asked Her Majesty’s Government what steps they are taking to improve osteoporosis services within the National Health Service.
The noble Baroness said: My Lords, I welcome this opportunity to raise in the House the issue of how the National Health Service currently diagnoses and treats osteoporosis. I also welcome the fact that a number of colleagues who take a keen interest in this subject are present; I particularly welcome the presence of the noble Baroness, Lady Cumberlege, who chairs the All-Party Parliamentary Group on Osteoporosis.
I have no direct interest to declare, so I will begin by explaining how I first became interested in this issue. When I passed the landmark age of 60—a not unusual experience in this House—my GP said that she would have ideally liked me, in common with a number of her patients, to have a bone density scan, but that unfortunately the DEXA scanning facilities were not available in our area. As a result, I became interested in the availability of such scanning facilities. Through Parliamentary Questions, I became aware that the provision of DEXA scanners seems to be yet another example of the postcode lottery that we hear about and that provision is inadequate and patchy.
I realise that routine scanning—say of all women over 60—is not the best way forward, but what particularly concerns me about the current situation is that women and men who are at risk of developing osteoporosis are not being systematically identified and offered scanning or other osteoporosis services on anything like the scale needed. It is true that the Government have increased funding for DEXA scanners, but not to the extent required for good provision throughout the country. Neither was the money for scanners ring-fenced; in Answers to Parliamentary Questions I was unable to get any reassurance that all the money had actually been spent on scanners.
I am also concerned that, as I found from Answers given to my Parliamentary Questions and to those tabled by Members in another place, the department seems to hold so little information centrally on the availability not only of scanners but of other osteoporosis services throughout the country. Given that the Minister and the department are committed to improving services in this area, it is regrettable that so little information about what is actually happening on the ground is currently being collected or assessed at national level.
Although my initial contact with the issue of osteoporosis arose from the specific problem relating to scanners, I have since become interested in the wider question of how effectively osteoporosis is diagnosed and treated throughout the country. I would like to say how grateful I am to the National Osteoporosis Society, whose briefings and expertise have been a huge help. I am also grateful to the other organisations that have shown an interest in this debate, including Help the Aged.
There can be no doubt that osteoporosis is a very important issue for the NHS. It is said to affect as many as one in two women and one in five men in the UK. Although it principally affects older people, we must remember that, in a society like ours where life expectancy and the proportion of older people have increased, it is very significant. The National Osteoporosis Society has calculated that the combined cost of hospital and social care for patients with a hip fracture alone amounts to more than £1.73 billion, which is equivalent to the annual cost of treating coronary heart disease. I also understand from the Department of Health’s hospital episode statistics that fractures in patients aged 60 years or over account for 2 million hospital beds in England each year, which is more than for diabetes, heart failure and obstructive airways diseases.
The timely diagnosis and prevention of osteoporosis is therefore a telling example of where the principle of spend to save applies. It applies both in cost terms to the NHS in the long term but, just as important, by helping to prevent people from suffering life-changing and life-worsening fractures and thereby allowing those people to retain a much better quality of life.
There are three principal, interlinked ways in which the diagnosis and treatment of osteoporosis can be improved. They are all important if we are to get a properly integrated and effective national osteoporosis service. First, in relation to GPs, the quality and outcomes framework that rewards GPs and incentivises them financially to provide quality care in specific disease areas should be modified to include osteoporosis. I know that the National Osteoporosis Society has made a strong case for including clinical indicators for osteoporosis in the current review of the QOF and I hope that the Government will support this. It would ensure that a higher priority was given throughout the country to osteoporosis prevention and its treatment in GP practices.
Secondly, there is the important issue of osteoporosis and the current guidance from the National Institute for Health and Clinical Excellence. I shall refer to two aspects of the NICE guidance. Perhaps the most pressing and the most timely issue from the point of view of this debate relates to the technology appraisal of drugs used in treating osteoporotic fractures. NICE issued its final appraisal determinations in this area on 26 June this year, but only this past Monday, 22 October, was an appeal against this heard. The outcome will be known shortly. Perhaps in her reply, the Minister can say precisely when this will be published. The guidance issued in June by NICE, which is mandatory, stipulates that the drug alendronate should be prescribed to women at high risk of osteoporotic fracture, but the appraisal fails to provide any alternative treatment for women—I understand that this applies to one in four women suffering from osteoporosis—for whom alendronate is unsuitable and for whom the side effects are unacceptable. It is not clear at the moment how such women will be treated and this is causing concern and confusion. Surely it is essential that such women are able to access effective alternative treatments on the NHS.
The second aspect of NICE’s work in relation to osteoporosis is the clinical guidelines process. I understand that a clinical guideline on osteoporosis is in development. Such a guideline would be important in highlighting the best ways of preventing and treating the disease, but at the moment we have no publication date. Again, I would be grateful for any further information that the Government can give us on this.
Lastly, there is the important question of the National Service Framework for Older People. As noble Lords present will be aware, this was published in 2001 and included welcome guidelines on improving falls services and osteoporosis services in the NHS. The main problem, however, has been the slow pace of implementation. The Healthcare Commission audit published in March last year detailed the shortcomings in the organisation of falls services, particularly in hospital departments, including A&E.
As far as primary care trusts are concerned, there is some good practice. I have heard of examples in surgeries where specialist practitioner nurses look through records and identify people at particular risk of osteoporosis and then offer them a consultation. I would like to see that good practice translated throughout the country. However, I am not convinced that the mechanisms for translating such good practice are currently very effective. Again, the fact that the department collects so little information on these practices centrally reinforces the difficulty of trying to get good practice translated on the widest possible scale.
All the aspects that I have mentioned—effective implementation of the national service framework, better NICE guidance and the inclusion of osteoporosis in the quality and outcomes framework—are interlinked. Those three taken together would provide a package of measures that would greatly improve the situation and show a good way forward. However, the present situation is not satisfactory and so, in concluding my remarks today, I hope that the Minister in her reply will be able to assure the House not only that the Government are giving this issue the serious attention that it deserves but that the shortcomings that clearly exist at present will be properly and fully addressed in the near future.
My Lords, I would like to thank the noble Baroness, Lady Quin, for securing this debate, for her clear exposition of the issues involved and for her prompt that I should mention that I am co-chair of the All-Party Parliamentary Group on Osteoporosis. I am delighted to see the noble Baroness, Lady Royall, on the Front Bench. I know that she is extremely sincere and hard working and tries to be well informed, but she covers three departments. I am disappointed that the health Minister has felt unable to come today to answer what I think is a very important debate. After all, he is responsible and accountable to this House and, with his fellow Secretary of State and Ministers, for taking steps to improve services for osteoporosis and shaping the Government’s policy. I am sure that he is very diligent and will, in his busy life, read Hansard, but that is not quite the same thing as answering this debate. It is a very important debate because osteoporosis affects almost half of all women and one in five men over the age of 50 who will break a bone due to this distressing condition.
In 1993, when I was a health Minister, in the country osteoporosis was rarely talked about. As part of my portfolio I was responsible for women’s health. In an interview on ITV, I was asked what the Government of that day were doing about women’s health. I mentioned breast and cervical cancers, and maternity. In a throwaway line I mentioned osteoporosis. I was astounded: in the next few weeks I was bombarded by women asking me exactly what the Government were doing about this disease, and I had to say that they were doing very little.
So I set up an expert group under the chairmanship of Professor David Barlow to give advice on exactly how to take the issue forward. I asked the group to take a long, hard look at what was already known and to suggest what more could be done. In 1994, a year later, the group produced a comprehensive and a coherent programme directed at preventing, diagnosing and treating osteoporosis, and I was very grateful to it for its diligence.
I welcomed the report and accepted its advice on four major elements: first, that bone scans should be available for women at high risk of developing osteoporosis; secondly, that guidelines for treatment should be prepared; thirdly, that further work should be done on preventive measures, such as dietary calcium and physical activity; and fourthly, that specific research should be undertaken.
Much progress has been made in the intervening 13 years, a lot of which is due to the dedication of clinicians in the field; the National Osteoporosis Society—the noble Baroness mentioned that—and not least its patron, the Duchess of Cornwall; and women themselves. The network of 115 branches nationwide work hard not only to help themselves but also to give publicity to the condition and to raise funds for research. I have to say though that research is still wanting. There is a paucity and we need major funding to carry out a specific programme.
Osteoporosis is often referred to as the silent epidemic, and it is, in that those who have it are unaware. With an increasingly elderly population, the numbers are growing. That is why it is so critical to raise awareness among not only the population as a whole but among GPs and other clinicians, so that it is diagnosed and actively managed before a break or a fracture occurs. About 20 per cent of those who suffer a hip fracture die within a year, if they do not die earlier from MRSA or C. difficile, while those who survive are no longer able to live independently. In 2000, in a survey of older women published in the BMJ, 80 per cent said that they would rather die than experience the reduced quality of life that follows a serious hip fracture.
Vertebral fractures are typically under-diagnosed and under-treated, with only one-third of those evident on an X-ray brought to the attention of medics. Some 40 per cent of patients sustaining a clinical vertebrae fracture will be in constant pain and the majority will have difficulties with everyday activities. I should like to ask the noble Baroness, Lady Royall, to bring to the attention of the Minister the need to deliver better access to integrated osteoporosis services for men and women who are at risk. It is the necessity for GPs, rheumatologists, geriatricians, orthopaedic surgeons, obstetricians and clinicians working in emergency care not only to be aware so that they diagnose correctly, but also to act together so that information about a specific patient is shared and the patient properly treated.
As the noble Baroness, Lady Quin, has mentioned, the National Institute for Health and Clinical Excellence is developing a clinical guideline on osteoporosis to help clinicians to identify and treat those individuals at highest risk of a fracture. But this work is ongoing and the report is not due for some time. The noble Lord, Lord Darzi, has a unique opportunity in the review of the NHS to address this issue and include it in his final report to be published in the spring of next year. I should like to ask the noble Baroness to put this suggestion to the Minister, as sadly he is not with us today.
For some time, the All-Party Parliamentary Group on Osteoporosis has been campaigning to include osteoporosis indicators in the quality and outcomes framework, which was mentioned by the noble Baroness, Lady Quin. Those indicators should be in the GP’s contract. The renegotiation of the contract is also under review. Again, it is an opportunity to incentivise GPs to take this condition seriously and think of osteoporosis when in consultation with patients. The inclusion of indicators would support the achievements of policy objectives in the four nations of the UK. Will the noble Baroness ensure that this suggestion is put to the ministerial team?
Looking to the future, the population of 50 year-olds is expected to increase by 10 per cent by 2010 and by 25 per cent by 2020. By 2020, the number of osteoporotic fractures is set to increase annually by 21 per cent and the cost of treating people with hip fractures is expected to rise by 20 per cent at a cost of £20 billion per year. Those figures are based on the minimum costs of treating a single hip fracture, although recent evidence suggests that this figure could be up to three times higher than previously predicted, even without the cost of social care being included.
The all-party group also campaigned to get falls into the National Service Framework for Older People. The framework is now half way through its allotted life of 10 years, yet healthcare providers are still failing to roll out the standards of care that it recommends. These failures are recognised in separate reports by the Royal College of Physicians and the national director for older people, Professor Ian Philp. We know that frameworks in themselves are not executive. It is the implementation of them which is so difficult. What levers do the noble Baroness and her colleagues have to ensure the national service framework is fully implemented? Finally, in the knowledge that a range of drug treatments exist to reduce the risks of patients suffering an osteoporotic fracture, some costing as little 14p per day, does the noble Baroness agree that it is infinitely more cost effective to prevent than to treat, in which case can she suggest how this might be achieved and whether the PPRS system is a possible vehicle to do this?
My Lords, I thank the noble Baroness, Lady Quin, for asking this important Question. If osteoporosis services are improved, not only will it help human suffering, it will also be cost effective to the National Health Service in the long run. It is most appropriate that the noble Baroness, Lady Royall of Blaisdon, is replying to this debate, because she understands the problems of osteoporosis. As she works so hard answering so many of your Lordships’ health debates and Questions, would it not be possible to make the health Minister’s position in your Lordships' House a shared one? The noble Lord, Lord Darzi—Professor Darzi—is working part-time so that he can continue his vocation as an important surgeon. Would this not be a solution to solve the concern of the noble Baroness, Lady Cumberlege?
My aunt, my mother’s sister, daughter of a doctor, developed osteoporosis in later life. She was such an uncomplaining person, but as she shrank she suffered many falls and fractures. When one sees this distressing situation, the need for prevention becomes obvious. I wonder whether, had she taken HRT, her osteoporosis would not have been so severe.
Someone I know who lives in my home village of Masham and who was a theatre sister for years, with a very lively personality, is now wracked with arthritis and is very osteoporotic. She is in agony and implores the doctors to relieve her pain, which does not seem to be possible. Every time I see her, she has grown smaller.
This condition needs attention immediately, as we are an ageing population. The situation will only get worse unless it is tackled as a priority now. Almost half of all women and one in five men over the age of 50 will break a bone due to osteoporosis. These fractures, which occur most frequently in the hip, wrist or spine, have the potential severely to curtail a person’s quality of life. And now, when they have to be admitted to hospital, they have the added worry of acquiring a dreaded hospital infection. Each year, fractures in patients aged over 60 years account for more than 2 million hospital bed days in England alone.
The overall issue with the National Service Framework for Older People is a lack of implementation in relation to Standard 6, which concerns osteoporosis and the reduction of falls. Reports published over the past three years by the All-Party Parliamentary Group on Osteoporosis, by the Healthcare Commission and the National Clinical Director for Older People indicate a lack of progress in the development of a specialist falls service and integrated osteoporosis services as recommended in Standard 6 of the NSF. Despite the fact that the NSF is a mandatory 10-year national programme, the lack of uptake across the country has prevented any real improvements in osteoporosis services being achieved. Action must be taken to encourage PCTs to put the necessary standards in place as soon as possible. It will help to have a clinical guideline to assist clinicians in appropriately identifying and treating those individuals at highest risk of osteoporotic fractures, and a technology appraisal on the use of drugs to prevent primary and secondary fractures occurring in post-menopausal women.
The General Medical Services Contract guides the practice of the vast majority of GPs working in the UK. A component of this contract is the Quality and Outcomes Framework, the QOF, which covers some, but not all, clinical conditions. Through measurement of clinical indicators resulting in the award of points from which payments to GPs are allocated, the QOF is a crucial driver of practice for the achievement of many national standards and implementation of guidance, including some areas of medicine that have been selected for inclusion. But no indicators for osteoporosis are included in the QOF, despite the importance of the primary care setting in the prevention of osteoporotic fractures. Consequently, unlike other chronic conditions that are manageable in primary care, such as heart disease, there are no incentives to treat osteoporosis.
On Tuesday, I attended a very interesting health breakfast in another place on the subject of pain in women. We were told that pain in women could spread differently from pain in men. When research was being done on rats, only male rats were used. I asked why this was so and was told that female rats are more complicated, as is the pain in women. This could be a relevant matter in researching pain in women associated with osteoporosis. I hope that this matter will be looked at in the future.
My Lords, I am most grateful to my noble friend Lady Quin for having initiated this debate on a condition which does not receive the attention it deserves. While osteoporosis is mentioned in national policy, it tends to be side-lined and remains under-prioritised. I welcome the attention that is now being given to the needs of post-menopausal women, especially the one-in-four women who are not receptive to Alendronate—as my noble friend pointed out—the mandatory treatment recently approved by NICE. I should declare an interest as someone who broke a leg in a simple fall a few years ago and has been prescribed alendronic acid since then.
I hope that, through the work of organisations such as the National Osteoporosis Society, we are beginning to see progress so that osteoporosis is no longer taken for granted as an accepted facet of ageing, but is seen as a serious condition which requires prevention and treatment. However, that attention seems to be focused solely on the older population. Today, I want to highlight the needs of a group at an even higher risk of osteoporosis than the post-menopausal, but who receive scant attention when it comes to prevention—those who are long-term physically disabled with conditions such as polio, rheumatoid arthritis and spinal cord injury. Again, I declare an interest.
The fact is that osteoporosis is very common in the disabled community. Fractures can have a devastating effect on our lives, not only in social terms, but also in long-term unemployment. When I broke my leg, I became totally dependent for the three months while it healed, unable to leave the house and needing help with everything from getting into bed, going to the loo and having meals made. But it was hearing about the experience of Kamran Mallick, the director of my local disability organisation, which for me put this issue into very stark relief. He has given me permission to tell his story.
Kamran is a 35 year-old wheelchair user who was paralysed by polio when he was two. When he was 16, he had metal rods inserted by the Royal National Orthopaedic Hospital to support his spine, but his curvature has now worsened and the bone is fighting against the metalwork. He is in constant, appalling pain because his ribs are grinding against his hip bones. He referred himself back to RNOH in 2002, and the back specialist said that he could do further surgery. However, in the mean time Kamran had, by pure chance, met someone doing research into the bone density of disabled sportsmen. Out of curiosity, Kamran checked out his own bone density and discovered that it was very poor. The consultant, when informed of this, refused to do the surgery until his bones were strengthened. Kamran now wonders whether anyone would have picked it up, had he not done so, and whether the operation would have resulted in potentially disastrous consequences. No one had ever alerted him to the danger that he was in from osteoporosis.
Kamran has had regular bone-strengthening injections over the past four years, which have been pretty gruelling and ultimately not effective as his bone density constantly yo-yo’s, going up and then down again. He is now in a desperate situation with the pain, and is coping only by spending every night and all weekend on traction in hospital, then coming into work each day. This is an appalling quality of life in anyone’s book. His bone specialist consultant wants to prescribe Teriparatide, a drug which helps to regenerate bone. It can be given only for a maximum of two years and would cost £15,000 over that time, but at present it has been cleared only for women with osteoporosis over the age of 65. The consultant cannot prescribe it under the NHS unless the PCT will pay for it, and Barnet PCT is refusing to do so because of the cost. It could fund the drug, but is making use of the fact that it has not been cleared for younger people. Kamran has represented himself to the PCT panel twice on appeal, and has been refused. He is going for the final time in November.
What sense is there to this short-term, wasteful, blinkered silo mentality to funding? The cost of this drug is hugely outweighed by the cost of not funding it—the huge personal cost to Kamran, who is in constant severe pain, spending every night and all weekend on traction in hospital. This drug is his only hope to improve his physical situation, otherwise he is faced with a future of having to give up work and be supported by the state, not only for his income, but also for his care.
And what about that cost to the state, which he is trying to avoid? The state will be spending far more than £15,000 well within a year of him having to give up work, with escalating costs into the future. I declare an interest in the cost to HAFAD, Hammersmith and Fulham Action on Disability, the organisation of which he is director and I am the vice-chair. HAFAD is a sizeable local organisation of disabled people with a budget of approximately £800,000, about 20 staff, plus many volunteers. Kamran is an outstanding director who manages to fund and hold together a whole raft of projects, from welfare benefits advice to holiday youth schemes and support for direct payments, which help to provide equal opportunities for disabled people in the borough. He has established a thriving employment project, helping disabled people back to work, and is striving to turn the organisation into a social enterprise so that it can be self-financing— everything that the Government are aiming for in national policy for disabled people. But much of that would collapse if he was forced to give up.
Kamran’s experience shows the waste and tragedy that can result from fragmented services. Nowhere in the system is there recognition of what he contributes to society. Within the NHS, there has been no one who has treated his needs as a whole. As a result, since he had not seen his back specialist for over a year while he was getting the bone treatment, he then had to return to the bottom of the waiting list when he was re-referred for surgery, all adding to his frustration, pain and distress.
Surely this is a glaring example of the need for the Independent Living Bill championed by my noble friend Lord Ashley of Stoke, which was passed by your Lordships’ House but which has now fallen in the other place. His Bill would ensure that health and social services work together and pool their budgets so that the funding is used to provide the service which disabled people both want and need, and not wasted in this bureaucratic minefield.
Most importantly, Kamran’s bone density condition should never have reached this severe state. Why was preventive action not taken years ago? Why was it that it was only his curiosity which led him and his surgeon to know that his bones were crumbling? It is accepted that there are a number of long-term conditions which put people at a higher risk of osteoporosis—I have mentioned only three—so I ask my noble friend the Minister whether the Government will take urgent steps to raise awareness of the need for preventive treatment for osteoporosis, both among the medical profession and the disabled community? With government policy emphasising the need for people to take responsibility for their own health, it is essential that disabled people are made aware of the potential risks.
I am advised by Mr Fadel Derry, a spinal cord injury consultant at Stoke Mandeville Hospital, that osteoporosis is so common among spinal cord injured people that the use of bone density scans is actually academic and a waste of resources. In his view, it would be far more cost effective if the funding for prevention was channelled into the provision of standing frames and standing wheelchairs, which have other benefits as well. Will my noble friend give her support to this?
Furthermore, it is clear that too little is known about the effect of drugs in preventing osteoporosis among long-term paralysed people. Will the Government support research into both primary and secondary prevention in spinal cord injury and polio using biphosphonates to produce evidence of the effectiveness of the long-term use of these drugs? Will the Government also encourage NICE to include at least one spinal cord injury specialist in drafting the guidance on preventive drugs?
Considerable improvement also needs to take place within the NHS in the treatment of long-term paralysed people once they have sustained a fracture. GPs, accident and emergency teams and orthopaedic surgeons are not sufficiently aware that the treatment of a long-bone fracture in someone who is paralysed often needs to be quite different from treatment given to a non-paralysed person with osteoporosis, otherwise severe complications will arise—for example, there is considerable ignorance of the danger of pressure sores while the bone is in plaster. The pressure on specialist centres such as spinal cord injury centres as a result of these failures in treatment is considerable.
I am extremely grateful to my noble friend Lady Quin for having raised this important topic. I hope that it will lead to much greater attention being paid to all the groups who are at high risk of osteoporosis, not only post-menopausal women.
My Lords, as a man, I find myself in a minority group in this debate. That is a reversal of the usual balance between the sexes in this House. That brings me to the point that we do not consider men to be a stereotypical group of those who have problems with osteoporosis. As the noble Baroness, Lady Wilkins, has just pointed out, one of the stereotypical groups is that of elderly women. Many people probably do not know that men can suffer from osteoporosis.
One of the reasons why women are more susceptible to this condition is that they live longer and any other progressive condition may not manifest itself to the same degree. The fact that men have larger, thicker and denser bones than women also makes them less susceptible to the condition. However, the condition can be very damaging to men. If we are to achieve a greater equality in health for men, we shall have to address this problem, first and foremost by creating a greater awareness among the male population and healthcare professionals.
One of the themes running through the debate is that we are not paying enough attention to creating preventive methods and not raising awareness among medical practitioners and those who may suffer from the condition. The NHS is better at dealing with acute problems as they are presented than it is at creating long-term strategies for preventive healthcare. This applies not only to the NHS; it runs across the entire framework of government. We are much better at dealing with problems as they occur than at preventing them. We are also much worse at investing in prevention than we are at investing in a problem once it is presented.
The usual way in which we deal with such a problem, once we are aware of it, is to wait until it becomes acute; then there is a degree of pressure and there is a reaction. As the noble Baroness, Lady Wilkins, said, a series of case studies is brought forward, people then think about the problem and then we go back. The whole governmental structure in Whitehall tends to react in this way. It is our responsibility, and particularly the responsibility of whoever is in power, to address this problem and to get in early.
As we heard from the speech of the noble Baroness, Lady Wilkins—to which I can relate strongly from my experience with my previous portfolio—government departments tend not to support one another. The ongoing costs of not addressing this problem in the disabled community means that much of the Government’s drive towards getting people off benefits and into work may well be wasted. If we do not get departments to live up to their duties and make sure that they know that one group is more likely to suffer from osteoporosis than another, it does not matter how many interviews you have at various job centres or restart projects—call them what you like—you will still fail to bring in the money. I totally agree with the points made about the legislation that the noble Lord, Lord Ashley, has been championing. Unless we talk to one another across the silos, we will miss our targets.
We must ensure that the NHS decides what NICE is going to do and decides that NICE gives higher priority to preventive care. If we are to carry on with NICE, there is a case for us in Parliament to become the ultimate stage for appeals on its decisions, as opposed to saying that someone should give it better criteria to work to. We must ensure that we intervene more clearly and that on-costs are taken into account by other departments, otherwise we will always come back to saying, “If only we’d intervened quicker; with all the expertise going around, we could have done something else”.
To return to the under-represented male group, what do we actually know? The research that I did for this debate from the information provided for me pointed out that the male menopause is, as I am assured by most females, a reality, although not a medical reality, because we do not have the huge chemical change in our bodies. However, we produce less testosterone, the preventive and supportive hormone; the level of help and prevention that it provides reduces over time. That is what leads to this problem. The symptoms of wanting to buy motorbikes and fast cars as we hit the age of 45—I have about a year to go—may be psychological, but the fact is that we are suffering many of the same problems as women, although we have them at a slightly slower rate. Will the Government do some work to find out what is the safe, normal level of testosterone? What sort of supportive care can we offer at the moment?
What are we doing to make people aware of the diagnosis of osteoporosis in men? If you have a comparatively light fall and you break a bone, and you are male, what training is given to medical professionals to decide whether you should then be tested for osteoporosis? What is the guidance? Are we taking this seriously? Do people know that height loss, for instance, can be seen as a sign of the condition? Is this being taken as seriously for the male of the species as it is for the female? Are we addressing height loss and testosterone level testing seriously? Are all these packages being brought together and presented as something that doctors should know about? If we are successful in the testing, the benefits will roll out. If we manage to keep the average man living almost as long as the average woman, these problems will become more acute.
I look forward to hearing the Minister’s reply, but I would appreciate having some guidance given to us about where we are fitting the structure of preventive healthcare into our overall planning and what safeguards we have that any budget put forward cannot be raided the next time we have a cash-flow problem.
My Lords, it is extraordinary that this is the first time in over 10 years—I have checked this—that the House has had a full-scale debate on this extremely important subject, so the noble Baroness should be congratulated doubly for having tabled her Question. She was, of course, right in all that she said. The messages are stark: brittle bones and bone fractures are the source of immense amounts of pain and distress among older people, and the cost to the NHS and to the country is commensurately huge and rising. The combined cost of hospital and social care for patients with osteoporotic fractures is reported as being more than £1.8 billion a year, a figure that the noble Baroness mentioned. One in two women and one in five men is likely to suffer such a fracture after the age of 50. Out of every five orthopaedic beds, one is occupied by someone who has had a hip fracture. Twenty per cent of those patients die within a year as a consequence; another 20 per cent end up in a nursing home. In fact, the suffering that arises from a fall and a hip fracture in old age cannot really be measured. So great is the dread of immobility arising from a serious hip fracture that, as my noble friend mentioned, over 80 per cent of older women said in a survey that they would rather be dead than experience the reduced quality of life that that would bring.
As with so many issues in the public health arena, we know what we should be doing about all this but the evidence, unfortunately, is that we are just not doing it. There have been improvements in NHS provision over the years; we have the NSF for Older People, and we have recognised preventive treatments. But as the British Orthopaedic Society reported last month, most eligible patients miss out. A recent UK audit showed that fewer than 5 per cent of women with a history of fracture underwent a DEXA scan for bone density, and fewer than 10 per cent were treated with drugs to reduce the risk of further fractures. The sobering part is that we know it is possible to predict a great many of the hip fractures that occur in the elderly, and therefore to prevent them. The biggest predictor is a fracture that has happened to someone previously. In fact as many as half to two-thirds of patients who present with a hip fracture have broken a bone before. The unpleasant conclusion is that many people at risk are not being looked after properly by their doctors.
That brings us to the whole question of the quality and outcomes framework. GPs are perfectly placed to be targeting those patients at risk of brittle bone fractures, but all the evidence is that this kind of proactive, preventive doctoring is not happening nearly enough. Doctors are well aware that there is a range of a priori risk factors for osteoporosis: being white and female; having had an early menopause; having a low body mass index; being a smoker or a drinker; leading a sedentary lifestyle; being on steroids—all these are predisposing factors. The QOF provided a golden opportunity to bring uniformity to the way in which fragile bone disease is targeted throughout the country, but the opportunity was not seized. It would be very helpful if the Minister could bring us up to date on this. What representations have been received on the subject by her department, and is she aware of any plans for osteoporosis to be included in the framework in future?
Part of the problem, so I understand, is that many of the signs or symptoms that might otherwise sound the necessary warning bells are not always recorded. For example, the fact that someone has been on a long-term course of steroids is very seldom flagged up on computer recordings, and older patients who have a history of falls are very unlikely to have that fact recorded. The same applies to the investigations associated with a previous fracture: the patient record often does not highlight them. One of the main conclusions from the report published in the summer by QResearch was that computer recording of diagnoses of osteoporosis needs to be improved so that patients at risk of fracture can be more easily identified. There needs to be better recording of the interventions and treatments delivered to those at risk. In particular, there need to be much better systems in place to prevent bone fractures among older people living in residential care homes, where it was found that only one-third of such people are receiving the very basic and extremely cheap therapy of extra calcium and vitamin D. So there are a number of very simple indicators, which the QOF could include, that would make a huge difference to the burden on secondary care arising from bone fractures and an equal difference to the workload of falls services.
Falls services are extremely important. A couple of years ago, the Royal College of Physicians discovered in an audit exercise that, although about three-quarters of trusts in England are part of a co-ordinated falls service, there were key parts of hospitals, such as A&E and fracture units, where falls and bone health are not adequately addressed. The amount of actual clinical activity in these areas was surprisingly low, and it was noticeable that public health strategies often failed to mention either falls or bone health. Part of the problem that the Royal College identified was that trusts found it difficult to get the necessary information from PCTs relating to either issue. It would be useful if the Minister were able to tell us whether things have improved over the past two years since the royal college audit was done. The gold standard nowadays is for every trust to be part of an integrated, multi-agency, multi-professional service for falls; and that a quarter of trusts should not be is clearly unacceptable.
The noble Baroness, Lady Quin, rightly referred to the guidance published by NICE. I have spoken to two doctors about this, who both echoed the concerns that have been expressed recently by the National Osteoporosis Society and the Nuffield Department of Orthopaedic Surgery, among others. A decision to rule out NHS funding for all but one of the generic first-line treatments will leave doctors without any ability to exercise their clinical judgment to prescribe something else, if the patient cannot tolerate that particular treatment. Alendronate is known to cause nasty side effects, which some patients find intolerable. I do not as a rule criticise NICE’s decision-making, because it is an organisation of which I approve, but I very much hope that it will listen to the representations made to it on this subject and that it does not leave doctors in a position in which they can choose from a menu of only one.
Prevention is one part of this equation and treatment is the other part. I was encouraged to see that a new audit is under way to improve the care of patients who have suffered hip fractures. The aim of this is to audit hospitals against six standards set out in a guide to best practice published by the British Orthopaedic Association and the British Geriatrics Society. The two key standards are that patients with hip fractures should be admitted to an acute orthopaedic ward within four hours of presentation and that surgery should be performed within 48 hours on all those who are medically fit. Some 75,000 people every year break a hip. Sadly, the evidence is that at least half those people wait more than 48 hours for an operation; and a delay beyond that period means that you are more likely to die or suffer permanent disability. I very much hope that this audit process will lead to faster response times and a general raising of standards.
The Minister has been given a lot of food for thought in this debate—at least I hope so. She will need no convincing of how important it is that we tackle this awful condition in a systematic and co-ordinated way across the country. The good news is that it is well within our capability to do it. All we need are the systems, the incentives and, of course, the will.
My Lords, this has been an excellent and long-awaited debate and I thank my noble friend Lady Quin for enabling it to take place. I am grateful to all noble Lords who have spoken, and I am especially grateful to the noble Baroness, Lady Cumberlege, not only for her expertise but for being the catalyst in many ways of some of the pioneering work that has taken place over the past few years.
My noble friend spoke eloquently about osteoporosis and the devastating effect that it can have on people living with the condition, their families and those who care for them. Here I must declare an interest in that my mother had chronic osteoporosis before the wonderful new drugs had been developed. She was a wonderful, gentle, long-suffering woman who shrank swiftly. In the end, after years of suffering, she fell out of bed in hospital, broke her hip and died in a month—because, basically, she did not want to live. She did not want to be immobile with a broken hip. I, too, have low bone density, so I have a vested interest in all this and am acutely aware of the problems. I am a proud member of the National Osteoporosis Society and thank it for its brilliant work in raising awareness, raising money for research and providing invaluable advice and support to those who suffer from osteoporosis.
While osteoporosis affects some younger people, together with falls it has important implications for the older population and we recognise that they represent a significant and growing burden on our health and social care system. Just this week we learnt that there are now more pensioners than children in this country, and we all want to remain as healthy and independent for as long as possible. I thank the noble Lord, Lord Addington, for raising awareness of the often-overlooked fact that men as well as women suffer from osteoporosis.
In 2001, the Government published the National Service Framework for Older People, the first ever comprehensive strategy to ensure fair, high-quality, integrated health and social care services for older people. Among other things, it highlights the importance of services for key conditions, including osteoporosis, and acknowledges that falls are a major cause of disability, and the leading cause of mortality resulting from injury, in people aged over 75. Osteoporosis is closely linked with falls prevention, as the risk of fracture after a fall increases with age. Prevention and effective management of osteoporosis has a significant effect on both the numbers and the social and economic cost of fractures. The development of integrated falls services was a key objective of the NSF and support for the local development of those services has been provided through guidance published by the Department of Health and through a co-ordinated approach with other national organisations with an interest.
The noble Baroness, Lady Masham of Ilton, referred to Standard 6 of the NSF. There is a lot more to be done to ensure that Standard 6 is being respected throughout; however, I draw the noble Baroness’s attention to a national audit of falls services for older people, which was undertaken by the Royal College of Physicians in January 2006, which confirmed that 74 per cent of trusts had part of a co-ordinated, integrated, multi-agency service for falls. Overall, the audit results suggested that most areas have the infrastructure with the potential to identify need and provision of specialist fall assessment and treatment. That is not enough but we are getting there. There are many innovative and effective projects around falls up and down the country. For example, in the north-east the ambulance service works in partnership with local councils, using computer programmes to identify “fall hotspots” such as uneven pavements or ungritted paths in winter in areas with a high concentration of older people. Such schemes should be commended.
The National Director for Older People’s report, A Recipe for Care, highlights that a modest investment by the NHS in developing falls and bone health services in line with NICE guidelines would produce significant benefits in reduced mortality, increased quality of life and savings through a reduction in hospital admissions—spend to save, as my noble friend said. We know what needs to be done. The policies are there but we have to ensure that they are translated into firm action by the NHS and councils. Local commissioners must decide how these things can be achieved but the Department of Health has a role in improving the way in which this commissioning is undertaken.
I am, of course, aware that Falling Short, the APPG report on osteoporosis services, recommended the inclusion of osteoporosis in the Quality and Outcomes Framework—something of which many Lords have spoken. Clearly there is good evidence for the efficacy of multi-professional falls interventions in reducing the risk of a fall and osteoporotic fracture. Work in other clinical areas such as coronary heart disease, asthma and diabetes has shown that both the quality of data recording and the level of care for these conditions can be greatly improved by incorporation in the Quality and Outcomes Framework.
The QOF is part of the General Medical Services Contract. It is a voluntary incentive scheme that rewards practices for achieving quality indicators across a wide range of clinical and organisational areas. It is a “living” document that is subject to a process of change and improvement over time. Recommendations on priorities for new areas in QOF, for negotiations regarding the 2008-09 contract, are being considered at the moment but it would not be appropriate for me to comment or to speculate. However, if osteoporosis is not included in 2008-09, we will certainly consider including it in QOF for 2009-10, and I will follow that up. However, in the mean time I am sure that much more could and should be done to raise awareness of osteoporosis among GPs to ensure that they see the telltale signs, diagnose accordingly and that the correct treatment can be prescribed. I note the point made by the noble Lord, Lord Addington, that men especially should have their awareness raised because so many GPs are not aware that this affects men as well as women. In the 21st century there is no reason why it should be undiagnosed in primary care.
I will write to the Chief Medical Officer suggesting that he should draw GPs’ attention to osteoporosis in one of his forthcoming CMO updates. We must do more to raise awareness and diagnosis especially for people with long-term disabilities. I am very grateful to my noble friend Lady Wilkins for drawing our attention to that. I will, of course, draw it to the attention of my colleagues in the ministerial team. Kamran is clearly an extraordinary young man who is suffering from a fragmented system—the sort of system that the noble Baroness, Lady Cumberlege, rightly spoke of—and needs better access to integrated services for osteoporosis. I am sure that that is one of the things that my noble friend Lord Darzi will look at in his review.
The noble Earl referred to the QResearch and the fact that patient computer records need to be improved. This is something that the Department of Health is looking at and I will come back to the noble Earl in due course. He also highlighted the importance of a better flow of information from primary care to acute care and between local authorities and the health service. That again is something that my noble friend Lord Darzi will look at, although, of course, his review cannot be a panacea.
As many have said, DEXA scanners are vital in identifying those at high risk of developing osteoporosis, enabling the appropriate advice and treatment to be given so that the number and severity of fractures can be reduced. DEXA scanning has long been regarded as the gold standard procedure in determining whether treatment is appropriate. In 2005, the department announced that a cash injection of £20 million would be invested into bone density scanning to improve access to DEXA scanning and reduce waiting times. An initial £3 million was allocated to those areas with longest waits for the purchase from the independent sector of additional scans in 2005-06. A further £17 million has been allocated to SHAs as strategic capital for 2006-07 and 2007-08 to improve NHS capacity through investment in new DEXA scanning equipment. I note the concern about the patchy availability of DEXA scanners and I do understand that because the additional investment is not ring-fenced, it could potentially be used for a purpose for which it was not intended. But the reduction in waiting times clearly demonstrates that there are now many more DEXA scanners. Since January 2006, the Department of Health has been collecting waiting time and activity data for 15 diagnostic tests or procedures, including DEXA scans.
The latest data show that the number of patients waiting more than 26 weeks—which is outrageous—for a DEXA scan has been cut from nearly 4,000 to just 61. Only 800 patients are now waiting more than 13 weeks for a scan, which is down from nearly 9,500, and the total number of patients waiting for a DEXA scan is down by nearly a third. That is all very good news, but more needs to be done. For example, at a local level we need to ensure that scanners are working to maximum capacity. I am sure that most people would not mind if their scan was outside the 9-to-5 “normal” time for scanning.
NICE guidance and its recent appraisal have been a key focus of this debate. The National Institute for Health and Clinical Excellence has been carrying out two technology appraisals on a number of treatments for the primary and secondary prevention of osteoporotic fragility fractures in post-menopausal women. The treatments that have been appraised are alendronate, etidronate, risedronate, raloxifene and strontium ranelate for both the primary and secondary prevention of osteoporotic fragility fractures. Teriparatide has also been appraised in the secondary prevention of osteoporotic fragility fractures. As noble Lords have said, NICE’s recommendations on those drugs are the subject of an appeal and the outcome will be announced in due course. I am afraid that I do not have the date at present, but as soon as NICE informs the Department of Health, I will inform noble Lords.
I could speak about NICE at length, but I am running out of time. I well understand the concern expressed, especially about those people who may have some adverse reaction to alendronate. I cannot make detailed comments, and I certainly would not wish to undermine the excellent NICE guidance in any way. I simply note the current clinical practice whereby patients who are unable to take one drug are offered another. I cannot see that situation changing.
Through the Musculoskeletal Services Framework, we have also taken steps to improve assessment, diagnosis and treatment for osteoporosis and other musculoskeletal conditions in England. The goal is to ensure better outcomes for patients through a more actively managed patient pathway, with explicit sharing of responsibility agreed between all stakeholders—all health and social care clinicians and managers, the voluntary and community sector, patients and the public.
Notwithstanding the many real concerns that have been expressed today, the initiatives that I have described clearly demonstrate that the Government are doing much to support NHS organisations to improve osteoporosis services. There is greater awareness, better diagnosis, waiting time for scanning is at a record low and more services are now in place for older people who have fallen. We are also doing much on the preventive front, with general lifestyle messages around diet, exercise, reducing smoking and avoiding excessive consumption of alcohol, which are all important in the prevention of osteoporosis.
I do not underestimate how disabling, painful and debilitating this silent epidemic is for those who suffer, or the impact on their families, or the impact on health and social care services. I am confident that real advances have been made and will continue to be made. I assure noble Lords that the Government are absolutely determined to support the development of good services.