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Taken in the round, the framework would undoubtedly mean treatment being delivered to patients in a more timely and effective way. Why is it, then, that apart from the 18-week target for orthopaedics, virtually nothing has been done about the report since it was published more than a year and a half ago? It is almost as if the framework document is sitting on a shelf in Richmond House gathering dust. I happen to know a bit about documents that gather dust in the Department of Health. When I presented my own report some years ago, a senior civil servant, who shall remain nameless, told me that it would simply collect dust on the shelf, along with others. When I told him that I cared not about the report but rather about disabled people, he shrugged, so we got Mrs Thatcher—now the noble Baroness—to straighten him out.

I respectfully submit that this report really needs an injection of ministerial enthusiasm. As far as I can see, no Minister has stood up to give wholehearted backing to the framework, or to put in place what is required, which is a sort of clinical champion to pick up the recommendations in the MSF and run with them. One problem with doing so is the complete absence of outcome measures. That is a major deficiency, because at the moment we have large variations in expenditure on musculoskeletal conditions between different PCTs around the country, as has been mentioned already. Without any measure of outcomes, these variations and what they mean for patients are very difficult to interpret.

The national budgeting database reveals that, as a percentage of spending, musculoskeletal conditions account for as much 10 per cent of the budget in some areas, and less than 1 per cent in others. Why is there that enormous variation, and what does it mean? Without an investigation by a neutral body, such as the National Audit Office, we will not know the answer. It suggests to me that, at the very least, the quality of care that some patients are receiving is a good deal less than it should be. That should worry us, given the scale of the problem that we are dealing with.

The estimates that I have seen are that nearly a quarter of all adults and around 12,000 children are affected by musculoskeletal problems which limit everyday activities. More than 1 million people under 45 are affected in one way or another. According to the framework document, up to 60 per cent of people on long-term sick leave cite musculoskeletal problems as the reason. The real figure may be considerably higher, because a large proportion of arthritis sufferers experience depression, which is another significant cause of incapacity, as many noble Lords have already mentioned.

In terms of the burden on the NHS, musculoskeletal conditions represent the sixth-largest area of expenditure, at over £3.3 billion, accounting for about 30 per cent of patients who visit their GPs. That statistic alone, which has already been

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mentioned, makes the absence of musculoskeletal conditions from the quality and outcomes framework really quite astonishing. If they were included, it is certain that we would have a lot more data about the outcomes than we currently do. Would the Minister consider such an inclusion?

Perhaps it would be helpful to mention that the GP general medical services contract governs the provision of primary care services in the UK. Under the contract, primary care service provision is measured against a quality and outcomes framework, or QOF. GP services are measured in points, up to a maximum of just over 1,000, and each point is worth a nominal amount of money to the GPs, thereby incentivising them to tackle those clinical areas included in the QOF. There are no points in the QOF for musculoskeletal disorders, such as ankylosing spondylitis, and so there is no contractual incentive for GPs to make these a priority.

I would like to raise the plight of the 200,000 British adults who have been diagnosed with ankylosing spondylitis, one of the MSDs mentioned in the report we are debating today.

Unlike many other rheumatic conditions, ankylosing spondylitis disproportionately affects young men, and commonly starts before the age of 30, striking people in their late teens and their twenties. Ankylosing spondylitis is a chronic inflammatory disease which affects the spine, joints, tendons and ligaments and, in its severest form, can result in complete spinal fusion causing extreme physical limitations. What may not be appreciated by noble Lords is that the joints between the spine and the ribs are affected, which severely limits breathing. Expansion of the chest occurs when the ribs move upwards, forwards and outwards. This movement is prevented when the joints are fixed. Respiration is then maintained only by movements of the diaphragm.

These patients may present in different guises; for instance, a young man aged 18 came to see me with what appeared to be an injured thumb. An X-ray showed arthritis of the thumb and a blood test surprisingly revealed ankylosing spondylitis. The disease can be very difficult to diagnose in the early stages and can easily be overlooked due to the large number of people who complain of back ache. The report cites a survey undertaken by the National Ankylosing Spondylitis Society, which found that the average time it took patients to see a rheumatologist was 27 months.

Sick leave, work disability and even withdrawal from work is common among ankylosing spondylitis people, with resultant costs to the state in lost productivity and incapacity benefit claims, not to mention the social and economic costs to the individuals and their families. About one-third of people with ankylosing spondylitis may be unable to work at any one time. The report cites a recent study that estimates the average total cost to society of a person with ankylosing spondylitis as just over £6,000 per year, largely as a result of early retirement caused by the disease. The study, Fit for Work?, page 48, also found that of the direct costs per patient, hospital costs were the greatest burden, while drug treatment

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represented a very low percentage of the total, which I think has been mentioned already.

We have already heard from the noble Lord, Lord Harris, of the overwhelming benefits that early detection can have on a patient’s condition. A wait of more than two years to receive a diagnosis is unacceptable for people suffering from such progressive, chronic diseases. One of the most significant proposals in the musculoskeletal service framework was the development of clinical assessment and treatment services, known as CATS. The team brings together skilled professionals from primary and secondary care, including GPs with special interests, and rheumatologists and nurse practitioners for faster assessment, diagnosis, treatment referral to other specialists, and to support a return to work.

The problem is that no additional funding has been allocated to implement the new services proposed, and there appears to be no mechanism to ensure that the quality of the service is improved or even kept at today’s standards. This system of CATS is a wonderful idea on paper, but early detection and treatment will be possible only if these teams contain professional expertise and diagnostic tools to ensure that MSD sufferers receive the swift diagnosis and speedy treatment, which is so essential to their rehabilitation.

Time and again we have heard that the Department of Health deflects its responsibilities to the PCTs when they are asked how implementation is progressing. With no information being collected centrally, how can the Government possibly assess how their guidance is being implemented? What guarantee is there that the quality of care being given to MSD patients is what it should be? What MSD patients want from CATS is swift access to an experienced rheumatologist. Without proper assessment of how these teams are structured, the quality of care they are receiving remains unclear. This is just not acceptable for people whose future quality of life depends on early diagnosis of their condition.

Ankylosing spondylitis seems to me to be exactly the kind of illness that the CATS should be able to identify and diagnose quickly but, I ask the Minister, how can we be sure that this will happen without a guarantee of suitable clinical expertise on each CATS team?

If the NHS is to diagnose and treat quickly, and help patients return to work, it needs the necessary resources to do so. I noted with interest last week’s Health Select Committee report into NICE and its recommendations regarding the need for an assessment of the wider societal costs of treatment, as the noble Lord, Lord Harris, mentioned. If NICE considered the benefits to the taxpayer of supporting patients to work, it would undoubtedly conclude that it was worth the investment in the NHS to deliver returns to the Exchequer.

I would also ask the Minister to take steps to alert the Healthcare Commission and strategic health authorities about the need for the NHS to implement NICE guidance on arthritis and related conditions, which the evidence shows has not been properly taken

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up. Inevitably in all such debates there has been criticism about mistakes and deficiencies. We all make mistakes, so I would like to make a constructive suggestion which I mentioned during Question Time yesterday. Clinicians throughout the country meet regularly once a week or so to discuss all the mistakes that they have made.

At Guy’s we were fortunate to have the senior surgeon Mr Rex Lawrie to chair these meetings. He was expert at doing so because he created an atmosphere that was friendly and not threatening. They were the most popular meetings that we had. When some poor registrar stood up to confess some mistake that he had made with the sweat pouring off his brow and seeing his future prospects disappearing in the distance, the senior surgeon would reassure him by telling him of a bigger mistake that he himself had made recently. He was creating an atmosphere in which people were honest about their mistakes. That is the ideal environment in which to learn how to minimise their mistakes. It became rather like the general confession, and just as therapeutic. I wonder whether the Minister would consider introducing similar meetings to the Department of Health. It would certainly improve matters for the patients and for those who work in the NHS. Who knows: the Department of Health might start a fashion throughout all government departments.

3.57 pm

Baroness Royall of Blaisdon: My Lords, this has been an excellent debate and I thank my noble friend Lord Harris of Haringey for enabling us to discuss issues that are fundamental to the health and well-being of individuals, our economy and our society. His speech will provide us with invaluable reflections in the Department of Health, the Department for Work and Pensions and DBERR. I am grateful to all noble Lords who have contributed to this informative debate. We welcomed last year’s publication of the Work Foundation’s report Fit for Work?, which raised a number of important issues for the Government to reflect on. Fit for Work? highlights the challenge that musculoskeletal conditions pose, not just for individuals but for the health service, society and the economy as a whole.

Musculoskeletal conditions can be associated with a number of employment-related difficulties, including unemployment, absenteeism and reduced productivity in the workplace, or so-called presenteeism. Yet we know that work can be good for people with musculoskeletal problems, in terms of both their physical and psychological health and well-being, and as part of the rehabilitation process, as mentioned by many noble Lords. Work brings dignity and a sense of purpose. It has an impact not only on the individual but on their family and sometimes the wider community. Of course, for some, work may no longer be a practical option as serious and debilitating conditions worsen. However, for the majority, better and earlier treatment holds the key to reducing the impact of musculoskeletal conditions on an individual’s ability to work. That need for early intervention, with effective partnerships between

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patients, employers, GPs and specialists, is a key theme of the Fit for Work? report. My noble friend rightly said that organisations were still a long way from that reality, but we are truly working across government to try to break down the barriers both in Whitehall and at local level.

Of course, central government also has its role to play and we are working closely across government to help people with health conditions to remain in or to return to work. The health, work and well-being strategy has brought together the three departments with the most interest in these issues, the Department of Health, the Department for Work and Pensions, and the Health and Safety Executive. Much good work has happened since the strategy was launched in 2005 and we are starting to see a real stakeholder commitment to this agenda.

The noble Lord, Lord Addington, and Fit for Work? both emphasise that resoundingly early access to appropriate treatment and support is a priority for employers, healthcare professionals and patients alike. Through publication of the musculoskeletal services framework in 2006, we have taken steps to ensure better outcomes for people with musculoskeletal conditions by setting out evidence-based best practice on the provision and commissioning of musculoskeletal services. I am very grateful for the welcome for that framework expressed by the noble Lord, Lord McColl, and others. I can assure noble Lords that this document is not gathering dust.

Throughout the summer and autumn of 2007, 10 regional road shows were hosted to help local health economies to develop intermediate orthopaedic services that will help to reduce long waits. The framework has produced examples of good practice in orthopaedics on the 18-week website to help organisations to learn from the success of others, precisely so that people all over the country can get good and swift treatment and advice. A series of 18-week commissioning pathways, including some for common orthopaedic conditions, has been published. The purpose of the pathways is to support discussions between key local stakeholders around the services that they should be commissioning to meet and sustain the figure of 18 weeks. They have been developed and agreed between clinicians, managers, professional groups and the royal colleges.

Early intervention is also a key theme of the reforms announced by the Prime Minister last week. There are now more than 15 million people in England with a chronic or long-term condition. With the ageing population and the rise in the so-called lifestyle diseases, the NHS finds itself faced with new challenges in supporting and caring for patients.

Historically, pressures on the hospital system meant prevention and a personal service took second place. But the record levels of investment since 1997 have opened up the potential to fund new preventive programmes and care that is more tailored to need. This will ensure an NHS that can identify clinical needs earlier on, that keeps people healthy and fit,

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and that puts them far more in control of their health—empowering them to become genuine partners in care.

The noble Baroness, Lady Masham of Ilton, drew our attention to the painful realities of rheumatoid arthritis. I pay tribute to the voluntary organisations she mentioned. I will certainly read Women’s Insight into Rheumatoid Arthritis. I was disturbed to hear of Carrie’s views of treatment in the NHS, but I can assure the noble Baroness and Carrie that millions of people really are receiving improved services. For one thing, they have joint operations far more swiftly than they did before, which must be good for those concerned.

In response to the question about consultant rheumatologists, I can say that there are 511 out of a total of 32,874 consultants working in the NHS in England. That is 10,500 more consultants than were working in the NHS in 1997. Forecasts show that there will be around 2,500 more consultants by 2010, in accordance with the increasing demand for more specialist doctors. The emphasis of CATS is on multidisciplinary working, and evidence shows that many successful teams are led by other professionals such as nurse practitioners, but that is not to say that I denigrate the role of consultant rheumatologists, who do the most fantastic job, where they are available.

I also want to mention the vital role of research in this area. The Department of Health and the Medical Research Council support a range of research projects concerned with arthritis and other rheumatic diseases. The MRC wants to expand its portfolio of musculoskeletal research. Last summer I had the privilege of visiting the Bath Institute for Rheumatic Diseases—BIRD—an independent registered charity which raises funds to support research and education into many aspects of bone and joint diseases. The research it carries out is first class but its real value-added is the way in which it works in close collaboration with the Royal National Hospital for Rheumatic Diseases trust and the University of Bath, thus enhancing benefits for patients. It is an example of research going to patients at the bedside, which is very good.

The emphasis on shared responsibility and ownership is also crucially important in a broader sense, as effective and targeted services are only possible with the involvement and commitment of a range of stakeholders. Partnership is a key theme of the Commissioning Framework for Health and Well-being, which we published for consultation last March.

The noble Baroness, Lady Finlay of Llandaff, was right to draw our attention to the importance of commissioning. The framework contained an important chapter recognising the interdependence between work and health and the importance of addressing the health problems faced by those of working age. Commissioning of services is clearly essential. With early access to treatment so vital, it is important that commissioners understand the needs of their local populations and the role they can play in the services that will help working-age people.



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We now have to build on this and ensure that commissioners have the support that they need to make this vision a reality. As many noble Lords have pointed out, employers are essential to the health and well-being agenda. We need employers who are prepared to employ people with health conditions or disabilities, who protect and promote their employees’ health and who support staff to stay in work when they are having problems.

As part of the health, work and well-being strategy, we are working to improve the support that is available to employers. A key element of this is the activity of the Health and Safety Executive, which works to ensure that employees are not injured or made ill by their jobs. Musculoskeletal disorders are a major cause of work-related ill health in Great Britain. A priority for the HSE over the last decade, therefore, has been to reduce the number of musculoskeletal disorders caused by work. The HSE has been working closely with employers and trade unions to improve risk management and to give managers, staff and safety representatives the tools they need to prevent musculoskeletal disorders developing because of work. One example of this is its Better Backs campaign, which has been mentioned.

Since February 2006, the HSE has also been piloting a free occupational health and return-to-work support service for small and medium-sized enterprises, consisting of an advice line and workplace visits. The pilot, which has been well received by participating businesses, is due to end as planned in February this year. We now need to consider what we can learn from it as we plan the best way to support employers, particularly smaller ones. The suggestion from the noble Baroness, Lady Thomas of Walliswood, that managers of SMEs should get together to discuss these issues is a very good one and I will take that on board.

Employers do not necessarily know the best way to support their employees. That is why we have set up a vocational rehabilitation taskforce to look at the best ways of encouraging and supporting employers to provide good-quality rehabilitative services to their staff. The task group has commissioned an evidence review to assess the effectiveness, including cost-effectiveness, of measures designed to ensure the rehabilitation and return to work of adults suffering from common health problems and from injuries.

On occupational health services, we can learn a great deal from the example of Transport for London, cited by my noble friend, which sounded fantastic. We are determined to change the fact that only a small proportion of the population have access to such services and, as part of the health, work and well-being strategy, we are working to engage employers to show them the business benefits of taking action to support their staff. We know that we need to go further, and improving access to occupational health support will be a key focus of the health, work and well-being strategy as we take it forward. Indeed, it has been the key focus of Dame Carol Black’s review, to which I will return. I take this opportunity to pay tribute to the occupational health

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and safety officers here in Parliament, who do an excellent job. They provide many facilities such as physiotherapy.

Several noble Lords have mentioned NICE and the economic perspective. I am personally sympathetic to the recommendation in the report that, while the prospect of considering wider societal costs and benefits is initially an attractive one, it is important to recognise that the position is not straightforward and that there would be winners and losers from any change. For example, if we instruct NICE to attach additional weight to treatments that can get people back to work, that, by implication, means that we are attaching less weight to improving the health of retired people or those with terminal illnesses who will never be well enough to return to work. The consequences of any change would therefore need to be considered very carefully, including any interplay with anti-discrimination laws. However, it is an issue that the Government are looking at actively.

We also need to work more with healthcare professionals, and GPs in particular, to ensure that they better understand occupational health issues, the links between health and work and the role that they can play in helping patients to remain in or return to work. We want healthcare professionals to appreciate that a return to work should be one of the indicators of a successful outcome of the care that they provide to their patients. The Government are working with the professional medical bodies to provide tailored education and support.

The other day, I saw some research that had been carried out by Doctors.net.uk in September last year. It was based on a survey of 1,500 GPs and found that two-thirds of doctors were unaware of the evidence that work is good for health. There is therefore much to do in that area. However, we are doing a lot of work with GPs, examples of which include a training programme for them that the Department for Work and Pensions has been piloting in partnership with the Royal College of General Practitioners, and modules in health and work that have been developed for inclusion in undergraduate medical degree syllabuses.


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