HL Deb 21 November 1979 vol 403 cc248-72

8.55 p.m.

Lord FERRIER rose to ask Her Majesty's Government what plans they have to integrate chiropractic into the National Health Service. The noble Lord said: My Lords, I beg leave to ask the Unstarred Question in my name on the Order Paper. The campaign of which this debate is a part began five years ago with a Question and Answer about the exchange of X-ray photographs between chiropractors and National Health Service hospitals. The campaign continued with a debate in May 1976; and, as my intention is to be brief, I will not repeat the stories of the debt that my family and many others known to me owe to chiropractic. Suffice it to say, that all these have inspired in me the compassion that I feel—and many of your Lordships share it with me—for people who suffer from pain and have no recourse to manipulative therapy.

My immediate concern is for sufferers from back pain. I quote from the Industrial Relations Services Bulletin for July this year, which, on the first page, says: Back pain costs British industry 18 million lost working days last year compared with 9.3 million lost from strikes. It cost more than £900 million in lost production and cost the State £90 million in social security payments. Some 50,000 people are estimated to be off work every day because of back pain. It represents one of the major causes of sickness absence in industry today ". These statistics cannot include a large number of women because it is not possible to estimate the magnitude of the problem as it affects housewives, mothers and the self-employed. I think, for instance, that hospital nurses who are probably numbered in those figures are included, and they are particularly prone to back strain. And, of course, there can be no calculation in financial terms, no factor to cover pain and distress.

The story of the campaign unfolds. After our debate in 1976, the Minister of Health appointed a working group on back pain which we shall call the Cochrane Committee. Professor A. L. Cochrane was the chairman. By this time the sterling work of the Back Pain Association, which I know we shall hear more about tonight, was making its impact on local authorities and public opinion. But why do I confine my Question to chiropractic? It is for various reasons, the chief of which is that this science—for such it is—has achieved recognition over almost all of the world. I say "almost" because this country is far behind the international level. If one looks at the figures of qualified doctors of chiropractic related to population, one compares the USA with one chiropractor for 13,000; Canada, one for 20,000; New Zealand one for 45,000; Denmark, one for 47,000; Switzerland, one for 81,000; and so on, until we come to the United Kingdom with one for every 635,000. That is why I say "almost universal ".

As a matter of interest, the British Chiropractic Association submitted, on request, a case to the Cochrane Committee and an effort was made to get a doctor of chiropractic included in the Committee's personnel. But this was unsuccessful. Of course, one must accept that the medical profession in the ordinary way do … not look kindly on people who practise the healing art without having received the traditional education of a teaching hospital, an attitude partly excused by the sincere wish to protect the public from quacks professing to cure disease ".

This quotation is from the Dictionary of National Biography, in their entry on Sir Herbert Barker. Your Lordships will recall the dramatic story of his life, before, during and after the First Great War, and it can be followed by anybody who cares to do so by reading this entry in the DND. In that entry it says: What is a quack? ', The Times was asking in 1912 ". However, my Lords, much water has flowed under the bridge since then. Modern chiropractic is far from being an unscientific cult. It has its own training colleges; there is one, the Anglo-European College of Chiropractic in Bournemouth. It runs a four-year course and last year qualified some 38 students, two-thirds of whom were for Europe.

The struggle for recognition has been an uphill one, even today. For instance, the profession applied for inclusion under the Professions Supplementary to Medicines Act, but was refused. No reasons were stated. There was an absolute refusal to this apparently reasonable request. This induced an appeal to the Privy Council, which said it could not compel the PSM Council to disclose its reasons. I understand the matter is being proceeded with. Be that as it may, my personal view is the PSM Council's refusal to state their reasons can only spring from a guilty feeling that it is founded on bigotry, the nature of which led to the persecution of the late Herbert Barker and his associates.

If the contrary is the case—and I hope it is—I shall be the first to rejoice because I have, save in this respect, the greatest faith in the medical profession and their very proper concern for the protection of the public. However, to return to the Cochrane Committee, their report was submitted early in 1978. For some unexplained reason, it did not emerge from the Ministry of Health until the autumn. The committee have gone into the back pain problem in a painstaking way—and I am not trying to be funny, my Lords—contending that further study and action should command high priority. Accepting as it does the seriousness of the situation, it urged that … basic research inquiries should involve multi-disciplinary contributions ". That is a quotation from the Cochrane Report.

I think I am right in saying that the massive report of the Royal Commission on the National Health Service makes no reference to manipulative therapy at all, which surprises me. There is an organisation called the Health Education Council to whom I wrote and asked their views, but they replied that it was not this Council's responsibility to have attitudes about such problems as that of manipulative therapy ".

Do I hear a distant "quang quang", my Lords?

Only the other day came the news of the report of the New Zealand Government's Commission on Chiropractic tabled in their Parliament on 23rd October. I do not have a copy yet, but I can quote from the New Zealand Press Association's coverage: Chiropractic is far from being an unscientific cult ". I have already quoted that. Chiropractors are the only health practitioners who are necessarily equipped by their education and training to carry out spinal manual therapy … In the public interest and in the interests of patients there must be no impediment to full professional co-operation between chiropractors and medical practitioners ". At the same time it also says that there is no reason why any of the findings of the report should lead to any lack of faith or confidence in the medical profession. "Hear, hear,", say I.

I for one and, I have no doubt, many of your Lordships, look forward to studying the report when it comes to hand. But—and it is a big "but "—what is this proposal, which underlines my Question, going to cost? My contention is that it holds out, on the contrary, a financial saving. If the proposal involved an increase in expenditure at a time like this, when we are straining every nerve to cut down our outgoings, I would not have put this Question to your Lordships' House. The fact is that an acceptance of this therapy should represent a marked saving to the nation as well as a boon to sufferers: less days of work lost; less social security benefits to pay; less drugs to be consumed; less burden on overworked physiotherapists; less hospitalisation; and less surgery.

My Lords, as I began, so I shall end—less suffering, less incapacity. These facts tempt me to quote the words of Robbie Burns, my national poet: But Facts are cheels that winna ding, An' downa be disputed: ". It remains for me to thank in advance other Peers who will be contributing to this debate, and I thank them in advance because I shall have no opportunity to reply at the end. In view of the lateness of the hour, which is not of our seeking, I have cut my speech to the bone, leaving out much that could be said, I look forward to the contributions of other Peers and especially to that of the noble Lord who will be replying from the Front Bench. His task has been complicated by this news from New Zealand. However may I ask that he will at least give an undertaking that the Government will lose no time in studying the report from Down Under, and perhaps write to me regarding the Department's reactions to it?

9.10 p.m.


My Lords, I am grateful to the noble Lord, Lord Ferrier, for introducing this Question, for I find it a pleasant relief not to be engaged in a matter involving political beliefs. This is the first occasion for some considerable time that I have been at the Dispatch Box when I have not got to worry about political philospohy.

The noble Lord reminded us that in setting up the committee on 26th July 1976, my right honourable friend Dr. David Owen, then Minister of Health, said—and I think it is important that we should have his reasion for setting up the Cochrane Committee: Back pain is a major source of discomfort and disability to many people and a serious problem in terms of lost production, sickness benefit and cost of treatment ". I do not propose to repeat the statistics which the noble Lord was good enough to give to your Lordships but I wish he had repeated them, because it represents not only an enormous sum of money hut indicates a tremendous problem of personal suffering. When he talks about the 18 million lost working days and the enormous number of people—I think he said 50,000 a day—who are suffering and receiving treatment, let us remember that we are talking about the tip of the iceberg. We are not talking about the problem as a whole, for the simple reason that we do not know the extent of the problem.

I was interested to look at a piece of research undertaken by Dunnell and Cart-wright in 1972, and it is interesting to note that in their research they indicated that 21 per cent. of the adults had experienced back pain in the 14 days preceding their survey: I repeat, 21 per cent. of the adults whom they interviewed had experienced back pain in the 14 days preceding their research.

A conservative estimate of the cost to the community can only be evaluated in terms of sickness and absence from work. It does not take into account the vast army of women who experience—some continuously, others almost continuously—very acute pain. One of the regrettable features, I think, in our society has been the fact that it has been generally accepted that women, on reaching middle age, can expect back pain, and that we, as a community, have unfortunately accepted it and done very little about it. Those who are engaged in professional social work, and certainly members of the medical profession, know very well that it is not just a question of the person who is suffering the pain, particularly if it is a wife or a mother: it affects the whole family, and the whole family suffers as a consequence.

The report states that an increased frequency of back pain in boys is found today, and that the position as far as the elderly is concerned is under-estimated. So whatever figures we have, there is an under-estimation of the problem. This complaint makes a disturbing inroad into the lives of a vast number of people, and it not only stays with them and, directly or indirectly, affects everyone close to them, but makes everybody around feel completely helpless. I notice that the report goes on to say: … no age group appears to be exempt ". Turning to page 11, the report states: The Working Group "— that is, the Cochrane Committee— is … concerned that current expectations in this field are unreasonably high, and also that the potential to help is reduced as long as nearly all involved are misguided by what appears to he ill-substantiated notions ". I have to confess that I do not understand what that means. I do not know whether it means that the expectations of people who suffer from back pain are unreasonably high. But the Group went on to say that they were, … exercised by the suggestion that the majority of the medical profession do not make use of the most appropriate techniques of examination in their assessment of patients suffering from back pain ". Perhaps one of the most useful things they said was that, All these considerations reinforce the conclusion that action to improve the present situation should command high priority ". I was interested to note that the Working Group stated that back pain is a symptom and not a disease. It would seem that the causes are known in some cases, but not in others.

Reference was made to the 18 controlled studies that have taken place, and the report went on, There is little to suggest that any of the reported trials have materially influenced clinical practice on any wide scale ". If that is so, I suggest that this matter needs to be looked at very carefully. Does this mean that almost total reliance is placed on relieving pain by drug treatment, with little hope of effecting a cure? I think we have to keep in the forefront of our minds the fact that when back pain moves in it may become a permanent lodger. Does it mean that nothing can be done, except to offer some relief by drugs? I often feel that the treatment of back pain is the Cinderella of the medical profession. It is not spectacular, nor glamorous, nor has it the drama of open heart surgery and the like. Yet the contribution of the back pain consultant is of supreme importance to the sufferers, because it is something that they may have to live with day after day, week after week, month after month or year after year.

I ask the noble Lord the Minister—and I do not expect a reply tonight, because this matter would need looking into—how many of these consultants who specialise in back pain receive a merit award? My guess is very few of them. I should be surprised if many of these merit awards—and I think there are four or five groups of merit awards, starting at around £2,000 a year and rising to £10,000—went to back pain consultants. At the Radcliffe in Oxford, we have an exceptionally able and competent person who I know does not get a merit award. He is well qualified and has written quite a number of papers on this matter. How can we hope to improve this form of consultancy, if the same rewards are not being given to such consultants as are given to those who are involved in the more glamorous and dramatic forms of nursing?

I am glad that the Cochrane Committee—rather, the chairman, to put it more accurately, of the Working Group—held discussions with the secretary and registrar of the General Council and Register of Osteopaths, with the principal of the British College of Osteopathy and with the representatives of the British Acupuncture Association. I myself was in New Zealand on an official visit when I was a Minister. I know what the opinion of chiropractors in New Zealand is. As the noble Lord has quite rightly pointed out, recently they decided to incorporate it into their national health service. I sometimes wonder what China would do, with its teeming millions, where there is a tremendous amount of back pain. I was in China some four years ago. There they depend, I would say almost entirely, upon acupuncture—and, I heard from those I talked to, very successfully.

The problem is so acute in this country that we cannot afford to disregard the contribution which these non-medical groups can make. In this field we need to think more about co-operation between the medicals and the non-medicals. The time has gone when there should be this very rigid dividing line between the medical side and the contribution which can be made on the non-medical side. It has got to be done for the benefit of those who suffer. The suffering must, I think, take precedence over professional jealousies; it is no good closing our eyes to the fact that this has been the position for a good many years.

I am very glad that the working party, under the chairmanship of Professor Cochrane, has made some progress. Professor Cochrane has had discussions with these three non-medical groups. I understand that there has been agreement in principle by the organisations representing the chiropractors, the osteopaths, the acupuncturists and the General Medical Council—which is important—that trials should take place, presumably with a view to using the skills of these three organisations. All I hope is that the expressed intention will materialise quickly, for in the last analysis it is the patient who really matters, not sectional interests.

I want to conclude by asking the noble Lord the Minister just two questions. Again, I am not necessarily asking for a reply this evening. If the Minister is unable to reply tonight, I should like to have an answer in writing at a later date. First, may I ask him what the Government are doing, or are proposing to do, by way of implementing the recommendations of the Cochrane Committee, because this report is now with the Department of Health and Social Security? I believe that it is for them to take the next step. Secondly, may I ask the Minister whether he can give an assurance that the Government will watch very carefully the particular recom- mendation that the three non-medical organisations, with the co-operation of the General Medical Council, will undertake trials and that they will see that it is carried into effect without too much delay?

9.25 p.m.


My Lords, in view of the late hour I intend to be very brief on this subject. Before I commence my remarks I feel that I must express some admiration for my noble friend Lord Ferrier for his persistent championing of the needs to integrate chiropractic, or as I would probably rather see it, some form of physical medicine, into the National Health Service or to make it more generally available to the public. Figures from the working party report are quite astounding. I must repeat the figure quoted by the noble Lord, Lord Wells-Pestell—21 per cent. of all adults in a fortnightly period. That is quite fantastic. My intervention tonight is because the figures are far worse for the members of my own dental profession. Thirty per cent. of us suffer from some sort of muscular skeletal disorder from our working position—and I am one of them. Because of the size of the problem it seems to me to be economically sensible to take steps to get the sufferers back on their feet and back to work. At present the resources of the National Health Service are inadequate to deal with this problem and many more trained personnel are needed.

The working party told us that many sufferers either do nothing or perhaps they treat themselves or eventually consult their general practitioners before even considering unorthodox treatment. Those who see their doctors probably end up as out-patients at the local hospital and usually undergo some form of physiotherapy, having first been through the radiographic X-ray department. In many cases this is the only treatment provided and time is the actual healer of the back complaint.

We need positive treatment for these complaints. Although I am only a dental surgeon I have personally referred many patients to practitioners of physical medicine and I could recount many cases of dramatic and instant relief. Since deciding to take part in tonight's debate I have visited both osteopaths and chiropractors and discussed the problem with that well known orthopaedic physician, Dr. Ronald Barber. Despite some personal medical knowledge I find it difficult to distinguish between the osteopathic and the chiropractic form of diagnosis and treatment. Although the question tabled by my noble friend Lord Ferrier refers specifically to chiropractic I feel that both skills must be considered and collectively referred to as "physical medicine ". I am disappointed, after my meetings with these practitioners, that both chiropractors and osteopaths still tend to belittle each other, and during my talks I got the distinct impression that each consider themselves to be superior operators. There is no doubt that practitioners of both types of physical medicine must undergo a period of training and become registered after passing the necessary examinations. Great emphasis must be placed on correct diagnosis. We have heard tonight and in the past about the importance of radiographic examination. This is admittedly an aid to diagnosis, but even well-known orthopaedic physicians find it difficult to diagnose from X-ray plates. It is knowledge and experience that influence the final decisions as to the correct forms of treatment.

There is no doubt that positive treatment by trained practitioners of physical medicine, whether they call themselves osteopaths or chiropractors, has much to offer the public and the overworked National Health Service. I should like to see more co-operation and more co-ordination. I feel that osteopaths and chiropractors should combine their skills, perhaps first training at a college teaching a combination of the sciences over a four-or five-year period, the resultant graduate becoming a doctor of physical medicine. Such a doctor could then be involved in the orthopaedic departments of hospitals and with help from physiotherapists treat the majority of cases of back pain, leaving the orthopaedic surgeons to concentrate on the job for which they have been trained; namely, that of bone surgery.

9.30 p.m.


My Lords, I shall also be extremely brief tonight. I think that, on this question, we should ask ourselves why the use of largely unmedically qualified chriopractors has grown to such an extent. The answer must surely be that they provide a service which is not available from hospitals or the medical profession in general. As I understand it, chiropractors concentrate on back pain and manipulation, and we have heard some impressive statistics on this. But it is only one of a wide range of pain affecting all moving parts of the body which may be classified as soft tissue lesions, much of it being covered by the layman's term of rheumatism. We have already heard the DHS figures which are those of 13 million working days a year lost through disorders of the lower back, and this represents only about 50 per cent. of the total of soft tissue lesion cases.

In fact, almost no one escapes some trouble of this sort during their lives. So far as I can gather, conventional medical education in the United Kingdom provides almost no training in the diagnosis and logical treatment of these disorders. Methods for doing this were pioneered by Dr. Cyriax of St. Thomas's Hospital many years ago. They have been adopted and are taught in Holland and in Belgian medical schools. They are institutionally available in Germany, where hospital stay times have been reduced by over 80 per cent. and visits which frequently covered several months often cut to a single session. In England, if you hurt your shoulder or back, or suffer from referred pain in, for example, your leg as a result of a slipped disc the outlook is very bleak. The surgeon will say that there is nothing wrong with the bone structure, and of course the X-ray hardly shows up at all the question of a slipped disc. You will then be passed to the physiotherapy department. Although they cannot give a diagnosis, except in general and often unmeaningful terms, they will do their best but with treatments which are almost wholly ineffective.

In effect, my Lords, there is a department or section missing in every United Kingdom hospital. It should cover all soft tissue lesions, and abroad is called the Department for orthopaedic medicine. To create this facility it is only necessary to extend the physiotherapy syllabus, but if their chartered society continue to resist such change there are other administrative ways of achieving the same end.

I am afraid that I cannot wholly agree with the noble Lord, Lord Ferrier, on the role of the chiropractors in providing a solution to the problem. First, I do not think they should officially work without qualified medical liaison, and it would be difficult to arrange this. Moreover, their own organisation for vetting practitioners would need careful examination. Secondly, and most importantly, they cover only about 50 per cent. of the type of cases I have mentioned in the field of soft tissue lesions.

Dr. Cyriax's methods have been tried out and proved, not only in his own hands but in other countries. Basically, they are methods for accurate and useful diagnosis and treatment. The latter in most cases consists of manipulation, heavy traction, and injection of the seat of the trouble.

I have already referred to what is known as "referred pain" where one gets pain somewhere which has no relation to the seat of its cause. Why is it, therefore, that, with the enormous suffering of patients from inadequate treatment, nothing is done to validate these methods here in the United Kingdom? It is not even a question of danger to the patients which would make the inertia of the establishment more understandable. After what has been said this evening as regards the importance of this matter, I am appalled by the nature of the reply that I received to a Written Question on this subject. I think that it was one of the most unhelpful replies that have been written for a very long time.

9.36 p.m.


My Lords, I also welcome very much the opportunity which the Question of the noble Lord, Lord Ferrier, gives us of discussing that major and much neglected scourge—back pain. Back pain causes intolerable pain to very many people and places an unacceptable burden on the community and the Health Service. Although the Question of the noble Lord, Lord Ferrier, is specific, I intend, with your Lordships' permission, to devote most of my time to discussing back pain in a more general way as a background to the Question.

First, may I declare my interest. I have been associated with the Back Pain Association for a number of years. I was its chairman for some years, and more recently became its honourary treasurer. The Back Pain Association is a registered medical charity whose objectives are: To encourage research into the causes and treatment of back pain; to help to prevent damage by teaching people to use their bodies sensibly; to form groups which would help disseminate useful information, provide neighbourly help to sufferers "— and last, and by no means least— to raise money to further their aims ". The Association is unique in this country and we believe that it is unique throughout the world, because it concerns itself solely with the problems of back pain. It is multidisciplinary since back pain knows no frontiers, and it seems to me a pity that we should ourselves seek to erect professional frontiers.

I have said that back pain causes intolerable pain to very many people and is an unacceptable burden on the Health Service. I should like to quantify those remarks, and I apologise for repeating some figures which your Lordships may have already heard. It is known that 80 per cent. of the people of this country will have back pain at some time in their lives, and, as the Cochrane Report said, no age group seems to be exempt. Every year some 1.5 million people go to their doctors with back pain. It has been estimated that 7 per cent. of the time of a GP is taken up with back pain—that is to say, one patient out of 14 who goes to his doctor, goes to complain of pain in his back. Every day some 56,000 people are away from their jobs because of back pain. The resultant loss of production has been put as high as £700 million. It could easily be £500 million, and that takes no account of losses due to people going to work in pain and not doing a full day's work. In addition, the cost to the Health Service itself must be of the order of £100 million. As has already been said, those figures pay no attention whatever to the disruptive effect in the home due to the widespread incidence of hack pain among housewives. That is most serious.

So, back pain is undoubtedly a major scourge. Fortunately, there is a rather brighter note: much of back pain goes away. There seems to be a natural tendency for recovery without professional help. But far too many people seem to be chronic sufferers. Equally important, much back pain can be prevented. Thus, in addition to research into the causes and treatment of back pain it is essential that we educate people to look after their backs and avoid pain.

I said in my opening remarks that back pain has been neglected. Dr. Owen was the first Minister concerned with the Health Service to emphasise the serious problems caused by back pain. He set up the Cochrane Working Group, as we have heard, in July 1976, its report being published in May last. I shall quote again the first sentence of its terms of reference: Back pain is a major source of discomfort and disability to many people and a serious economic problem in terms of lost production, sickness benefit and cost of treatment ". Let me also quote one sentence from the report which says: There is profound and widespread dissatisfaction with what is at present being done to help people who suffer from back pain ". That sentence alone justifies the Working Group. I am very pleased to say that Dr. Vaughan has also shown a keen interest in the problem. Recently he was good enough to attend the annual general meeting of the Back Pain Association, which was held in a Committee room in another place and attended by many sufferers. He now has the task of implementing the recommendations of the Working Group.

But some of your Lordships may well ask—as do many people when we try to interest them in these problems—if back pain is so serious and so widespread, why has it not been tackled before in the way that other ailments are being tackeld? Why has it been neglected for so long? I do not claim to know, but I make these suggestions. First, it is a highly complex matter. We know far too little about its causes and it follows that we know far too little about its treatment, as so many sufferers know to their cost. It cuts across many disciplines—rheumatology, neurology, orthopaedic surgery, anatomy, biology, biochemistry and psychiatry, quite apart from other disciplines, such as ergonomics, chiropractic and osteopathy. Therefore, back pain has been the concern of no one discipline; it seems to fall between every stool. This must raise special problems for general practitioners who have been taught little or nothing about back pain when studying for their exams, and who do not know where to turn when one patient out of 14 comes to the surgery in pain.

As my noble friend Lord Wells-Pestell said, back pain is not emotive; it does not kill; it makes no dramatic appeal. Indeed, it is too often a matter for ridicule, except for the people who suffer from it. Far too many people, especially women seem to regard it as inevitable. It is almost too widespread. So there has been no incentive for a nationwide, dedicated attack upon the problem. Research into back pain has been extremely small. It may well not exceed £250,000 a year, much of which is spent by the Arthritis and Rheumatism Council within its own terms of reference.

But research is a primary objective of our Association and the research projects that we have been able to finance have been very important. I can give many examples, but time is short. I believe that the Government themselves must find some means of supporting more research. The amount of money required is small—£250,000 a year would go a long way. In his report Cochrane says: … sustained and increased support for research … is not only essential but should also command high priority ". I hope that the Government will heed those wise words.

I have also referred to prevention. Much back pain arises because people do not use their bodies sensibly; nor does the equipment we all use in the factory, the office and at school, quite apart from motor cars and beds, pay regard to the risks of back pain. So there is room for a real drive to educate people on the avoidance of back pain and the promotion of self-care. Here again, the Association has made a good start through its education committee.

Then there is the problem of Samaritan work. How can we expect a young housewife with severe back pain to look after her young children? To where does she turn for help? I suggest that it is not good enough, as happened in one case we know of, for a young housewife in great pain and with two young children, to be told by her doctor that she must "learn to live with it". The Association is encouraging the formation of local groups where back pain sufferers can meet, learn about one another's problems and hear from experts about what is going on as regards research into the causes and treatment. "Prevention" is the key word, and so is Samaritan work.

One of the disappointments that we have had in dealing with these problems is the virtual impossibility of persuading industry to take these problems seriously. For example, we recently wrote to 1,400 top trading firms in this country asking for their help and telling them about the problem. The response was lamentable. We have received 175 replies and 30 companies have offered £2,800. More than 1,200 companies did not even bother to reply. So there is something more that the Government could well do; as, after all, health and safety is recognised as a matter of importance, and this neglect of back pain by industry we find most surprising. Oddly enough—perhaps not oddly enough—the nationalised industries have been more far-sighted. The railways, the docks, the coalmining industry and the Post Office are all taking the problem seriously and doing something about it. I am also bound to say that we have fared little better with the trade unions, who seem to disregard the fact that tens of thousands of their members are chronic back pain sufferers.

I should like to turn briefly to the specific Question which the noble Lord, Lord Ferrier, has tabled. May I say from personal experience and from the experience of our Association, that chiropractors are making a real contribution towards solving back pain problems. We have had more than 20,000 letters from sufferers, most of which amply confirm the comments of Cochrane that there is profound and widespread dissatisfaction with what is at present available to help people who suffer from back pain. If the Health Service cannot help people have to turn somewhere else, and many of them have turned to chiropractors and osteopaths, and not in vain. So I hope very much that the DHSS will consider how chiropractic can be recognised.

This brings me to one specific point. In my view it is disgraceful that 15 per cent. VAT should be levied on patients who go to chiropractors and osteopaths for relief of suffering. The sum of money involved is tiny but I suggest that the principle is totally wrong. Lastly, may I join the noble Lord, Lord Ferrier, in asking the Government to tackle back pain as a matter of real urgency. Cochrane was published in May. As my noble friend Lord Wells-Pestell said, time is passing. What is being done? As I understand the general views of this Government, they believe in individual initiative, increased efficiency, saving of waste, reduced public expenditure and sound investment. Let them look at an attack of back pain. Individual initiative seems to have done more than the Health Service. So why not give it more support and encourage self-care? Efficiency can be increased and public spending can be cut.

What a splendid investment! If the cost of back pain to this country could be cut by only 10 per cent. we could save £60 million a year. And the cost of the investment? Probably about a quarter of a million pounds a year. Where would you find a better investment? And just think of the suffering you can save people. The Working Group said that back pain was a subject of great public interest, and all these considerations reinforce the conclusion that action to improve the present situation should command high priority ". Here is a golden opportunity for the Government to show that it has regard to the public interest and to the suffering of many people.


My Lords, before the noble Lord sits down, he mentioned the question of incidence of back pain among children. Would he agree that one of the allied problems is that the size of children is increasing as years go by which means that increasingly primary school furniture is getting too small?


My Lords, I could not agree more. I do not know whether any of your Lordships have been in a school room recently. Children do not just seem to get bigger; their variation in size seems to get greater. There seems to be no desk that can fit every child.

9.48 p.m.


My Lords, I am also much obliged to the noble Lord, Lord Ferrier, for the opportunity to repay a great debt of gratitude. I have gained lasting relief over many years from the ministrations of chiropractors, and I know of many more who have gained relief from more acute distress. I have a modest interest to declare as a recent patron of the Chiropractic Advancement Association, but alas it offers no remuneration and only immense psychic satisfaction.

I assume that the noble Lords still present owe their remarkable vigour and liveliness to having discovered the boons of chiropractic and related therapy. If that is so, I wish it were more widely understood and enjoyed. We have heard that chiropractic manipulation can relieve back pain, but after my intensive inquiries I discover that it can often also relieve pain in the leg, neck, shoulder and arms, and it can frequently assist with pain ascribed to rheumatism or arthritis, or so-called slipped discs, and even in the extremities to troubles attributed often to sinusitis and migraine.

The credentials of chiropractic are no longer in doubt. If we go back to the debate in 1976, the late Lord Platt, whom we miss so much, acknowledged from his very migh medical eminence: The medical profession is not very good at treating many things, including back ache, and people who have been brought up to study these conditions, even in a somewhat unorthodox way, can effect cures where the medical profession has signally failed to do so ". May I take you back to 1975 when the Chiropractic Association applied for registration under the Professions Supplementary to Medicine Act 1960. They were cavalierly thrown out without even the courtesy of an explanation. How can this be so?

I am a professional economist, and I frequently find that Adam Smith throws light on many strange situations. My favourite quotation from Adam Smith for this occasion: People of the same trade seldom meet together even for merriment and diversion but the conversation ends in a conspiracy against the public ". What Adam Smith was referring to was the widespread tendency of sectional interests to exclude competition. If I may say so, the Council under the 1960 Act, though it does not seem to have much to do with Adam Smith's merriment and diversion, seems to me to act in the spirit of a monopolist, the mean, narrow, exclusive spirit of a medical trade union, slamming the door on specialists who might tackle some infirmities better than general practitioners or even surgeons themselves.

If there were time I would tell your Lordships of the terrible complication arising from the fact that treatment under the NHS is so-called free. It may come to many patients as free, but it does little good because it does not have the remedy for their particular problem. But they may be attracted to take a free non-remedy rather than seek out the chiropractor who will make his modest charge, who does not advertise and who relies entirely on recommendation.

I have no doubt that chiropractors could relieve an immense amount of daily continuing distress among all ages, from the young to the very elderly. The great problem about Lord Ferrier's proposal that it should be incorporated in the Health Service is that there are only about 100 chiropractors available in this country. I want the Minister to address his mind to the fact that the action of the Council for the Professions Supplementary to Medicine, in rejecting chiropractic, makes more difficult the possibility of building up the number of chiropractors and attracting students by treating them as beyond the pale. By ostracising them and by denying them even access to the maintenance awards which they would get as students practising other callings which may be less effective for many purposes, the numbers of students are reduced below what they might be.

I am not practised in the limits of parliamentary language, but I would hazard a description of the attitude of the council under the Act as outrageous, as scandalous and as a conspiracy against the public welfare. I have read that a number of Ministers of both parties have said that they would see how far they could go in the disclosure of the reasons, or encouraging another appeal through the Privy Council. I therefore ask the Minister if he might hold out some hope that a further renewed application to the council by the chiropractic profession will not be treated in such a disgraceful manner.

9.54 p.m.


My Lords, the noble Lord, Lord Ferrier, and I, as he well knows, have something in common: We both believe that there are, outside the medical profession, common law practitioners who have proved to the satisfaction of their patients that the therapies they offer are extremely effective in the treatment of back pain, spinal disorders and related conditions. It would be wrong of me, in speaking in reply to his Question on behalf of Her Majesty's Government, to seek to conceal the fact that I have long had an association with the General Council and Register of Osteopaths and the British School of Osteopathy which cannot be greatly dissimilar from that he must have with the British Chiropractors' Association, the Anglo-European College of Chiropractic and the Chiropractic Advancement Association. I have been interested during the course of the debate to hear a great many things that I have heard over many years from osteopaths, and I now find myself in the slightly complicated position of having to give the standard reply to what has been raised.

If chiropractic has proved efficacious in the treatment of conditions which, in the experience of many, doctors have failed to treat equally well, then it must seem unreasonable that those who cannot afford to pay for it at the hands of private sector practitioners should be wholly deprived of its benefits. I therefore sympathise with the noble Lord when he asks what plans the Government have to make chiropractic available on the National Health Service so that all may have access to it, as they do to medical treatment. Unfortunately, there are difficulties which make it impracticable for the Government to meet the wishes of the noble Lord, Lord Ferrier, and of those who share his very reasonable point of view.

First, let me seek to explain the legal position. Section 29(1) of the National Health Service Act 1977 states: It is every Area Health Authority's duty, in accordance with regulations, to arrange as respects their area with medical practitioners to provide personal medical services for all persons in the area who wish to take advantage of the arrangements ". This means that a citizen who wishes to take advantage of these services under the National Health Service must first register with a doctor in general practice who is under contract to provide primary medical care in the Health Service. If such a person then becomes ill—except in such urgent circumstances as might take him directly to the casualty department of a hospital—he must call on, or call in, his NHS general practitioner to prescribe his treatment. The law excludes the general practitioner from referring his NHS patients to a private practitioner of whatever discipline or profession at the expense of the National Health Service.

Once the NHS patient has been referred to the hospital consultant, then it is for the consultant to treat the patient himself or to prescribe his treatment, under his own supervision to the extent that he remains responsible for the patient's well-being, by another doctor or by some other member of the staff of the hospital, such as a physiotherapist or an occupational therapist, or a member of one of the other State-registered professions supplementary to medicine working in the National Health Service.

If a NHS patient, having seen his doctor, decides not to go to the hospital and keep the consultant or other appointment made for him, but instead to seek treatment from a chiropractor, or an osteopath, or an acupuncturist, in private practice, then the patient must pay for that treatment himself, even though his doctor may have agreed to his seeking it. The position is the same if the patient does not go to his NHS doctor at all, but decides to go instead to a chiropractor, since, for the purposes of the treatment he thus seeks of his own volition, he is opting out of the arrangements offered by the National Health Service.

Noble Lords may argue that not all primary health care in the NHS is provided by medical practitioners, that patients can go directly to dentists, to opticians, and, if they qualify, to chiropodists and obtain NHS treatment by paying no more than such charges as law and regulations permit and prescribe. Why, therefore, cannot they also go to chiropractors? The answer is that chiropractors provide medical treatment, or some aspects of medical treatment, for the same conditions as are treated by the general practitioners with whom the patients are registered for NHS treatment. Our National Health Service legislation does not offer (as, to a minor extent, the health insurance systems of some countries do) the opportunity for the patient to exercise a choice in how he shall be treated and in who shall treat him. The NHS patient cannot decide that for this condition he will seek treatment from his doctor, but that for another he will seek treatment from a chiropractor. To make such a choice of practitioner available to NHS patients would require an amendment to the law. It would have to be made the responsibility of the Area Health Authority to arrange with other practitioners, as well as registered medical practitioners, to provide treatment on the National Health Service for all those persons in their areas who wished to take advantage of the arrangements. Need I say that this could be pretty expensive, as all these alternative practitioners would have to be paid without any diminution of what is paid to the general practitioner doctors under the terms of their NHS contracts.

However, let us suppose that the law was amended and the money found to make this choice of practitioner and treatment possible. Where, then, should we find the practitioners? On 1st October 1978 there were 2,363 general medical practitioners providing personal medical services in the National Health Service in England and Wales. At the same time—I take my figures from a count made in the Register of Members of the British Chiroporactic Association for 1978—there appear, as the noble Lord, Lord Harris, has just mentioned, to have been only 91 chiropractors practising in England and Wales, and their distribution was very uneven. Had all of them been employed full time in providing services for NHS patients, how could they possibly have coped should there have been a substantial demand for their services? No more patients would have been treated than were already being treated as private patients; or, if the number had been greater, the treatment would inevitably have been more perfunctory. And is it not to escape from the little personal attention that their hard-pressed general practitioners can give them that many patients do in the first place decide to seek private treatment, whether it be from a doctor, a chiropractor or an osteopath?

This problem of inadequate numbers would still remain if the chiropractors were retained under contract with the Health Service to provide treatment on a sessional or fee-per-treatment basis for NHS patients in hospitals or in their own surgeries, with the patients having first had to be referred to the chiropractors by their general practitioners or by their hospital consultants. Furthermore, would the chiropractors accept such a role, with the medical practitioners determining which patients and what conditions they were competent to treat? Might there not be many doctors, unconvinced of the validity of the principles on which chiropractic is based, who would not refer their patients to them? Might there not be many health authorities, equally unpersuaded of the efficacy of chiropractic, who might well not employ any chiropractors even if they could find some to employ? The Government could not dictate to the doctors or to the health authorities in this regard.

I am aware, as has been mentioned by several noble Lords, that the chiropractors have sought to secure state registration as members of a profession supplementary to medicine under the provisions of the Professions Supplementary to Medicine Act 1960. I am equally aware that, when the Council for Professions Supplementary to Medicine rejected their application, it declined, and could not be compelled by the Privy Council, to give its reasons for doing so, and that the chiropractors and the Chiropractic Advancement Association are aggrieved. However, I believe that, if the chiropractors sought by their application to achieve a longer-term acceptance by the medical profession of what they have to offer and their own ultimate integration into the National Health Service, then their action in making the application was correct. My right honourable friend the Minister of Health has already commended to them that they should seriously consider making a further application.

The Working Group on Back Pain—the Cochrane Working Group—recommended in its report, published in May of this year, that there should be comparative trials of manipulative treatment for back pain, and that these should include both orthodox (that is, medical) and other means of treatment. The chiropractors have been assured that soundly-based proposals for such trials, which need not be limited to comparisons of their own manipulative treatment with medical manipulative therapies alone, will be considered sympathetically for financing from public funds; and I understand that the chiropractors' own research officer is already considering with others the protocols for such trials, and that the chiropractors have expressed willingness to participate in them. This I consider encouraging.

My Lords, I was asked one or two questions. I was asked by the noble Lord, Lord Wells-Pestell, what the Government are doing about the report of the Cochrane Working Party on Back Pain. Most of the recommendations in that report were about research. In a Written Answer to a Question in another place, my honourable friend Sir George Young said Research into the causes of and treatments for back pain is already given high priority by the Department. My right hon. Friend is satisfied that adequate resources are available to the Department and to the Medical Research Council for support to be given to any soundly-based research proposals in this field, including comparative studies involving heterodox therapies ". I understand that the British Chiropractic Association is shortly to seek the views of the Department of Health and Social Security on the protocol for such a comparative study. As the rest of the same reply states, the other recommendations in the report on back pain research centres, on the issue of questionnaires to ascertain present treatment for back pain and the establishment of a panel for proper ongoing advice were still under consideration and a statement will be made in due course.

I was also asked a question by the noble Viscount, Lord Hanworth, who kindly let me know beforehand what he was going to ask. He mentioned that medical education in this country provided almost no training in the diagnosis and logical treatment of soft tissue lesion cases and referred to the method of treatment pioneered by Dr. Cyriax. It is not for me to say how soft tissue lesions should be treated. This is a matter for medical judgment, and so is the matter of how doctors should be taught to treat them. The content of the training of medical students is the responsibility of the education committee of the General Medical Council as imposed upon it by Section 15(1) of the Medical Act 1978. Whether Dr. Cyriax agrees with the principles of chiropractic or how his own views diverge from them, I am not qualified to say; but we should not overlook the fact that during all the years he worked as a consultant physician to the St. Thomas' Hospital, Dr. Cyriax had what might be described as a capitve audience of medical students who must have learned from his ideas and practices; and he was also involved in post-graduate training.

Dr. Cyriax's associates recently formed the Society of Orthopaedic Medicine and, what is more, my honourable friend Sir George Young attended on behalf of my right honourable friend the Secretary of State for Social Services, the Press conference which launched it. It is now for the medical profession to decide whether what that Society calls for—a separate specialty or orthopaedic medicine—is what is needed. Certainly, it is not for Her Majesty's Government to dictate to it, nor for it to tell the physiotherapy board or the Chartered Society of Physiotherapy what physiotherapists need to know and should be taught to do.

Finally, coming to my noble friend's Unstarred Question, for reasons which I have sought to explain the Government have no present plan to integrate chiropractic into the National Health Service. However, they recognise that in the private sector and in those places where there are chiropractors in practice, the regard in which their patients held them and the results obtained from their treatment of certain conditions are obvious evidence of the contribution chiropractors are making to health care generally. The Government also welcome the very obvious efforts which common law practitioners in the field of health care—not just chiropractors—are making to organise their professions and their training courses in such a way as will achieve for them the increased respect of parallel professions.

In the fullness of time there may be achieved what my noble friend Lord Ferrier and others so much desire. Speaking purely personally, I hope that in due course arrangements may be made by which qualified chiropractors, osteopaths and acupuncturists could if they so wished, make their skills available to National Health Service patients. I understand however that there are many osteopaths who would not wish to be deprived of their right of diagnosis and choice of treatment, and that the General Council and Register of Osteopaths has no present intention of making an application to the CPSM.