HC Deb 29 March 2000 vol 347 cc467-74

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Pope.]

11.43 pm
Mr. Paul Burstow (Sutton and Cheam)

My interest in the subject of pain management was first aroused by correspondence from constituents—people writing with concerns and complaints about the fact that they were having difficulty securing access to services locally, and in particular that they were waiting a considerable time.

From those initial inquiries and the correspondence that I had with the local NHS trust, I began to develop an appreciation of the pain management services available to my constituents—their value and their potential.

One person who, I know, values the help and support that she received from the centre of pain education at Sutton hospital, which is part of the Epsom and St. Helier NHS Trust, is Denise. She even wrote a poem to the staff to show how much she appreciated their efforts. Denise was first diagnosed as having rheumatoid arthritis in 1977, when she was just 21 years old. She has lived with pain ever since. With the exception of the period following the initial onset of the disease, she has managed to hold down a full-time job and the running of a household. As she says in her own words: Pain rules everything you do. It affects your relationships, as you become irritable and self-obsessed. It affects your social life, as outings have to be carefully planned to take account of your mobility, comfort, etc. It also prevents you joining in with many everyday events because of your special needs. However, pain management has transformed Denise's life.

I have not sought this debate because I have a beef with the Government. Rather, I hope to encourage the Minister to consider pain management, particularly the management of back pain, as a candidate for development and investment as part of the Government's NHS modernisation programme. I believe that investment in pain management services would substantial dividends for individuals, their families, their employers and society as a whole.

In preparing for the debate, I have been grateful to the patients and staff at the centre of pain education at Sutton hospital for their help and advice. I am also grateful to BackCare, which is the only national charity concerned solely with back pain and reducing its impact. BackCare has done an excellent job of collating a wide range of facts and figures about the prevalence and causes of back pain, many of which exist within Department of Health statistics, but it has brought them together in a way that makes them more comprehensible. I appreciate the work that it has done.

From that work, it is clear that back pain is clearly the No. 1 cause of disability in Britain. More than 1 million people are disabled by it. But back pain can affect us all. The most recent figures suggest that two in five of the adult population—more than 16 million people—have had back pain lasting for more than a day. One in five of the UK adult population have had pain which lasted for more than four weeks. For 2.5 million people, back pain is constantly with them, day in, day out, without respite.

Back pain costs the UK some £6 billion a year. As much as two thirds of that is accounted for by 180 million lost working days every year. The cost to the NHS alone is put at between £360 million and £640 million a year, with 900,000 hospital bed days per year being taken up by people with back pain.

The longer someone is off work with back pain, the greater are the odds that they will never return to work. In one in three cases of back pain the condition becomes chronic. For many long-term sufferers, their condition is not susceptible purely to physical interventions or medication. Often psychological or social factors are at play.

I am interested in how effective care pathways can be devised to integrate primary and secondary care to treat acute back pain with earlier diagnosis and appropriate medication and treatment. Were such pathways developed, the number of people suffering chronic back pain could be reduced significantly.

Since the UK Clinical Standards Advisory Group reported in 1994 and recommended a number of treatments for back pain, research has found that the availability of pain management services throughout Britain is patchy—perhaps another case of the previous Government's postcode legacy.

Research for the Medical Research Council and BackCare by the Wolfson Institute of Preventive Medicine concluded that efforts to improve access to those services should be focused on health authorities and primary care groups.

This month's issue of Professional Nurse features an article entitled "Early management of patients with back pain" by Jan Austin of the James Paget Healthcare NHS trust. The author puts it this way: The focus of early management should be to relieve symptoms of pain and prevent disability by prescribing simple analgesia, encouraging the person to take up appropriate activities and arranging physical therapy. At the same time, the GP should encourage the patient to think positively about his or her recovery and return to work, providing advice, reassurance and support using appropriate terminology to avoid the negative effect of poorly chosen language.

It is worth stressing that bed rest is not recommended. In fact, in many cases, it makes matters worse. But GPs are still recommending that course of action to as many as one in four of the people who come to see them about back pain. That is crazy. Such bad advice fuels a vicious circle of disability. Less activity leads to less mobility, which in turn leads to more pain and greater disability, and so on.

The fact that such poor advice is being given is worrying, because in 1996 the Royal College of General Practitioners issued guidelines on the management of acute lower back pain, which explicitly ruled out bed rest for back pain. Despite that, studies have found that the management of back pain by GPs falls well short of the guidelines.

I understand that work is in hand by the National Institute for Clinical Excellence's orthopaedic protocols advisory group. The referral protocols that it is drawing up for back pain will be crucial to further progress. I hope that the Minister may be able to give some idea of how that work is proceeding and when it will be concluded and published.

Aside from the wider benefits of investment in pain management and the benefits for the individual, there are, as I said, savings for the NHS. Evidence from an evaluation of pain management for chronic lower back pain conducted by the centre of pain education at Sutton hospital in 1995 found that every 100 people who completed its pain management course produced a saving of £32,000 on analgesics and epidurals. The evaluation also found that seven out of 10 people completing the course had no further appointments with or referrals to consultants.

The centre of pain education, or COPE, runs 10 out-patient pain management courses a year for people who live with back pain on a daily basis. The programme is provided through a multi-disciplinary team, which comprises a psychologist, a physiotherapist and a nurse, who, under the medical supervision of a pain consultant, use and teach a wide range of techniques for managing pain. Physiotherapy, acupuncture, aromatherapy, relaxation and counselling feature in the COPE armoury.

The COPE philosophy is holistic and can have a powerful effect. It delivers results. When I recently attended a COPE support group meeting, one person who had been on the course described it to me as coming to an accommodation with pain. COPE has six clear objectives: to reduce depression and anxiety; to increase independence; to review and reduce use of analgesic medication; to reduce absence from and promote return to work; to increase self-confidence in managing pain; and to reduce dependence on the NHS.

In 1997, 147 people were referred to the unit; in 1998, a further 136 referrals were made; and 120 more people were referred in the first six months of last year. Demand for the service and, consequently, waiting times, have increased. COPE evidence and the testimony of people who have attended the course show that it can change lives.

The courses stop the downward spiral of increasing use of ever stronger drugs, with all the side effects that that may involve. They give people the confidence and knowledge to ask about their medication. As one course attender described it to me: Too familiar is the patient that started off with back pain and ended up by going into renal or liver failure or both. Perhaps that is a stark view, but it is echoed by many members of the support group whom I met.

I should like COPE to develop an outreach programme, perhaps on a pilot basis, in Sutton. It would be based at GP clinics, thus providing easier access and education for patients as well as support for GPs. Such an approach could cut waiting times and allow earlier interventions to occur.

In the same way, collaboration between GPs, practice nurses and pain management services could lead to guidelines being drawn up on the use of pain relief drugs. A common protocol would go a long way to helping patients who suffer from chronic pain to secure access to effective drug regimes and, if they so desired, strategies for coping with pain with fewer or no drugs.

COPE currently provides a service only for those who suffer from lower back pain. However, a pilot scheme last year expanded that to include other sites of pain. It showed that other groups of patients responded well to its philosophy. I wonder whether the Minister will therefore encourage such co-operation between primary and secondary care, not only in my constituency, but in other places, especially on developing common protocols and outreach work.

As a participant in the COPE programme put it to me: Having attended the 8 weekly visits to Sutton Hospital COPE Unit my overwhelming regret is that I was unaware of how much difference the skills of the team could have made to my life had I known of them three years ago. That person suffered three years of constant pain. Like many other sufferers, she needed primary and secondary care to collaborate closely.

The article in Professional Nurse to which I referred summed up the point: Working within guidelines ensures that patients are referred to the most appropriate point of secondary care, preventing a journey through services with long waiting times and resulting delays in assessment, diagnosis and rehabilitation. Delays fuel frustration and despair, with the patient often waiting months or even years for a referral to a pain clinic when other disciplines have discharged them. Illness behaviour and pain is by then well-established and more difficult to manage. Managing pain can make a dramatic difference in the quality of a person's life. It can reduce their dependence on drugs and help them to get back to work; it also has knock-on health benefits.

I shall end where I began, with Denise. In a letter that she wrote to me, she painted a good picture of what pain management meant to her. One of the passages in her letter particularly struck me and underlined the way in which pain management makes a difference at a personal level. She said: One other part of the course that sticks in my mind was the day when we were invited to bring a close relative or friend to one of the sessions. My partner, who has been with me for 17 years, came to the meeting. We realised that although we had coped with my problems for all those years, we had never actually talked about it! He said he learnt a lot about what I had to cope with and I learned how much more he wanted to help me. I realised that I had been struggling needlessly due to a sort of pride and embarrassment. We felt closer afterwards, and since.

There are beacons of hope and good practice. The Centre of Pain Education in my constituency is one of them. We now need clear guidance to GPs and primary care groups and trusts to build and signpost the care pathways and ensure that the necessary people-centred services are commissioned and provided in primary and secondary care.

The final sentence of the Clinical Standards Advisory Group 1994 report gave a stark warning. It stated: If we do nothing to improve the situation, total social costs of back pain in Britain are likely to continue to increase by up to £0.5 billion per annum. We need to do something about that; I hope that the Government will be able to do so.

11.55 pm
The Parliamentary Under-Secretary of State for Health (Ms Gisela Stuart)

I congratulate the hon. Member for Sutton and Cheam (Mr. Burstow) on securing this debate on pain management and I am pleased to have the opportunity to address the issues that he raised.

Pain is a major problem and a common consequence of ill health. Indeed, it is a major cause of ill health. It affects us all at some point in our lives and the experience is always unpleasant and often emotional. It is therefore important that good quality pain management is provided to patients to improve their health care and their quality of life. The debate is timely. The hon. Gentleman mentioned the work of the Clinical Standards Advisory Group and he may be pleased to learn that tomorrow we shall publish its last four reports, including one on pain management. I reassure him that that is purely coincidental, although I congratulate him on brilliant timing.

When pain strikes, it does so in a very individualised way. Therefore, the management of pain must be customised to meet individual needs. The hon. Gentleman raised the case of his constituent, who is suffering from chronic rheumatoid arthritis. Denise's testimony is moving, but, unfortunately, not uncommon in the circumstances. We take the concerns of such people very seriously. The treatment and management of her pain will be very different from the management of pain experienced by a patient recovering from surgery.

If we experience pain, most of us can get quick relief simply by taking a pill. For some patients—those with hip or joint pain associated with osteoarthritis, for example—a pill offers only temporary respite. Permanent relief may come with a hip or other joint replacement operation, but sadly there is no permanent cure for some people. The group of people with chronic pain conditions such as back pain are sent to specialist pain management clinics, often after entering the national health service system in other specialties and being referred on.

In this country, pain management began some 50 years ago. In those early days, the pioneer anaesthetist responding to the needs of other doctors would carry out nerve blocks through local anaesthetics that blocked the nerves carrying the pain messages to the brain. However, in the 1960s clinicians and patients began to recognise that pain relief was effective in treating debilitating and distressing illness. As demand grew, the NHS began to establish formal clinics dedicated solely to managing pain in multi-professional teams.

The Pain Society, which was then known as the Intractable Pain Society of Great Britain, first met in 1962. Virtually every clinician working on pain relief attended—all 17 of them. Today, some 40 years on, almost every acute hospital has a pain service, although there are still considerable local variations in how those services are staffed and the range of treatments that they offer. However, next week's meeting of the Pain Society at the university of Warwick will be attended by more than 700 health care professionals.

I say this to show how far we have come. In many places, the development of chronic pain services was ad hoc, which has led to some extreme variations in services. Not every health authority can claim to provide the type and range of multidisciplinary services offered at the Centre of Pain Education in Sutton. I congratulate all the people working there on their great dedication and the way in which they have co-ordinated their services in the interests of the patients in that health authority. However, the increasing availability of services means that more patients can be treated. In England in 1998–99, there were more than 82,000 new referrals and more than 236,000 subsequent attendances in pain and anaesthetic clinics compared with some 71,000 new patients and slightly more than 211,000 subsequent attendances in 1996–97.

Let me now deal with the epidemiology of back pain. I do not argue for a moment with the figures given by the hon. Gentleman, which come from reputable sources and were used to support the clinical standards advisory group's study of the epidemiology and cost of back pain in 1994. That is still an important document, which underpins our strategy for dealing with back pain.

An issue on which the hon. Gentleman and I might disagree is the number of back pain cases that become chronic. That may depend on how we define "chronic". I would argue that back pain is often short-lived and able to right itself without the need for medical treatment; only in a comparatively small number of cases does it become chronic. However, for those in whose cases it does become chronic it is very serious, and merits full attention.

Back pain is not only tragic for individuals, but the biggest single cause of sickness absence. It accounts for an estimated 12 million GP consultations. Some estimates put the cost to the NHS at as much as £480 million, and refer to some 880,000 out-patient attendances. Some identify a £5 billion cost to industry, and the loss of 11 million working days. That represents a considerable economic loss to the community.

One way in which we are tackling the occupational health problems is through our "back to work" initiative, which is intended to encourage employers to help us to reduce the incidence of back pain. We also want employers to be more helpful, and to behave more flexibly to patients suffering from back pain on their return to work. I was interested by the hon. Gentleman's observation that the longer someone is off work with back pain, the more difficult it becomes to go back to work. Last month, we announced funding for 19 successful projects to tackle the problem of back pain in the workplace, committing nearly £700,000.

The clinical standards advisory group's 1994 report on back pain made many practical recommendations about NHS services. It supported the multi-professional approach, and a rehabilitation programme including education and training in back function as well as the teaching of relaxation and coping strategies. The type of service that the hon. Gentleman encountered at the Centre of Pain Education in Sutton would fit its model very well. It is a highly acclaimed local service, with a multi-disciplinary pain management programme running 10 courses per year for patients with back pain for whom current medicine has been unable to find a cure.

Following the 1994 report, the Department of Health provided funds for a multi-disciplinary working group, led by the Royal College of General Practitioners, to implement some of the recommendations. The hon. Gentleman mentioned those.

The hon. Gentleman may be interested to learn that today a new set of guidelines was launched, sponsored by Blue Circle and based on work carried out under the auspices of the Faculty of Occupational Medicine and the Royal College of Physicians. The aim is to improve understanding and management of back pain at work.

As I said earlier, tomorrow we will publish the report of the Clinical Standards Advisory Group on Pain Services. One of the most striking aspects of the report is the fact that it highlights the variations in care and health services across the country—an issue that Ministers are committed to tackling. While we can offer the very best in many areas, in others services we have a long way to go. One of our aims, as part of the modernisation and extra resources announced in last week's Budget statement, is to ensure equal access to good services.

I share the hon. Gentleman's concern about adherence to professional guidelines aimed at improving the treatment of acute back pain and preventing longer-term problems. That is why we shall underpin the reports of the clinical standards advisory group and the guidelines of the Royal College of General Practitioners with advice from the National Institute for Clinical Excellence.

The hon. Gentleman asked about the timetable for the work being undertaken by NICE. We have asked NICE to produce protocols offering advice to GPs on when to refer patients with acute lower-back pain to specialists. We recognise that variations in referral practices can make a marked difference to individual patients. Patients' access to the service and to secondary care may be delayed because the system becomes clogged up owing to inappropriate referrals, but there are those who, although they have been referred at the right time and to the right place, end up waiting longer. By proper management of the system, they could find relief and have better and faster treatment elsewhere.

The aims of the NICE protocols will be to define the condition itself more clearly, to set out precisely what specialists can offer and to set out criteria for prompt referral. Key reasons why a patient should not be referred must be equally clearly defined. Last but not least, the aim will be to set levels of urgency for each referral criterion, so that those in the most urgent need will receive treatment at the earliest opportunity. NICE is looking at a range of issues, but I have been assured that its work in that area will be completed later in the spring.

It should not be forgotten that, although chronic, intractable pain is primarily a physical, rather than a mental, health problem, the psychological consequences can include severe depression, anxiety and relationship difficulties. I could not have put it better than the hon. Gentleman's constituent, who described what it did not just to her life, but to her relationship with others and, in consequence, their life. People can have problems sustaining a job and a life. As was demonstrated, they can become very dependent on others.

Psychological approaches, particularly cognitive behavioural approaches, have been shown to be highly effective in helping chronic pain patients to regain some independence. Systematic reviews provide strong evidence of their efficacy. Psychologists are increasingly employed as team members to support staff in their delivery. I have seen in some centres of pain management the use of alternative therapies, whether aromatherapy, reflexology or acupuncture. A whole range supplements allows patients to manage their condition much more effectively.

I support the need for a collaborative approach to pain. I trust that the additional £8.64 million for Merton, Sutton and Wandsworth health authority, part of a total allocation of £600 million that was announced in the House earlier this week by my right hon. Friend the Secretary of State for Health, will allow the authority to develop pain services in Sutton further. Our plans to modernise the NHS include making all parts of the health care system work better together, delivering better health and fast, fair and convenient services that depend on what is wrong with a patient, not where a patient lives.

We support the adherence to the CSAG guidelines on back pain, which still apply, despite the fact that they were first published in 1994. Those are backed up by further work and by wider use of the Royal College of General Practitioners guidelines on back pain. Those will soon be underpinned by the NICE referral protocols.

I hope that the hon. Gentleman will feel that that provides him with some reassurance that we are taking the matter seriously. Although there are no straightforward answers or easy solutions, there are possibilities through a co-ordinated approach to allow people suffering from chronic pain to manage their condition and to live a much fuller and more useful life.

Mr. Burstow

rose—

Mr. Deputy Speaker (Sir Alan Haselhurst)

I think that the Minister has concluded her speech.

Question put and agreed to.

Adjourned accordingly at eight minutes past Twelve o'clock.