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More than 50 per cent. of the population have reported musculoskeletal pain at one or more sites for at least a week. Population surveys show that back pain is the most common site of pain, and the prevalence of physical disability is higher in women than in men. It increases with age; 60 per cent. of women aged over 75 who live in the community have reported some physical limitations. In individuals of working age, musculoskeletal conditions,
particularly back pain and generalised widespread pain, are a common cause of sick leave and long-term work disability. Hence, they are a big problem for the individuals affected and have significant economic consequences for society.
Rheumatoid arthritis, osteoarthritis and osteoporosis are associated with loss of independence and sufferers require more support in the community or admission to residential care. Between 15 and 20 per cent. of GP consultations are about musculoskeletal conditions-they take up a significant time in GPs' surgeries-and many of those people are referred to allied health professions, such as physiotherapists, occupational therapists or chiropractors. We should not underestimate the huge impact that such professionals have in improving the life and prospects of people with musculoskeletal conditions. Then we have the rheumatologists, orthopaedic surgeons and the rehabilitation specialists, of whom the hon. Member for Wyre Forest (Dr. Taylor) is one-we always welcome not only his professional expertise but his significant contribution to debates such as these.
In most European countries, total joint replacement-knee or hip-is one of the most common elective operations for old people. We are therefore talking about a significant disease that has a significant impact on our economy and the well-being of the people in this country. Much of the treatment is not complex: massage, physiotherapy, drug self-management and vitamin or mineral supplements are all used to relieve pain. As the disease progresses, joint surgery and more complex drug treatment are also necessary.
In 2006, the musculoskeletal services framework recommended offering care closer to home, with improved ways to access diagnostic services. The document aimed to help local health communities to improve orthopaedic services and to deliver a waiting time of 18 weeks. However, as hon. Members have said, there are problems about diagnosis. Setting a target of 18 weeks may be laudable, but the clock starts ticking only when a patient has that much-needed diagnosis.
The musculoskeletal services framework dealt with such issues by describing best practice, which is built around evidence and experience. It also promoted a redesign of services, full exploitation of skills and roles, and better outcomes for people with musculoskeletal conditions through more actively managed patient pathways, as well as sharing of information and responsibility agreed between stakeholders in all sectors. The central tenet of the document was to provide the appropriate level of high-quality information, support and treatment to those with musculoskeletal conditions. Sadly, however, that is not happening.
If the problem is bad now, it will get worse with an ageing population. The associated problems, which have been touched on, are not just a loss of working days and the cost of musculoskeletal problems, but an increase in mental health problems. As people become less mobile, they become more isolated, and the burden is then placed on family and friends. I repeat: the problem will only get worse with an ageing population.
It is very hard for people with musculoskeletal conditions to get the attention they deserve. Despite the figures, public and media attention is often difficult to grab. Questions continue to be raised about whether GPs always recognise the problem-I have already mentioned the problem of diagnosis. We must focus on GP training
and continuing professional development. Complaints about diagnosis relate not only to musculoskeletal conditions, but to illnesses such as epilepsy and asthma. It is an area that we must get right. I know that a great deal is put on the plate of GPs, but it is vital that they continue their professional development and that we continue to emphasise the importance of early diagnosis.
I smiled to myself when the hon. Member for Wyre Forest mentioned multi-disciplinary teams. Multi-disciplinary teams go in a little box of things that I remember coming into being in the early 1980s, when I was a district nurse-the Minister may share this memory. Like many things from 30 years ago, the idea appears to have languished on the beaches-although it is often mentioned in documents, it is, sadly, rarely put into practice. There is no doubt that multi-disciplinary teams have a huge role to play in treating musculoskeletal conditions. We need to see them working on the ground. The teams need a lot of leadership from not just Government but local PCTs and GP practices to ensure that they play their part in treatment.
In my party, we have talked about speeding up National Institute for Health and Clinical Excellence drug appraisals; that is critical, particularly in the later stages of treatment. If that were done, fewer drug cases would have to go to exceptional cases panels, because PCTs would have earlier guidance on what should be prescribed for such conditions. We also believe that the societal costs of disease should be taken into account in NICE appraisals. That is particularly relevant for people with musculoskeletal conditions.
Individual budgets have a crucial role to play. If someone with a long-term condition who was living at home could be assessed through a single assessment process, which incorporated both health and social care needs, a "pooled budget" could be determined for them. The calculation of the budget would consist of two parts: one would relate to social care and be means-tested, the other would be health care-related and free. Based on that, an individual and their carer would be given the flexibility and empowerment-most important if one is suffering from a long-term chronic illness-to choose their providers and where they get the care to alleviate their problems. They should be able to exercise that flexibility across the social and health care divide.
Giving real choice to patients and allowing professionals to decide on the best strategies for providing health care will not be possible unless GPs, patients and providers can access sophisticated data about the performance of treatments, hospitals and doctors. I am confident that the provision of high-quality information, available in the public domain and presented to patients by GPs, will make the providers of NHS care truly accountable to patients and improve the standards of care. I am even more confident that, as information drives greater choice for patients, so patients' experience of their health care will improve.
Some 20 to 25 per cent. of our constituents suffer from musculoskeletal problems, and they account for one in four visits to GPs. Up to 28 million working days a year are lost due to musculoskeletal problems, which is some 22 per cent. of our long-term capacity. Will the Minister tell us what the Government have done and what they intend to do to resolve the huge range of problems?
ARMA states in its audit of PCTs that only 60 per cent. of those responding have mapped resources for long-term conditions and their use by people with musculoskeletal problems. Some 60 per cent. of PCTs have not audited outcomes, which is shocking, and 57 per cent. have not linked up to local pathways-to- work schemes. Most important, David Nicholson, the chief executive of the NHS, agreed that improving the outcomes for people with musculoskeletal problems was about management and planning rather than additional money. That is a joy to the ears of all of us in these very difficult financial times. We have a chance to improve the mobility, the well-being and the productiveness of millions of people without additional costs.
I have a number of questions for the Minister. What can be done to improve the working practices affecting sufferers of a musculoskeletal condition? According to a survey by the Office for National Statistics, the majority of MSC sufferers over 60 do not have access to health services due to a lack of information and help from their GPs. What can be done to ensure that those who need both information and care receive them? Is the Minister aware-this was also raised by the hon. Member for Manchester, Blackley (Graham Stringer)-that the King's Fund report of 2006 found that spending on musculoskeletal problems varied eightfold across PCTs in the country?
The Minister must also be aware from work on the Government's musculoskeletal services framework that MSC patients have endured some of the longest waiting times for hospital care and have, in many areas, faced fragmented and incoherent services that provided poor access to care. Four years on, can the Minister tell us what has happened and what she is now doing to address the situation? Will she also say why the Department of Health does not take a clinical lead? I mentioned leadership earlier and said that leadership must not only come from Government, but that a Department of Health clinical lead would have a significant impact by giving people and their musculoskeletal problems the attention that they deserve. Finally, what steps is she taking to improve commissioning of services?
The Parliamentary Under-Secretary of State for Health (Ann Keen): I begin by congratulating the hon. Member for Rochdale (Paul Rowen) on securing the debate. I would also like to add my own tribute to you, Mr. Streeter, as we serve under your chairmanship today.
I want to acknowledge the gallant leadership that has been shown by the nurse sitting opposite me today: the hon. Member for Guildford (Anne Milton). In this debate, of course, we have heard from two nurses, in the hon. Lady and me; a physician, the hon. Member for Wyre Forest (Dr. Taylor); and a scientist, my hon. Friend the Member for Manchester, Blackley (Graham Stringer). I am not sure about some of the attributes that other hon. Members present have brought to the debate, along with their concern for their constituents, but they have been able to demonstrate their abilities and interests in this area. I also congratulate the hon. Member for Rochdale on his relationship, as a trustee, with the Arthritis Research Campaign. I applaud the imaginative title of "Joint Working?", the Arthritis and Musculoskeletal Alliance report to which that he referred.
Before I address in detail the concerns that the hon. Gentleman and other hon. Members have raised, I would like to recognise the excellent work of NHS staff that is taking place across the whole of Rochdale. Those staff are delivering a better quality health service than ever, which benefits the hon. Gentleman's constituents and those of other hon. Members.
It is estimated that nearly a quarter of adults and about 12,000 children are affected by long-standing musculoskeletal problems-with your permission, Mr. Streeter, I will refer to musculoskeletal as "MSK" throughout the rest of my speech. MSK conditions, such as rheumatoid arthritis, osteoporosis and other bone, joint, spinal and muscular diseases, can cause tremendous pain and anxiety to sufferers and their families on a daily basis.
When someone sees their GP with a suspected MSK problem, there is often no single diagnostic test that can confirm a particular condition, because symptoms can vary, as was set out earlier in the debate. For example, the symptoms of rheumatoid arthritis are similar to many more common conditions. The hon. Member for Wyre Forest gave a very good description of the symptoms that people might experience when they awake from sleep. As he did so, I looked around the Chamber and I could see Members and officials perhaps thinking, "Was that how I felt this morning?", as they awoke with stiffness and swelling of joints. It is very common for us to feel that anxiety about such symptoms with which we struggle in many areas of our life. Of course, "struggle" is what most people do if they have any of those conditions.
Early diagnosis of those debilitating conditions is essential, because if treatment is started early, the damage to joints can be minimised. There is an increasing amount of evidence that aggressive treatment soon after the onset of symptoms can lead to remission.
Hon. Members have quite rightly raised the issue of why some primary care trusts fund GPs with specialist interests while other PCTs do not. Some PCTs have alternatives to GPs with specialist interests. For example, we now have consultant-led teams working in the community and, as has been mentioned already, we also have nurse-led clinics that have access to a consultant.
For example, the Pennine MSK partnership in Oldham adopts a community-based approach. Norfolk and Norwich University Hospitals NHS Foundation Trust co-ordinates care between hospital departments, and GPs and nurses in the community. Of course, the very important physiotherapists and occupational therapists also play their role. As is the case with so many long-term conditions, there will now be a team approach to MSK conditions. PCTs need to decide how best to provide services with their local populations.
Commissioning is exceptionally important. World-class commissioning will help PCTs to align their more strategic priorities with the key health outcomes that will deliver for their particular local population. PCTs need to ensure that they commission the services that are needed for their patients.
In the Department of Health, we continue to work closely with key stakeholders to share this learning, because learning is what we are doing. We are learning how to treat long-term conditions of a very difficult-often chronic-nature together in the community. Therefore, good practice must be shared.
Dr. Pugh: I think that the Minister said before that diagnosis of some of those conditions is quite a complex matter and that it is not quite as simple as the hon. Member for Wyre Forest represented it earlier. Clearly, there will be differential patterns of success with regard to early diagnosis. What I want to know is whether there is a statistical basis for examining those patterns. In other words, are data collected on the success of particular practices, or particular PCTs, in the early identification of versions of rheumatoid arthritis?
Ann Keen: I hope that I will go on to demonstrate that, because we have published examples of good and innovative practice in MSK services. We have also introduced a national orthopaedic coaching programme, which is working with 80 NHS organisations across all 10 strategic health authorities, to spread learning across local health communities, to share good practice and to deliver improved services.
Dr. Pugh: The Minister is talking primarily about differentials in therapy or treatment-or whatever-and the variety of good and bad practice that exists in treatment. What I was wondering about was whether there was any statistical base for suggesting that there is good and bad practice in diagnosis, either in practices within the same PCT, or in PCTs themselves.
What is being done to help GPs to understand the symptoms of MSK conditions? We are providing information for patients and professionals on the symptoms and treatment of a variety of MSK conditions via NHS Choices, NHS Evidence and the map of medicine. We are publishing good practice and commissioning pathways for inflammatory arthritis for PCTs to adapt locally. We are developing that programme to include a layer of information for patients to cover all aspects of their stages of treatment. Of course, it is very important that we remember that the patient is at the centre of this information-giving activity and that, in many instances, they will be very aware of all the information that they require, which might at times be a difficulty-not a threat, but a difficulty-for some health professionals who have less knowledge of this particular subject than others.
We are attending events across the country to promote the 18-week commissioning pathway for inflammatory arthritis. For example, the Department of Health recently attended a Nursing in Practice event in Birmingham to help to promote the pathway and information about rheumatoid arthritis among primary care nurses. We also attended the National Association of Primary Care conference to promote good practice among a wider audience, including GPs, PCTs and practice-based commissioners.
On rheumatoid arthritis specifically, we are working with clinicians and support groups to understand how awareness among GPs and the public can be raised. For example, we are considering how to support the Rheumatology Futures Group and the Royal College of General Practitioners to raise awareness of rheumatoid arthritis.
NHS Choices is a comprehensive web-based information service that is intended to help the public to make choices about their health, from lifestyle decisions through to the very practical aspects of finding and using NHS services in England. It provides a wealth of information to patients and health care professionals on a wide range of conditions, including information on the symptoms and treatment of rheumatoid arthritis.
The map of medicine provides GPs with information to help them to determine the best possible treatment options for their patients, including information on the various patterns of onset, diagnostic tests and medical treatment of rheumatoid arthritis. It is a map of best available research evidence and of best-evidence clinical guidelines. It displays this knowledge in a pathway that is easy to use and presented in a particular format, reflecting the patient journey and providing a framework for developing local pathways.
The Rheumatology Futures Group is examining how to raise GPs' and primary health care professionals' awareness of inflammatory arthritis, including through educational material for GPs and practice nurses to increase awareness of early inflammatory arthritis in primary care. It is also examining pharmacists encouraging their patients who attend regularly for analgesic medication to seek advice from their GP, if inflammatory arthritis is a possibility. That is a different approach, as I am sure hon. Members will recognise. If someone regularly attends a pharmacy for anti-inflammatory painkillers, the pharmacist could ask, "Have you been to your doctor?" From all the evidence that I have described, it is evident that there is a willingness, a desire and a need to treat MSK conditions differently.
Hon. Members have rightly mentioned the economy and Dame Carol Black's review. We agree on the importance of early diagnosis, and PCTs need to work with their providers. In our response to Dame Carol Black's review of the health of the working-age population, "Working for a healthier tomorrow", the Government set out a number of new and existing initiatives to support people entering, staying in or returning to work.
Pathways to work, which is available to all individuals claiming benefits due to a health condition or disability, offers a mixture of mandatory interviews and voluntary programmes. I heard what was said about the interviews, how they are called and, in some instances, the ridiculousness, in terms of access, of where they are held-[Interruption.] I think that the hon. Member for Guildford has spread her throat infection rapidly across to me, although I am not sure how that has been achieved. The interviews need to be reviewed. I note the serious comments that have been made, not just as a Minister but as a constituency Member of Parliament, because I am also aware of some of the concerns.
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