Westminster Hall
Tuesday 19 January 2010
[Mr. Gary Streeter in the Chair]
Musculoskeletal Conditions
Motion made, and Question proposed, That the sitting be now adjourned.-(Mr. Mudie.)
9.30 am
Paul Rowen (Rochdale) (LD): Good morning, Mr. Streeter. It is a pleasure to serve under your chairmanship for the first time. I thank the Speaker for granting me the opportunity of this Adjournment debate.
I declare a non-pecuniary interest as a trustee of the Arthritis Research Campaign, one of the largest medical research charities in the country, which is soon to be renamed Arthritis Research UK, which indicates the sort of work that it does. As a major research charity, ARC has pioneered much of the research on arthritis and many of the developments in its treatment, including anti-TNF drugs-tumour necrosis factor blockers-and has supported the medical research community in the UK.
The UK is a world leader in research into musculoskeletal conditions, which, unlike cancer and heart conditions, are not immediately life-threatening for most people. Sufferers are not traditionally the most vociferous in shouting about the shortfalls in care and their needs, but I hope that that is about to change with the advent of Arthritis Research UK, which has set 10 ambitious goals. They include ensuring that people with arthritis remain active; reducing the economic impact on patients, their families and the wider economy; reducing the number of deaths and severe complications of arthritis in all its forms; and reducing pain and disability in childhood arthritis, leading to a normal future.
I acknowledge the help and support of ARMA, the Arthritis and Musculoskeletal Alliance, of which ARC is a member, and particularly for the work of Ross Meek and Tony Redmond and their support and advice when preparing this debate. ARMA's report, "Joint Working? An audit of the Department of Health's musculoskeletal services framework", provided a major impetus for this debate, along with Dame Carol Black's 2008 review of the health of Britain's working-age population, "Working for a healthier tomorrow", the National Audit Office report "Services for people with rheumatoid arthritis", as well as my early-day motion 1930, which was tabled on 20 July 2009.
"Musculoskeletal conditions" is a broad term encompassing more than 200 problems affecting the muscles, joints and skeleton. They include sprains and strains, pelvic fractures, low-back pain, repetitive strain injury, osteoarthritis, osteoporosis, rheumatoid arthritis and chronic pain syndromes such as fibromyalgia and Marfan syndrome. Such conditions affect more than 10 million people, or one in four of the adult population, and last year the NHS spent more than £4.2 billion-more than £11 million a day-on their treatment, which is the fifth highest programme budget of all NHS gross expenditure.
Bob Spink (Castle Point) (Ind): I declare an interest in that my family is affected by rheumatoid arthritis. Does the hon. Gentleman agree that drug access is absolutely central to the problem, particularly the new biological anti-TNF drugs, and that their prudent and early use may not only help the patient tremendously, but have a massive societal and economic impact and reduce further costs for the NHS in the longer term? We must ensure that those drugs are used effectively and quickly.
Paul Rowen: I am grateful to the hon. Gentleman for making that point. I was about to come to the effect on society. I agree with him that early treatment-not just drug treatment, but other support such as pain relief and so on-is vital. This debate is different from most debates because I am not asking the Minister for huge sums of money for new miracle drugs; instead, I am asking that the available money be better co-ordinated and better used.
Dame Carol Black's report, "Working for a healthier tomorrow", which referred to the point made by the hon. Gentleman, found that musculoskeletal conditions are the most common work-related illnesses, costing society more than £7 billion a year. The Health and Safety Executive estimated that, in 2007-08, 28 million working days were lost in the UK, a quarter of them due to musculoskeletal conditions. In their response to Dame Carol Black's report, the Government said:
"Every day, working people are calling on the NHS for support, especially for mental health and musculoskeletal disorders. We are committed to improving access to key services that are proven to be effective in helping people with these conditions manage their return to work."
That is a laudable aim, but ARMA found that 57 per cent. of primary care trusts had made no contact with the Department for Work and Pensions' pathways to work providers to ensure that local people were assisted back to work, despite Dame Carol Black's review finding that, once in receipt of incapacity benefit or employment and support allowance, those with a musculoskeletal condition had a greater probability of returning to work. The musculoskeletal services framework that the Government adopted in 2006 stated:
"PCT's...are strongly recommended to make links with the DWP Pathways to Work pilots...being set up in their area",
but clearly, that has not happened. Making such links is an urgent priority if the Department for Work and Pensions is to get people on incapacity benefit back to work. The framework emphasises my point that this is not about needing new drugs or new money, but about using what is available to assist people to live normal lives.
Andrew George (St. Ives) (LD): I declare an interest, having suffered for 35 years with ankylosing spondylitis, a condition that my hon. Friend has not mentioned. The National Ankylosing Spondylitis Society has been considering the problem and I have been working with the society to make representations to the Government urging the introduction of a national clinical director of musculoskeletal conditions. My hon. Friend is entirely right in what he says about the Department of Health and the Department for Work and Pensions working together. That requires not extra money, but cross-departmental co-ordination to improve people's lives and to reduce the amount of benefit that is paid to support people when they are off work.
Paul Rowen: I agree entirely with my hon. Friend. I requested this debate because we could do a lot with the available money if there were better co-ordination.
In 2006, the Government published a framework for musculoskeletal services, "A joint responsibility: doing things differently". It did exactly what my hon. Friend says and was produced with input from a range of Departments, including the Department for Work and Pensions and the Department for Transport, to produce a co-ordinated response on dealing with such conditions. However, unlike other frameworks that predated and followed it, there was no clear standard or framework to guide the development of services for people suffering from musculoskeletal disorders. For example, despite one in five patients presenting with a musculoskeletal disorder, standards were not written into the GP contract, no network was created and no health tsar was appointed to ensure the establishment of a common framework. That is in stark contrast to diseases such as cancer or heart disease, where treatment, time frames and follow-ups have been rigorously applied nationally.
Funding for musculoskeletal conditions is incredibly variable across PCTs. ARMA reported a threefold variation in the average funding provided for each person with a musculoskeletal condition, ranging from £204 per patient in Camden PCT to £632 in Gateshead. In my region in the north-west, average spending in 2007-08 was £474 per patient, compared with a national average of £401. Only 18 per cent. of PCTs in the north-west reported that they had audited the outcomes of people living with long-term conditions such as a musculoskeletal condition, compared with a national average of 40 per cent. If we do not audit what happens to people and the services that are provided, how can we make the best use of the huge financial resources?
Only 25 per cent. of PCTs in the north-west reported that they had mapped the resources available to support people living with long-term conditions such as a musculoskeletal condition. Such mapping is a key recommendation of the musculoskeletal services framework, but again, the national average for that is only 16 per cent. In the north-west, 47 per cent. of PCTs have made links with local pathways to work-I mentioned that earlier. It is a key pledge and recommendation in Dame Carol Black's report, and we must ensure that it is done. On mapping and indicators, Bury PCT-which is next door to my constituency-was perhaps the most honest: in response to the ARMA questionnaire, it said that it did not use outcome indicators because there are no nationally agreed outcomes. Clearly, that is a glaring error.
At a meeting of the Public Accounts Committee on 23 November 2009 to consider the National Audit Office's report on rheumatoid arthritis, David Nicholson, the NHS chief executive, agreed that improving musculoskeletal services and outcomes was primarily about management and planning rather than additional resources. I hope that the Minister will assure us that we will see that co-ordination and planning to ensure uniformly good provision on the ground. There are huge variations between what is available and what patients can receive. In my view, Oldham PCT, which is next door to my constituency, is a beacon that shows what can happen
when a primary care trust gets its act together and brings together teams of clinicians and support to assist people to live normal lives.
Yesterday, I visited the Chapel Allerton centre in Leeds, which has been supported by ARC and NHS research and is a model of the research community working with the NHS to improve clinical outcomes and services that are provided for people in the north of England. However, there is a totally unacceptable postcode lottery. Why should where someone lives or which condition they have determine the level of their treatment? That is unacceptable for cancer, where clear targets have been set-the Government are to be congratulated on that-so why should a condition that affects one in four of the working population and which, as I have said, costs the country dearly, not have the same co-ordination? Again, I emphasise that this is not about additional resources; it is about using what is available and better co-ordination.
We would like to see the following proposals, which were mentioned by ARC in its report and picked up by my hon. Friend the Member for St. Ives (Andrew George) First, to improve co-ordination and ensure delivery on the ground, we need the appointment of a national director to ensure that current and future initiatives have a strategic focus and to help to develop a proper musculoskeletal network across the country. Treatment should not depend on where someone lives or on a particular hospital or PCT in their area. People should get the early treatment that they need, which can make such a difference.
The second point, which was picked up by Dame Carol Black, is that because GPs are on the front line and many of their patients present with a musculoskeletal condition, there should be enhanced training for GPs, through both PCTs and centres of excellence, to ensure that doctors are kept up to date. A key Government response to Dame Carol Black's report set targets for that to happen.
Thirdly, we need better information about expenditure and outcomes, so that we do not have a repeat of the situation where Bury PCT reported that it did not bother measuring outcomes because there was no set standard. There must be agreed outcomes. If we have a standard on getting people seen within 18 weeks, why can we not do the same for people with musculoskeletal conditions, so that they know what they can expect? Another important point picked up in the ARMA report is follow-up: it is no good seeing someone within 18 weeks if they then have to wait six months for a follow-up appointment to see how they are getting on. People could move backwards.
The fourth thing we need is better information about spending and outcomes, including a common framework. Finally, we need to improve public awareness, so that people know where to seek treatment, what is available and what they should avoid.
We are not asking for a new miracle drug or for the Minister to commit billions of pounds to new research facilities-ARC already provides the bulk of such research. We are not asking for brand new hospitals, although a centre such as the one in Leeds is a model and beacon of what can happen. We are asking for co-ordination and better use of that £4.2 billion of resources, so that patients-our constituents-do not face a postcode lottery, but can go to a doctor where they live and be
guaranteed early treatment, continuing support, advice and, when they need it, a specialist centre. I do not think that that is a lot to ask in the 21st century.
9.48 am
Graham Stringer (Manchester, Blackley) (Lab): Good morning, Mr. Streeter. We occasionally see each other's post because our names begin with the same few letters, and it is a pleasure to serve under your chairmanship for the first time. May I congratulate the hon. Member for Rochdale (Paul Rowen) on securing this important debate? He made a comprehensive and compelling case, especially his last point about the introduction of a clinical director for musculoskeletal conditions. That is the first-possibly the most important-point that I want to make, and I would like an answer from the Minister.
When we look across the provision of health services in the country and see that there are 17 clinical directors-so-called tsars-it is difficult to see why, when there are 9 million to 10 million people suffering from musculoskeletal diseases and so much money is spent on them, we do not have a tsar for those conditions. That is particularly the case given that, as the hon. Gentleman explained, we could have much better services and, if we want to consider the economics and the effectiveness of it, better value for money if there was better integration and co-ordination of those services. If there is any doubt about that, he gave the figure that has been spent-£4.2 billion-and said that was a £600 million increase on recent budgets. Did that £600 million increase going into the budget for people suffering from those conditions lead to better outcomes? Rather tragically, the answer is no, which is another indication that we need better co-ordination of services.
When the Minister deals with the question of why there are 17 clinical directors for other services, but not for musculoskeletal conditions, will she tell us what criteria can lead to a decision to give us directors in other areas, but not in this one? If we consider the intensity of pain, the need for better provision and better co-ordination of services and the number of people involved, I cannot think of any criteria for setting up directors that would not include musculoskeletal conditions. That case has been well made and I look forward to my hon. Friend's reply.
I would like to focus on something to which the hon. Member for Rochdale referred-rheumatoid arthritis, which is an auto-immune disease. Many people do not know that it is an auto-immune disease and just think that that is a name for another kind of arthritis, which it is not. Approximately 500,000 people suffer from it and 26,000 new cases are diagnosed a year. About one third of the people diagnosed stop working within two years of diagnosis.
Professor Emery of Leeds university has said that rheumatoid arthritis is the most common cause of treatable disability. If one third of people diagnosed are out of work very quickly and it is a treatable disability, why is more not being done? The hon. Member for Castle Point (Bob Spink) made the point that many drugs are available now. We have gone through a process whereby analgesics were the main treatment. Then it was DMARDs. I have to look up what DMARDs stands for-disease-modifying anti-rheumatic drugs. We
are now in a new era of biologics, and whereas DMARDs can lead to remission for a period, biologics-used either on their own or in combination-can lead to true remission. I keep returning to the point that the hon. Member for Rochdale made: not enough people are receiving that treatment as quickly as possible, and speed is important.
There have been four recent reports: the National Audit Office report, the King's Fund report, the new clinical guidelines from the National Institute for Health and Clinical Excellence and the ARMA report. All, in different ways, point to exactly the same solution to the problem. Diagnosis does not take place quickly enough. There is not co-ordination and integration of the different services that sufferers of rheumatoid arthritis need. Public awareness, so that people go to their GPs quickly, is not what it should be, and GPs themselves have a low awareness of rheumatoid arthritis.
I shall give some statistics, as the hon. Gentleman did, that apply to my own city and constituency, but if we go back to the previous statistics and do the division sums, we see that about 40 or 50 cases a year are presented to GPs per constituency and that that is less than one case per GP. If there are 800, 900 or 1,000 sufferers per constituency and less than one case per GP per year, it is not really surprising that GPs are not as aware as they should be of the disease. It was a very strong recommendation of the National Audit Office report, supported when the Public Accounts Committee had its hearing, that GPs be made more aware of it.
I then looked at the statistics applying to Manchester, and in a way, the situation is worse than a postcode lottery. The figures vary, from £95 being spent per patient in Lewisham to £1,379 spent in west Cheshire. It is an extraordinary range, with an average of £407. In Manchester, £348 is spent per patient. We have to ask why. We do not expect exactly the same amounts of money to be spent, because there are different areas of the country, different conditions and different patients, but there can be no justification for that extraordinary range of expenditure by different primary care trusts. In terms of the previous statistics, Manchester is not a bad primary care trust. On the four things that it was asked to do, it did not audit outcomes, like a majority of primary care trusts, and it did not map the resources available, but it did link with the pathways to jobs and it did assess the clinical services, so it was a very mixed report. However, there can be no justification for the range of input of cash and not checking the outputs in the service.
It is clear that the musculoskeletal community-that sounds bizarre, but it is the community that deals with people suffering from rheumatism and arthritis-has three main demands. One, as I have explained, is for a clinical director. The others are for an update of the musculoskeletal framework and, partly to deal with the lack of co-ordination and coherence of the service, for stronger commissioning of the services from primary care trusts. I cannot see how the Minister could not respond positively to those very reasonable demands.
I shall finish by thanking the British Society for Rheumatology for providing some of the statistics and information that I have used and by reflecting on the first point that the hon. Member for Rochdale made, about shouting loudly. I first became involved in campaigning on health issues in the 1980s, when members
of the Government and certain editors and members of the tabloid press thought that HIV and AIDS were not an infectious disease, but a moral condition. Trying to get the right treatment and services for people was a major campaign in the 1980s, as was getting the public health information out, but it made me realise that there is not an objective set of criteria in the Department of Health-there is not some philosopher king sitting there, deciding on the allocation for brains, kidneys, livers and cancer. The apportionment of resources partly depends on how loudly both the advocates on behalf of particular patients and the patients themselves shout.
Today, the Minister is hearing those who represent sufferers of arthritis, rheumatism and rheumatoid arthritis shouting on behalf of patients. They are not necessarily asking for more resources, but want more direct and better co-ordination of services to ensure that we have better health service delivery to patients.
10 am
Dr. Richard Taylor (Wyre Forest) (Ind): It is a pleasure to speak under your chairmanship, Mr. Streeter. I am grateful to the hon. Member for Rochdale (Paul Rowen) for allowing me to climb on to one of my hobby-horses, although I shall try not to detain hon. Members for too long. My interest in this issue comes from the fact that I have spent a large part of my professional career battling on the side of patients with the inflammatory arthritises, so I am pleased to be able to speak.
I will talk under four headings, the first three being diagnosis, management, and work capability assessments for people with long-term conditions. I will then repeat the recommendations that were made so eloquently by the hon. Gentleman and the hon. Member for Manchester, Blackley (Graham Stringer).
Diagnosis is one of my hobby-horses. How can we treat anybody in medicine unless we have the correct diagnosis? Right at the beginning, we have to divide the musculoskeletal disorders into two groups: the inflammatory illnesses, which can lead to crippling deformity and disability, and the disorders that are due to acute strains, backache and degenerative change.
The word "arthritis" is an absolute bugbear. When a GP tells somebody that they have arthritis, they immediately leap to the conclusion that they have the worst sort of progressive arthritis. The word needs explanation. I have looked at the current dictionaries and, to my great relief, the "Chambers", "Oxford" and "Webster's" dictionaries all get the definition right. They define arthritis as a disease that causes painful inflammation and stiffness of joints, which is absolutely right. When I look at "Black's Medical Dictionary", however, it says:
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