Examination of Witnesses (Question Numbers
23 NOVEMBER 2009
Q1 Chairman: Good afternoon. Welcome
to the Committee of Public Accounts where today we are considering
the Comptroller and Auditor General's Report on Services for People
with Rheumatoid Arthritis. We welcome back to our Committee David
Nicholson, who of course is the Department of Health's accounting
officer and chief executive of the National Health Service. Would
you like to introduce your colleagues please, Mr Nicholson?
Mr Nicholson: Yes. David Colin-Thomé,
the national clinical director for primary care. Gary Belfield,
the acting director general for commissioning and Dr Alan Nye,
who has a variety of roles but he helps the 18 week team. He is
a general practitioner and an expert in the field.
Q2 Chairman: If we look at this Report,
Mr Nicholson, we can see that too many people with rheumatoid
arthritis have not been diagnosed and treated early enough and
that, once they are diagnosed with this debilitating disease,
they do not always get the services they need. There are obviously
value for money considerations here because many people find it
very difficult to work, so if we could get them diagnosed and
treated early enough it would both save money and of course help
them enormously. We want to try and pursue these issues with you
in as positive a frame of mind as we possibly can. What are you
doing, Mr Nicholson, to try and make GPs better at spotting the
signs of rheumatoid arthritis and referring the patients to specialists
Mr Nicholson: I think it is worth
saying to begin withI am sure my clinical colleagues at
some stage will talk about thisthat it is quite a difficult
thing to do, the early diagnosis of rheumatoid arthritis. We can
see that by the response of general practice and people in the
clinical community. It is not through want of effort or trying
that people have had difficulties in this area. There are three
areas that I think we would focus our attention on. The first
one is recognition and diagnosis. There is a whole set of issues
around information to patients through patient choices, through
the various leaflets and documents that both ourselves and the
voluntary sector put out. There is the work that the Royal College
of GPs is doing around the training and education of general practitioners.
There is a whole set of issues around public recognition of this
particular illness. All of those things need to be pursued in
terms of recognition and diagnosis. The second issue I think is
in relation to timeliness that you describe and again it is very
important for us to continue to drive forward the 18 week programme
because of the effects that has on rheumatology generally; the
publication of commissioning guidance, making sure that our commissioners
are absolutely on top of it. The final issue is about the effectiveness
of treatment, again focusing on the delivery of the various guidance
that NICE has put out about what works and the commissioning guidance
that they are about to put out later on this year. All of those
things together I think, driven from the department, will have
a significant effect in this area.
Q3 Chairman: Presumably you have
no trouble, Mr Nicholson, with recommendation (a), paragraph 18
on page nine: "The Department of Health should explore the
cost-effectiveness of options for raising public awareness of
the symptoms of inflammatory arthritis, including rheumatoid arthritis,
to encourage people to present to the NHS promptly after symptom
onset." You have no difficulty with that?
Mr Nicholson: I think it is absolutely
the right thing to do but that is not to under estimate how difficult
it might be. There is not a particular time of the year when this
particular condition comes about. There is not a particular patient
group, so it is quite difficult to focus your attention and make
it happen. We are considering, I think quite actively at the moment,
a bid from Birmingham, as it happens, for research into the area
of public awareness so we can absolutely focus our attention on
things that will work. We are open to that.
Q4 Chairman: Have a look again at
paragraph 2.6 on page 17 of this Report which describes how GPs
may carry out diagnostic tests. It is still not clear to me why
GPs are wasting resources and not getting people promptly to a
specialist. They are risking people's health, unless you get this
dealt with very quickly. As I understand itcorrect me if
I am wrongwith modern drugs it is possible on most occasions
to arrest this or alleviate it but you have to start very quickly
indeed. If you read paragraph 2.6, it seems that either GPs are
not sufficiently trained in carrying out these tests or recognising
what they do or they are simply not doing it. It is worrying,
is it not?
Mr Nicholson: I am sure it can
be done better. Just to put it in contextAlan might say
something about this clinically in a minuteabout a quarter
of all the work that general practitioners do is in the area of
musculoskeletal problems. Quite a lot of work that GPs do is in
this area and it is quite difficult in that group of patients
to identify specifically the ones that would benefit.
Q5 Chairman: Let us ask Dr Nye then.
He is the expert in this. What is the problem?
Dr Nye: If I may try and put this
in context for you, as David Nicholson says, around 20% to 25%
of all GP consultations are musculoskeletal related. The average
GP sees one new case of rheumatoid arthritis a year, so there
is a real issue about sorting that one case out from the many
hundreds, if not thousands, of musculoskeletal problems that a
GP sees. Added to that there is not a single way in which rheumatoid
arthritis presents. It can present in many, many different forms.
Further complicating it, when a GP gives standard treatment for
a patient with joint pain such as anti-inflammatories, patients
with rheumatoid arthritis often respond very well in the initial
stages, which can further cloud the issue as to what can be going
on. As regards the diagnostic tests, there is a multitude of clinical
conditions that can present with joint pain. I think it is often
completely appropriate that GPs carry out a range of diagnostic
tests to make sure there is not some other condition that requires
prompt treatment for their patients.
Q6 Chairman: It says that you are
doing quite well on meeting this 18 week standard but, as I understand
it Dr Nye, ideally you should be in with a specialist in six weeks.
Is that not right?
Dr Nye: That is what the Report
Q7 Chairman: You really have to move
fast. How could we incentivise GPs to refer people who are diagnosed
more quickly, do you think?
Dr Nye: I think there is a number
of steps that we have taken. We have published an inflammatory
arthritis commissioning guide in the summer of this year, which
is there to encourage commissioners, both PCT and practice based,
and clinicians to work together to actually redesign and deliver
better services to people with inflammatory arthritis and obviously
rheumatoid arthritis is part of that. We are also carrying out
a range of training events. I am in Leeds on Wednesday looking
at shifting services into community settings, so we are trying
to improve the services for local health communities, trying to
encourage them to look at redesigning and managing this problem
Q8 Chairman: Can we talk about depression
because this is often a very big problem with rheumatoid arthritis,
is it not? If we look at 3.16 in this part of the Report here,
we see that only one in seven trusts is providing help for people
with depression. Are you doing enough to get this message down
to the primary care trusts?
Mr Nicholson: There is no doubt
that the relationship between physical and mental health has not
been well supported in the past and not well understood, I do
not think, in the past. It was one of the reasons that Lord Layard
wrote his report in 2006 and it is one of the reasons why we have
launched the whole set of issues around psychological therapies.
That is why we are rolling it out across the NHS as a whole. You
will no doubt know that 75% of our PCTs now have access to psychological
therapies as part of a general picture. We do believe that the
clinical guidelines set out by NICE that are coming this year
will reinforce the importance of psychological therapy to people
who have rheumatoid arthritis.
The other issue is that a lot of these patients would see their
GPs as well. This often happens with chronic disease. It would
be via access through their GP to the psychological therapies
and some of the counsellors that we employ ourselves that patients
could get access. Just measuring the acute trust referral patterns
would not cover the whole picture of referral for depression.
Q9 Chairman: What about supporting
people now once they have this disease? If we look at paragraph
4.18, we see that the help that they receive in trying to get
them back to work is really totally haphazard. Is there any more
progress you can make on this, do you think?
Mr Nicholson: I think this is
a really important issue for us, not just for the general population
but also for our own staff. We have 1.3 million people in the
NHS, some of whom have long term conditions as well. Today we
have announced the Bowman Report on staff health. I will ask David
Colin-Thomé to talk about this and people with rheumatoid
arthritis in general.
It is an area we have not done well in but I think Carol Black's
review last year has given us the focus to do better. The work
that generated from her is now rolling out. There are several
things. We have had Pathways to Work, which is an opportunity
funded by Jobcentre Plus for patients with issues about work to
go and get a consultation and help to go back to work. We have
found that the studies show that that produced a lot more people
going back to work or staying in work than the control group.
They were not as good for mental health problems and that is why
we have this condition management programme which focuses more
on mental health problems. We have a major bit of work. Since
Carol Black's work, we also have the Fitness to Work pilots, because
there are several bits. One is that Carol has recommended now
that we should have a fit for work note for GPs rather than a
sickness note to change the thinking about people's opportunities.
We want to have more opportunity for occupational health and employment
advisers to be based in general practice. This is the work that
we will be producing from next year as a result of Carol Black's
work. For people in work to stay in work, we need support which
is what we are offering, but also for the workless some of these
programmes will help them get them back to work when they have
been out of work for some time.
Q10 Chairman: Some of these patients
will be in unbearable pain. What work are you doing to try and
ensure that they get the services they need promptly and easily,
that they are specially helped, targeted and all the rest?
They are seeing their specialist but also their general practitioner
and I think the mixture of the pain relief plus the anti-rheumatic
drugs is the way forward.
Q11 Chairman: I mean help day or
We have both us available as well as our community nursing services,
some of which maybe are not working overnight at the moment, but
that is the area we will be looking to try and develop in the
future. They would have access. What we have done in this particular
group of patients, as with other people with chronic conditions,
is at least give them access to a key worker, a case manager,
so that, for the more complex end of these conditions, they can
have access to somebody. That would not be day and night, but
it would give them a tremendous amount of cover, more than they
have had hitherto. That is part of our chronic disease programme
for all people with chronic diseases.
Q12 Chairman: Could I ask the Treasury
a question finally? If you look at paragraph 3.10, we do not want
to get fixated on the costs to the economy because clearly people
are suffering appallingly from this and what is important is to
get them helped and treated, but as far as the Treasury is concerned
we see that for those of working age the NAO's model suggests
that this earlier treatment could result in productivity gains
of £31 million for the economy due to reduced sick leave.
A very high proportion of people who get rheumatoid arthritis
have had to leave work, but there is no particular incentive on
the NHS, is there, to fund this? Do you take a view on this when
you are funding the NHS? Do you say that this has an enormous
impact on the economy and therefore we want to fund the NHS in
such a way that they are incentivised to deal with it; or do you
just wash your hands of it and say, "It is over to them"?
Ms Diggle: I had precisely the
same reaction as you do. It seemed to me that if we could do something
about earlier diagnosis it would be extremely welcome because
it would mean less living on benefits, more tax coming in. That
would almost certainly well cover the cost of extra treatment.
However, the sad point of the story is that it is very hard to
diagnose. Having talked to the people who are in front of you,
I do understand that it is very, very hard to spot people with
this disease any quicker. If it could be done, I think there would
be a jolly good case for looking at that equation.
Q13 Angela Browning: Dr Nye, are
you the clinical lead for the Department of Health in musculoskeletal
Dr Nye: No, I am not. I am clinical
adviser for elective care for the department.
Q14 Angela Browning: Who is the clinical
lead in the department?
Mr Nicholson: We do not have one.
Q15 Angela Browning: Why do you not
Mr Nicholson: We do not have a
clinical lead for every condition. If we did, there would be over
200 clinical leads in the department. It is not necessarily the
case that, because you have a clinical lead, it means that focus
is put on it. There are lots of other services that improve without
having a clinical lead per se at national level.
Q16 Angela Browning: When we see
that back in 2004 there were guidelines set down about the length
of time between referral from GP to a consultant, has anybody
taken the initiative within the department to review it, if there
is no clinical lead? I am asking because obviously we have all
read about this window of opportunity.
Mr Nicholson: Just because there
is not a clinical lead does not mean there are not clinicians
involved in all this. We put it into the pathway guidance that
went out. We have strengthened it. It will be in the NICE guidance
that comes out this year and we expect all organisations to follow
Q17 Angela Browning: Could I just
ask you to look at page 19, paragraph 2.12? We heard a little
bit just now about the difficulty because the average GP would
only see one case presented a year and obviously with patients
like that one can understand it would be difficult to just pick
up these odd cases. There is quite a damning paragraph there about
the way trainee GPs are still being tutored in musculoskeletal
conditions. It says here, "Seventy per cent of GPs had tutorials
... receiving an average of two hours teaching" and the most
common topics were back pain, joint injections and osteoarthritis.
Just where does rheumatoid arthritis feature in all of this?
It would fit in with musculoskeletal conditions. When you are
a GP registrar, a GP in training, which is a three year programme,
it covers a wide range of the responsibilities. Musculoskeletal
conditions cover a lot but rheumatoid arthritis is a part of that
so it would be covered in that training. Then we have to learn
about cancer, diabetes and all the others, so it is probably an
area that maybe we should improve but everybody else has pressures
as well as to what slice of the GP training programme they get.
Q18 Angela Browning: It does say
in this paragraph that the GPs who were surveyed here felt that
their training on musculoskeletal conditions was inadequate.
Completely. In fact, that is why we have the Royal College of
GPs focusing on thisAlan is involved with working with
themlooking at improving the curriculum around postgraduate
education for GPs. The issue is that if you are a generalist,
which I was until I retired, every condition is part of our responsibility
so trying to allocate it sufficient training for all is quite
a difficult area. Every condition comes to us, whether it is diabetes,
angina and so on and so forth. In that, if there has been a highlighted
need that GPs are identifying, that is why we are looking with
the Futures Group at how we might get better training for GPs.
I can see why in the past there has been so much conflicting pressure.
Now we have some harder evidence I think your group, Alan, is
going to be focusing on this.
Dr Nye: The Rheumatology Futures
Group and myself, the Royal Colleges and some patient groups are
working to help produce some educational material for GPs to help
them spot those difficult to detect early warning signs. Hopefully,
we will produce something by later this year or very early next
year on that.
Q19 Angela Browning: I think, Mr
Belfield, this is probably for you. We have heard that once a
GP has made a referral, time is of the essence etc., but we understandI
must say I am a little confused by thisthat because of
the way commissioning is exercised once a consultant has seen
the patient for the first time they go back into the care of the
primary care field and that there is great difficulty for some
consultants in being able to actually initiate follow-up appointments.
Everybody is shaking their heads but we have this on very good
evidence. It is something I really would like to be followed up,
because I understand it is not to do with patient care per
se; it is to do with the ramifications of how commissioning
is carried out in this country. It is to do with money, I think.
Mr Belfield: I do not recognise