|Previous Section||Index||Home Page|
"Arthritis refers to any condition of joints of the limbs or spine associated with inflammation or structural change".
Straight away, it lumps osteoarthritis-degenerative change-with all the other conditions. We really should have a campaign on that to ensure that people with a degenerative change or a strain change realise that it is not potentially progressive.
If we are to have better diagnosis, as has been said, we need better training for students, refreshers for GPs and greater awareness among people more generally. As with the cancers, there is a group of common symptoms that presents for the inflammatory arthritises. The first
is stiffness that is much worse in the morning. Anybody who has painful joints with swelling, morning stiffness and signs of inflammation has an inflammatory arthritis, and they will have to jump up and down until their GP organises the basically simple blood tests that will confirm that they have an inflammatory illness. If it is potentially progressive, the earlier it can be tackled, the better.
Andrew George: The hon. Gentleman hits the nail on the head-early diagnosis is a significant issue. I mentioned that I have ankylosing spondylitis, but I was not diagnosed for six years. Late diagnosis is a common concern, particularly as the condition progresses a great deal. However, the problem goes across the specialties, because AS can present as iritis or in other ways. Will he comment on the idea that we need to work across the specialties? This is not just an issue for rheumatology; the specialties have to talk to each other.
Dr. Taylor: I thank the hon. Gentleman for his intervention. Ankylosing spondylitis is a very specific and interesting inflammatory arthritis, but it needs early diagnosis. The treatment for most back pains is "Put 'em to bed and rest 'em," but somebody with ank spond who is put to bed to rest will stiffen up. We see people walking around who were treated years ago yet even now have stiffened up in a hopelessly bent condition. When I was in the Air Force, I had to treat a high-ranking officer with ankylosing spondylitis. He had been treated badly and had curled up. The only time he was comfortable was when he was lying in a fighter aircraft, in which pilots would lie with their feet stretched out and their head looking in the same direction. Amazingly, this chap was still allowed to pilot an aircraft.
Dr. John Pugh (Southport) (LD): The hon. Gentleman says that there is a simple blood test to establish whether people have rheumatoid arthritis. Given that, why does the NAO report say that many GPs are quite slow to make a diagnosis?
Dr. Taylor: I thank the hon. Gentleman for his intervention. I actually said that there was a simple test to determine whether an inflammatory process was going on, not whether someone had rheumatoid arthritis. Obviously there are tests for rheumatoid arthritis, as the Minister knows, but the crucial thing is the simple test for inflammation.
I hate to put it like this, but ankylosing spondylitis is one of the most interesting of the inflammatory arthritises for the doctor treating it, because it affects so many bits, although I will not describe all those that it could affect for fear of upsetting the hon. Member for St. Ives (Andrew George). However, it is vital that an early diagnosis is made, and anti-TNF drugs are useful in treating this condition, too.
I now turn briefly to the management of conditions. Obviously, everything depends on the diagnosis. Although I want to concentrate mainly on the inflammatory arthritises, it is now recognised that the medical profession treats backache badly, and some osteopaths and alternative practitioners are probably just as good, if not better. On the inflammatory arthritises, however, it is crucial that sufferers are treated by a multidisciplinary team. Gone are the days when someone saw a consultant rheumatologist and that was that. People must have specialist nurses, physiotherapists, occupational therapists, podiatrists and ready access to psychologists and orthopaedic surgeons.
There are huge worries about such provision, however, given that financial resources will inevitably be reduced over the next few years. The attack will come on specialist nurses and physios-
Dr. Taylor: I am glad to see the Minister shaking her head because physios and occupational therapists are always seen as low priorities when we talk about emergency medicine and emergency surgery and it is important that we protect them.
Obviously, I have seen huge changes in treatment during my professional life. Until about 15 years ago, disease-modifying drugs were very toxic and not that effective. We had things such as gold and penicillamine. Then we had methotrexate, which was quite a breakthrough. Recently, we have had the unbelievable advance of the so-called biologicals, which have been mentioned. When they work, they can be almost like a miracle, but they require careful follow-up and specialist staff, particularly specialist nurses, are needed to do that follow-up. With such conditions, people cannot be referred back to primary care for follow-up unless the GP has been specially trained in following up people on anti-TNFs, so they have to be followed up by the specialist in the hospital.
The take-up of anti-TNF drugs has been mentioned. I was at a meeting of the National Rheumatoid Arthritis Society last February at which Professor David Isenberg, a consultant rheumatologist at University college London, said:
"Postcode prescribing results in huge variations across the country. Why does it happen that one patient can get a NICE-approved drug straight away, but for another patient they might have to wait three months?"
"So far as the anti-TNF treatments for RA are concerned, only 5-10 per cent. of UK patients are receiving them, despite NICE approval."
Hon. Members have already mentioned the crucial importance of better records and information-I echo those comments. As for employment, since emphasis was placed on capacity for work rather than incapacity, and since the change from personal capability assessments to work capability assessments, I have heard several complaints about the nature and accuracy of the medical assessments, particularly for people with long-term conditions. The tests are performed by a firm called Atos, and some of those about which I have heard complaints have been overturned on appeal. I wonder whether the Minister has received complaints about those medical assessments, and especially about lack of notice. I was so concerned that I wrote to the Department for Work and Pensions, and I received a reply from the Under-Secretary of State for Work and Pensions, the hon. Member for Chatham and Aylesford (Jonathan Shaw), who is the Minister responsible for disabled people. A particular concern was that medical evidence that had been submitted was not really taken into account. The Minister wrote:
"The guidance for examining healthcare professionals specifies that they are required to read and consider all the evidence on file in preparation for the interview with the claimant."
"The healthcare professionals carrying out the WCA receive training tailored specifically to the task of carrying out the assessment...As the purpose of the assessment is to identify the functional effects of those conditions, the specific training which they receive focuses on disability analysis."
"It may be beneficial if I explain that the HCP provides their medical opinion based on the documentary evidence, the interview and observation of the customer and on an appropriate medical assessment".
We therefore have it absolutely straight that the previous illness and medical evidence must be taken into account. I should be interested to hear from the point of view of the Department of Health whether the Minister has had complaints about such assessments.
Dr. Taylor: I am grateful for that intervention, because I did not realise that that was the number. I am encouraged to think that it is worth hon. Members continuing to take the matter up with Atos and the Department. There is nothing more distressing than seeing someone with a genuine, very long-term condition being put through unnecessary appeals. I know of one case when that happened once and then again the following year, and the person concerned won the appeals.
Dr. Pugh: The situation is even worse than the hon. Gentleman suspects. People in my area were called for interviews to a building with no disabled access, so people with very serious complaints could not get in to establish that they were disabled.
I must finish, so I shall summarise my points. A priority for people with long-term conditions that has not been mentioned is prescription charges. Professor Ian Gilmore of the Royal College of Physicians is carrying out a study on that, and I wonder whether the Minister has any inkling of when the report will be published. As patients with cancer are being excused prescription charges, I hope that the same will go for people with long-term conditions.
I support the wish for a national clinical director. Cancer and cardiac care have come on tremendously, at least in part because of the appointment of the clinical directors. In the case of the inflammatory arthritises, we have the almost miracle of anti-TNFs, which can be equated with the huge advances that have happened in cardiac care. We want someone to push forward so that such drugs are rapidly made widely available. We have mentioned training, public awareness and better information gathering. If the Minister addresses all those things, we shall have done some good for people with long-term conditions, particularly the musculoskeletal ones.
Dr. John Pugh (Southport) (LD): It is a pleasure to serve under your chairmanship, Mr. Streeter. I think that this is the first time I have done so. I am sure that your elevation was recent, and it is certainly well deserved.
I congratulate my hon. Friend the Member for Rochdale (Paul Rowen) on initiating this important debate and taking up the cudgels on behalf of musculoskeletal sufferers. This is clearly an important topic, but it is also, as my hon. Friend made clear, a huge one, covering a range of conditions, some of which have clear and definite physical symptoms that can be seen on an X-ray, and some of which, such as fibromyalgia, are rather more difficult to tie down, and to treat. The topic is huge also in the sense that it involves 10 million people in the UK. It is important to the sufferers, who endure daily torment, but also to the nation. The National Audit Office report established that better treatment of rheumatoid arthritis could save the nation £1.8 billion, and we could do with an extra £1.8 billion at the moment. Apparently, £7 billion is lost to the economy from all musculoskeletal disorders.
It is important that the NHS should get the treatment of those 10 million sufferers right. All the research that I have looked at identifies a crucial role for primary care to play-particularly GPs. The NAO report, which I think centred exclusively on the issue of rheumatoid arthritis, said that there was sometimes a nine-month wait between when symptoms first occurred and the start of treatment, which made quite a difference to long-term outcomes. If things are not got right in the early stages, the disease will progress more rapidly, with more damage. There is thus a crucial role for primary care.
The literature makes it apparent that there is a crucial role for the primary care trusts. In every PCT worth its salt, there is talk about the expert patient initiative-and voluble talk about how long-term conditions can be managed by the patient and practitioner together. Much of that, however, going by evidence presented by my hon. Friend and others, is lip service, because there is not effective bespoke commissioning everywhere.
PCTs without such commissioning can learn something from those where it exists about employing interventions that work-because things are not going that well in the national health service. According to statistics given to the Liberal Democrats under the Freedom of Information Act, in the past three years, 3,337 NHS staff with a range of conditions, the bulk of which were of the musculoskeletal kind, went for treatment outside the NHS. That leads one to be suspicious about whether they were able to find good enough treatment wholly available within the NHS. Then, of course, there is the collateral damage to the ability and confidence of those affected. There is also the unspoken problem of mental health. People who cannot move very well and do not feel very good about themselves may suffer more frequently with depression and the like.
Three quarters of people diagnosed with rheumatoid arthritis are found to have it while still at working age-a point made by the hon. Member for Manchester, Blackley (Graham Stringer). When identified, the prognosis is rather dim. They end up being off work for long periods and, worse still, sometimes without much sympathy. The back has always been the passport for malingerers wanting to get out of a job, so those who have a genuine problem with their back do not necessarily get the sympathy that they might receive if they had another sort of complaint.
Given all that, an awful lot of people tend to be plain philosophical. My mother suffers with rheumatoid arthritis, but she just gets on with it. She moans about it from time to time, but she does not do anything about it. She regards it as an occupational hazard of getting old. She does not like us drawing attention to it, because its disfiguring aspect upsets her. She prefers to ignore it and get on with her life as best she can.
It is obvious that if such conditions are allowed to develop unchecked, they will become severely disabling. There are knock-on consequences for other aspects of health. For instance, the cardiovascular system can be affected, and mental health problems can occur. If it is unchecked in the nation-or at least not well checked-it could have a huge social and financial impact.
What needs to be done? We obviously need to tackle the problem with more urgency. We also need something that was alluded to earlier-a recognition that we need more diversity. If 200 different problems can be encompassed in musculoskeletal conditions, as we were reliably told by my hon. Friend the Member for Rochdale, and I believe him, it is unlikely that they can all be resolved with the same solution. Various professionals will be involved in the treatment-physiotherapists, physiologists, occupational therapists, and even acupuncturists and bone surgeons-but it is important to recognise that it is a diverse problem that requires a range of solutions.
My hon. Friend spoke of the need for more co-ordination and coherence, and we cannot argue with that. Certainly a good interconnection is needed between those who prescribe and those who manipulate, between the secondary and the primary sectors and between the workplace or the Department for Work and Pensions and the surgery.
The literature that I have seen does not demand that the Government do something new, but they have been asked in parliamentary questions whether they have any intention of updating the musculoskeletal framework. They responded in various ways. They did not reject the need to do something, but they pointed out that they are committed to improving care and outcomes for people with long-term conditions. They said that they want to improve the quality of service in a safe and effective way; that they will start fit-for-work pilots; and that they have learned something from "Working for a healthier tomorrow". All those things were said in answer to parliamentary questions, but clearly not to the satisfaction of many hon. Members here today.
I have a small element of sympathy for the Government. We can give too much credence to a framework, as though it would magically abolish the problem-as if, once it is in place, and the tick-box exercise has started, everything will be better. I an anxious that the Government may be too firm and overarching in dictating local priorities, as all hon. Members would want to support local provision.
I have a little sympathy with the Government's wish to conduct pilots. Before they tell people what to do, they genuinely need to know what is best practice and what works best. The problems that we are debating are slightly different from those linked to cancer, which was mentioned by my hon. Friend. For a start, there is greater variety. I know that cancers vary, but musculoskeletal conditions vary even more.
Some people may fear that pilots will become a substitute for action-that a pilot is doing something about a problem to which the Government have been alerted. There is clearly no need to pilot certain things. For example, as the hon. Member for Wyre Forest (Dr. Taylor) said, key conditions such as rheumatoid arthritis are well understood and are relatively easy to diagnose. We do not need to reinvent the wheel. The challenge for the Government is to act on National Audit Office findings and the many representations made here today and by the associated bodies and charities that support people with such conditions. Unless we take another hard look at ensuring effective action to deal with the problem, we will be wasting money and wasting people's lives. We will also be wasting known medical expertise.
I congratulate the hon. Member for Rochdale (Paul Rowen) on scoping out so well some of the issues that face those with musculoskeletal problems. "Joint Working? An audit of the implementation of the Department of Health's musculoskeletal services framework" by the Arthritis and Musculoskeletal Alliance quoted a number figures, as have several hon. Members who have spoken today. I shall try gather them together-they vary, but I hope to show at least some of the range.
The ARMA report noted that musculoskeletal conditions place a significant burden on the NHS, accounting for between £3.5 billion and £4.5 billion of NHS spending every year. They also cause a loss of working days every year: we were given a figure as low as 11 million but it could be as high as 28 million. The report expresses concern, which is shared by hon. Members who have spoken in the debate, that the Department of Health's musculoskeletal services framework has been implemented inconsistently, and recognises the variations in standards of care across the UK for patients living with those conditions. That concern should be addressed. The report also calls on the Government to consider the recommendations, and I am sure that the Minister will want to respond to them.
There are between 150 and 200 musculoskeletal diseases and syndromes, which are usually but not always progressive and which are associated with pain. Indeed, a number of hon. Members here could say that they have at some point suffered from a musculoskeletal condition, albeit minor-except for the hon. Member for St. Ives (Andrew George), who is no longer in his seat, for whom it is more significant. Such conditions result from trauma and inflammation or a number of other factors. Rheumatoid arthritis, osteoarthritis, osteoporosis, low- back pain, and limb trauma are particularly significant.
|Next Section||Index||Home Page|