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Pain Management Services (England)

Volume 491: debated on Monday 20 April 2009

Motion made, and Question proposed, That this House do now adjourn.—(Mr. Ian Austin.)

In the United Kingdom, 7.8 million people live with pain, day in and day out; that is the equivalent of about one in seven people in every single parliamentary constituency. I have asked for this debate in order to draw attention both to their problems and, more importantly, to some solutions that would not only improve the quality of life of so many of our constituents, but reduce public expenditure on health, social care and incapacity benefits. If anyone is wondering why I, as a Scottish MP, am raising the issue of pain management services in England when health is a devolved issue, it is because I am the chairman of the recently set up all-party group on chronic pain. I suppose I should also declare an interest: I am one of the 7.8 million people in the UK who live with chronic pain.

There could not be a better opportunity to consider the problem and suggest solutions. People in pain and the health professionals helping them have been pushing at a closed door for many years now. They have argued for early recognition of the needs of people in pain, early access to expert advice and treatment, and referral to a specialist pain clinic when necessary. That door was closed until recently; suddenly, it looks as though it is opening, and I am grateful to the chief medical officer for beginning that process. His latest annual report, only just published, includes a chapter called “Pain: breaking through the barrier”. Sir Liam Donaldson looks at the issue of people living with pain in a sensitive and comprehensive way, and concludes with this statement:

“A major initiative to widen access to high-quality pain services would improve the lives of millions of people.”

The all-party group that I chair and voluntary and professional groups represented on the Chronic Pain Policy Coalition agree with that conclusion and are committed to ensuring that the vision set out in the CMO’s report moves from recommendation to practical implementation. That means making improving pain services a priority for the Department of Health, and for every strategic health authority, primary care trust and provider to NHS trusts. That is because pain is part of a patient’s experience, in GP surgeries as well as in acute hospital wards and in operating theatres. Patients may discuss their pain and its management with any number of health professionals, including a pharmacist, a nurse, a physiotherapist or their GP, yet effective co-ordinated services are few and far between.

The evidence suggests that although pain services do exist in most secondary care NHS trusts, they are patchy, and variable in their resources and in the services that they provide. Crucially, the CMO’s report makes this point: each year, more than 5 million people in the United Kingdom develop chronic pain, but only two thirds will recover. Clearly, much more needs to be done to improve outcomes for patients. He reminds us that pain affects 7.8 million people, and that more than a third of households have someone in pain at any given time. Those figures are rising. Indeed, recent surveys suggest that chronic pain is more common now than it was 40 years ago.

Pain is becoming more common, but the effect that it has on individual lives is immense. The CMO highlights the fact that pain has a major impact on people’s lives, causing sleeplessness and depression, and interfering with normal physical and social functioning. That often leads to unemployment. He points out how it affects all age groups. Perhaps most worryingly, he states that 8 per cent. of children experience severe pain, that back pain alone costs the economy £12.3 billion per year and that early intervention may prevent pain from becoming persistent. In fact, it has been shown that the cost of chronic pain is greater than that of heart disease or diabetes.

Looking at the limited number of specialist pain clinics, the CMO points out that systems and infrastructure do not meet need or demand, and that better co-ordination of services, and services designed around patients’ needs, are essential. Pain needs to be considered in its own right, because it is often the pain that dominates the patient’s life, not the illness or condition that causes the pain. As one patient has said:

“At first I presumed the pain would eventually go away and I would get better. I didn’t expect to develop chronic pain, or that it would stop me working and lead me to consider suicide. I just want my life back.”

Another said:

“I am in constant and debilitating pain, often unable to do even the most simple activity such as making myself a cup of tea. I have daily bad headaches, and have no quality of life. It is making me very depressed and life is hell.”

Clearly, we have a duty to ensure that the individual has access to the right treatment as early as possible. That treatment has to come from a properly trained professional, and a multidisciplinary team if needed.

I was surprised by the amount of interest that this debate has generated. I have been contacted by a number of organisations wishing me to raise their concerns. Age Concern and Help the Aged have particular issues relating to the elderly. They say that pain is not a normal part of the ageing process, and we should not accept it as such. We should challenge discrimination and ageist attitudes with regard to pain in older people. They say that constant pain can lead to a loss of dignity. Some 90 per cent. of calls to Arthritis Care’s helpline concern pain, most of them from people in severe pain. In the UK, pain crises account for 60 to 80 per cent. of emergency presentations in hospital admissions for sickle cell disorder.

This is not the first time I have had an Adjournment debate on the issue of pain. Ever since the Government first indicated that they intended to withdraw the analgesic co-proxamol, I have been trying to persuade Ministers that it should not be completely withdrawn as a small group of people still has not been able to find an alternative and certainly not anything so effective. These are all people who suffer chronic pain, who are saying that only co-proxamol works not because they want to be awkward but because it allows them to carry on with their life. One person in that position has said:

“With co-proxamol I had pain but it was bearable, now I can walk only a few steps before being forced to rest; before I managed to tend my flower garden, now I can only sit and feel depressed with pain and frustration”.

I have several constituents who depended on co-proxamol but cannot now get access to it. While the Government say that co-proxamol is available on a named patient basis, that is of cold comfort to those whose GPs are refusing to prescribe the drug at all. GPs are not comfortable prescribing off licence as they do not always feel that they have the specialist knowledge. But consultants at pain clinics do.

The main reason the Government gave for withdrawing co-proxamol was the suicide statistics. As it is now extremely difficult for even those who need the drug to access it, the incidence of suicide attributed to co-proxamol is now tiny. However, the use of stronger pain relief and particularly opiates has grown. A recent Pulse article says that there has been a 44 per cent. rise in prescriptions for morphine and a 61 per cent. rise in tramadol prescriptions. That cannot be good pain management, so I ask the Minister to look at this issue again.

I have not, however, sought this debate to lay blame at the Government’s door on this matter: rather, I hope to encourage the Minister to consider the recommendations laid out in the chief medical officer’s report and to give due regard to their feasibility. I do not have time to discuss them all, but I do want to take this opportunity to bring some to the Minister’s attention.

First, training on chronic pain should be included in the curriculum for all health professionals who deal with patients. I am aware that some progress has been made on this already. At an international level, the International Association for the Study of Pain has produced a core curriculum for all aspects of pain management. In the United Kingdom, the Faculty of Pain Medicine of the Royal College of Anaesthetists has described the core competencies for trainee anaesthetists wishing to be consultants in pain medicine. However, it is vital that this core training is extended to all health professionals, and in particular to GPs who, at the very least, should have pain training as part of their standard undergraduate education.

Secondly, consideration should be given to the inclusion of the assessment of pain and its associated disability in the quality and outcomes framework—QOF—in primary care. That is an extremely important point, because the inclusion of pain assessment in the QOF would strongly encourage health professionals to be proactive and to ask a patient about their pain, treat it promptly and reassess it to ensure that the treatment given is effective, rather than expecting the patient to raise it first. A recent report on osteoarthritis found that 50 per cent. of people said that they would need to be in frequently unbearable pain before considering seeing their GP—clearly this is a significant barrier.

Another recommendation was that a pain score should become part of the vital signs monitored routinely in hospital. Indeed, the Chronic Pain Policy Coalition has been campaigning for some time now for pain to be adopted as the fifth vital sign. If implemented, this recommendation would ensure that health professionals become proactive in asking their patients about pain. People would recover faster and reduce the burden of care on others.

The final recommendation I want to highlight relates to the development by experts of a model pain service of pathways of care with clear standards. The work could build on the excellent 18-week cross specialty chronic pain pathway developed by patients and clinicians that has been supported by the Department of Health. It is an important step forward and should be extended to ensure that all patients are offered comprehensive treatment options. That would improve rapid access and reduce the current variability in treatment that patients receive. Patients need to be confident that they can be offered effective options wherever they live.

Commitments have already been made both in Scotland with the “Getting to GRIPS with Chronic Pain” report and in Wales under the “Designed for Life” programme to assess and improve the services available for patients with chronic pain. I hope I have shown the Minister that there are patients, third sector organisations such as Arthritis Care and health professionals in England anxious to get hold of these recommendations and take them forward. They will need encouragement and flexibility in the way in which integrated services are funded and in how outcomes are measured.

Above all, people in pain need a champion. Tsars such as Mike Richards for cancer and Roger Boyle for cardiology have shown how such champions can make a difference. Pain affects cancer patients and heart patients as well as millions of others with back pain, arthritis, pelvic pain and a multiplicity of conditions. Surely the numbers involved and the importance of early intervention demand a pain champion.

I know that the concerns I have raised in this debate are shared by a number of my hon. Friends and indeed by many of their constituents. I thank the Minister for hearing me out, and I hope that she can give consideration to the points I have raised.

I must begin by congratulating my hon. Friend the Member for Aberdeen, South (Miss Begg) on securing this Adjournment debate on a most important topic, which Professor Sir Liam Donaldson chose to highlight recently in the 150th report of the chief medical officer.

Chronic pain is a fact of life for many people suffering from a wide range of conditions. As my hon. Friend has highlighted, those conditions include arthritis, so it is particularly appropriate that we are debating this at the start of Arthritis Care awareness week. I am sure that the organisation will have taken note of the debate.

My hon. Friend referred to the recommendation that all those dealing with patients should receive training in dealing with chronic pain. The House might know that I trained and worked as a nurse in the NHS, and as a nurse I saw daily the effect that pain has on people, as well as the effect that it can have on the wider family as they try very hard to manage the patient who has that pain. That is why I know that all clinicians need to be involved in the assessment and management of pain. It should be at the heart of good clinical practice.

In my opinion, pain is what the patient says it is. The patient has to be believed about the level of their pain. I have witnessed ward rounds for medication being done with someone saying, “Anything for pain?”, as though it was not being taken as seriously as it should be taken. I am well aware that those days have long gone.

Chronic pain is defined as pain that persists beyond the usual healing time or is present in diseases where no healing occurs. We have already heard from my hon. Friend that it is estimated that more than 7.8 million people in the United Kingdom suffer chronic pain and that chronic pain is more common now than it was 40 years ago. We have also been reminded of how chronic pain ruins the lives of children and adults alike. She highlighted the effect on work and employment and on the finances of the family. She also highlighted not just the human cost, but the cost to our economy.

The report of the chief medical officer is an independent report to Government on aspects of the nation’s health and, as such, draws attention to a number of different major health challenges. In his annual report for 2008, the chief medical officer called for a major initiative to widen access to high-quality pain services to improve the lives of millions.

My hon. Friend made a persuasive and eloquent case in support of the report’s key recommendations, as well as raising a number of other key issues. She highlighted the recommendation that consideration should be given to including an assessment of pain and disability in the quality and outcomes framework. The process for proposing changes to the framework is managed by the National Institute for Health and Clinical Excellence—NICE—with decisions on the prioritisation of topics being made by an independent advisory committee. The public consultation on suggestions for change closed on 2 February, and I understand that the next opportunity to submit suggestions for new indicators to NICE will be this summer. I hope that the chronic pain policy coalition will take the opportunity to suggest specific indicators at that stage.

Let me put those issues in the context of the next stage review, led by Lord Ara Darzi, and the report, “High quality care for all”, which was published in June 2008. A key recommendation in that report is the establishment of a national quality board to advise Minister on clinical priorities, and to provide strategic oversight and leadership on quality across the NHS. The board is chaired by the NHS chief executive, David Nicholson, and it met for the first time on 30 March this year. It includes representatives from the key bodies responsible for improving the quality of the NHS, including the chief medical officer, as well as a range of a range of expert and lay members. The board will give advice to Ministers on how to improve the quality of the NHS. Its advice will be based on a systematic methodology, which will allow decisions to be made about where work to improve the quality of care is most needed. I can assure my hon. Friend that recommendations in the chief medical officer’s report, including the management of chronic pain, will be considered in that new framework.

“High quality care for all” also highlighted the need for high-performing professional teams to be able to measure what they do and use that information to support real improvements in the quality of care. We have to energise that vision across all strands of health care—for example, through the reinvigoration of clinical audit. At the end of 2008, the national clinical audit and patient outcome programme issued a call for new audits to join the national clinical audit programme. The national clinical audit advisory group identified a national pain database as a priority topic for national tender. Tenders came in during February 2009, and the evaluation of those is now complete.

I am delighted to inform my hon. Friend and the House that I received a letter from Professor Black, the chair of the advisory group, just before the Easter recess, and it recommended that the national pain database, run jointly by the Royal College of Anaesthetists and the British Pain Society, should be funded as part of the national clinical audit programme. The House will wish to join me in welcoming that recommendation. Subject to clarification on a few points of detail, funding will now go ahead. It will support continuing quality improvement in the delivery of pain services through the collection of data on the activity of pain services; the benchmarking of services; continuous quality assurance processes for contributing centres; research on the pain population for both common and rare conditions; and the evaluation of treatment outcomes.

My hon. Friend said that the pain professionals believe they have been pushing at a closed door, but that is not entirely the case. The Department of Health has already supported the work of the NHS on the management of chronic pain through a number of important initiatives, including the musculoskeletal services framework, the 18-week commissioning pathway for the management and treatment of chronic pain, and the NHS Choices website.

Pain is a common, distressing and sometimes disabling symptom in many musculoskeletal conditions. In July 2006, the Department published the musculoskeletal services framework, which provides the NHS with guidance to help communities improve orthopaedic and pain management services. The development of the 18-week commissioning pathway assists commissioners in delivering the appropriate services for their populations. A specific pathway for chronic pain was developed with leading pain clinicians and with the consensus of a wide range of key stakeholders. It will help to transform services with examples of good practice. It also recommends the use of the brief pain inventory to assess the level and impact of pain—an important tool in assessing the patient. Again, pain means so many different things to us as individuals, and must be assessed individually, with patients being able to express themselves. Having permission to have pain is part of that assessment tool.

The Department’s NHS Choices website provides information to put patients in control of their health care. It contains a number of sections dealing with pain and, in addition to providing advice to those suffering pain, it includes video clips of the personal perspectives of those affected by pain.

I take the opportunity to thank the Chronic Pain Policy Coalition for its work and its effect. I know that officials working with me are developing a good relationship with the organisation and are very grateful for its input in identifying and raising issues. I am pleased to learn of the all-party group on chronic pain, and I am particularly pleased that my hon. Friend will chair it. She spoke of the importance of a champion. In the House she has been a champion on so many issues, and there could be no one better to fulfil the important role of chairing that group. It saddens me that because of a diary clash and prior commitments, I will not be able to attend its meeting.

Once again, I thank my hon. Friend for bringing this important issue to the attention of the House. We cannot have people accepting pain and using expressions such as, “Well, I mustn’t grumble. I suppose I’m not too bad today,” when pain is affecting not only their life, but the lives of their loved ones, their families, their work and their finances. I am delighted that our chief medical officer has taken the issue so seriously in his report, which is independent and will be received in the spirit in which it is meant. I know that my hon. Friend will make sure that we fulfil the aims that I have set out.

Question put and agreed to.

House adjourned.