(13 years, 10 months ago)
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Lord Luce
My Lords, I am most grateful to the Minister for replying to this debate and to all noble Lords who are taking part in it. Why do I raise the subject? For over 40 years, I have suffered from chronic back pain due to musculoskeletal problems, but I am fortunate in that I have managed to live a full life with various public responsibilities due almost entirely to prompt, effective and dedicated support from specialists in the private sector. Very few people have access to it. Some 7.8 million people in this country suffer from chronic, as opposed to acute, pain, and my plea today is that the Government ensure that every single one of them has access through the National Health Service to multidisciplinary rehabilitation to help them to stay in their jobs and to live a life of at least tolerable quality. Given this support, I believe we can learn to manage our own pain.
The facts are horrific. One in seven individuals suffers from chronic pain, of which musculoskeletal pain or osteoarthritis is the commonest cause, although it includes cancer pain. It can be deeply damaging to the quality of life, causing sleeplessness and depression while interfering with normal physical and social life. Milton wrote,
“… pain is perfet miserie, the worst
Of evils, and excessive, overturns
All patience”.
Moreover, it has an adverse effect on the economy of the country as well as on the individual. Chronic pain takes up the equivalent of 4.6 million GP appointments, costing approximately £70 million per annum. In 2000, it was calculated that the total cost of back pain was just over £12 billion, and today 119 million working days are lost per annum because of back pain. A recent pain survey in Europe showed that 25 per cent of people in chronic pain had lost their jobs and that a considerable proportion of them never return to work. In the present economic climate, it is worth stressing that an effective preventive service could save overall costs in the long term.
A turning point came with the report on pain by the previous Chief Medical Officer, Sir Liam Donaldson, in 2008. He stressed that pain affects all age groups, not just the elderly. Worryingly, a quarter of school-age children have reported pain and 8 per cent suffer from chronic pain. Sixty-eight per cent of pain clinics in the UK do not see children, according to the British Pain Society. The most affected are those at work in their 40s and 50s. Sir Liam highlights the fact that only 14 per cent of those suffering from chronic pain have seen a pain specialist, normally an anaesthetist, and that the infrastructure is inadequate, unco-ordinated and unevenly resourced, which results in a variable quality of service provision—in other words, a postcode lottery. Generally, interest from primary care trusts and strategic health authorities in establishing better pain services seems to be low.
The report’s conclusion is clear; pain needs to be recognised as a disease in its own right, and a pain score should become one of five vital signs to be monitored routinely in hospitals and elsewhere. Above all, it advocates that a multidisciplinary approach should be vital in the prevention, assessment and management of pain and that there should be a national network of rapid-access pain clinics providing early assessment and treatment, as early intervention is critical for improving the long-term outcome. The report adds that all health professionals dealing with patients should be trained in chronic pain and that the assessment of pain should be included in the quality and outcomes framework in primary care. Other recommendations include the creation of a model pain service of pathways of care and the maintenance of a proper database.
I am delighted to say that, to help us in all this, is the Chronic Pain Policy Coalition, under the chairmanship of Dr Beverly Collett, who runs a successful pain management unit in Leicester. It also supports an all-party parliamentary group—Anne Begg MP was re-elected today as its chairman—that has a growing membership, in this new Parliament, of more than 20 parliamentarians. We are now most anxious to see the recommendations of the former Chief Medical Officer implemented.
For my part, I have witnessed some successful multidisciplinary operations in the NHS. In my own county, I have visited the West Sussex Primary Care Trust and seen its chronic pain management services in Bognor, where it aims to achieve integrated musculoskeletal, rheumatology and pain management services. Key to this is its provision of tools for patient self-management with the help of hydrotherapy, muscle-pain clinics, physiotherapy, fit-for-work schemes and clinical psychology. I was particularly impressed by my visit to the Pain Management Centre, which is led by Dr Baranowski at the National Hospital for Neurology and Neurosurgery in London. It has had success in treating patients on a multidisciplinary basis.
Another centre of excellence is the Pain Management and Neuromodulation Centre at Guy’s and St Thomas's in London under the leadership of Dr al-Kaisy, whose excellent residential unit gives prospects of a better life for many patients who had been in despair from their suffering. I have also seen the support given to cancer patients suffering longer-term pain at the Palliative Medicine and Pain Unit of the Royal Marsden Hospital, which is led by Dr Williams. The unit has a multidisciplinary strategy that gives options ranging from medication, physiotherapy and psychology to interventional support. It is good that pioneering work, principally on the spinal cord and the brain, is being carried out, mainly in some university research departments. I hope that it may eventually lead to improved methods of treatment.
There is therefore clear evidence to show that, with the right expert support, people can be encouraged to manage their own pain, improve the quality of their lives, and in many cases stay in employment or, indeed, return to work. The provision of access to multidisciplinary pain clinics would in itself be a good investment for the country. This is best highlighted by Dame Carol Black's 2007 review of the health of Britain's working-age population. She stressed the business case for employers' investment in employees’ health. Much can be done through preventive and remedial measures with more flexible working patterns and wider provision of support and therapeutic sessions. A key recommendation was to change the nature of the GP’s sick note so that the GP focuses on what can be done to encourage the patient to go back to work rather than stay at home.
I should highlight the fact that Scotland has set something of a lead in managing chronic pain. In 2007, the Scottish Health Minister recognised pain as a long-term condition in its own right, and he has appointed a pain tsar to co-ordinate all pain service development. Last summer, I was briefed by the pain management service in the Shetlands, which caters for a population of 20,000. The Welsh Assembly Government have recognised pain management as one of five areas for improvement by providing services nearer to people's homes.
I am glad to note that the National Institute for Health and Clinical Excellence has issued guidelines on the early management of persistent low-back pain. I understand that the new National Quality Board is considering where chronic pain fits into the level of clinical priorities for quality improvement in healthcare.
I hope that the Minister will be prepared to meet me and some interested parliamentary colleagues before long to discuss the way ahead. The previous Government can take credit for laying the foundations, and I look to this new coalition Government to make a determined effort to establish multidisciplinary rehabilitation pain management services that are accessible to all those suffering from chronic pain in England. My experience tells me that if they do that, they will give hope to many people of all ages in this country.
Baroness Masham of Ilton
My Lords, I thank my noble friend Lord Luce for this important short debate on chronic pain and congratulate him on his ongoing campaign to make conditions better for people with continuing chronic pain. Some years ago, when I was sitting next to my noble friend at lunch, he had such excruciating pain in his back that he had to go out and lie on a bench, and an ambulance was called. I have always had the greatest admiration for his tenacity in holding down an important position while enduring such chronic pain. It is good to see him still bringing this matter up. Who knows better what pain means? He is an expert and I hope that the Government will listen.
I know excruciating pain. I broke my back and fractured many ribs in an accident many years ago. When I arrived at the spinal unit at Stoke Mandeville Hospital I was not given any painkillers for fear of addiction. In those days, that was the policy because we were turned only three-hourly to prevent pressure sores. Cramp used to set in and I understand the expression “blood, sweat and tears”.
When a doctor told me that the pain should ease off in three weeks, that was the light at the end of a very dark tunnel. It is important that the psychological implications of chronic pain are understood—for example, how it can cause depression, break up partnerships or loss of jobs. Pain can eat into people’s lives. In 2008, there was hope in the Chief Medical Officer’s annual report, which wanted,
“to widen access to high-quality pain services”.
What action has been taken in the past two years by the National Quality Board on clinical priorities for the NHS? What are the Government’s views on this subject?
The public need education in what to expect from analgesics and in how they can help themselves to cope with chronic pain. Postgraduate training is needed for the safe and appropriate prescribing of analgesics and the use of other therapies. Often, GPs prescribe pain-killing drugs to patients who are not reviewed and end up becoming dependent and addicted. About 8 million people of all ages suffer from chronic pain. Only about 14 per cent of them have access to any pain specialists. Long-term pain can have a devastating effect on the lives of sufferers and families. Forty nine per cent suffer from depression; 25 per cent lose their jobs; and 16 per cent feel suicidal.
Pain can be very complex. I am president of the Spinal Injuries Association. Some of our members have root pain or phantom pain, which is not well understood. Some people turn to alcohol, which may help but can damage their kidneys. Something has to be done to improve the situation. There is much need for research into pain and for multidisciplinary pain management services across the NHS which encompass doctors, physios, nurses, occupational therapists, psychologists and expert patients who are all trained in pain care. There needs to be co-operation and co-ordination, and not fragmentation. I wait in anticipation for the Minister’s reply.
Baroness Gardner of Parkes
My Lords, pain management is very important and I am grateful to the noble Lord, Lord Luce, for introducing this debate. I should declare an interest in that I have a daughter who has had multiple sclerosis for almost 30 years. To a degree, she has been fortunate in that she has not suffered pain. But many sufferers of multiple sclerosis suffer severe pain. Some of them have pain in their mouths—trigeminal neuralgia. In oral dental training, the trigeminal nerve is a very important nerve in the face. It is the one that we have all heard about and we all hope that people will never get trigeminal neuralgia as it is considered to be the most horrendous pain that exists and is very difficult to deal with. Although various things can be done, sometimes that involves surgery, and for someone with multiple sclerosis that is very difficult. So pain is a major issue.
Many years ago I went to the Eastman Dental Hospital to see Professor Harris. When I got there, they said, “Have you come for the pain control clinic?”. I said “No”. I had never heard of the clinic. But it was interesting that Professor Harris was doing tremendous research at the Eastman Dental Institute into pain control. He must have retired some time ago, but this work is being continued.
Someone sent me a valuable tome on trigeminal neuralgia, which I kept for years. I occasionally glanced at it, but I never really read it. I offered it to the Lords Library but was told that it was far too specialised. I eventually sent it to one of the dental training schools because it was too important to be thrown out.
Pain affects many people. The noble Lord, Lord Luce, talked about acute pain, as well as chronic pain, which is what we are dealing with now. Chronic pain can be severe pain, which is the most worrying aspect. People can manage to put up with a little unpleasantness from time to time, but severe, constant pain is terrible to endure. Apart from anything else, it is demoralising and exhausting. Pain can be a valuable warning that something is wrong, but I agree with the noble Lord, Lord Luce, that pain should be classified as a disease in its own right.
In 2006, I fell off one of those old buses, which I foolishly tried to hop on. It was at the lights and, unfortunately, I did not make it. I was tossed in the air and I broke one of my vertebrae, but I did not discover that for some time, although it was a little painful. By the time I was diagnosed it was too late to do anything about it surgically, but I was put on hydrotherapy, which was fantastic and dealt with the problem.
Another important point is that, often, the specialist nurses and therapists who work with these individuals pick up the pain issue and are able to refer people to the right place for pain management control.
Unfortunately, my time is up and I cannot say any more. This is a most important debate and I thank the noble Lord again.
Baroness Greengross
My Lords, I, too, thank the noble Lord, Lord Luce, for introducing this important debate. Pain can last for many years and some people have life-long symptoms. Sometimes it starts after a specific injury, but it is not always clear why people suffer in this way. As we have heard, some people suffer with continuing low back pain, pain related to joint inflammation or pain related to a nerve injury. Pain can follow an operation or an amputation, or even after what seems to be a not- very-serious infection, such as shingles.
We know that the effects of chronic pain can be disastrous and many people will need support in managing their symptoms. While specialist services are available in the community and in hospitals, I am aware that many people spend far too long without appropriate treatment. We are talking about large numbers of people and the accompanying huge costs spent in welfare benefits when people have to leave work and stop being productive in the community. We also know that death by suicide in chronic pain patients is double that of the general population and that severe chronic pain is associated with an increased 10-year mortality.
Much remains to be done with chronic pain management generally. I am particularly concerned about the status of older people in this regard. The recent National Audit Office health inequalities audit stated that much progress remained to be made on the issue, which would not be surprising as older people usually experience discrimination in the form of health inequalities, but also in poorer chronic pain management targets. Given the current austerity programme that the public sector is facing and the even greater importance of value for money, I hope that the Minister can assure the House that this aspect will be considered in terms of where any cuts will fall—bearing in mind that while we have been reassured that the NHS budget is ring-fenced, in fact that promise includes an existing £20 billion cut in expenditure.
In a survey, the BMA found that 43 per cent of those trusts which responded to it stated that there was a freeze on recruiting doctors and nurses and that many treatments, including varicose vein operations and blood tests, were being rationed. Set against this background, it is hard to see how the parlous state of chronic pain management services will be speedily remedied.
Finally, evidence strongly suggests that a human rights approach could have a practical role to play in this new era of austerity, breathing life into the Government’s promise to protect the most vulnerable and enabling us to interpret large sums into consequences for human beings. Public bodies have a duty to protect people who are suffering from inhuman and degrading treatment, and prolonged pain is in fact a category that would come under that heading. In their review of the Human Rights Act, the Government have said that they will keep these obligations intact, so an approach involving human rights could help public sector staff to remain aware of the huge human costs involved in chronic pain management. For example, the Mersey Care Trust has pioneered the use of human rights to give people with mental health problems and learning disabilities a meaningful role in the organisation, and there have been positive results. Service users and carers are involved in staff appointments, and this has led to a greater emphasis on finding staff with empathy and understanding as well as good technical skills. Perhaps such an approach to joined-up chronic pain management could reap enormous dividends.
Baroness Pitkeathley
My Lords, like other noble Lords, I want to confine my remarks to my own experience of pain and pain relief and to speak solely as a patient. Unlike the noble Lord, Lord Luce—I thank him for securing this debate—my experience is more of acute rather than chronic pain, and I am happy to say that I am now pain free. However, the principles I want to set out apply equally to both. While I endorse absolutely the view that co-ordination is all-important and a multi-disciplinary approach entirely the right one, when it comes to pain relief, I believe that these must be supplemented by the very best of communication.
This communication must have two aspects, the first of which is communication between professionals—the doctors and nurses, of course, but also the professionals ancillary to medicine such as the physiotherapists, radiographers and dieticians. If the medication for pain relief means that my feet are too numb to enable me to do the walking practice that the physiotherapist has recommended, what help is that to my recovery? If I can take absolutely nothing by mouth, and everything has to go by a Hickman line, the staff administering pain relief have to be very aware of it. I must put in a plea here for the extra services so often provided by volunteers in hospitals which all contribute to patient recovery but are not necessarily prescribed. I remember how, at a time of the most awful physical pain, the most relief I experienced did not come from drugs but from a nice young man who gave me a foot massage with scented oils.
Communication between departments is also vital. When you come out of intensive care, especially when coming back on to a ward, as I did four times in one hospital, there is nothing more frustrating than to lie there in pain with no one able to give you relief because your notes are caught up somewhere in the system. This applies particularly at night. Many patients still experience being in severe distress, but because far fewer doctors are available during those hours, they have to wait for someone—and at that point you feel that anyone would do—to administer some pain relief. So communication between professionals and between departments is vital, but in my view, no communication is more vital than that between the person administering the pain relief and the patient.
It is fine for an anaesthetist to say that an epidural is best for severe abdominal surgery, but if the epidural means that incontinence is a result, many a patient would prefer to endure the pain. Similarly, if the result of self-administered measured doses of morphine—in theory an excellent idea—is severe nausea to the point of exhaustion, surely the patient should be allowed to decide on other forms of relief. In one stay in hospital that lasted for about seven months, my worst memories are not about the pain, awful though it often was, but about the times when my wishes regarding pain control were ignored. However, I am happy to record that it is to the great credit of the NHS that those occasions were mercifully few. The best memories always centre around the way that caring people were prepared to consider me as an individual, and even to depart slightly from the rules; to discuss with me how drugs could be administered when I was unable to swallow anything for five months; and to maintain my dignity when those drugs had to be administered in most undignified ways. I recall also people like the young Nigerian charge nurse who would himself shed tears of sympathy when trying to find somewhere to inject me that did not cause excruciating pain to a body already like a pin cushion from repeated injections. As in many things, nothing can substitute for good communication when it comes to pain relief, either for chronic or acute pain.
I hope that the Minister will be able to endorse the importance of communication when any new policies are being developed.
Baroness Emerton
My Lords, I wish to add my thanks to my noble friend Lord Luce for initiating this short debate, following up his previous attempts to improve the multi-disciplinary approach to managing chronic pain. I declare an interest as a retired nurse and fully support multi-professional involvement. I certainly agree with the noble Baroness, Lady Pitkeathley, about the importance of care, compassion and communication as vital accompaniments. I also support my noble friend Lord Luce in urging the introduction of the fifth vital sign. It is extremely important that that is implemented.
There also appears to be a hold-up in extending the prescribing role of nurse consultants to patients suffering from chronic pain, although they are able to prescribe opiates to those suffering from acute pain or if they hold the role as a palliative care nurse. However, in a chronic pain clinic they have to refer the patient back to the GP. I understand that this causes great frustration to the patient, the GP and the nurse, and is wasteful of resources. I urge the Minister to look into this, please, to see whether it can be untangled.
I wish also to draw the Minister’s attention to an aspect of chronic pain that is preventable and very cost-effective. Reference has already been made to Dame Carol Black’s 2008 report, Working for a Healthier Tomorrow, which found that early intervention enables staff to return to work quickly, particularly where illness has the potential to become chronic and long-lasting, such as in the musculoskeletal disorders. Her report found that for employees with lower back pain, early intervention sees them return to work up to five weeks earlier than under normal care and reduces the recurrence of back pain in the following year by up to 40 per cent.
The Secretary for State for Health has made much of the need for an NHS that is focused on prevention and wider public health. Taking measures to safeguard nurses from back pain could be a tangible commitment to this. According to the Boorman review of November 2009, NHS Health and Wellbeing, which was acknowledged by the former Government, sickness among NHS staff in England currently accounts for 10.7 million lost work days at a cost of £1.7 billion. Some 30 per cent of the staff of the NHS are nurses. A national audit into clinical back pain management found that nurses and nurse support staff were more frequently absent than any other healthcare professionals with back pain caused by the level of manual handling in their jobs. It is not clear what the exact cost of back pain related nurse illness is to the NHS, but as nurses comprise the largest part of the workforce, it must make a significant contribution to the costs highlighted by Boorman. In addition, professional compensation awards can be significant. In recent years, awards of £800,000 and £400,000 have been made for work-related injuries. Early intervention to prevent nurse back pain related illness could help prevent a genuine risk to patient safety.
In the interests of ensuring patient safety, saving large sums of money as a result of preventive action and producing a healthier workforce, will the Minister add to the requests of other noble Lords my request for government action to encourage regular risk assessments, training in updated manual handling procedures and the supply of adequate equipment, especially in the community services, as well as a recognition of the need for early intervention in signs of lower back pain in nurses, support workers and other healthcare professionals? There is a saying that prevention is better than cure. Focus on prevention in this field would be of great benefit to patients, staff, management and the economy generally.
Baroness Morris of Bolton
My Lords, the noble Baroness, Lady Masham, has grown even more in my estimation. At 17, I fractured my spine—and if I had not had regular and large doses of morphine I do not know how I would have coped.
Just over four years ago, for reasons known only to itself, my immune system started to attack my body and I experienced the most excruciating pain in my feet, which spread to my hands, my wrists and then just about every other joint in my body. I could walk only if I wore the clumpiest of trainers, and I will always be grateful to your Lordships for allowing such glamorous footwear to be worn in the Chamber. At times the pain I experienced was so bad that my husband would walk downstairs in the morning to find me with my hands inside the deep freeze, so desperate was I to find relief.
I am not alone in my discomfort, and when I recount my own experiences I know I speak on behalf of around 600,000 people in the UK who suffer from one form or another of inflammatory arthritis. Some 380,000 of these have rheumatoid arthritis, which affects three times more women than men. Therefore, I am most grateful to the noble Lord, Lord Luce, for securing this debate.
According to the Arthritis and Musculoskeletal Alliance, musculoskeletal disorders are the second biggest cause of work-limiting health problems and sickness absence in the UK, with an estimated cost to society of some £7 billion per annum—and that is at 2007 prices.
There is a high divorce rate among women with this disease, probably because there are times when we cannot lift a kettle, cut a loaf of bread, do the washing up or iron a shirt. There are some days when you just cannot do anything. We need understanding and supportive families, and I am blessed with a great family.
I now inject drugs which keep most of my symptoms at manageable levels. I am lucky, if that is the right word to use, that I contracted this horrible disease at a time when medical research is making such tremendous breakthroughs. It has been my experience and, as research shows, the experience of most people, that services are most effective when they are delivered through a well-established multi-disciplinary team. The care I get from the rheumatology department at Bolton, which I will probably receive for the rest of my life, is second to none. As well as having had my drug regime sorted out, I have had physiotherapy, occupational therapy, Pilates lessons, warm hand waxes, podiatry and, best of all, acupuncture, which simply took the pain away and left me feeling beautifully relaxed. If I had wanted it, I could have had counselling or hydrotherapy. You name it; there was something for every need.
The acupuncture was so popular that it was difficult to book sessions, which were available only during the working week. I ask my noble friend the Minister whether there are plans to train more practitioners in acupuncture, and might we ever see weekend clinics for all forms of pain relief? I know that Bolton has been running some sessions to train patients in the self-administration of acupuncture, the results of which would be interesting to look at.
I have had excellent access to care in the NHS but, as the noble Lord, Lord Luce, said, this is unevenly resourced. For anyone suffering from chronic pain it is vital, not only for the well-being of the individual but for their families and society as a whole, that they get quick and consistent access to drugs and pain relief, delivered over a range of disciplines, so that they can lead as normal and economic a life as possible.
Lord Walton of Detchant
My Lords, I, too, am grateful to my noble friend Lord Luce for initiating this crucial debate because pain is one of the most distressing of human experiences. I shall concentrate on the importance of accurate diagnosis of the cause of pain before an appropriate programme of treatment can be initiated.
Everyone recognises chronic pain in osteoarthritis and multiple arthritis and in patients with cancer and terminal illness, but a number of chronic pains are recurrent and not continuous. The noble Baroness, Lady Gardner, referred to trigeminal neuralgia, which is a momentary acute lancinating pain in the face that may be precipitated by touching the face, by washing, by cold winds, by chewing. It is momentary and lancinating, and is a very severe and distressing pain that must be distinguished from the chronic low-grade continuous pain in the upper jaw that is not uncommon in middle-aged people and that has been shown to be a psychogenic regional pain that not infrequently responds to anti-depressive agents once dental causes have been excluded.
There is another form of pain called cluster headache in which people, every few months, may have every night—often at the same time, such as two in the morning—a hugely intense pain around the eye and in the face lasting for about half an hour, or a full hour, which wakes them from sleep time after time. It disappears after two or three months and then comes back again two or three months later. It is not migraine, but it, too, is a special headache syndrome that remarkably has been shown to respond to a drug called indomethacin. Accurate diagnosis is crucial, which is why the education of medical students, of young post-graduate doctors and of other healthcare professionals in the recognition of the different pain syndromes is so important.
Several speakers have stressed the importance of multi-disciplinary management. I, too, stress that because, in my experience, some people with chronic low-back pain have become so anxious and tense because of it that it builds up a kind of vicious circle in which the pain is accentuated by anxiety and tension. This can sometimes be helped enormously by the prescription of anxiolytic drugs and anti-depressives, alongside analgesics. That is why the multidisciplinary approach is crucial.
There are, of course, many physical methods of treating pain, including manipulation, injections, occasionally acupuncture and cutaneous nerve stimulation. There is a huge number: far too many to mention in this setting. However, at the same time, the recognition of the nature of the pain is crucial.
Another curious pain, proctalgia fugax, is an agonising pain in the anus that lasts for five to 10 minutes. It may recur completely out of the blue and for no reason at all. I have experienced it and so have two of my daughters. It is totally benign; it is alarming but of no serious significance. Its recognition is important.
I simply stress, as have others, the important work of the Chronic Pain Policy Coalition. It has highlighted five areas of action which I hope will be accepted in principle by the Government. I also hope that the vital report by the previous Chief Medical Officer, which contained so much invaluable material, will be accepted by the Government as a principle and will not only persuade local health authorities of all kinds—primary care trusts and so on—to embark on a programme of improving the establishment of pain clinics across the country, but will be used by educational bodies for the education of healthcare professionals.
Lord Alderdice
My Lords, the noble Lord, Lord Luce, who introduced the debate, and an astonishing number of other noble Lords have described how their own personal experiences have given them a profound insight into the importance of the dread subject of chronic serious pain. They have also shown an understanding and deep appreciation of the possibilities of treatment of this disorder.
In the short time available to me, I wish to stress three points. The first is the biopsychosocial aspect of pain. I hope that my noble friend will help the department to understand, as the noble Lord, Lord Walton of Detchant, pointed out—so clearly as he always does—the hugely important physical and biological aspect of much pain, and as other noble Lords have pointed out, its psychological aspects, particularly the noble Baroness, Lady Masham of Ilton. Others have pointed out the social aspects, as did the noble Baroness, Lady Morris of Bolton. Pain of this kind is sometimes largely physical in its origins, but, at other times, the psychological and the social components play a very important role as well. They do so not only in its origin but also in its treatment and management. All those elements are extremely important. There is a tendency sometimes to think that the biological side of things is only about pain relief in the form of medication. There are other kinds of physical approach to the treatment of pain. My first point then is the need to understand the biopsychosocial nature of the disorder and its treatment.
My second point is the need to pay attention to the needs and wishes of the patient, as the noble Baroness, Lady Pitkeathley, pointed out. In principle, at least, that is not so difficult when the patient’s cognitive function is intact and they are able to communicate. Many patients suffer from pain, but their cognitive function is impaired and they may be suffering from dementia. Many elderly people suffering from dementia do not have their pain understood and attended to because they are not able to communicate it clearly. That is also true at the other end of the age scale. Many children are unable to communicate their pain clearly because they cannot even understand what is happening to them. Their pain is not properly dealt with and their misbehaviour is sometimes treated inappropriately. Likewise, the pain of those with psychiatric disorders is sometimes simply dismissed—“Oh, it is all in their head”—and is not properly dealt with. Those with learning disabilities also have great difficulty in communicating the nature of their pain. As the noble Baroness said, attending to the needs and wishes of the patient is crucial, but it is not always easy, and I trust that my noble friend the Minister will be able to assure us that it is appreciated that attending to the needs and wishes of patients is more complex than simply listening to them.
My third point is that, although it is extremely important to have expert pain clinics, only a minority of patients will ever be able to get to them. What can be very helpful to doctors, nurses and other clinicians who deal with patients with pain is to be able to contact such clinics and ask over the telephone directly for advice on how they might handle them. We shall never be able to train all our practitioners, GPs, community nurses and so on in the most up-to-date and complex ways of dealing with these patients, but we can make sure that they have access to those who are up to date. When I was a psychiatrist, it was possible to contact other clinicians who understood how to deal with such things and to receive advice from them and then make it available to my patients. I trust that my noble friend will be able to reassure us that practitioners will be able and encouraged to make such contact, and that it will be seen not as a failure of their professional ability but as a fulfilment of it if they do so.
Lord Tunnicliffe
I congratulate the noble Lord, Lord Luce, on initiating tonight’s debate. When preparing for this debate, I was shocked to learn of the suffering of so many of my fellow citizens, and commend the noble Lord, Lord Luce, on his determination that this issue should be given the priority that it deserves in healthcare planning. The account of his personal experience and that of other noble Lords serves to illustrate the need for a national and co-ordinated approach.
I accept the argument that chronic pain requires a multidisciplinary approach and rapid-access pain clinics to provide early intervention, as advocated by both the Chief Medical Officer in his report of 2008 and NICE in its May 2009 guidelines on the treatment of chronic low back pain.
In May last year, my noble friend Lady Thornton said in answer to a Question from the noble Lord, Lord Luce:
“My Lords, we welcome the recommendations on the management of chronic pain in the Chief Medical Officer’s 2008 annual report. Many of the recommendations are already in line with existing guidance and practice in the NHS. We will consider what further action may be needed in the context of advice from the National Quality Board on clinical priorities for the NHS”.—[Official Report, 6/5/09; col. 543.]
The first question that I therefore need to ask the Minister is whether the CMO's report was considered by the National Quality Board, and if so what its advice was and whether it has been acted on.
Chronic pain affects 7.8 million people; 25 per cent of them lose their jobs or have to leave them; and £3.8 billion a year is spent on incapacity benefit payments to those diagnosed with chronic pain. The noble Lord, Lord Luce, made a very valid point when he said that it is more cost-effective to deal with chronic pain through investment in teams at PCT level than to leave treatment and support to chance and the patchwork that exists, at least in some places, at the moment.
My second question, therefore, is whether the Government will address this kind of investment in their reconfiguration of the National Health Service. Further, I hope that the Minister will agree to meet the noble Lord, Lord Luce, and the Chronic Pain Policy Coalition to discuss their legitimate concern that the impetus to deliver a national and co-ordinated approach will be lost in the change in government and the proposals of the coalition to devolve commissioning to GPs.
It is no longer acceptable in the modern world to tell people to grin and bear it when it comes to chronic pain. For many, medical and pharmaceutical advances mean that the remedies are available. Political will on the part of the Government and the management of the NHS is required to deliver effective solutions.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, this has been an excellent debate. I begin by expressing my gratitude to the noble Lord, Lord Luce, for calling it and congratulating him on the eloquent way in which he has introduced a topic which I know is close to his heart.
Chronic pain can be a devastating condition, as many of your Lordships have testified. It affects a large proportion of the population, especially those of advancing years. The noble Lord has already quoted a number of relevant statistics; let me just add another. Data from the Health Survey for England suggested that more than half of the total impact of disease on quality of life is due to pain.
There are examples of really effective, joined-up, multidisciplinary pain services providing support to patients as and when they need it. As the noble Baroness, Lady Pitkeathley, said, that is how it should be. But, all too often, patients do not get the support and the treatment that they need.
In his 2008 annual report, the then Chief Medical Officer, Sir Liam Donaldson, described how the system was failing to give sufficient priority to chronic pain. A key response from the previous Government was to agree funding for a national pain audit. We are maintaining support for this initiative, which is led by the British Pain Society in collaboration with Dr Foster. More than 200 pain clinics are already signed up to provide data. The work is being piloted and data collection will begin later this year. We are expecting a report in the early part of 2012. The audit will not only assess the organisation of local services—location, staffing and equipment—but also assess the quality of patient care across NHS providers by measuring activities and outcomes.
What can the Government do? Our vision for the NHS is for a transfer of power away from the centre down to the people who really understand what is needed: to patients, GPs and other front-line health professionals. It is only by doing that that we will fashion a health service that is truly patient-centred. This is why we intend to devolve budgets to GP commissioners, working in small local consortia. They are best placed to understand their patients’ needs and to prioritise and commission appropriate services, including multidisciplinary pain management services.
On average, someone with chronic pain will have direct contact with a health professional for only around three hours a year. The rest of the time they care for themselves. Patients therefore need to be informed. By our educating people about their condition and ensuring that they have access to support from others in a similar situation, people’s health can be significantly improved. This also helps to reduce the number of GP visits and prevent unnecessary hospital admissions as well as reducing the length of any hospital stays.
I recognise that some patients cannot take decisions for themselves or express themselves, among whom are children, as my noble friend Lord Alderdice rightly pointed out. The detection of children's pain can, however, be improved by strategies to facilitate their expression of pain in ways that are appropriate to their cognitive development and that can be understood by the adults caring for them. So there is work going on in this area.
Good management of chronic pain takes account of the whole person. People agree goals and actions to be taken in a personalised care plan. This allows people to make choices about the care that they receive. The issue of choice was rightly mentioned by a number of noble Lords. It puts people at the centre of any decisions about their care. As my right honourable friend the Secretary of State put it recently,
“no decision is made about me, without me”.
Information from care plans can also help commissioners consider how to use funds most efficiently to support people to self care and identify services that are successfully meeting patients’ needs and expectations. It also enables them to recognise gaps where there is unmet need. This is an important way for the patient voice to have direct influence over the design and commissioning of services in a particular locality.
Of course, devolving decision-making in this way does not mean that the Government are devoid of responsibility. There are a number of ways in which the Government and other organisations can support patients and front-line staff, ensuring that funding is spent on appropriate and effective services. First, we can ensure that clinicians and commissioners have up-to-date, evidence-based clinical guidance. The National Institute for Health and Clinical Excellence plays a key role here. As the noble Lord, Lord Luce, mentioned, NICE issued a clinical guideline last year on lower back pain and has more recently published a guideline on neuropathic pain. Over time, NICE will create a library of quality standards that support NHS organisations as they look for evidence on how to improve outcomes for patients.
Secondly, we can promote the development and diffusion of ideas on the service models that work best for patients. Patients with long-term conditions want services that are based in the community and which support and affirm their ability to manage their own conditions. They want to be referred to secondary and tertiary care only when really necessary. That requires excellent co-ordination between all levels of the system. One of the workstreams of the quality, innovation, productivity and prevention programme is focused on delivering this approach for people living with long-term conditions such as chronic pain.
Thirdly, we can promote the development of indicators of the quality and outcome of services. Outcome indicators will help patients to exercise choice and hold providers to account. They will help service providers to benchmark their performance against their peers and improve the services that they offer. They will help to ensure that any serious failure in quality is identified quickly and action taken to ensure the safety of patients.
An aim of the national pain audit will be to measure patient outcomes using the brief pain inventory scale—an accepted pain management assessment tool. This, combined with an assessment of patients’ outcomes using other patient-reported outcome measures, will make for a comprehensive review of the quality of care. The audit will help to identify indicators that could be suitable for routine use.
Finally, we can ensure that the right financial incentives are in place. The tariff system already ensures, in broad terms, that money follows the patient and that providers are rewarded for delivering best practice. We will build on that by increasing the proportion of provider income that is responsive to the quality, not just the quantity, of care provided. It is just worth adding that in due course, patients with long-term conditions may be able to influence their choice of treatment and provider even more directly through the use of personal health budgets, which are being piloted at the moment.
My noble friend Lady Morris spoke about acupuncture. Use of acupuncture in the NHS is quite limited. The National Institute for Health and Clinical Excellence provides guidelines to the NHS on the use of treatments and it currently recommends that acupuncture is considered as a treatment option for lower back pain. However, it is often used to treat musculoskeletal conditions and a wide variety of pain conditions. Unfortunately there is an absence of clinical evidence in this area. We simply do not have the evidence base to be sure that it works for many of the conditions for which it is often used. More scientific research is undoubtedly needed to establish whether acupuncture is effective against many conditions.
My noble friend also referred to the problem of gaining access to hospital appointments at weekends. There is an important case for services such as pain control to be provided outside working hours. We would encourage local commissioners to continue to develop services such as this to meet the needs of the working public. The noble Baroness, Lady Greengross, with her wide experience, pointed out that the elderly frequently suffer worse treatment than those in other age groups. Those who commission services locally clearly have a duty to ensure that the needs of the whole community are met, with particular attention given to vulnerable older people. The multidisciplinary nature of teams is pivotal in making pain relief available to all age groups in society.
The noble Lord, Lord Luce, asked whether we would consider a national strategy for chronic pain or indeed a tsar. I am not persuaded at the moment that a tsar or a national strategy for chronic pain over and above our current policies for improving the quality of services is necessary. We need to liberate front-line staff as a first priority to enable them to work with their patients to improve the quality of services that they provide or commission. We need to ensure, too, that they have access to the guidance that is available. As I mentioned, there is a wealth of available guidance, including a commissioning pathway published by the Department of Health, and guidance for secondary care and primary care has been published by the British Pain Society, as he will know.
The noble Lord and the noble Baroness, Lady Emerton, asked whether a pain score should become part of the vital signs that are monitored for patients in hospital. Current guidance from NICE recommends that all patients admitted to hospital should be assessed and a decision made on which clinical indicators should be monitored. A pain score is one of the indicators that should be considered.
The noble Baroness, Lady Emerton, referred to nurse prescribing and how that might be improved in this area. In prescribing medication it is essential that the right person gives the right medication at the right time and that stands to reason. Nurse prescribing is a welcome development that can benefit patients significantly. She would agree that services should continue to look at what professional mix can best deliver safe, timely and effective treatments for patients. She also referred to the need for risk assessment among nurses. I have every sympathy with that point. Back pain among nurses as a result of injury at work is a great concern, both for the nurses and their families. Local employers also have a duty of care to provide safe working environments and prevent unnecessary and avoidable harm.
The noble Lord, Lord Tunnicliffe, asked about investment in services at a local population level. We share a commitment to improve health and healthcare. This is our driving principle and our proposals for reconfiguration of the NHS will drive the improvement for all patients.
I conclude by reassuring noble Lords that I should be happy to meet the noble Lord, Lord Luce, and the Chronic Pain Policy Coalition to discuss these issues further.