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Musculoskeletal Diseases

Volume 530: debated on Monday 4 July 2011

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

The genesis of this debate was four reports into musculoskeletal disorders from about two years ago. The first was from the National Audit Office, one was the King’s college report, there was another from the umbrella organisation, the Arthritis and Musculoskeletal Alliance, and the final one was the clinical advice from the National Institute for Health and Clinical Excellence. Those four reports led to an excellent debate in Westminster Hall on 19 January 2010 at column 1WH of the Official Report. I advise the Minister to take a look at that hour and a half debate in which many more points were made than—[Interruption.]

Order. I apologise for interrupting. There are Members behind the Chair making a frightful racket and it should not happen. They should leave the Chamber and show some courtesy to the Member who is developing his speech. I apologise to the hon. Gentleman who should now resume.

Thank you, Mr Speaker.

Many more points were made in that debate than it is possible to make in a half hour debate in this Chamber. What the then Government were essentially being asked was to take action to ensure better clinical outcomes for the money being spent on musculoskeletal disorders. The real ask from the community was for a clinical director or so-called tsar. In a sense, however, the most important ask is not that, but that there is an outcome strategy that improves the outcome for people suffering from musculoskeletal disorders. In many ways, in spite of those four reports and the debates that have taken place since, the situation nationally remains much the same. The statistics are worth going through in some detail. The amount of money spent on musculoskeletal disorders is large—£4.76 billion, which is the fourth-largest category spend within the NHS. That money is spent on 25% of the population as one in four people have a musculoskeletal disorder. That is 9.6 million adults and 12,000 children. Many people think that arthritis and rheumatism affect only older people, but that is not true. They can affect people of any age, as is perfectly illustrated by the fact that 12,000 children suffer from it. In terms of costs, the magnitude of the issue is that one visit in every four to a general practitioner concerns musculoskeletal disorders and 10.8 million working days are lost because of such disorders.

Those are the statistics. The problem is that there is no equality of outcome and no sense that when money is put into the system outcomes improve. About two years ago, partly in response to the reports, the previous Government put £600 million more into the system, but there was no noticeable improvement in outcomes. The NHS atlas of variation shows a threefold difference in spending in different parts of the country, but it does not relate to differences in incidence, prevalence or severity of the problem; nor does it necessarily relate to better outcomes. Although there is a threefold difference generally, the difference for rheumatoid arthritis is five times, for hip replacements 14 times, cemented hips 16 times and for uncemented hips it is 30 times. Clearly something unusual is happening in that area of the service and it requires examination.

Quite simply, current services do not ensure swift treatment of arthritis, which in many cases is vital. I shall give an example from one category of disorder: rheumatoid arthritis. People think it is the same as any other arthritis but it is not; it is an auto-immune disease and few people suffer from it. Many GPs see only one new case every year or so, which is surprising but true. Because GPs do not see such cases regularly, patients often have to visit their GP about three times before they receive treatment, but early treatment is vital. The time before treatment means not only pain but also that the rheumatoid arthritis is not cured. Since a third generation of drugs—the biologics—has been developed, the disease is curable in a large number of cases if treatment is given quickly enough. Even if the disease is not curable, what matters is getting the patient to a multidisciplinary team of physiotherapists, consultant surgeons, doctors and community nurses as quickly as possible.

My hon. Friend is setting out his stall powerfully. It is a difficult subject. Does he agree that early intervention is good not only for the patient, because they can recover faster or get to grips with the condition, but also for the economy, because the person is more likely to be able to continue active employment, and for the health service because early intervention is likely to cost less in the longer term?

Precisely. I mentioned the total number of lost days. In the vast majority of cases of rheumatoid arthritis, people stop working two years after diagnosis, but if diagnosis and treatment are earlier it is most likely that even if the person is not cured they could continue working for longer.

The Arthritis and Musculoskeletal Alliance—ARMA—is calling for a number of things, but before I put its case I note the following points. The fact that there are unsatisfactory differences in inputs and outcomes is not completely an accident. By and large, the services have not had the attention they deserve. I am not making a party political point; the situation has been going on for a number of years and unfortunately it continues. The quality and outcomes framework contains no indicator for musculoskeletal conditions. Why not? The musculoskeletal services framework of 2006 lacked leadership and was largely ignored by the centre in the NHS, GP training in musculoskeletal conditions remains poor, despite the evidence I have just given about the importance of GPs recognising precisely what form of musculoskeletal disorder a patient has, and only two of the NICE policy standards announced so far relate to musculoskeletal conditions—for hip fractures and osteoarthritis—out of the vast range of some 200 conditions covered by this generic term.

ARMA is calling for an outcomes strategy as a vital first step in addressing the current failures in provision of treatment and care for people with these disorders. What would that strategy look like? It would cover a number of areas, including outcomes, demonstrating how high-quality musculoskeletal services can deliver improvements in the outcomes measured in the NHS outcomes framework, particularly gaining independence and returning to work, as my hon. Friend the Member for Scunthorpe (Nic Dakin) pointed out.

The useful slogan, “no decision about me without me”, should also be a guiding factor, enabling patient involvement and shared decision making at all points in the patient pathway and, in particular, encouraging better self-management and at the same time improving general public awareness of musculoskeletal conditions. The information revolution is also relevant for setting out and making public the key sources of data on the performance of and expenditure on musculoskeletal services and improving our understanding of outcomes beyond hip and knee replacements, which account for only 20% of expenditure. There must be co-ordinated service delivery, joining up delivery across the NHS and social care services. Commissioning should describe the measures of success that will be used to assess clinical commissioning groups and set out the support that will be provided to commissioners. Training for GPs in musculoskeletal medicine is also important. We must enhance the currently small component in training to support GPs in providing effective and timely treatment and care to patients, as well as informing their commissioning decisions.

ARMA’s request of 18 months ago for a direct musculoskeletal service was reasonable. Even if there is to be no service director, ARMA’s requests are quite reasonable, because surely the Minister cannot be satisfied with how services are being delivered across the country, with different inputs and massively different outputs.

I finish by quoting Professor Emery of Leeds university. He was talking about rheumatoid arthritis, but this applies to any of these conditions. He said that it is the “most common treatable disability”. Essentially, it is not treated as well as it should be and the disability could be removed. I look forward to the Minister’s response, and hopefully he will respond positively to what should be a reasonable way forward.

I congratulate the hon. Member for Blackley and Broughton (Graham Stringer) on securing the debate and bringing to the House’s attention an important issue. He has rehearsed the statistics, but behind them are people with real lives, in some cases suffering in agony and having difficulty getting on with their lives as a consequence of musculoskeletal disease.

Let me make it clear from the outset that the Government fully recognise the impact that musculoskeletal disease has on individuals and society as a whole and that, although there are excellent services in some parts of the country, there is still far too much variation in the availability of services and the outcomes they secure for people. This debate is about how we will respond to that evidence and to the concerns that the hon. Gentleman has brought to the House tonight, and about how we will deliver the change on the ground that we all want to see as constituency Members.

The hon. Gentleman argued for a national outcomes strategy on musculoskeletal conditions. He made some important points and I will try to address directly some of the concerns that sit behind them. The 34 organisations in the Arthritis and Musculoskeletal Alliance, which he has spoken on behalf of this evening, make some important points. They have been in discussions with the Department of Health about their concerns over how we will ensure that the differences between services around the country are addressed so that people get access to the right services at the right time.

On 19 April, officials wrote back to the alliance to confirm that we would

“ask the National Quality Board to look at this area as a potential topic for a national outcomes strategy”.

By that, we mean that it will consider whether there are problems in our approach to these conditions that go wider than the NHS. It is important to understand that an outcomes strategy produced by the Department of Health looks out from the NHS to wider impacts on health and considers how those might be influenced to improve health outcomes for people. It will also look at what needs to be done about efforts that are already in hand, to ensure that the NHS is more responsive to patients’ needs and that there is an uptake of good clinical practice.

I do not believe that the case has been fully made for such an outcomes strategy, and I want to explain to the hon. Gentleman, and through him to members of the alliance, why that is. A number of steps have been taken in the past 12 months that have moved us on significantly from the debate that the hon. Gentleman spoke about at the beginning of his remarks. I understand that the National Quality Board will consider its future work programme at its meeting this month. It will decide whether it is appropriate to commission the necessary work to look at the case for a Department-led outcomes strategy. I assure the hon. Gentleman that I will ensure that not only this debate but the debate that took place in 2010 are cited by the members of that board.

I will spend a little time describing what is happening now. The hon. Gentleman referred to the musculoskeletal framework that the Department published in 2006. He spoke about the impact of that strategy, and I will say more about that in a moment. The document was developed in collaboration with a wide range of patient and professional organisations. It set out a vision for services based on the concept of an integrated care pathway—exactly the sort of pathway that the hon. Gentleman talked about. The clear aim was to help the NHS to organise services so that patients could access a variety of primary and secondary care services according to their need, including physiotherapy, clinical psychology, specialist rheumatology and surgery, and have a seamless transition from one service to another.

The model proposed depended on the idea of a multidisciplinary clinical assessment and treatment service, or CATS, for musculoskeletal services. That would bring together clinicians from primary and secondary care, assess patients’ needs, treat them locally where possible, and where necessary refer them on for specialist hospital care. The document recognised that different health communities would implement the framework in different ways, and that it should be possible in some circumstances to offer patients a choice of pathways.

Three years after the publication of that document, in spring 2009, the British Institute of Musculoskeletal Medicine held a symposium to review progress in implementing the framework. Today’s debate echoes the frustration that was felt there. Although the symposium found that a number of excellent services had been developed, incorporating the vision of services integrated around the needs of patients, which this Government strongly endorse, interestingly it also found that those services were very different from one another. Some were still based in hospitals, some were in the community. Some were a see-and-treat type of service, but others had triage-based systems to refer people on to the most appropriate service. However, as the hon. Gentleman identified, there was still a patchiness to the provision.

The hon. Gentleman touched on the need to integrate services, which the Government are determined to drive forward in order to deliver better results for patients. We need to do that at the same time as acknowledging that people want to be able to exercise the maximum possible control and choice over their treatment. We set out our course clearly last year in the White Paper on the NHS, and just recently in the response to the NHS Future Forum we made it clear that we would be placing explicit duties on clinical commissioning groups to promote integrated services for patients. We will also further strengthen existing duties planned for the NHS commissioning board. We will amend the proposed duty of Monitor to make it clear that its core duty is to promote and protect the interests of patients, rather than to promote competition as an end in itself.

We intend those amendments, taken together, to create a strong incentive for local commissioners to take forward more integrated services, which I think all of us in the House wish to see delivered for people with musculoskeletal disorders and other patients. However, we have to go beyond just health integration and ensure that we achieve integration across health and social care. The hon. Gentleman was right about the concept of “no decision about me, without me”. We need to ensure that it is hard-wired into the way the NHS works.

The Minister has spelled out the Government’s position carefully. Will they publish a response to the Public Accounts Committee’s report, which responded to the National Audit Office, in taking forward the matter of musculoskeletal disease?

As ever, there is a clear obligation on us to respond to reports and recommendations of the Public Accounts Committee, which we happily fulfil. I am sure that we will do that if we have not already done so, and I am grateful to the hon. Gentleman for asking.

I turn to the specific issue of outcomes. The Government believe that a focus on outcomes is key to how we can drive improvements in the NHS. It is also how we can hold the NHS to account. That was why we published the NHS outcomes framework, to which the hon. Member for Blackley and Broughton referred, in January. It has five key domains that are populated by measures that will be used to judge outcomes. They are preventing people from dying prematurely; enhancing quality of life for people with long-term conditions; helping people to recover from episodes of ill health or following injury; ensuring that people have a positive experience of care; and treating and caring for people in a safe environment and protecting them from avoidable harm.

The second domain, improving the quality of life of people with long-term conditions, is clearly the most relevant to the debate. It includes an instrument known as EQ-5D, which is to measure people’s quality of life in a number of respects including mobility, pain and the ability to carry out the usual activities of daily living. The inclusion of that measure was the result of feedback from the public consultations last year on the outcomes framework. It is clear from the analysis done by the Department’s economists that almost half the total burden of disease, as measured by that instrument, is due to musculoskeletal disease.

In other words, the inclusion of that instrument in the NHS outcomes framework highlights clearly the importance of musculoskeletal conditions to the population, and why commissioners and clinicians need to focus their efforts on designing and delivering care pathways of the type outlined in the framework in 2006. It shows how that can have a significant impact on the aggregate score in the outcomes framework on enhanced quality of life for people with long-term conditions. It will not be possible to achieve success, as set out in the framework, without making progress in that way. There is a powerful new lever in the system as a consequence of the outcomes framework.

The hon. Gentleman talked about the atlas of variation, which is also a powerful tool for identifying outliers and allowing the appropriate challenge of commissioners and others on the decisions they have made. We intend it to be used by commissioners in that way, to drive improvements in the service.

I welcome the fact that the hon. Gentleman sees quality standards as a useful tool. NICE has already developed a quality standard for osteoarthritis, and we are looking at the scope for the development of a quality standard in pain management. We are about to see a further consultation on a range of subjects for the next batch of clinical quality standards. We have the hon. Gentleman’s suggestions on a musculoskeletal condition standard in mind.

This short but timely debate has highlighted an important area of health policy in which we need significant improvements on the ground. The evidence and clinical advice to provide excellent services is there, but we need clinicians to use their leadership role in the NHS to drive change, and we need to take the opportunities of changes in clinical and commissioning leadership to drive forward those reforms. I shall certainly ensure that the debate is referred to those who need to take such decisions, and I thank the hon. Gentleman for bringing the matter to the House tonight.

Question put and agreed to.

House adjourned.