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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.
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