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The report your Lordships are discussing today was produced by the Work Foundation, with a grant from Abbott. It links in very well with the book Women’s Insight into Rheumatoid Arthritis, which was produced two years ago in collaboration with the National Rheumatoid Arthritis Society and Arthritis Care, with sponsorship, again, by Abbott. Ten Members of the Parliaments, including the noble Baroness, Lady Wilkins, and myself, were very pleased to take part in interviewing 10 women with RA. These were all people who had managed to get their lives together with the correct treatment and drugs and to go on living and working with the care they needed. I congratulate the two voluntary organisations, the National Rheumatoid Arthritis Society and Arthritis Care, on the support and information it gave its members. They helped them to focus on the positive, not the negative, and to come to

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terms with the condition. They give back lost confidence and experience, which helps many people to get back into paid employment.

I enjoyed meeting Carrie and interviewing her for the book. Many people think that RA is a condition of elderly people. I give Carrie’s story to illustrate that this is not the case. Carrie was diagnosed with juvenile RA at the age of three, when her mother noticed a persistent limp. All through her life Carrie has had to have joint replacements, otherwise she would not be able to live on her own, drive, work and walk. The operations are only half the story; there is also the day-to-day treatment. Carrie is on one drug for the disease long term and one drug each day: one is to stop the progression of the disease and the other is to get her out of bed in the morning.

This Christmas I had a card and letter from Carrie. I wrote back to her telling her about this report and the debate today. In her letter, Carrie told me that she had had surgery on her left shoulder; the stay in hospital was, as ever, not good. At one point her surgeon advised her to leave hospital as soon as possible owing to the fact that it was such a dangerous place because of the risk of infection. Luckily the surgery was a success and she remained infection-free. She went on to say:

This is direct patient care. I hope the Minister will do her best to influence the departments so that those people who want to work and do so but have long-term conditions are given the help they need. Carrie is a firm advocate of disabled people working if they can. It builds confidence and increases social life; in theory, it is financially beneficial; and it keeps you physically active, within reason. She told me that she knows many people who just vegetate at home and lack the confidence even to pick up the telephone. There should be hard-hitting courses to get people back into work. There is far too much soft-soaping, she told me. She says she knows many people, far fitter than she is, who will not even try as they do not want to lose their benefits. Carrie says that that attitude is incredibly insulting to her and others who make the effort to retain employment. Although it is a controversial view, she has always believed that the best incentive the Government could use to reduce the number of unemployed within the disabled sector would be to cut benefits.

Having talked to people with long-term musculoskeletal disorders, it seems to me that there should be a flexible approach. When surgery for joint replacements has to be undertaken and medical appointments kept, that should be taken into consideration and both employers and employees should be helped with such a flexible approach. On 14 January 2008 this Written Question was asked in another place:



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Ann Keen replied,

If this situation is not rectified, I see nothing but problems. Surely this is a matter of joined-up government between the Department of Health and the former department of employment, now called Business, Enterprise and Regulatory Reform.

On page 16 the report asks,

About 30 per cent of GP consultations are for musculoskeletal conditions. Patients need to be diagnosed correctly and given the correct medication and rehabilitation. There is concern that maybe not all of them will see a rheumatologist. Are there enough consultant rheumatologists? Last year the NHS introduced a musculoskeletal service framework. That was welcome, but there is some concern that the clinical assessment teams may not be led by a rheumatologist. There is also much concern that doctors in their training may not have enough hours to conclude the complex matters surrounding the health issues of MSDs. There is even more concern about how the hours of medical education for doctors may be reduced, due to the European working time directive. I hope that will be seriously looked at when the Tooke report is considered.

Misdiagnosis of these serious conditions, leaving patients to deteriorate, is often seen, as I found in Bradford. One often hears that nurses could be left to deal with these patients. That is confusing for everyone concerned. A specialist doctor needs to do the diagnosing and updating of drugs, while the patient’s journey needs the involvement of a team with advice and treatment from physiotherapists, occupational therapists and nurses.

The employers need advice too. So much help can be given with the correct equipment, such as the correct office chairs, tables at the correct height, computers, lavatories, access to buildings, adequate transport and parking and much more.

I have seen a young man so desperate with a bad back that he had to lie on the floor of a train when travelling. The report includes people with back pain, a huge problem for many people who are desperate to continue to work. With the correct treatment, they will do so.

The report mentions the sick note culture, a great frustration for many employers. When GPs find writing a sick note is the easy way out, it is not good for the patients or the employers. I hope the report, Fit For Work?, will make many people realise how important it is to give people with MSD the right advice, help, medication and medical treatment. I am sure the Minister, who really cares, will do her bit to help and make things better.



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3.24 pm

Baroness Finlay of Llandaff: My Lords, I, too, thank the noble Lord, Lord Harris of Haringey, for instigating this debate and for his speech, which was packed with important points. I thank him on behalf of the healthcare professionals who work with patients suffering from musculoskeletal disorders and on behalf of those patients living with those disorders. I hope that this debate will do a great service to everyone.

The noble Lord has highlighted the plight of those suffering from musculoskeletal disorders and laid out the wider repercussions of those disorders in society and the workplace. From the Engineering Employers’ Federation survey last year, we know that musculoskeletal disorders were attributed by over 68 per cent of employers as the main reason for long-term absenteeism from work, while the Department of Health tells us that 60 per cent of those on long-term absence leave cite musculoskeletal problems as their reason. Many of those people never return to work, resulting in 22 per cent of people on incapacity benefits being musculoskeletal patients—an enormous number.

I wish to concentrate my remarks on the management of chronic pain and declare my interest as the lead for the chronic pain management programme in Cardiff, and as president of the Chartered Society of Physiotherapy. In our little pain management programme, which I know is in Wales and not in England, so I do not expect the Minister to answer for any devolved health issues, we see people who often have had many thousands of pounds spent on them. They have had treatments to no avail and are still searching for the magic bullet, which, sadly, does not exist. For some, their problems go back many years into childhood; for others, their problems started with abuse, which was the beginning of their chronic pain and their chronic pain experience. For all of them, their condition has resulted in a series of losses: a loss of role or job, the loss of relationships, or failed intimate relationships. They become depressed, withdrawn and isolated.

Many try to do what they can on a good day, only to pay for it later by having a flare-up of their condition; that is called underactivity/overactivity cycling. On the pain management programme, they learn about chronic pain and ways to pace their activities to avoid that cycling. They also learn to adapt to their limitations and to have the courage to resume a lifestyle, fully aware that life will never be as it was before the condition started.

Our programme is run, on a day-to-day basis, by a physiotherapist and a clinical psychologist who teach the patients about the interplay between pain mechanisms and the actions of drugs, and why those drugs often do not work for them. They teach the effect of fatigue and depression on the patients’ overall pain experience, and the influence of their social situation on that experience, which covers both work and family demands, including intimate sexual relationships.

Our patient outcomes are really dramatic; I am very proud of them. Average patient scores for anxiety and depression almost halve. Patients’ quality

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of life scores more than double, while their scores on functioning—and their self-satisfaction scores with it—improve dramatically. Scores are trebled and are being maintained at a six months’ follow-up after the programme.

We have now started a programme to try and keep those still in work there by intervening to stop the downward spiral—and this, our latest programme, has shown even better outcomes than we normally achieve. I know that the numbers are small, and I ask your Lordships to forgive me that, but they are quite impressive. We have only run the programme once: of the seven who completed the programme, six attended a follow-up. Depression and anxiety scores were now normal for four of them, while they had fallen significantly for the other two. Five admitted that they were now taking less time off work; four had visited their GP less, while the other two had visited no more than previously. In all, their functioning scores showed a marked improvement.

So yes, I am proud of this little programme. My point is that when you empower patients—when you help them help themselves—they can do so much, but such programmes are few and far between. They do not cost much. Our costs are less than £1,700 for each patient completing the programme. That includes the costs of all those who drop out or who, at assessment, clearly will not benefit. The programme is only NHS funded. We integrate with rheumatology, psychiatry and anaesthetic-led pain clinics.

It is important that people learn to change their own work environment and are empowered to search out and create the support that they individually need. It is tragic that such high numbers are on benefit when, with the best of today’s medical care and pain management, they could be supported to carry on working. We have too often seen what happens to people who leave the workplace due to illness or disability. They languish on incapacity benefit. Depression and worsening health take their toll, and, crucially, they then have a lower chance of getting back into work.

On average, if you are off sick for six months, you have an 80 per cent chance of being out of work for five years. Once someone has been claiming incapacity benefit for two years or more, they are more likely to retire or die than return to employment.

A strong evidence base suggests that this psychosocial model of intervention effectively informs the management of musculoskeletal disorders in both clinical and occupational settings. The noble Lord, Lord Harris, outlined a workplace-based programme. That principle forms the basis of the World Health Organisation’s International Classification of Functioning, Disability and Health, which is widely seen as the authoritative guide for vocational rehabilitation.

However, there is limited understanding of the model among patients, GPs and employers, who often find it difficult to look beyond immediate overwhelming physical symptoms. The Department of Health’s musculoskeletal services framework makes only passing reference to rehabilitation and

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back-to-work vocational reintegration, which is unfortunate, as the pain management model helps us to understand what is happening to people with musculoskeletal disorders and how and why they drop through the net.

The model has implications for the stakeholders and employees of both the Department of Health and the Department for Work and Pensions. The health, work and well-being strategy may be the best place for such a model now to sit. Dame Carol Black, who, as has been said, is the national director for health and work, expressed the hope that,

However, she went on to say:

Her vocational rehabilitation task force will look at why so few employers offer occupational health or vocational rehabilitation to their employees.

The Work Foundation report also makes an important point about self-management, advising us to,

I therefore suggest that commissioners in health must work in conjunction with vocational services to ensure that rehabilitation to work is well integrated into mainstream clinical practice and that a return to functioning becomes a valued outcome for patients, because it can be the first step towards a return to work.

3.34 pm

Lord Addington: My Lords, we must thank the noble Lord, Lord Harris, for bringing this report forward. When I read it for the first time late at night earlier this week, my initial reaction was, “No”—expletive deleted—“Sherlock”, because most of what it said was obvious. I then realised that I was being unfair on the report, because I had never previously seen a combination of effects put together in the same place. People were admitting the quite obvious fact that if you have a debilitating physical condition that removes your ability to go to work and carry out a normal life, you will be more likely, for instance, to be depressed. They go hand in glove. In addition, I have covered virtually everything that is mentioned in the report in many other areas on which I have spoken in this House.

We have talked about physiotherapists. Regarding soft tissue injuries, last year I ran a small and probably not very successful campaign. It was all about getting in early, getting the right treatment, making sure you are treated early and making sure you listen to the advice. In that way, you will get over the condition—it will not become chronic. That is exactly what this report says. It also says that if you need a drug treatment, you should get it early and you will probably get the benefits early. You will not get the chronic condition—you will not get the wear and tear.



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This is not a great surprise to anyone when you think about it. We then try and cross-reference it again. Having had the disability brief for a long time, I have become very aware that certain people who have a condition will be able to access and do certain things, but not everything. It is the idea of what you can do, as opposed to being properly fit and that you can do something. There are many organisations available; they are probably not the ones represented by this group, but if Parliament cannot help people talk to each other, who else can? People are not addressing the fact that they should concentrate on what they can do.

Employers should be given the right information early and told that it is not that expensive—this is a mantra I have gone through I do not know how many times. They should be told about early intervention, for example, about breaking up the working pattern or, in this case, about repetitive strain injuries or conditions that aggravate. Then the person will or can still be an active part of your workforce or can go and do another job. If that is done, you can carry on. These are small changes.

However, we come back to a series of problems that have occurred again and again. The first one is ignorance, at every single point in this process. The GP knows about prescribing painkillers and now also anti-depressants. Having done so for the immediate problems for the patient in the waiting room—the sick note Britain culture is also an issue here—he may well, in his own eyes, be fulfilling his job.

People might not see themselves doing any other job than the one they have already done. I think I have mentioned young males—a young male who does a hard physical job and probably has low academic qualifications will find great difficulty in even comprehending the idea of retraining. Indeed, the higher people’s academic qualification, the much more likely they are to have a full role in society. Disabled lawyers in wheelchairs do not do too badly. It is that simple. At the higher end of the social and economic scale, jobs tend to be less physically demanding. As your skills are more valuable, people are more readily available to make adaptations for you. That is why the multiplier effect comes down.

The noble Baroness, Lady Finlay, mentioned this statistic, which I think I first heard during the passage of the Welfare Reform Bill. With X amount of time on benefits, a person is more likely to die than get a job. It is something that carries on. The real message behind this report is one of co-ordination among Government. The noble Baroness, Lady Royall, and I had a conversation about this. We are on very familiar ground. As the noble Lord, Lord Harris, said, if the Department of Health gets it right, the Department for Work and Pensions saves money. It is all Treasury money—that is, public money.

However, trying to punch holes in Chinese walls within Whitehall is something with which, in the time that I have been here, every Government has had a challenge. Trying to save the initial investment to go somewhere else is always a challenge to Whitehall. It is not just this Government. They have had their successes and failures. I wish them well on this, but trying to get

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people to co-ordinate still too often depends on a couple of Ministers recognising the problem and being prepared to work together. If there is that sort of co-ordination at the top, something can then be done—but it still relies on that. You need institutional structures to disseminate information downward to people who may not be used to reading forms or publications to discover about their condition; GPs need to relate this condition to people who go to them and trade unions need to make sure that they know about the condition, and so on. Information needs disseminating so that people can act early enough to stop the chronic situation; that is what is at the heart of this. If this report inspires the Government to start acting in this way, they will have achieved a great deal.

I have a couple of questions that I can fairly ask the Minister. First, what is the formal interaction between the Department of Health and the Department for Work and Pensions on this situation? In the last welfare reform, the Department for Work and Pensions set up a series of training posts and interviews to get people back into jobs, often concentrating on mental health. I was a part of that project. How is that process feeding back into the Department of Health? That is a fair point, which we should all hear about very soon.

Secondly, have we improved the situation of access to physiotherapy to ensure that it is more immediately available and that people do not have to wait for it? If you have to wait on painkillers and you have deteriorating physical health, when muscle tone and mass disappear, you will find it technically more difficult to take exercise. You will have to go through an even longer period of help, which costs, or you will be permanently in a situation of chemical management.

What is happening with those two situations? I would appreciate it if the noble Baroness could give me some information now or at least make sure that we know soon. Unless information is disseminated along with the processes that support it, this problem will simply carry on in its traditional merry way.

3.42 pm

Lord McColl of Dulwich: My Lords, I, too, thank the noble Lord, Lord Harris, for initiating this debate. I welcome the opportunity to speak on a subject that has concerned me for some years; I also welcome the Work Foundation’s report, which has posed some intriguing questions for both the Government and the health service.

The noble Lord’s Motion calls for a concerted approach to these matters, and the Government’s own musculoskeletal framework seems to me a perfect starting point for such an approach. It is fair to say that this framework—MSF—is recognised by patient groups and clinicians alike as an excellent policy document. The vision that the document presents is really very imaginative. It would promote the development of services in the community; provide patients with better information with which to manage their own conditions and thereby avoid being admitted to hospital; improve the way in which the

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flow of patients is currently managed; and—pertinently, in the context of the noble Lord’s Motion—it would facilitate an individual’s return to independent living, including a return to work, as several noble Lords have said.


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