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Health: Musculoskeletal Disorders

2.48 pm

Lord Harris of Haringey rose to call attention to the Work Foundation report Fit for Work? Musculoskeletal Disorders and Labour Market Participation and the case for a concerted approach to reduce the social, economic and work impact of musculoskeletal disorders; and to move for Papers.

The noble Lord said: My Lords, I am pleased to have secured this debate today and I welcome those noble Lords who have come to speak about the issues raised in the Work Foundation report, Fit for Work? Musculoskeletal Disorders and Labour Market Participation. This report, published last September with the support of a grant from Abbott Laboratories, highlights a topic of great importance and one of serious concern to many millions of people in this country. I say millions advisedly. More than 2.5 million people in the UK visit their GP with back pain each year. At any one time, a third of the population is suffering with back problems, and it is estimated that up to 80 per cent of the adult population will suffer significant back pain at some time in their life. What is more, in the vast majority of cases there will be no specific diagnosis. Those who have suffered from back pain know how debilitating it can be. It affects mobility, it affects agility, and the strains produced diminish stamina. The pain affects concentration, the ability to think and rationality, and it necessarily affects the sufferer’s mood. It may make them irritable and can lead to severe depression.

There has been much debate about the impact of mental health conditions and the associated stigma and difficulties that can lead to people losing their jobs. Amid the concern about the psychological well-being of the UK workforce, those with physical problems have often seemed to have received less attention. The number of working days lost to psychological problems or stress is, of course, high. However, as the Work Foundation report points out, almost twice as many workers are affected by musculoskeletal disorders such as back pain, arm or neck strains, or diseases of the joints. Back pain and similar problems affected over 1 million people in 2005-06 and, according to the Health and Safety Executive, were responsible for 9.5 million lost working days, at a cost to society, in 2007 prices, of over £7 billion.



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What happens when these people visit their GPs with a complaint? All too often, out of compassion and concern for their patient, the GP will issue a sick note advising that they take time off work. They may be advised to stay at home for weeks or months while they wait for tests and then treatments to make them feel well again. For those of us who fall ill with flu or minor infections and spend a week in bed, this probably sounds like common sense. However, for many people with long-term acute conditions, it may not always be the right approach. As the report says:

The physical conditions of work may indeed have caused or aggravated a musculoskeletal condition but, equally, prolonged inactivity may well make the condition worse. Moreover, absence from the work environment and the associated isolation may worsen the depression associated with the pain and make recovery less likely. Certainly, many GPs and employers mistakenly believe that sufferers from musculoskeletal disorders must be 100 per cent well before any return to work can be contemplated.

Some employer surveys suggest that back pain and other musculoskeletal problems account for as much as two-thirds of long-term sickness absence. The Department of Health estimates that almost a quarter of the more than 2.6 million people of working age claiming incapacity benefit suffer from these problems. Surveys of people affected suggest that thousands of people in this country want to work and think that they are capable of work but are instead stranded on incapacity benefit. One survey undertaken by the National Rheumatoid Arthritis Society, aptly titled the I Want to Work survey, tells how people with rheumatoid arthritis desperately want to keep working but encounter a raft of barriers. The most commonly cited barriers are the inability to get fast access to their rheumatologist and the attitude taken by employers once they learn that an employee has a diagnosis of rheumatoid arthritis. Nearly 400,000 people in the UK have rheumatoid arthritis and 12,000 new cases are reported each year. Unlike other forms of arthritis, rheumatoid arthritis affects people of all ages, hitting people in their 20s or 30s at the early stages of their careers. Almost a quarter of those with the disease stop working within five years of the diagnosis, at a cost to the taxpayer of £89 million a year.

With an ageing population comes the increasing prevalence of a host of chronic conditions and an increasing number of people who do not want to be written off. They want to be independent and economically active. We have to address the barriers to their participating in the labour force if we are to have a sustainable future economy. The Work Foundation report considers the interrelationship between improving health outcomes and improving work outcomes. It suggests that perhaps if employers were more educated about their employees’ conditions and flexible over adapting tasks, and if the NHS was better geared towards helping people stay in work, we could both reduce public spending and better support people with musculoskeletal conditions who want to work but find it impossibly difficult.



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The report suggests that changes in the attitudes of both healthcare professionals and employers are needed to help people with MSDs to stay in work. Not only does each need to think in terms of how to support people in their jobs; they also need to think about how to collaborate better. GPs, rheumatologists, nurses and employers should talk to each other about the support that their patients or employees need and how to work round the illness, rather than letting the illness itself dominate.

Some employers, of course, are enlightened. I am an adviser to the board of Transport for London. TfL and its predecessors have long had extremely progressive policies on staff welfare—that is, despite what you may have heard from the RMT trade union. Its occupational health service has undertaken a programme to address back pain. There has been an in-house physiotherapy service for lower back pain since 2001. Attractive educational materials including a CD-ROM with amusing video clips and job-dependent exercises for staff were developed and widely distributed in 2005-06. They are now provided internally in some types of training. A back exercise class was introduced to augment one-to-one physiotherapy for back pain and is focused on maintaining and improving back fitness and flexibility.

A two-hour class in pain physiology is an entry requirement into this exercise class and employees learn complex concepts about it with remarkable ease. Each exercise class includes some educational content and the employee who attends all 10 classes will learn about anatomy, soft-tissue healing, how to stand, how to lift, how to adjust your chair and so on. The classes are run three times a week at different times to allow employees to attend without interfering with their shifts. Employees are encouraged to continue to attend once their back pain has been relieved, if they would like to, in order to keep up the level of back fitness that they have achieved. One big change in approach is the relatively new expectation that employees attend such classes in their own time if they are not off sick. TfL is moving from a paternalistic approach to a partnership approach with employees. The responsibility for an individual's health remains with that individual and all the work of the occupational health team supports that basic reality. Further work has been undertaken to develop a lower-limb exercise class, primarily for those with knee or ankle problems. This was introduced in 2007 and has proved enormously popular. Evaluation of the impact of this class will begin soon.

The analysis that has been done so far on the effectiveness of these TfL services, in particular the ones on lower back pain, is relevant to today's debate: A pilot study carried out in 2001 demonstrated that employees who received physiotherapy intervention returned to work 12.6 days sooner than would be predicted using historical data when employees did not have access to a physiotherapy service. A more recent study, in 2003-04, found that employees who were referred to the back pain service after more than six weeks’ absence had twice the length of absence of those referred within six weeks and four times the

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length of absence of those referred within two weeks. Thus early referral for physiotherapy can be seen to have significantly reduced further time off. Sitting at home waiting for the problem to resolve just prolonged the amount of time that people took off work. Moreover only 13 per cent of employees referred to the lower back pain service in September to December 2005 for first-episode lower back pain had a recurrent episode leading to absence during the following year; and only 23 per cent of employees with a previous history of lower back pain had a recurrent episode leading to absence during the following year. This compares favourably with recurrence rates of 26 to 37 per cent reported in research. This confirms so many of the conclusions of the Work Foundation report.

Let me just say a few further words about the importance of early intervention. It is now widely acknowledged that early intervention is essential to support people with musculoskeletal diseases to continue with their jobs. For many, as the TfL work has shown, fast access to physiotherapy can make a huge difference, while early access to drug therapies for those with progressive illnesses such as rheumatoid arthritis can slow or even halt the progression of their condition. Delay in getting the right diagnosis or treatment therefore increases the probability of the person losing their job or prolonging their absence from work.

The Government recognise that in their Health, Work and Well-being Strategy, and we have the welcome appointment of Dame Carol Black as national clinical director for health and work. But the aspiration of an NHS geared to support people in work and flexible working for those who need it is far from the reality. The Fit for Work? report tells us of long waiting times for care, certain employers’ lack of capacity to deal with sickness, lack of employee awareness about conditions and their management, and mixed messages on the effectiveness of various methods of workplace interventions or return-to-work programmes, all of which are barriers to making good and healthy work a reality for those suffering from MSDs. It goes on to advise that:

As many of these conditions cause a decline in functional capabilities over time, early detection and the targeted treatment of specific diseases such as rheumatoid arthritis are crucial in enabling a patient to manage their condition and improve their quality of life. It is clearly essential that this message permeates through the NHS and I look forward to hearing from my noble friend the Minister about what steps are being taken to make sure that this happens.

Of course, bringing savings to the budget of the Department for Work and Pensions is not something that the Department of Health is formally tasked with bringing about, but joint working on this issue is essential. The Work Foundation report makes 27 recommendations in all, some aimed at employers, some at employees, and others for GPs and other occupational health professionals. It is not possible to go through all of those in my remaining time but I

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would like to highlight one that is specifically targeted at the Government, and again I wait with interest to hear my noble friend’s response to the point. It concerns changes to the National Institute for Health and Clinical Excellence. The Work Foundation makes a strong case for a change to the statutory instruments governing NICE to allow the institute to take appropriate account of the benefits of full and active labour market participation when assessing the cost-effectiveness of treatments. This recommendation could not be more timely. Last week’s Health Select Committee report on NICE recommended that wider benefits and costs, such as the costs borne by carers and social care services, be more fully incorporated into NICE’s assessments. Surely work costs and benefits should also be considered when NICE issues guidance and advice to the NHS.

As noble Lords will know, NICE evaluations of treatment currently concentrate only on assessing the clinical costs and benefits—that is, those borne by the NHS. It is currently beyond NICE’s statutory remit to consider the wider consequences of keeping more employees in the labour market, so the recommendation is not critical of the institute, which indeed conducts a range of important and helpful work, but rather suggests that its terms of reference and working methods need to be updated. If the Treasury was able to consider the fuller economic impact of MSDs, it might be more inclined to support further joint working and partnership between the Department of Health and the Department for Work and Pensions to train and motivate the professionals working in these spheres.

The Department of Health already acknowledges in its Musculoskeletal Services Framework issued in July 2006 that the year-on-year costs of anti-TNF drugs which are used to treat rheumatoid arthritis, ankylosing spondylitis and other MSDs are likely to be offset by keeping patients with rheumatoid arthritis at work and reducing the need for them to claim incapacity benefit. Indeed, it was the Prevention of Work Disability Study commissioned by Abbott and presented to the American College of Rheumatology in November 2006, which showed how anti-TNFs can help to keep people in work, that gave rise to the report we are discussing today. However, these costs and benefits are not taken into account by NICE. As the report points out:

Since NHS policy and practice can impact on a patient’s ability to return to or remain in work, health policy makers need increasingly to take into account the broader work-related benefits of treatments as well as their more traditional clinical benefits. Employers need to engage with the NHS and avoid adopting a risk-management approach of easing people out of their jobs just because they have a long-term health condition. With the right support, thousands more can thrive in the workplace, contribute to society and enjoy the benefits of work.

This is, of course, a plea for that clichéd holy grail: joined-up policy making. Like any grail quest, there are many obstacles in the way, but the natural overlap

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in the issues we are discussing today between the policy areas of health and work offers the potential for success. Some 2.5 million sufferers, at an annual cost to society of £7 billion, are reason enough for overcoming the obstacles. I hope that this short debate will send a powerful message to my right honourable friends the Chancellor of the Exchequer and the Secretaries of State of Health and for Work and Pensions to sort these problems out, so that we invest to save—invest in the health of those 2.5 million sufferers so as to save on the costs of maintaining them on incapacity benefit. That is already, in principle at least, government policy. I call on my right honourable friends to support patients with back pain and other musculoskeletal disorders to enable them to continue in the workplace—a greater priority as they look to tackle public finances. I beg to move for Papers.

3.05 pm

Baroness Thomas of Walliswood: My Lords, the noble Lord, Lord Harris of Haringey, has done the House a great service in bringing this matter before us today. His spirited and detailed speech means that we do not need to go into much detail. Almost everything in the report has been covered in one way or another. I must say that I found his account of the situation and his ability to express the interrelationship between the various points made in the report and the recommendations to the Government particularly interesting.

I was drawn to making a brief contribution to today’s debate because, ever since working for the National Economic Development Office in the 1970s, I have been interested in matters which affect employment and management. This was partly because I could see a connection with the EU Select Committee report on the effect of mental ill health and stress on employment, and because this report covers certain matters which affect women in a particular way. As the noble Lord has explained, the thesis of the report is straightforward. The incidence of musculoskeletal disorders within the workforce is large and increasing, imposing severe costs in terms of lost output, treatment costs, the non-earning of pensions, on businesses, the NHS, affected individuals and the economy in general. Indeed, the report maintains that these conditions are now more common and impose greater costs than does mental illness, which we considered in the EU report.

The report suggests that the way this problem is tackled by employers, doctors and to some extent by sufferers themselves is not as effective as it could be, with the result that some employees are either persuaded to, or feel they must, leave employment altogether. Not only does this mean that they have no resources on which to live during their working years, they also do not earn themselves a pension. The effect on employees’ personal well-being in later life and the costs to the state of supporting people who have not earned a pension are likely to grow in parallel with the growth in the percentage of the population that is over the age of 65, like quite a few of us in your Lordships’ House.



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The report considers a number of ways of improving the response of doctors, employees and employers to the problems of joint pains, back-ache and other more serious disorders such as rheumatoid arthritis and makes two interesting points in this context. First, that the advice of doctors that sufferers should take time off work is not always helpful, and secondly, that the tendency of employers to persuade employees to leave their employment compounds the problem. The report also points out that:

Unfortunately, it seems that once affected workers have left their job for any length of time they may, as a result of a combination of circumstances, never return to work again. The report suggests a number of ways of tackling these problems and I look forward to the Minister’s responses to the points put to her by the noble Lord in his opening speech.

I would particularly like to ask the Minister about the kind of help that should be given to small and medium-sized enterprises in tackling the interrelated problems of modifying working conditions so as to enable workers to continue in work, and thus avoid the cost of recruiting and training new employees, while at the same time maintaining output. Such companies are likely to feel themselves overburdened by regulation and paperwork—a cry of pain frequently heard while I chaired Sub-Committee G. Would the Minister consider a scheme that would bring the managers of SMEs together at the local level, possibly through chambers of commerce, for training and the exchange of effective information, including health advice, about what actually works in practice? The learning process might be started at that level with greater ease than in other ways.

A particular concern highlighted by the report is the double burden carried by women who are caring for children and/or elderly relatives as well as working. As the number of women in the workforce increases, women are particularly likely to be exposed to the risk factors associated with the conflict between work and care roles. Does the Minister consider that employers are sufficiently alert to the damage that can be done to women, as to men, by very repetitious work—for example, at the keyboard—to which they are often assigned? If so, would better training and informing of managers help to improve the situation?

Women are already less likely to earn a full pension than are men because of the demands of family life, although the new pensions provisions may improve that situation. Can the Minister tell the House if this new provision is likely to assist women to have a better chance of continuous long-term employment and the security in old age that goes with it?

I look forward to hearing the remainder of the debate. The report is very interesting and apposite, but the benefits of its insights into the interaction of musculoskeletal disorders and the well-being of workers, businesses and the economy at large will not have their due effect unless the Government take steps to put at least some of the recommendations within it into effect. I look forward to the Minister’s response.



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3.11 pm

Baroness Masham of Ilton: My Lords, I thank the noble Lord, Lord Harris of Haringey, for introducing the debate on the impact of musculoskeletal disorders. This subject needs bringing to the notice of many people in the hope that improvements will be made in the many parts of the country which are not giving priority to the treatment and rehabilitation of long-term conditions such as the ones we are discussing today.

For many years this has been the case. When I was a member on the Regional Health Authority of Yorkshire, I used to look down the agenda for the next 10 years and find that physical disability was not even mentioned. I should like to go back into history for a moment. Years ago, when I came to live in Yorkshire after I got married and I was campaigning for better facilities for disabled people, I was contacted by a young woman from Bradford who had rheumatoid arthritis. This was my first introduction to RA. I went to visit Theresa in Bradford. She was living in a tiny, one-room bed-sit in a terraced house, with the kitchen in a cupboard and, I suppose, the lavatory in another cupboard. She shared this cramped room with her elderly mother. This disabled young woman used a wheelchair; there were a few steps to enter the room. She had difficulty in eating because of a stiff jaw—she had a similar problem with the rest of her body. Even with all these difficulties, her spirit was wonderful.

A little time after my visit, Theresa contacted me to say that her mother had had a stroke in the early hours of the morning and had fallen half out of bed. Theresa could do nothing until the paperboy passed her window at about 7 am. She attracted his attention by knocking on the window with her long-handled fork, which she used for eating. He went to get her sister, who lived in the same street a few houses down. It is this which made me think that there should be better treatment and facilities for such cases and which made me move an amendment to the Chronically Sick and Disabled Persons Act 1970 that disabled people at risk should have a telephone and be able to make contact to get help.


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