§ On resuming—1.30 pm
§ Mrs. Teresa Gorman (Billericay)
I am pleased to have this opportunity, 10 years after the launch of the National Osteoporosis Society and two days after the first World Osteoporosis Day, to tell the House about brittle bone disease, or osteoporosis, and how it relates to our lives.
It is an old disease in two senses. Fossil skeletons show that Cro-Magnon woman suffered from it—if she survived being dragged off by some caveman to bear him umpteen children. Most such women would have been dead by 50, the age after which people become increasingly vulnerable to the disease. We can all look forward, if that is the right expression, not only to a ripe old age but to the risk of the disease.
Today, the average longevity of women is 84; for men, it is 79. It is not surprising that the disease is becoming more and more common. The incidence has almost doubled in the past 30 years. In 1990, according to the World Health Organisation, 1.7 million osteoporotic hip fractures occurred in the western world. If we do nothing about it, the number is predicted to rise to 6.26 million by the year 2050. That is an awful lot of people and an awful lot of pain and cost. Osteoporosis is reckoned to cause around 200,000 fractures in Britain alone each year and it costs the national health service around £750 million to care for those people.
Fairy tales are full of stories that feature old crones—women shrunken, bent double and hobbling along with a stick, or long in the tooth as we say. Those problems are all due to osteoporosis. The tooth problem is caused by shrinkage of the jaw. Today, we hide people in that condition in old people's homes and give them zimmer frames. It was in such homes that I first became of the aware of the extent of this crippling disease. Osteoporosis can affect all parts of the skeleton. We shrink as we get older. Two or 3 in is common, but 10 or 15 in is not unknown. Such cases involve great curvature of the spine, the head sinks into the chest, pressure is caused on the lungs, and the people afflicted often die from lung disease before the bone disease gets them.
If the crones were young today, the National Osteoporosis Society would be there to tell them how to prevent distorted frames and save them from their suffering. It does a wonderful job with the money that it raises and it deserves as much as the Government can give it. Apart from anything else, it would be a terrific investment. About a third of our hospital beds are occupied by people being treated for osteoporotic fractures. Some never get out of their beds; they are crippled for life. We must thank the society and its campaigning for the fact that women, in particular, are much more aware of the risks that they run. However, it is still difficult to get women to do something about the problem sufficiently early. Not for nothing is it called the silent disease; it creeps up on people over the years. By the age of 60 to 70, people are at severe risk of fractures; by 70 to 80, there is a one in three chance of something serious happening to the skeleton.
At first glance, bones look solid, but that is far from being the case. When they are young, they are hollow and the material of which they are made is full of tiny holes. 315 As we grow older, the holes get bigger, like in a piece Swiss cheese, and the bones become fragile. One can suddenly suffer a broken bone from a fit of coughing, lifting a grandchild or using a vacuum cleaner. One does not have to fall over to sustain a fracture in one's 60s or 70s. When such people fall over, they have a big chance of breaking their ankles, wrists or pelvic girdles. Such fractures can be lethal; 15 per cent. of women who fracture their pelvic girdles—which are not to be confused with hip joints—die of the condition, even though they are operated on. Patching up that part of the body is difficult, because the bones are naturally thin. There is a good chance that people who survive will need zimmer frames for the rest of their lives. The quality of life is greatly reduced.
In the past, women over 50 were considered to be over the hill or on the shelf, partly because of the decline in their health. There are many things that such women can do with their talents, but good health is essential. The early treatment of osteoporosis can go a long way towards improving the chances for older women to continue to make an important contribution to our society.
The good news is that osteoporosis is preventable and treatable. A healthy diet with lots of calcium, which means butter, cheese and milk, gives bones strength. Vitamins are important, especially vitamin D3, which is obtained from dairy products and sunlight. Exercise is important; during exercise, the muscles pull on the bones, which strengthens them. However, the most important ingredient in preventing bone loss in women is the replacement of the natural hormones, which begin to decline as women grow older.
It is a well-known medical fact that, if hormone replacement therapy is taken by women of 50 and over for 10 years after the menopause, the risk of brittle bones is very much reduced. A study of 6,000 women in Hull between the ages of 50 and 54 showed that 37 per cent. of them were already experiencing bone loss. Most of them went on to hormone replacement therapy, and the bone loss stopped. Not all women want to take hormone replacement and the pharmaceutical industry is developing non-hormonal treatments to counter the disease.
Baroness Cumberlege, the Under-Secretary of State for Health, has taken much interest in the subject. She is actively encouraging health authorities to provide a comprehensive service for osteoporosis sufferers. So far, 12 per cent. of health authorities have responded. The number is growing, but clearly we want to encourage them to do more. More hospitals have scanning facilities for measuring bone loss, although it is, of course, much better for people to take precautions when they are younger and not wait for the loss to begin.
Fewer than 10 per cent. of the sufferers of osteoporosis receive adequate treatment, but if a woman's mother or other women in her close family display some of the crippling problems of old age, she should think seriously about requesting a bone scan. The more people ask for that, the more chance that facilities will be made available in Britain for women and, I might say, for men.
Above all, professional and public education is needed. It would be, as I have said, a tremendous investment. We would be saving hundreds, possibly thousands, of millions of pounds in the future each year, because more and more 316 people would avoid this crippling disease which, in the past, has been taken for granted as part of the problems of old age.
For myself, I certainly take this treatment. I am told that I have the skeleton of a 15-year-old and that my jaws and teeth are in equally good condition. Sometimes we forget that teeth are part of the skeleton and the fact that old people lose their teeth has as much to do with bone loss as it has to do with the condition of their teeth.
I have talked a lot about osteoporosis as it affects women. It is true that most of the sufferers are women. On average, one in three women are likely to suffer a fracture as they get older. But, of course, men can suffer too. One in 12 experience bone loss during their lifetime, although the onset usually occurs much later.
My observation is that medical problems receive much more attention when they are considered to affect men. That is certainly true for heart disease. Therefore, I have decided to ask the hon. Member for Woolwich (Mr. Austin-Walker), who also takes a great deal of interest in the subject, to put the case for his own sex, because then I know that our health authorities, many members of which are men, will take the problem much more seriously, and the problems of osteoporosis will become a top priority in the treatment for what is an avoidable disease.
§ Mr. John Austin-Walker (Woolwich)
I only hope that my voice will last long enough to allow me to make my points.
First, I thank the hon. Member for Billericay (Mrs. Gorman) for giving me the opportunity to participate in the debate and for having requested it. I fully endorse all her remarks about the work done by the National Osteoporosis Society. I draw the Minister's attention to early-day motion 1037 in my name which was tabled on Monday to coincide with World Osteoporosis Day and which I understand has now been signed by more than 200 hon. Members on both sides of the House.
The hon. Lady is correct to say that osteoporosis is a devastating illness for women. She is right to point out that it is not exclusively a women's disease. She has said that one in 12 men can expect to experience a fracture as a result of osteoporosis at some time during their life. Recent research has suggested that the figure may be as high as one in eight. What is worrying is that the figure is increasing. Therefore, we must address the early identification and treatment of the disease.
The hon. Lady has mentioned that about 200,000 fractures a year are caused by osteoporosis. The National Osteoporosis Society estimates that there may well be 40 premature deaths every day as a result of this crippling disease; but, as the hon. Lady has said, it causes misery not only for those affected by this disabling disease but for their families and loved ones.
The main thing that we have to say is that prevention is possible and early diagnosis can lead to effective treatment. The hon. Lady has referred to hormone replacement therapy. She is affectionately known as the queen of HRT. My secretary has asked it to be known that, if the hon. Lady is the queen, she claims the role of princess. But it is clear that HRT has been shown to reduce the risk of osteoporosis in menopausal and post-menopausal women. However, there is a need for a wide public education programme about other ways in which the disease can be reduced in both men and women.
317 First, smokers are more at risk of osteoporosis than non-smokers. As the hon. Lady has said, diet is also an important factor. Exercise has certainly been shown to be effective in building up bone density. Some drugs can be effective in treating osteoporosis, but much more research needs to be carried out into prevention through non-hormonal drug programmes. Further research, monitoring and prevention will ensure that future generations of men and women, but more particularly women, can lead full lives unhindered by the pain and disability of osteoporosis.
The hon. Lady and I ask the Government to give a higher profile and priority to osteoporosis. As the hon. Lady has said, one third of orthopaedic beds in the NHS are occupied by patients with osteoporosis, and the estimated cost to the NHS of fractures caused by osteoporosis is around £750 million a year. But that is only part of the cost. One in five people sustaining a hip fracture die within six months, and more than half cannot walk independently afterwards, many becoming highly dependent. There are then the unseen costs of care in the community and the on-going costs of drugs, physiotherapy, occupational therapy and other support services provided by the NHS and local authorities. There is also the cost to an individual in terms of the quality of life and the quality of a carer's life. The chronic pain, the disability and the possible deformity which were outlined earlier cannot be overestimated.
Diagnostic tools should be more widely available. The facilities in the United Kingdom for measuring bone density are scarce, although I recognise that they are increasing. But in my view and that of the National Osteoporosis Society, every health authority should have a designated lead clinician with a special interest who can update other professionals on the prevention and effective management of osteoporosis.
The primary and the secondary services must work together to provide a seamless service, and funding for osteoporosis needs to be positively and definitely included in local contracts. Action is needed at local level. A local health commission could set up an effective osteoporosis service for about £50,000, which is less than the cost of treating two weeks' hip fractures. There needs to be action by Government. Osteoporosis should be given key area status in the Government's "The Health of the Nation" programme.
The Minister will know that Baroness Gardner and I jointly chair the all-party osteoporosis group. Informally, we have had a sympathetic and encouraging response from Baroness Cumberlege, his ministerial colleague in the other place. I hope that we shall have a formal and positive response from the Minister today, and a commitment to recognise osteoporosis in "The Health of the Nation" targets.
§ The Parliamentary Under-Secretary of State for Health (Mr. John Horam)
I am grateful to my hon. Friend the Member for Billericay (Mrs. Gorman) for initiating a debate on osteoporosis in the middle of National Osteoporosis Week. She said during her speech that her jaws and teeth were in good condition; I can assure her that the House and, in particular, the 318 Government have never had any doubt about that. I believe that this is the second such week—the first World Osteoporosis Day was on Monday—the main initiative for which came from the National Osteoporosis Society.
I should also like to take this opportunity to pay tribute to the society and its achievements during the past 10 years in giving osteoporosis sufferers everywhere a voice. The NOS has also organised this week the fifth annual conference on osteoporosis and bone mineral measurement, in Bath, bringing together the leading experts in the field.
As my hon. Friend said, the debate can only help to raise the profile of a condition which has been described as the silent epidemic. Osteoporosis is undoubtedly a major public health problem. It has been estimated to affect as many as one woman in four in the United Kingdom. Each year in this country, there are about 60,000 hip, 50,000 wrist and 40,000 vertebral fractures which are due to osteoporosis. Most of these occur in older women, but about 20 per cent. of the hip fractures occur in men. I noted the comments about that by the hon. Member for Woolwich (Mr. Austin-Walker), the chairman of the all-party group. Almost half of all women will have experienced a fracture by the time they reach the age of 70.
In March 1993, my colleague Julia Cumberlege—I acknowledge the tributes paid to her work—decided to look at what we were doing in the whole field of women's health, for which she has particular ministerial responsibility, and to examine the outstanding issues. She concluded that, at that time, osteoporosis was the single most important women's health issue yet to be addressed by the Department: it had not been given the attention that it deserved. She resolved to put this right by setting up the advisory group on osteoporosis, or AGO.
The group's remit wasto establish what information about osteoporosis is available, what research is being conducted and what further work needs to be done, and to report to Ministers".AGO submitted its report in November 1994 and, having accepted its recommendations, Julia Cumberlege published it in January 1995. The AGO report was widely distributed both within and outside the NHS, and we have reprinted it three times since then—a pointer to its popularity among health professionals and the public.
Since publication of the AGO report, progress has been made on a number of fronts in developing osteoporosis services. Two of the report's recommendations were directed at the NHS. Julia Cumberlege wrote to the chairmen of all NHS bodies about these on the day before the report was published, and has subsequently discussed them with regional chairmen.
The first of AGO's recommendations specifically for the NHS was that health authorities should facilitate improved co-ordination and communication between the various groups of professionals and specialists—general practitioners, nurses, gynaecologists, rheumatologists, radiologists, orthopaedic surgeons and others—involved with different aspects of osteoporosis. That may sound like a statement of the obvious, but we have made it clear to NHS chairmen that we think that it is worth taking a bit further—looking at whether having a lead clinician for osteoporosis in each locality would be cost-effective and desirable. Osteoporosis should be tackled with a "shared care" approach among all sectors of the NHS.
319 The advisory group's second recommendation for the NHS was that bone densitometry should be made available to assist clinical decision making with certain groups of patients identified as being at high risk.
The National Osteoporosis Society, the leading voluntary body, published in January the results of a survey it had carried out among health authorities of the services provided around the country for people with osteoporosis. My hon. Friend referred to this work. It is fair to say that the results of that survey clearly highlight the fact that the NHS has a lot of work to do before the recommendations of the advisory group can be considered to be successfully met. It is clear that some health authorities have a great deal of work to do in improving local osteoporosis services. I note the percentage of them that my hon. Friend mentioned. That said, it would be unrealistic to expect services to improve radically overnight, but there are many points that need to be improved on.
A number of the recommendations of the advisory group on osteoporosis were directed at the centre, and a great deal of work towards implementing the recommendations has already been done. For example, a group led by the Royal College of Physicians is working on clinical guidelines for osteoporosis. I also understand that the Clinical Standards Advisory Group will take the AGO report into account in its own report on community health care for elderly people, which is expected to be submitted to the Department later this year. Osteoporosis is now also specifically referred to in "The Health of the Nation" fact sheet on accidents.
There has been much debate about the role of bone density scans. In such debates, the findings of the "Effective Health Care Bulletin on Screening for Osteoporosis", produced by the York centre for reviews and dissemination, are often cited in defence of decisions not to increase the availability of bone scans, as recommended in the AGO report.
The "Effective Health Care Bulletin" considers the evidence for establishing a population screening programme for osteoporosis and concludes that, on current evidence, it would not be advisable to do so. The AGO report reaches the same conclusion. However, the latter goes on to say that, once someone at high risk of developing osteoporosis has been identified—usually by the GP asking a few key questions in the surgery—there is an important role for bone density measurements to confirm the diagnosis where the patient is reluctant to agree to treatment and to monitor the treatment to encourage the patient to continue with it.
This use of bone density measurement is not considered by the "Effective Health Care Bulletin"—which is why the AGO report recommended that it should be reviewed. AGO rightly concluded that the bulletin as it stands has misled health care purchasers into believing that there was no role for bone density measurement in local service provision. The NHS executive is in discussion with the York centre about updating this and other bulletins in the context of a new contract for further clinical effectiveness work.
Of course, bone density scans are not the solution to osteoporosis; but I believe that their availability, in the circumstances set out in the advisory group's report, is an important element in a good local osteoporosis service.
320 The Department of Health has considered the contribution that nutrition can make to maintaining bone health on several occasions. In 1991, the Government published updated dietary reference values for assessing the adequacy of dietary intakes of nutrients. The nutrients generally regarded to be most important in bone health are calcium and vitamin D, but many other nutrients have been implicated, including copper, fluoride, phosphorous, vitamin C and protein. In addition, the risk of fracture in old age is related to body composition—for once it seems to help to be a little bit plump. I make no reference to my hon. Friend the Member for Billericay in this context, of course.
I also noted with great interest what my hon. Friend said about HRT, and I know of her other concerns in that area. Much of what she said about it made great sense.
The report of the advisory group on osteoporosis also recommended better public and professional awareness of the condition. It also made recommendations in respect of the nursing professions; indeed, a key quotation from the section on the role of nurses said:with appropriate preparation this group is in a prime position to make a significant contribution to any programme for the prevention, early diagnosis and treatment of osteoporosis".Nurses can do this only if they have a full understanding of the disease and its implications. Therefore, the next logical step was to build on the existing literature by producing a comprehensive and detailed resource pack for nurses.
I am therefore delighted that, on Monday, at the fifth annual conference on osteoporosis and bone mineral measurement in Bath, Julia Cumberlege launched just such a resource pack on osteoporosis for nurses, midwives and health visitors. I have one with me; it is an excellent document, hot off the presses, and I can recommend it to nurses and to hon. Members. The resource pack was produced jointly by the Royal College of Nursing and the National Osteoporosis Society, and my Department gave a grant of £5,000 towards its production costs.
The resource pack takes the form of short fact sheets in an easy-to-use folder. The simplicity of its production belies the depth of the information which it contains. The subject matter is fully covered and I am sure that it will be an invaluable aid to the expansion of the nurse's role in this field. The pack is available, free of charge, to any nurse, midwife or health visitor and can be obtained from the NOS.
I hope that I have revealed the importance that the Department of Health attaches to osteoporosis, which is also reflected in the financial support which we give to charities in this field—not only to the National Osteoporosis Society but to Women's Health Concern and the Amarant Trust, of which my hon. Friend was a founder. We shall continue to work with them and with other interested parties, with the NHS and health service professionals, to increase awareness of osteoporosis and to improve its treatment.
§ It being two minutes to Two o 'clock, the motion for the Adjournment of the House lapsed, without Question put.
§ Sitting suspended, pursuant to Standing Order No. 10 (Wednesday sittings), till half-past Two o'clock.