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Back Pain Treatment (Costs)

Volume 493: debated on Wednesday 3 June 2009

It is, as always, a pleasure to serve under your chairmanship, Mr. Bayley, during today’s final debate. It is also a pleasure to see the Minister in his place; no doubt he has come hotfoot from his Department. As he well knows—I arranged a little pre-briefing for him—I shall address the issue of low back pain costs and the relationship to complementary and alternative medicine and integrated health care, and I shall refer specifically to the National Institute for Health and Clinical Excellence’s new guidelines, in which his Department no doubt had a hand.

I should like to provide some background. In 1914 the General Medical Council issued a warning notice to qualified doctors, directing that there should be no associating with unqualified persons or collusion with therapists using alternative therapies without the appropriate qualifications and registration with the GMC. We have moved on light years since then, and there have been three defining moments in the pursuit of the integration of complementary and alternative medicine in the health service. I say that with 20 years’ experience in the House, during which time, as the Minister knows, I have led debates on this subject on many occasions.

The first milestone came in the 1990s when the then Member for Loughborough, my right hon. Friend the Member for Charnwood (Mr. Dorrell), while Under-Secretary of State at the Department of Health, introduced guidelines stating that doctors could contract with complementary and alternative medical practitioners provided that they took clinical responsibility. That was the first time that the health service moved towards the provision of care with complementary and alternative practitioners. Running almost in parallel came the Osteopaths Act 1993 and Chiropractors Act 1994, which were introduced as private Members’ Bills. I had the honour to serve on both Committees. For the first time osteopathy and chiropractic were regulated by Acts of Parliament and started to develop their own registers, which were later recognised.

The second milestone was a House of Lords report in 2000 that, for the first time, officially categorised the different types of therapy into broad classifications, making it easier for legislators, the Department and Members of Parliament to think about complementary and alternative medicine. This debate focuses on disciplines in the first category—osteopathy, chiropractic and acupuncture, which are referred to in the new NICE guidelines. Some of the recommendations in the Lords report have been implemented, but others have not. In the nine years since, there has not been the growth in access to complementary therapies through the NHS that we might have expected, despite the enormous public demand for such services. There is a bit of a lag there.

The third milestone is the recent publication of NICE’s guidelines on low back pain. Finally, NICE has issued guidelines to physicians suggesting that complementary therapies, whether osteopathy, chiropractic or acupuncture, can be employed for a given period and that patients can use any of them. This is a tremendous breakthrough because, as I understand it, the guidelines are backed by carefully controlled studies that have given the Department the confidence to do this. Perhaps the Minister can confirm that. The guidelines open up wonderful opportunities for the further development and roll-out of complementary services in the health service.

In low back pain the Minister has found a wonderful target, given the massive amount of time taken off work because of it. It is a very big problem—not only is the Minister nodding, but so are you, Mr. Bayley. I could hardly receive a greater vote of confidence without going through the Division Lobby. But anyway, about 20 per cent. of people with low back pain—one in 15 of the population—will consult their GP about it. As an exercise programme, NICE has recommended a course of manual therapy, which includes osteopathy or chiropractic, or a course of acupuncture, and GPs can offer a range of options if necessary.

What are the problems? The first, which I hope that the Minister will talk about, is roll-out. How will people access these services across the country? Until very recently, most were provided privately. There is a postcode lottery. It is estimated that only 10 per cent. of primary care trusts refer any patients for osteopathic treatment, despite more than 7 million osteopathic treatments being carried out in the UK each year. What is the cost to the economy? In 2006, 175 million working days were lost, at a cost of between £103 billion and £129 billion. We are talking about astronomical sums of money. According to the Department for Work and Pensions’ figures, a combination of stress and musculoskeletal disorders accounts for up to 75 per cent. of work-related sickness. The Government could hardly have chosen a better target for this new policy.

Much action is needed, however. Studies have indicated the existence of a turning point: after four to six weeks the likelihood of an employee with low back pain returning to work rapidly falls. We need to be very aware of that window. Although the new NICE guidelines for persistent low back pain are welcome in increasing the options for patients and clinicians, I respectfully suggest to the Minister that we need to consider greater options during the stage prior to the sixth week.

I want to comment on the three main disciplines, and then address some other issues, such as the attacks made in the press, and the Health Bill, which no doubt the Minister is looking forward to considering—I think that Second Reading is on Monday. I have experienced all three treatments. Many years ago, I had a bad fall and broke some vertebrae in my back, and I am grateful to both osteopaths and chiropractors for putting me back together, rather like Humpty Dumpty—although hopefully sizeism is not an issue here. An American Senator said to me the other day that all health care basically relates to diet and exercise, and I am inclined to agree with regard to the origins of problems. But anyway, I must not digress, Mr. Bayley, because you might call me to order.

Osteopathy and manipulation, as distinct from physiotherapy, offer fantastic relief for people whose back matrix is out of order, and some very good studies have supported that conclusion. In 1999, the Royal College of General Practitioners concluded that osteopathic manipulation can provide pain reduction and an improvement in activity levels. The UK back pain exercise and manipulation—UK BEAM—trial, funded by the Medical Research Council, also came up with some positive results, as have other health service studies. For example, the Oxford and Buckinghamshire Mental Health NHS Foundation Trust found that

“rapid access to an osteopath can prevent or reduce sickness absence and allow employees to benefit physically from early intervention”.

Many of the press reports that have been positive about the NICE guidelines point out that the cost of bringing in such treatments will probably be, at the very least, no cost at all because of the savings made. The treatments may even have a positive outcome for health budgets at a time when we have an overburdened health service—we could make another speech on that and the Minister could reply. Anything that can reduce demand on conventional services and give surgeons more time to operate must be a good thing.

We have studies, such as the 1990 British Medical Journal study, that are very supportive of chiropractic. The Clinical Standards Advisory Group study in 1994 found that both chiropractic and osteopathy worked, and the Wiltshire study in 1999 also referred to the use of chiropractic. Although that is a good body of work, we need more research because then the Minister would feel confident in allowing other forms of treatment to be used. For example, cardiac, upper back, lower limb and circulatory problems could all be helped through chiropractic, osteopathy and acupuncture. A significant body of research supports the view that osteoporosis, post-operative pain, neck pain, headaches, nausea and vomiting can all benefit from acupuncture. I have used the treatment extensively to improve my own health. I believe that it has improved my eyesight, too, because I have had to reduce the strength of my glasses. I think that was due to the treatment of internal organs, which improved my ability to circulate energy. I have no scientific proof that that is the case, but I believe it to be so.

To help to pave the way forward, primary care commissioners need to be given effective advice. I have been asking for such advice in the Chamber for years. The time has come for NICE to give its blessing to osteopathy, chiropractic and acupuncture. Please get some advice out to health care commissioners about how to do that. We need a review of existing NICE guidance on complementary and alternative therapies. NICE has recently incorporated the National Electronic Library for Health into the newly launched NHS service. It will now be possible for NICE to review that guidance, which it has produced on a range of conditions, and to assess the potential to include CAM research bases there. There should be increased investment in CAM research, which could be modelled on that produced in the US or Australia. In Australia, there is the National Institute for Complementary Medicine, which might be a very good model for this country.

I was about to call you Mr. Deputy Speaker, Mr. Bayley. We used to call you that in what was the Grand Committee Room. We served on the Committee of the Channel Tunnel Rail Link Bill in that room for a year—long enough to walk to Madrid and back. Anyway, to return to the debate, I am concerned about some misleading attacks in the press by people who should know better. David Colquhoun, professor of pharmacology at University College hospital, states that despite all the evidence acupuncture is

“a rather theatrical placebo”.

He goes on to define chiropractic as

“an invention of a 19th century salesman.”

Such people are working in the Minister’s hospitals. Can he not send out a warning shot to them, to say that now that these therapies are available on the health service, we want no more of this nonsense about science? I look forward to the Minister’s reply.

Let me being by congratulating the hon. Member for Bosworth (David Tredinnick) on securing this debate about the cost to the NHS of treating back pain. He has quite clearly shown his depth of experience and interest in the subject, which he has gained from his personal experience and use of various therapies. Moreover, he does a huge amount of work in the House as the joint Chair of the all-party parliamentary group for integrated and complementary health care. I expected a fairly impassioned call for greater regard for complementary medicine, and I was not disappointed.

Anyone who has suffered from chronic back pain knows just what a debilitating condition it can be. In the worst case, it can devastate people’s careers, their family life, their leisure time and their entire psychological well-being if it is not properly addressed. The chief medical officer made that point abundantly clear in his recent annual report, which found that people with chronic pain are seven times more likely to quit their jobs due to ill health, and that a quarter end up losing their job.

I was interested in the figures that the hon. Gentleman mentioned. Regrettably, back pain is on the rise. It is at least twice as common as it was 40 years ago. Some 7.8 million people in the UK have suffered moderate to severe pain lasting more than six months. More than 1.6 million people develop back pain lasting more than three months.

The hon. Gentleman was right to point out the considerable financial cost to the NHS. According to one report published in 2000, the cost to the NHS of treating back pain stood at around £1 billion a year in 1998. We can assume that that figure has increased. He used some other remarkable figures about the wider cost to the community. The study that I have just mentioned demonstrated the price that was paid by the wider community. It estimated that the total cost to society was somewhere between £6.6 billion and £12.3 billion, of which lost productivity accounted for at least £3.5 billion. Clearly, we have an issue that we need to address, and to continue to address in the way that we have in the past few years.

The hon. Gentleman was right to emphasise the importance of effective treatment for those who are unfortunate enough to suffer from this condition. I definitely share his pleasure at the final clinical guideline on lower back pain that was published by NICE last week. As he said, that guideline is based on the best available evidence, and it provides detailed advice for GPs and other clinicians on what treatments should be considered for patients presenting with lower back pain for more than six weeks. That is an important step forward. Like him, I hope that it is a spur to encourage the NHS to do even more to help those whose lives are blighted by chronic back pain.

I should like to put on the record my thanks to Professor Martin Underwood, the chair of the guideline development group, to Professor Paul Watson, the clinical adviser, and to other members of the group for their very thorough consideration and for the clarity of the resulting guideline.

The work by NICE builds on the work that we have already done to improve access to specialist pain services of all kinds. The hon. Gentleman will forgive me for saying that, because of the amount that we have invested in the NHS, we have moved from a position in 1998 where the typical waiting time for access to specialist pain services was 16 weeks for non-urgent cases, a quarter of patients had to wait for more than 28 weeks and, in the worst cases, patients had to wait nearly three years to be seen. Thankfully, the situation is now much better. Waiting times for pain clinics, as for other specialist services, have been brought down to an absolute maximum of 18 weeks, and the average wait across all specialities is now four weeks for out-patient treatment, or nine weeks for treatment requiring an in-patient stay.

As part of that 18-week initiative, we are doing more to support local commissioners and clinicians in helping patients to manage chronic pain. For instance, we now have generic guidance to support the 18-week programme, and the Department of Health will be holding a series of regional seminars on chronic pain management, bringing together members of voluntary organisations, patients, commissioners and providers. All that should stand us in good stead in ensuring that the NICE guidelines on low back pain are properly implemented. I shall say more about that in a moment.

Let me turn to the role of complementary therapies, which was the central point of the hon. Gentleman’s contribution. He is right to state that complementary treatments, such as acupuncture and spinal manipulation, are represented in the guidelines, alongside the use of painkillers, structured exercise programmes and patient education. The Government’s position on back pain, as with all other conditions, is quite straightforward. We want to open up the fullest possible range of treatments to patients—but only if the evidence base is there to justify it. Our position on complementary therapies, as on any form of treatment that NICE considers, is that we keep an open mind. If the experts tell us that acupuncture or other forms of manipulative therapies, including chiropractic therapies, osteopathy or physiotherapy, can be effective, as they have done in this case, we are happy to see them added to the clinical armoury available on the NHS.

The hon. Gentleman was right to ask, “That’s fine, but is it going to happen in practice? Is it going to be delivered on the ground? Can we ensure that what is written in a NICE guideline is what happens in practice when a patient with back pain goes to a GP?” The NHS has proved to be very responsive on the issue of back pain in tending to its own staff. Interestingly, in 2003, the National Audit Office estimated that an NHS trust with a budget of £100 million was likely to be paying out £1.25 million for staff who could not work because of back injuries. I am delighted to say that since that time, the NHS has achieved a 7 per cent. reduction in lost days from musculoskeletal problems, so within the NHS at least, there is a strong awareness of the issue and action is being taken.

On implementation, NICE has developed detailed guidance on costings and commissioning, which is available on its website. Obviously, it includes advice on the full range of treatments set out. However, guidelines are just that. Decisions on what treatments GPs suggest for patients remain with GPs. They need to take into account the safety of a treatment, its effectiveness and the availability of suitably qualified practitioners, but they are obviously best placed to know the individual circumstances of the patient. Likewise, the commissioning of local services must remain at the discretion of local PCTs, based on their understanding of the needs of their local community.

Maintaining autonomy for local practitioners to make local decisions is paramount for running an effective NHS, even though it means some variations in services. The hon. Gentleman used the term “postcode lottery”. The Government believe—I hope he agrees with us—that the closer to the community and the patients we go, the better the decisions. It would be entirely inappropriate for a Minister to promote one treatment over others, however effective it is. Ultimately, decisions about the most appropriate treatment for a patient must be made by them and their GP.

A number of developments should help to ensure that the full range of NICE-approved treatments, including complementary treatments, gets a fair hearing with clinicians, commissioners and patients. First, last year’s Next Stage Review clearly set out a future for the NHS in which primary care services are increasingly influenced by the patient’s individual needs. The review clearly states that GPs and PCTs should have an innovative and entrepreneurial approach to developing new services for patients. We are beginning to see a culture change throughout the NHS that should encourage GPs and commissioners to be more creative, ambitious and flexible about the treatments they offer. That shift presents new opportunities for complementary and alternative therapies.

Will the Minister assure me that he will write, on the basis of this new development, a general instruction about the availability of the new service, so that there is no confusion?

As I said earlier, such decisions are ultimately a matter for the GP and local commissioners, who look at the NICE guidelines. I want to assure the hon. Gentleman that we are doing what we can to draw attention to the new guideline, which was published only last week. That will make a big difference. Generally encouraging the NHS to be more entrepreneurial and responsive, and to offer a full range of treatments, will have a direct impact of the kind that we would both like.

Personal health budgets, which we are piloting at this stage, could be a powerful mechanism to broaden the range of available options. We are not being prescriptive about the areas for personal health budgets that should be piloted, but through some 40 pilots, we want to investigate the use of personal health budgets to provide services for people with long-term conditions, which could include people with chronic back pain. The provisional pilots are still developing their proposals and we will know more about their scope in due course. However, in time, personal health budgets could indeed be another mechanism to support the wider use of complementary medicine in back pain relief, if, of course, the patient wants to go down that route.

The hon. Gentleman mentioned research. The Department of Health commissions research to underpin policy and practice in health and health care through the National Institute for Health Research and the Department’s policy research programme. Our research programme includes £3.4 million for a complementary and alternative medicine personal award scheme. That forms part of our research capacity development programme. The scheme supports 18 CAM researchers at the doctoral and post-doctoral level. They are developing a programme of research and nurturing the methodological skills of the more junior researchers in their teams. Their presence in the programme has allowed factors specific to CAM practice to be incorporated into approved research methodologies. That is an important step forward.

We are also funding complementary and alternative medicine evidence online, which is a collaboration between the Research Council for Complementary Medicine and the university of Westminster school of integrated health. That involves a detailed review and critical appraisal of the published research on specific complementary therapies, focusing on their use in NHS priority areas. The Department has also put money into research on the role of CAM in cancer patient care, and on the use of complementary medicine in primary care.

Finally, regulation is crucial when it comes to giving alternative techniques the credibility and respect that they need in the eyes of GPs and the general public. At present, there is no statutory regulation system in the UK governing the practice of complementary and alternative medicine, with the exception, as the hon. Gentleman said, of chiropractic therapy and osteopathy. As he said, he played an important role when, during his long service in the House, he sat on the Committees that brought the measures into being.

We will, however, soon be launching a public consultation on whether and how we should regulate practitioners of acupuncture, herbal medicine and traditional Chinese medicine. That comes from the recommendations of one of the working groups that were established in 2006 to implement proposals in the “Trust, Assurance and Safety” White Paper, so there is more work under way. Once the consultation is completed and when we have assessed the response, Ministers will make a decision on the way forward.

People with chronic back pain expect the NHS to do its utmost to help them to manage their condition. The new NICE guidelines will bring new clarity and choice to patients, in line with the Next Stage Review vision and the work we are doing to improve pain management in general. I expect clinicians and commissioners to pay equal attention to the full range of options that the new NICE guidelines advocate. The Government are playing their part to ensure that all scientifically proven treatments are considered on their merits, including complementary techniques.

The bottom line is quite simple: we want all patients to have access to the best possible treatments for them. I believe that the NICE guidelines are another important step towards achieving that for people suffering with the misfortune of chronic back pain. A debate such as this is another good opportunity to raise public awareness of the changes that are being made and of the enthusiasm of the hon. Gentleman and others for our work, and to ensure that patients, GPs and commissioners take the issue seriously and take it forward in the interests of the wider community.

Question put and agreed to.

Sitting adjourned.