Pain Treatment

– in Westminster Hall at 4:00 pm on 14th June 2006.

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Photo of Malcolm Moss Malcolm Moss Shadow Minister (Culture, Media & Sport), Culture, Media & Sport 4:00 pm, 14th June 2006

I start by expressing my gratitude for this opportunity to raise such an important subject, which affects the lives of millions of people in this country daily.

Chronic pain affects one in seven people in every parliamentary constituency throughout the United Kingdom. Inadequately managed, conditions associated with pain can have a devastating impact on the quality of life of individuals and their families. In terms of repeated appointments, chronic pain costs the NHS the time equivalent of 800 full-time general practitioners, and it generates an incapacity benefit bill that is estimated by the Department for Work and Pensions to exceed £3.8 billion a year. The biggest cost of chronic pain is borne by employers and the wider UK economy. More than £18 billion a year is wasted in lost working days and reduced productivity.

The commonest causes of chronic pain are back pain and arthritis. Other causes include headache, injury, nerve pain, vascular pain, pelvic pain, cancer and rarer forms of pain, such as complex regional pain syndrome, or reflex sympathetic dystrophy syndrome, as it is sometimes called.

I applied for a debate on this subject because of a courageous constituent of mine, Trudy Lapinskis of Whittlesey, who suffers from an advanced form of RSD. She has borne and continues to bear her condition with great stoicism, but not fatalism, and has shown great determination to publicise RSD to as wide an audience as possible, in order to help other sufferers, particularly those in the early stages, when diagnosis and treatment could be so effective in improving quality of life. In Trudy's case, early diagnosis would have avoided the severe disability that she has to live with today. This debate is by way of a tribute to her and her unstinting work on behalf of other RSD sufferers.

RSD is a chronic pain disorder. Common symptoms include intense burning pain, extreme sensitivity to touch, swelling, sweating, and changes in the colour and temperature of the skin over the affected limb or body part. RSD affects the nervous system, bones, muscles, skin and circulatory system. The aetiology, or cause, of RSD is most commonly a trauma or injury to an extremity, although it can affect any part of the body. The trauma does not have to be severe. Unfortunately, something as common as a sprained ankle, a knock or even a splinter in a finger can lead to RSD, which can then become a potentially disabling and lifelong problem.

In some patients, an exact cause cannot be identified. The first symptom associated with RSD is a pain that is usually described as a constant burning or deep aching pain. It progresses into severe chronic pain and swelling usually occurs in the injured extremity. At that point, the oedema is localised and the skin is very sensitive to touch, with even a slight breeze being capable of causing pain. Diminished motor function and a decrease in muscle strength are associated with the joint in the extremity. Tremors and muscle spasms can also be present.

Most patients experience a significant difference in the temperature of one limb as compared with the other. Osteoporosis might be noted on bone scans and, as swelling in the injured area becomes pitted, the risk of skin infections increases. In some cases, those symptoms spread to other extremities, where no injuries have occurred, and the disorder becomes much more difficult to manage. Out of all chronic pain conditions, RSD is the most severe. According to the McGill pain index, arthritis has a pain rating of 18, a fracture rating of 19, cancer 26 and chronic back pain 27, while incredibly, RSD has a rating of 42.

RSD can affect anyone—male or female, adult or child—and at any age, but studies show that it is more common in people between the ages of 25 and 55 and is seen more frequently in women than in men. It is not more prevalent in a particular race. RSD used to be considered rare in children, but there has been a recent increase in the number of cases reported among children and teenagers. In view of all that, it is imperative that awareness should be raised among GPs and consultants, with early diagnosis and treatment encouraged, to minimise the terrible suffering brought on by the disorder.

I turn to a more general analysis of the problem of pain. Back pain affects most of us. Four out of five people will experience back pain lasting for more than a day at some time in their lives. It is the nation's leading cause of disability, with 1.1 million people disabled by it. At any one time, 430,000 people in the UK receive social security payments primarily for back pain.

A recent national opinion poll showed that pain is experienced every day or on most days by one in five of the 975 people surveyed, which equates to almost 10 million people throughout Great Britain, while a further one in four people said that they had pain some days. The proportion of people with pain taking time off work has increased from 35 per cent. in a group surveyed in 2002, to 49 per cent. in 2005. Half of those questioned were depressed because of their pain and 72 per cent. were less active because of their pain, with work, household activities, family life, sex, social and leisure activities, and the enjoyment of life being affected.

Pain in the elderly is common. There is much evidence that it is treated badly because the elderly are often uncomplaining, because pain is not recognised, and because doctors are frightened of using strong painkillers, especially after the Shipman inquiry. Children also suffer from chronic pain, which is under-recognised and under-treated. Unrelieved pain in childhood can lead to long-lasting effects on social and physical development, and increases the chances of lifelong pain in adulthood.

Pain is the commonest presenting symptom at the first consultation with a doctor and is second in the top 10 most important symptoms listed by patients, but all too often it is ignored and thought to be unimportant. Why is that? Pain is generally regarded as a warning signal, and it is thought by doctors and lay people alike that, when the cause of the pain is discovered and treated, the pain will go away.

There are acute pains that indeed behave in that way, such as appendicitis, toothache, bone fractures and infections, but chronic pain—that is, pain lasting for longer than three months—serves no useful purpose. It is usually caused by a defect in the signalling mechanisms for pain within the nervous system and is poorly understood. The patient with chronic pain is often subjected to investigation after investigation and multiple consultations, only to be told that a cause for the pain cannot be found, or that it is "only arthritis" and that no treatment is available. How demoralising is that?

Rarer types of pain, such as complex regional pain syndrome or RSD, might not be diagnosed at all, leading to long-term disability from pain, and an implication that it is all in the head. Cancer pain is dreaded by all. The cause might be known, but for about 8 per cent. of sufferers the pain is so severe that it cannot be relieved, even by large doses of morphine.

What can and should be done to manage chronic pain? Sadly, chronic pain cannot be cured, but in 95 per cent. of people it can be partially relieved and managed, such that the sufferer regains control over his or her life. Health professionals in this field want pain to be designated as the fifth vital sign after pulse, blood pressure, temperature and respiratory rate, so that pain is measured whenever a patient consults a doctor or nurse and so that the level is recorded consistently when a patient is in hospital.

The important first step is for the health professional to believe that the pain is real, to decide where the pain is coming from and to treat the pain, not necessarily the disease. That can be done by alternative medicine practitioners, nurses, physiotherapists and doctors. It may not be easy and may require a high level of skill and training to get it right. However, treatments will not be effective if the patient does not understand his or her pain and continues to seek a reason.

Treatment includes the judicious use of drugs—not just painkillers but drugs that modify the pain signals, such as anti-epileptic drugs and antidepressants. Physical methods are also used, such as TENS—transcutaneous electrical nerve stimulation—acupuncture, injections, nerve blocks, sophisticated spinal stimulators and spinal drug therapy. An effective way of helping with control over pain is a specialised pain management programme. I am talking about a multidisciplinary approach to pain management whereby a doctor, nurse, psychologist and physiotherapist, working together over a period, help the patient to gain control over the pain.

However, all that takes time, and pain management does not fit easily into the target-driven, rapid-treatment ethos of the modern NHS. The recent NOP survey shows that now 14 per cent. of patients with pain have seen a pain specialist compared with only 7 per cent. in 2002, but what of the other 86 per cent? Facilities for pain management are much more developed in the USA and parts of Europe. There is a desperate need for education of general practitioners: as undergraduates, medical students receive, on average, about four hours' training on pain and they spend even less time on the prescribing of drugs for pain.

Specialist services exist in most hospitals in the United Kingdom, but their services are stretched, and some hospital services, such as at Oxford, have been withdrawn. In Southampton, the service closed and has been relocated in primary care, and at other hospitals—for example, East Sussex—there are threats of closure. Relocating a pain service in primary care should be achieved with adequate funding and planning, not by a sudden decision to close existing services or to dispense with the appropriately trained personnel. Primary care has many priorities, and pain services are unlikely to be near the top of the list. Pain management is generally known as a Cinderella service.

There have been schemes to link pain management with rehabilitation and back-to-work programmes, crossing the boundaries between the NHS, social services and the Department for Work and Pensions, but those have been sporadic, although the results have been encouraging. One scheme whereby patients with back pain were allowed to return to work part-time but retained benefits for a period proved very successful. Why are such schemes not more readily available? An individual approach is necessary; one size does not fit all.

It has been estimated that 10 specialist sessions in pain management are needed for every 100,000 of population, but nowhere in the United Kingdom achieves that, and services are scarcer in the midlands and Wales. Education is needed at all levels of the health service, and many more specialist nurses, doctors, psychologists and physiotherapists are required to support properly sufferers of the most severe pain. Proper pain management is not easy and presumably does not come cheaply.

Inadequate assessment and treatment of pain should be replaced by early recognition of the problem; listening to the real needs of the patient; education and more education at all levels of the health service; funding for high-quality clinical and scientific research; and adequate provision of specialist services in both primary and secondary care.

This was not a specialist area of mine, although I did spend two and a half magical years as the Minister for Health in Northern Ireland. The issue crossed my desk, but I have to admit that, given all the other priorities, I never spent the time on it that I should have. Perhaps it requires a constituent with this particular problem to bring the issue to the attention of an MP before these things are brought into the wider domain.

I welcome the opportunity to have the debate and to put these ideas on the table for debate. I hope that the Minister will presently answer the points that I have made. I end by paying tribute to a constituent of mine who suffers immense pain with stoicism and great bravery. She is planning a huge conference at the Methodist Central Hall in London in December and has attracted prominent speakers in this field from all parts of the world. I hope that her courage will begin to open the doors to knowledge about this condition for other pain sufferers.

Photo of Andy Burnham Andy Burnham Minister of State (Department of Health) (Delivery and Quality) 4:16 pm, 14th June 2006

I congratulate Mr. Moss on securing this debate on what is, as he says, an extremely important topic. I listened carefully to him. He spoke with clarity and commitment not only about the position that his constituent finds herself in, but more generally about the issues faced by those suffering from pain, and particularly chronic pain. I take on board the issues that he raised about the treatment and management of pain in the NHS. In particular, I listened carefully to his comments about the treatment of complex regional pain syndrome, or reflex sympathetic dystrophy. He is right to say that pain can have a devastating effect on the quality of an individual's life. It can take different forms and have different effects, depending on the individual. It is both a sensory and an emotional experience and is generally associated with tissue damage or inflammation.

I, too, pay tribute to the hon. Gentleman's constituent, Miss Lapinskis. I will look out for the proceedings and the conclusions of the conference that she is organising. I hope that he will pass on to her my best wishes for a successful conference. We will certainly want to see what progress the conference can make.

We are not starting from scratch when it comes to managing pain. In recent years, a number of initiatives have focused on pain and its management. In 1999, the clinical standards advisory group issued a report on pain services—"Services for Patients with Pain"—which the Government welcomed. The researchers undertook in-depth interviews in 12 NHS trusts with pain service staff, ward staff, post-operative surgical patients, pain clinic patients and carers. They undertook site visits to interview hospital managers, health authority officials and others, and undertook a range of survey work with organisations and individuals with a relevant interest.

The report concluded that pain services are highly cost-effective, producing savings for the national health service, but there is a "but", and perhaps here I will agree with the hon. Gentleman. The group found that there are variations in the commissioning arrangements for pain services and the resources dedicated to them. The group recommended that commissioners review local provision of pain services, looking particularly at the provision of more specialised treatments on a networked basis.

The Royal College of Anaesthetists believes that the relief of pain should be a fundamental objective of any health service. Good practice should ensure provision of an evidence-based, high-quality, adequately resourced service dedicated to the care of patients and to the continuing education and development of staff. The hon. Gentleman was right to draw attention to that point, and in particular to the training component of courses for junior doctors. I am sure that his comments will have been heard by officials in my Department.

Having considered what has gone before, I want to consider what is happening now and the plan for the future for the services that are available to deal with pain. As I said, pain can affect different people in different ways, so a range of different services and interventions will be needed to ensure that patients receive the care that is right for them. We are committed to ensuring that patients and their needs lie at the heart of all health and social services. As far as pain management is concerned, we need to ensure that patients receive help that is tailored specifically to their personal needs. That is why we have never centralised the management of pain services and why we believe that local flexibility is crucial to ensure that the NHS can and does respond effectively.

Services are generally provided across a range of providers, such as community services, teaching hospitals, specialist units and so on, to ensure that patients get the care that they need. Treatments range from education to spinal cord stimulation and complex psychological treatments. One-to-one physiotherapy is often delivered to individuals in a pain management service oriented to rehabilitation rather than pain relief. Sometimes other health professionals, such as occupational therapists, offer one-to-one treatments, too. More than one treatment is often necessary, particularly in the treatment of complex pain.

The treatment of long-term chronic pain is different from that of acute pain. We are talking about the ability not just to handle pain but to live with it in the long term. As the hon. Gentleman said, that is a different thing. Of course, it has an effect on a person's quality of life, their sense of well-being and their mental health, and all those factors are relevant considerations.

The hon. Gentleman might know that the Department has driven forward the expert patient programme, driven by the NHS, which provides opportunities for people who live with long-term chronic conditions to understand their condition in depth and to develop new skills to manage it better day to day. The number of course places on the expert patient programme will increase from 12,000 to 100,000 by 2012. The programme's success and the response of individuals who have taken part have been such that the Government are committed to trebling investment in it. In 2006-07 its budget will be £13.4 million.

We realise that commissioners may need additional support to set up specialist pain services, particularly in areas of the country where more provision is required, so we have issued guidelines to help. Those specialist national service definitions look specifically at specialised pain management services, which are for patients with chronic pain who require local specialist clinical expertise.

In North-East Cambridgeshire, to use the hon. Gentleman's constituency as an example, services are commissioned from a number of acute providers, including Peterborough, Addenbrookes, Hinchingbrooke, King's Lynn and West Suffolk. More distant providers include the input centre at St. Thomas' in London, the other major tertiary hospitals in London and the Queen's medical centre in Nottingham. Those pain management services all treat patients with a wide range of conditions.

Other local services include pain clinics. People with persistent pain may be able to attend a specialist pain clinic for assessment and possible pain management, together with advice on living a fuller life in spite of pain. Pain clinics vary in the treatments offered and not all hospitals have a specific pain clinic. Sometimes a consultant with an interest in pain will prescribe drugs or give injections to try to control it. Other clinics have teams of doctors, psychologists, nurses, physiotherapists, occupational therapists and others. The hon. Gentleman's constituents can take advantage of other sources of pain management. For example, most physio services will offer treatment for RSD and multiple sclerosis, including pain relieving treatment techniques.

This year, the primary care trust's local delivery plan has identified the need for more general physio and musculoskeletal specialist posts—I hope that the hon. Gentleman will welcome that—which will in turn provide faster access to such treatment. I understand that funding has been allocated to support that development.

I shall turn now from provision in the hon. Gentleman's area to that offered nationally. The Department is developing a musculoskeletal services framework to sit alongside the expert patient programme and specialist services work. It is designed as a good practice guide to help NHS patients with musculoskeletal problems, and is a core pathway-based approach for all stages of musculoskeletal problems. The system relies heavily on referral to hospital for most conditions, but many patients with musculoskeletal problems do not need to be treated in hospital and could receive faster and more appropriate care in a community setting. People in such a position need and want treatment closer to home and I think that there will be no difference of opinion about it being right to move in that direction.

The most common presenting symptom in people with musculoskeletal problems is pain. Qualitative studies have shown that what the group involved most wants from the NHS is pain control and help with improving functions. Providing services for prompt symptoms control through education, non-pharmacological and pharmacological treatment is pivotal to enabling an individual to maintain normal activities of daily living. Pain management is addressed throughout the framework. A patient booklet, co-sponsored by Arthritis Care and the Department of Health, has been developed alongside the framework.

A number of other initiatives are in train, too, which I shall mention briefly. End-of-life pain needs specific handling, so in March 2004 the then National Institute for Clinical Excellence published guidance on supportive and palliative care services. That important document sets out services that help patients and carers cope with cancer and its treatment throughout the cancer journey, including through the management of pain. Although it is orientated towards cancer, many of the principles and recommendations in the guidance apply equally to other conditions.

The NHS has been required to set out action plans to achieve compliance with the recommendations, and their implementation is being monitored by strategic health authorities. The implementation of the guidance will be incremental and will be supported through the increased funding provided to the NHS.

The hon. Gentleman mentioned the need for better training for health professionals. As he will know, the Department of Health is not responsible for settling curricular matters for health professional training. However, we share a commitment with statutory and professional bodies that all health professionals are trained so that they have the skills and knowledge to deliver a high-quality health service to all groups of the population with which they deal, whatever their condition. We take on board his points and I am sure that they will be borne in mind.

I want to say a brief word about the Government's manifesto commitment on palliative care. We made this pledge:

"In order to increase choices for patients with cancer we will double the investment going into palliative care services, giving more people the choice to be treated at home".

That is why we set out a programme of action on end-of-life care in the White Paper, "Our health, our care, our say". As it is developed and implemented, it will provide the necessary support so that all people, regardless of age or condition, can, where appropriate, choose where they die.

We have committed an additional £50 million a year to improve the provision of and access to specialist palliative care. Our latest information is that the allocation has funded a range of activity nationally, including the provision of an extra 44 palliative medicine consultants, 172 clinical nurse specialists and 46 specialist palliative care beds.

In conclusion, we recognise the need to broaden the access that patients with a variety of conditions have to high-quality care and pain management services. We recognise that there is still some way to go to ensure that all people who need it have access to such care, but we have started to implement a number of initiatives to stress the importance of pain management.

This has been a good debate. I am grateful and pleased that the hon. Gentleman has managed to secure it. He is right; it is the core business of the national health service to get the treatment and relief of pain right, and it is right that we consider it in the broad sense in which he has brought it to us. I wish his constituent well with her conference later this year and also congratulate her on the work that she is doing to draw attention to a condition that needs help and specialist support.