and communities themselves recognise and treat it as quickly as possible. The awareness-raising campaign is very focused on providing leaflets in different languages and—as I mentioned in relation to Bradford—briefings for doctors. That is the way in which to contain TB and to ensure that we deal with it in the proper fashion.
The Minister has identified one great weakness—that the London boroughs are acting so independently. It is the same with their approach to rough sleeping and the provision of hostels, as well as with vaccinations. What has been done to encourage more co-operation between the London boroughs so that there can be a pan-London approach to rough sleeping, homelessness and health matters?
The noble Lord raises a very important point. We are exhorting them and trying to persuade them, and we will continue to do so. Plans are in place to do this. There is no reason why, with cross-party and cross-borough effort, we cannot deal with this in a co-ordinated fashion in London.
Who is responsible for following up the contacts, which I understand is very important? In the past it was the local health officers in the local authority who followed up the contacts, and they often found many people who had been in direct contact with the TB cases and developed TB themselves. Who now has this responsibility?