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Health: Musculoskeletal Disorders

Volume 697: debated on Thursday 17 January 2008

rose to call attention to the Work Foundation report Fit for Work? Musculoskeletal Disorders and Labour Market Participation and the case for a concerted approach to reduce the social, economic and work impact of musculoskeletal disorders; and to move for Papers.

The noble Lord said: My Lords, I am pleased to have secured this debate today and I welcome those noble Lords who have come to speak about the issues raised in the Work Foundation report, Fit for Work? Musculoskeletal Disorders and Labour Market Participation. This report, published last September with the support of a grant from Abbott Laboratories, highlights a topic of great importance and one of serious concern to many millions of people in this country. I say millions advisedly. More than 2.5 million people in the UK visit their GP with back pain each year. At any one time, a third of the population is suffering with back problems, and it is estimated that up to 80 per cent of the adult population will suffer significant back pain at some time in their life. What is more, in the vast majority of cases there will be no specific diagnosis. Those who have suffered from back pain know how debilitating it can be. It affects mobility, it affects agility, and the strains produced diminish stamina. The pain affects concentration, the ability to think and rationality, and it necessarily affects the sufferer’s mood. It may make them irritable and can lead to severe depression.

There has been much debate about the impact of mental health conditions and the associated stigma and difficulties that can lead to people losing their jobs. Amid the concern about the psychological well-being of the UK workforce, those with physical problems have often seemed to have received less attention. The number of working days lost to psychological problems or stress is, of course, high. However, as the Work Foundation report points out, almost twice as many workers are affected by musculoskeletal disorders such as back pain, arm or neck strains, or diseases of the joints. Back pain and similar problems affected over 1 million people in 2005-06 and, according to the Health and Safety Executive, were responsible for 9.5 million lost working days, at a cost to society, in 2007 prices, of over £7 billion.

What happens when these people visit their GPs with a complaint? All too often, out of compassion and concern for their patient, the GP will issue a sick note advising that they take time off work. They may be advised to stay at home for weeks or months while they wait for tests and then treatments to make them feel well again. For those of us who fall ill with flu or minor infections and spend a week in bed, this probably sounds like common sense. However, for many people with long-term acute conditions, it may not always be the right approach. As the report says:

“Work can be both cause and cure”.

The physical conditions of work may indeed have caused or aggravated a musculoskeletal condition but, equally, prolonged inactivity may well make the condition worse. Moreover, absence from the work environment and the associated isolation may worsen the depression associated with the pain and make recovery less likely. Certainly, many GPs and employers mistakenly believe that sufferers from musculoskeletal disorders must be 100 per cent well before any return to work can be contemplated.

Some employer surveys suggest that back pain and other musculoskeletal problems account for as much as two-thirds of long-term sickness absence. The Department of Health estimates that almost a quarter of the more than 2.6 million people of working age claiming incapacity benefit suffer from these problems. Surveys of people affected suggest that thousands of people in this country want to work and think that they are capable of work but are instead stranded on incapacity benefit. One survey undertaken by the National Rheumatoid Arthritis Society, aptly titled the I Want to Work survey, tells how people with rheumatoid arthritis desperately want to keep working but encounter a raft of barriers. The most commonly cited barriers are the inability to get fast access to their rheumatologist and the attitude taken by employers once they learn that an employee has a diagnosis of rheumatoid arthritis. Nearly 400,000 people in the UK have rheumatoid arthritis and 12,000 new cases are reported each year. Unlike other forms of arthritis, rheumatoid arthritis affects people of all ages, hitting people in their 20s or 30s at the early stages of their careers. Almost a quarter of those with the disease stop working within five years of the diagnosis, at a cost to the taxpayer of £89 million a year.

With an ageing population comes the increasing prevalence of a host of chronic conditions and an increasing number of people who do not want to be written off. They want to be independent and economically active. We have to address the barriers to their participating in the labour force if we are to have a sustainable future economy. The Work Foundation report considers the interrelationship between improving health outcomes and improving work outcomes. It suggests that perhaps if employers were more educated about their employees’ conditions and flexible over adapting tasks, and if the NHS was better geared towards helping people stay in work, we could both reduce public spending and better support people with musculoskeletal conditions who want to work but find it impossibly difficult.

The report suggests that changes in the attitudes of both healthcare professionals and employers are needed to help people with MSDs to stay in work. Not only does each need to think in terms of how to support people in their jobs; they also need to think about how to collaborate better. GPs, rheumatologists, nurses and employers should talk to each other about the support that their patients or employees need and how to work round the illness, rather than letting the illness itself dominate.

Some employers, of course, are enlightened. I am an adviser to the board of Transport for London. TfL and its predecessors have long had extremely progressive policies on staff welfare—that is, despite what you may have heard from the RMT trade union. Its occupational health service has undertaken a programme to address back pain. There has been an in-house physiotherapy service for lower back pain since 2001. Attractive educational materials including a CD-ROM with amusing video clips and job-dependent exercises for staff were developed and widely distributed in 2005-06. They are now provided internally in some types of training. A back exercise class was introduced to augment one-to-one physiotherapy for back pain and is focused on maintaining and improving back fitness and flexibility.

A two-hour class in pain physiology is an entry requirement into this exercise class and employees learn complex concepts about it with remarkable ease. Each exercise class includes some educational content and the employee who attends all 10 classes will learn about anatomy, soft-tissue healing, how to stand, how to lift, how to adjust your chair and so on. The classes are run three times a week at different times to allow employees to attend without interfering with their shifts. Employees are encouraged to continue to attend once their back pain has been relieved, if they would like to, in order to keep up the level of back fitness that they have achieved. One big change in approach is the relatively new expectation that employees attend such classes in their own time if they are not off sick. TfL is moving from a paternalistic approach to a partnership approach with employees. The responsibility for an individual's health remains with that individual and all the work of the occupational health team supports that basic reality. Further work has been undertaken to develop a lower-limb exercise class, primarily for those with knee or ankle problems. This was introduced in 2007 and has proved enormously popular. Evaluation of the impact of this class will begin soon.

The analysis that has been done so far on the effectiveness of these TfL services, in particular the ones on lower back pain, is relevant to today's debate: A pilot study carried out in 2001 demonstrated that employees who received physiotherapy intervention returned to work 12.6 days sooner than would be predicted using historical data when employees did not have access to a physiotherapy service. A more recent study, in 2003-04, found that employees who were referred to the back pain service after more than six weeks’ absence had twice the length of absence of those referred within six weeks and four times the length of absence of those referred within two weeks. Thus early referral for physiotherapy can be seen to have significantly reduced further time off. Sitting at home waiting for the problem to resolve just prolonged the amount of time that people took off work. Moreover only 13 per cent of employees referred to the lower back pain service in September to December 2005 for first-episode lower back pain had a recurrent episode leading to absence during the following year; and only 23 per cent of employees with a previous history of lower back pain had a recurrent episode leading to absence during the following year. This compares favourably with recurrence rates of 26 to 37 per cent reported in research. This confirms so many of the conclusions of the Work Foundation report.

Let me just say a few further words about the importance of early intervention. It is now widely acknowledged that early intervention is essential to support people with musculoskeletal diseases to continue with their jobs. For many, as the TfL work has shown, fast access to physiotherapy can make a huge difference, while early access to drug therapies for those with progressive illnesses such as rheumatoid arthritis can slow or even halt the progression of their condition. Delay in getting the right diagnosis or treatment therefore increases the probability of the person losing their job or prolonging their absence from work.

The Government recognise that in their Health, Work and Well-being Strategy, and we have the welcome appointment of Dame Carol Black as national clinical director for health and work. But the aspiration of an NHS geared to support people in work and flexible working for those who need it is far from the reality. The Fit for Work? report tells us of long waiting times for care, certain employers’ lack of capacity to deal with sickness, lack of employee awareness about conditions and their management, and mixed messages on the effectiveness of various methods of workplace interventions or return-to-work programmes, all of which are barriers to making good and healthy work a reality for those suffering from MSDs. It goes on to advise that:

“Early action, preferably in partnership between GPs, the patient and their employer, can help achieve a balance between the individual’s need for respite and their need to work.

As many of these conditions cause a decline in functional capabilities over time, early detection and the targeted treatment of specific diseases such as rheumatoid arthritis are crucial in enabling a patient to manage their condition and improve their quality of life. It is clearly essential that this message permeates through the NHS and I look forward to hearing from my noble friend the Minister about what steps are being taken to make sure that this happens.

Of course, bringing savings to the budget of the Department for Work and Pensions is not something that the Department of Health is formally tasked with bringing about, but joint working on this issue is essential. The Work Foundation report makes 27 recommendations in all, some aimed at employers, some at employees, and others for GPs and other occupational health professionals. It is not possible to go through all of those in my remaining time but I would like to highlight one that is specifically targeted at the Government, and again I wait with interest to hear my noble friend’s response to the point. It concerns changes to the National Institute for Health and Clinical Excellence. The Work Foundation makes a strong case for a change to the statutory instruments governing NICE to allow the institute to take appropriate account of the benefits of full and active labour market participation when assessing the cost-effectiveness of treatments. This recommendation could not be more timely. Last week’s Health Select Committee report on NICE recommended that wider benefits and costs, such as the costs borne by carers and social care services, be more fully incorporated into NICE’s assessments. Surely work costs and benefits should also be considered when NICE issues guidance and advice to the NHS.

As noble Lords will know, NICE evaluations of treatment currently concentrate only on assessing the clinical costs and benefits—that is, those borne by the NHS. It is currently beyond NICE’s statutory remit to consider the wider consequences of keeping more employees in the labour market, so the recommendation is not critical of the institute, which indeed conducts a range of important and helpful work, but rather suggests that its terms of reference and working methods need to be updated. If the Treasury was able to consider the fuller economic impact of MSDs, it might be more inclined to support further joint working and partnership between the Department of Health and the Department for Work and Pensions to train and motivate the professionals working in these spheres.

The Department of Health already acknowledges in its Musculoskeletal Services Framework issued in July 2006 that the year-on-year costs of anti-TNF drugs which are used to treat rheumatoid arthritis, ankylosing spondylitis and other MSDs are likely to be offset by keeping patients with rheumatoid arthritis at work and reducing the need for them to claim incapacity benefit. Indeed, it was the Prevention of Work Disability Study commissioned by Abbott and presented to the American College of Rheumatology in November 2006, which showed how anti-TNFs can help to keep people in work, that gave rise to the report we are discussing today. However, these costs and benefits are not taken into account by NICE. As the report points out:

“Economically efficient guidance on drug therapies may protect the NHS budget, but can put extra strain on [the budget] of the DWP”.

Since NHS policy and practice can impact on a patient’s ability to return to or remain in work, health policy makers need increasingly to take into account the broader work-related benefits of treatments as well as their more traditional clinical benefits. Employers need to engage with the NHS and avoid adopting a risk-management approach of easing people out of their jobs just because they have a long-term health condition. With the right support, thousands more can thrive in the workplace, contribute to society and enjoy the benefits of work.

This is, of course, a plea for that clichéd holy grail: joined-up policy making. Like any grail quest, there are many obstacles in the way, but the natural overlap in the issues we are discussing today between the policy areas of health and work offers the potential for success. Some 2.5 million sufferers, at an annual cost to society of £7 billion, are reason enough for overcoming the obstacles. I hope that this short debate will send a powerful message to my right honourable friends the Chancellor of the Exchequer and the Secretaries of State of Health and for Work and Pensions to sort these problems out, so that we invest to save—invest in the health of those 2.5 million sufferers so as to save on the costs of maintaining them on incapacity benefit. That is already, in principle at least, government policy. I call on my right honourable friends to support patients with back pain and other musculoskeletal disorders to enable them to continue in the workplace—a greater priority as they look to tackle public finances. I beg to move for Papers.

My Lords, the noble Lord, Lord Harris of Haringey, has done the House a great service in bringing this matter before us today. His spirited and detailed speech means that we do not need to go into much detail. Almost everything in the report has been covered in one way or another. I must say that I found his account of the situation and his ability to express the interrelationship between the various points made in the report and the recommendations to the Government particularly interesting.

I was drawn to making a brief contribution to today’s debate because, ever since working for the National Economic Development Office in the 1970s, I have been interested in matters which affect employment and management. This was partly because I could see a connection with the EU Select Committee report on the effect of mental ill health and stress on employment, and because this report covers certain matters which affect women in a particular way. As the noble Lord has explained, the thesis of the report is straightforward. The incidence of musculoskeletal disorders within the workforce is large and increasing, imposing severe costs in terms of lost output, treatment costs, the non-earning of pensions, on businesses, the NHS, affected individuals and the economy in general. Indeed, the report maintains that these conditions are now more common and impose greater costs than does mental illness, which we considered in the EU report.

The report suggests that the way this problem is tackled by employers, doctors and to some extent by sufferers themselves is not as effective as it could be, with the result that some employees are either persuaded to, or feel they must, leave employment altogether. Not only does this mean that they have no resources on which to live during their working years, they also do not earn themselves a pension. The effect on employees’ personal well-being in later life and the costs to the state of supporting people who have not earned a pension are likely to grow in parallel with the growth in the percentage of the population that is over the age of 65, like quite a few of us in your Lordships’ House.

The report considers a number of ways of improving the response of doctors, employees and employers to the problems of joint pains, back-ache and other more serious disorders such as rheumatoid arthritis and makes two interesting points in this context. First, that the advice of doctors that sufferers should take time off work is not always helpful, and secondly, that the tendency of employers to persuade employees to leave their employment compounds the problem. The report also points out that:

“Work is, unambiguously, good for our health”.

Unfortunately, it seems that once affected workers have left their job for any length of time they may, as a result of a combination of circumstances, never return to work again. The report suggests a number of ways of tackling these problems and I look forward to the Minister’s responses to the points put to her by the noble Lord in his opening speech.

I would particularly like to ask the Minister about the kind of help that should be given to small and medium-sized enterprises in tackling the interrelated problems of modifying working conditions so as to enable workers to continue in work, and thus avoid the cost of recruiting and training new employees, while at the same time maintaining output. Such companies are likely to feel themselves overburdened by regulation and paperwork—a cry of pain frequently heard while I chaired Sub-Committee G. Would the Minister consider a scheme that would bring the managers of SMEs together at the local level, possibly through chambers of commerce, for training and the exchange of effective information, including health advice, about what actually works in practice? The learning process might be started at that level with greater ease than in other ways.

A particular concern highlighted by the report is the double burden carried by women who are caring for children and/or elderly relatives as well as working. As the number of women in the workforce increases, women are particularly likely to be exposed to the risk factors associated with the conflict between work and care roles. Does the Minister consider that employers are sufficiently alert to the damage that can be done to women, as to men, by very repetitious work—for example, at the keyboard—to which they are often assigned? If so, would better training and informing of managers help to improve the situation?

Women are already less likely to earn a full pension than are men because of the demands of family life, although the new pensions provisions may improve that situation. Can the Minister tell the House if this new provision is likely to assist women to have a better chance of continuous long-term employment and the security in old age that goes with it?

I look forward to hearing the remainder of the debate. The report is very interesting and apposite, but the benefits of its insights into the interaction of musculoskeletal disorders and the well-being of workers, businesses and the economy at large will not have their due effect unless the Government take steps to put at least some of the recommendations within it into effect. I look forward to the Minister’s response.

My Lords, I thank the noble Lord, Lord Harris of Haringey, for introducing the debate on the impact of musculoskeletal disorders. This subject needs bringing to the notice of many people in the hope that improvements will be made in the many parts of the country which are not giving priority to the treatment and rehabilitation of long-term conditions such as the ones we are discussing today.

For many years this has been the case. When I was a member on the Regional Health Authority of Yorkshire, I used to look down the agenda for the next 10 years and find that physical disability was not even mentioned. I should like to go back into history for a moment. Years ago, when I came to live in Yorkshire after I got married and I was campaigning for better facilities for disabled people, I was contacted by a young woman from Bradford who had rheumatoid arthritis. This was my first introduction to RA. I went to visit Theresa in Bradford. She was living in a tiny, one-room bed-sit in a terraced house, with the kitchen in a cupboard and, I suppose, the lavatory in another cupboard. She shared this cramped room with her elderly mother. This disabled young woman used a wheelchair; there were a few steps to enter the room. She had difficulty in eating because of a stiff jaw—she had a similar problem with the rest of her body. Even with all these difficulties, her spirit was wonderful.

A little time after my visit, Theresa contacted me to say that her mother had had a stroke in the early hours of the morning and had fallen half out of bed. Theresa could do nothing until the paperboy passed her window at about 7 am. She attracted his attention by knocking on the window with her long-handled fork, which she used for eating. He went to get her sister, who lived in the same street a few houses down. It is this which made me think that there should be better treatment and facilities for such cases and which made me move an amendment to the Chronically Sick and Disabled Persons Act 1970 that disabled people at risk should have a telephone and be able to make contact to get help.

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

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

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

“As each year goes by the resources seem to be cut in the NHS. I’ve never known it to affect me so directly from the prescribing of new drugs to having insoles put in my shoes”.

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

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

“To ask the Secretary of State for Health what support is available to employers to ensure patients with musculoskeletal disorders access early diagnosis and treatment to remain in work”.

Ann Keen replied,

“We are not aware of any support available to employers to ensure patients with musculoskeletal disorders have access to early diagnosis and treatment to remain in work”.—[Official Report, Commons, 14/1/08; col. 1027W.]

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

On page 16 the report asks,

“How well do GPs and occupational health professionals understand and deal with MSDs as they relate to the workplace? How well equipped is the NHS to provide early intervention, rehabilitation and other support for people with these conditions?”.

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

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

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

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

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

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

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

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

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

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

Our patient outcomes are really dramatic; I am very proud of them. Average patient scores for anxiety and depression almost halve. Patients’ quality of life scores more than double, while their scores on functioning—and their self-satisfaction scores with it—improve dramatically. Scores are trebled and are being maintained at a six months’ follow-up after the programme.

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

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

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

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

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

However, there is limited understanding of the model among patients, GPs and employers, who often find it difficult to look beyond immediate overwhelming physical symptoms. The Department of Health’s musculoskeletal services framework makes only passing reference to rehabilitation and back-to-work vocational reintegration, which is unfortunate, as the pain management model helps us to understand what is happening to people with musculoskeletal disorders and how and why they drop through the net.

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

“in time MSDs will become less relevant to work and working life”.

However, she went on to say:

“Until then, efforts to raise awareness of these disorders must continue with ever greater urgency”.

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

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

“help the individual to find strategies to manage their own condition, which will enable them to make their own decisions about their working arrangements”.

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

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

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

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

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

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

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

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

However, trying to punch holes in Chinese walls within Whitehall is something with which, in the time that I have been here, every Government has had a challenge. Trying to save the initial investment to go somewhere else is always a challenge to Whitehall. It is not just this Government. They have had their successes and failures. I wish them well on this, but trying to get people to co-ordinate still too often depends on a couple of Ministers recognising the problem and being prepared to work together. If there is that sort of co-ordination at the top, something can then be done—but it still relies on that. You need institutional structures to disseminate information downward to people who may not be used to reading forms or publications to discover about their condition; GPs need to relate this condition to people who go to them and trade unions need to make sure that they know about the condition, and so on. Information needs disseminating so that people can act early enough to stop the chronic situation; that is what is at the heart of this. If this report inspires the Government to start acting in this way, they will have achieved a great deal.

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

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

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

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

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

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

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

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

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

In terms of the burden on the NHS, musculoskeletal conditions represent the sixth-largest area of expenditure, at over £3.3 billion, accounting for about 30 per cent of patients who visit their GPs. That statistic alone, which has already been mentioned, makes the absence of musculoskeletal conditions from the quality and outcomes framework really quite astonishing. If they were included, it is certain that we would have a lot more data about the outcomes than we currently do. Would the Minister consider such an inclusion?

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

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

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

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

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

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

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

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

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

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

I would also ask the Minister to take steps to alert the Healthcare Commission and strategic health authorities about the need for the NHS to implement NICE guidance on arthritis and related conditions, which the evidence shows has not been properly taken up. Inevitably in all such debates there has been criticism about mistakes and deficiencies. We all make mistakes, so I would like to make a constructive suggestion which I mentioned during Question Time yesterday. Clinicians throughout the country meet regularly once a week or so to discuss all the mistakes that they have made.

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

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

Musculoskeletal conditions can be associated with a number of employment-related difficulties, including unemployment, absenteeism and reduced productivity in the workplace, or so-called presenteeism. Yet we know that work can be good for people with musculoskeletal problems, in terms of both their physical and psychological health and well-being, and as part of the rehabilitation process, as mentioned by many noble Lords. Work brings dignity and a sense of purpose. It has an impact not only on the individual but on their family and sometimes the wider community. Of course, for some, work may no longer be a practical option as serious and debilitating conditions worsen. However, for the majority, better and earlier treatment holds the key to reducing the impact of musculoskeletal conditions on an individual’s ability to work. That need for early intervention, with effective partnerships between patients, employers, GPs and specialists, is a key theme of the Fit for Work? report. My noble friend rightly said that organisations were still a long way from that reality, but we are truly working across government to try to break down the barriers both in Whitehall and at local level.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The DWP is also developing a range of tools to provide practical support for GPs and other healthcare professionals. For example, it has produced an online learning module for GPs about handling difficult consultations with patients on the subject of a return to work. This programme of work builds on ground-breaking independent research, commissioned by the DWP and published in September 2006, showing for the first time that work truly is generally good for health and well-being. In some areas, GPs and Jobcentre Plus are working together closely on the ground, and Jobcentre Plus representatives are working in health centres, which is excellent.

The noble Baroness, Lady Finlay, spoke about the management of chronic pain. I have visited her excellent clinic in Wales; it is not just a small clinic but a centre of excellence. The model that she cited is clearly best practice which should be further disseminated.

The noble Lord, Lord McColl, mentioned the QOF. GPs are, of course, at the forefront of managing musculoskeletal conditions. Work in other clinical areas, such as coronary heart disease, asthma and diabetes, has shown that both the level and quality of care for these conditions in primary care can be greatly improved by inclusion in the quality and outcomes framework. I know that many noble Lords see the inclusion of musculoskeletal conditions, such as osteoporosis, within the QOF as key to improving services.

The Department of Health is committed to developing new clinical areas within the quality and outcomes framework. Indeed, we have found it frustrating that the negotiating process has not succeeded in delivering the continuous quality improvements that we see as a fundamental feature of the QOF. That is one reason why my noble friend Lord Darzi signalled in his interim report that we intended to take a more wide-ranging look at how to reshape incentives for quality and outcomes in primary medical care.

The activity that I have mentioned is now starting to bear fruit and we are seeing a real and positive shift in the way that healthcare professionals consider employment. Perhaps I may give one example. Dame Carol Black has met more than 30 of the main medical colleges and health professional bodies to agree a ground-breaking consensus statement on health and work. However, it is clear that we need a real change in attitude if we are to help more people of working age to find and stay in work, regardless of health conditions. As is said in the report, Fit for Work? Musculoskeletal Disorders and Labour Market Participation, we need to be more positive, focusing on what people can do and not on what they cannot do.

To support this change in culture, the DWP is also currently revising the format and content of the statutory medical certificate, moving towards more of a “fit note” system than a “sick note” one. The department is working with employers, employees, healthcare professionals and their representative bodies to produce a certificate that will assist and encourage doctors to provide clearer and more helpful fitness-for-work advice for their patients. The revised certificate will also provide employers with the information needed to help to facilitate an employee’s earlier return to work wherever possible.

Alongside that, the DWP has been working to ensure that the welfare system supports people with health conditions to move back to work, rather than condemning them to a lifetime on benefits. Incapacity benefits are being replaced from October this year with a new employment and support allowance. The new allowance will have a revised medical assessment—the work capability assessment—which will be much more positive than its predecessor. It will consider what customers can do, as well as what they cannot. It will also consider the customers’ perceptions of their illnesses and the barriers that they create, as well as assessing the health interventions that would help to improve capability and the chances of a return to work. Comprehensive support will be made available to benefit recipients through the very successful Pathways to Work programme, which will be available across the country from April this year. Pathways support can include access to the ground-breaking condition management programmes, which help people to manage their conditions and return to work.

All that demonstrates just how much progress we have made, but of course there is more to do. That is why my right honourable friends Alan Johnson and Peter Hain asked Dame Carol Black to carry out a review of the health of working-aged people. The review, which is due to report shortly, will contain recommendations for government and should help to shape the agenda over the coming years. In particular, Dame Carol is likely to focus on ways to expand access to occupational health and early interventions, provide more support for employers, move to a more positive “fit note not sick note” culture, and improve links between GPs and employers—all the things that noble Lords have today rightly asked for.

In conclusion, we welcome this debate and firmly support my noble friend and others in their efforts to raise awareness of this critical issue. From my experience of working in the south Wales valleys with an MP and his constituents, I am well aware of the impact of musculoskeletal diseases on the lives of individuals, their families and communities. But that was 20 years ago, and there was not such great understanding then of the link between work and well-being. Work was seen as being for the fit and healthy—the wholly well. I am glad that attitudes have changed and continue to change and that work these days is much more flexible. The Government have recognised the importance of the issues raised and are taking steps to address them. Debates such as this will, I trust, not only act as a catalyst for further action by all partners involved, but in some way contribute to a much needed change in the culture.

My Lords, I am obviously enormously grateful to all noble Lords who have contributed to the debate. I should like to think that the importance attached to the issue is reflected by the substantial number of Members of your Lordships’ House who are present at 4.15 on a Thursday, but I fear that it may be rather more to do with the noble Lord, Lord Steel, than anything that was said during the past hour and a half or so. Nevertheless, many noble Lords who may have caught the last few minutes of this discussion will understand the salience of these issues, because of the prevalence of back pain and the importance of trying to bring together the work of different government departments. As the noble Lord, Lord Rea, said to me as he moved from one part of the Chamber to another earlier, this is all about joint working.

I was especially grateful to hear the vivid examples given to us by the noble Baroness, Lady Masham of Ilton, and about the importance of pain management, which the noble Baroness, Lady Finlay of Llandaff, raised. I was also grateful to the noble Baroness, Lady Thomas of Walliswood, for highlighting the issue of rising pension costs, which I do not think that we returned to during the subsequent discussion, and the position of SMEs.

I am obviously grateful to my noble friend Lady Royall for her response. Earlier, the noble Lord, Lord Addington, talked about the difficulty of punching holes in Chinese walls within government. The noble Lord, Lord McColl of Dulwich, apart from his chilling example of Mrs Thatcher—now the noble Baroness, Lady Thatcher—straightening out a senior civil servant, about which we might all have liked to have heard more detail, stressed the importance of having senior ministerial championing of the issue. It is very nice to see my noble friend Lord Hunt of Kings Heath in his place—I know that that is for another purpose—because in his previous roles in both the Department of Health and the Department for Work and Pensions, he was very keen to pursue this agenda.

I hope that my noble friend Lady Royall will take away from this—and will discuss with the senior colleagues she mentioned—that, in responding to the Carol Black review, this is not a zero-sum game. Resources can be moved. This is not just looking at the amount that the health service spends on drug and other treatment. This is about looking at the best way of using government resources to improve the health and well-being of this country. I hope that there will be a senior ministerial champion for following this agenda.

I am grateful to all noble Lords for participating in this debate, and I beg leave to withdraw the Motion for Papers.

Motion for Papers, by leave, withdrawn.