Jos Bell writes about the Andrew Lansley’s NHS bill’s failure to deal with complex long term conditions like rheumatoid arthritis in a coherent manner.
By NHS campaigner Jos Bell
How would you feel if one day you woke to find that instead of protecting you as designed, your immune system was actually attacking the thing which is designed to protect? Namely you.
This could of course be said of the behemoth Lansley bill which far from protecting the English populous from the ravages of the private sector, has seemed more intent on turning inwards to consume its’ own tail, scorpion-like, in self poisoning ideological torment.
Lifting itself above this mayhem, the contents of the erudite Lords debate last week swept all before it on the airwaves and obliterated many an interesting health factoid in the process, including a very telling report released by the National Rheumatoid Arthritis Society and the Chartered Society of Physiotherapy which explores how far the NICE recommendations for management of this extremely painful and debilitating condition (RA) are actually followed through in general practice via the snappily titled Quality, Innovation, Prevention and Productivity Programme (QUIPP – and I jest not!)
Indeed, this presents as a good test case for the widely touted integration approach to ‘nothing about me without me’ patient care packages. It raises questions about the quality standards the Government is intending to introduce more widely in the health reforms, and whether the new system will actually lead to an increase in clinical outcomes that the Government desires.
Whilst Lansley dismantles the PCTs and at the same time seeks to cover up such gems such as plans for replacement PCTs and SHAs, patients with long term conditions, and particularly in this case those with muscular-skeletal problems, are clearly finding that the promised integrated pathways of care commensurate with NICE guidelines are not being offered.
RA, a debilitating and fluctuating lifelong disease, with entirely unpredictable peaks and troughs, is little understood, and often confused with osteo arthritis (which is purely related to wear and tear aging).
It usually attacks sufferers at the peak of their lives between 30-55, causing inflammation and damage to eyes and lungs, and affects nearly 700,000 people in the UK. The immune system attacks the body instead of defending it, causing inflammation that often results in serious damage to bones, joints and tendons.
Most telling is the fact, established through evidence based research conducted jointly by NRAS and CSP, that although physiotherapy sessions should form part of the integrated package of care , as many as 1 in 3 patients are not being offered physiotherapy via GP referral – and as many as 50 per cent are not even allowed to self refer.
This, despite the fact that the clinical guideline, which sets out best practice for the treatment of the disease, states that all people with RA should have access to a physiotherapist, working as part of a multidisciplinary team, with regular review.
Frustratingly, this very cost effective treatment is also shown to enable patients to both enjoy a better quality of life and also to be more productive as a result (and the DWP/ATOS really should pay attention here – effective treatments withheld does not equal fit for work!).
The Lansley approach is allegedly to re-shape health services away from ’targetology’ and focus more fully on clinical outcomes. However, the double irony is that the National Rheumatoid Arthritis Society reports huge difficulties in securing communication with even those GP CCGs who purport to prioritise muscular skeletal conditions, let alone the more disinterested remainder.
This proven lack of adherence shows very clearly that many practitioners are not complying with the guidelines in England; as one charitysaid earlier this week:
“We are being sidelined in a horror story of ignorance – we have no Tsar and no teeth.”
In a webchat with the charity, held on National Arthritis Day (12th October), the Minister responsible for long term conditions, Paul Burstow MP, who prior to the 2010 election and holding a government post had been diligent in the long term conditions sector, even more diligently avoided reference to prior departmental assurances about the development of a Muscular Skeletal Strategy (Andy Burnham, in March 2010, was ‘minded to appoint a national clinical director’), but rather chose to focus on a generic long term conditions strategy.
So does this combination of apparent rationing and avoidance signal yet another government u-turn? For anyone who suffers from such a condition, they know that each manifestation requires a different approach and vital details of specific and essential care recommendation are likely to be lost in a ‘blob’ policy framework. Not all long-term conditions are the same and problems with musculoskeletal conditions are particularly acute.
The minister responded to this alert by saying GP referral rates needed to be ‘addressed’ and sought refuge in a pledge to instigate ‘referral to treatment data collection’ designed to highlight areas of excellence and under-performance in order to challenge clinicians. But for those patients whose referrals are blocked at the start this will make no difference whatsoever. There is clearly also a pressing GP training need.
Add to this the non-nuanced PiP (no relation to QUIPP!) and the outlook is bleak. Arthritis Research UK are currently researching exactly what this patient group need in the shape of giving them their PiP (and it does not bode well). Paul Burstow, meanwhile, said he believed personal health budgets could be ‘a powerful driver of integration’. The question would be how exactly – especially if the basic care package is not being offered as standard.
NRAS chief executive Ailsa Bosworth has stated that giving patients budgets could also undermine the core services provided through the multidisciplinary team (consultant, rheumatology nurse, physio, podiatrist, occupational therapist) that is supposed to be available to RA patients. So the very treatment programme designed to offset immune attack is in effect turned on the patient.
Biologic therapies have been identified as being expensive but cost effective in their application because sufferers of the disease are able to gain some degree of stabilisation in their condition, but if even the basic NICE recommendations are being ignored then what hope have these patients in receiving cutting edge therapies which will make a really marked difference to their suffering?
Given muscular-skeletal conditions are the fourth largest area of DH spend, the cost benefit to the Exchequer seems obvious.
The NAO estimate:
“…rheumatoid arthritis costs the NHS around £560 million a year in healthcare costs, with the majority of this in the acute sector, and that the additional cost to the economy of sick leave and work-related disability is £1.8 billion a year.”
The answer of course lies in a strategy for musculoskeletal conditions. After years of awareness-raising, and following the pledge of the previous minister being sidelined after the election, this year finally produced a parliamentary debate and subsequent commitment from the minister to get the National Quality Board to look into the idea, but the item unfortunately fell off the agenda at the tabled meeting.
All of which leaves RA sufferers clinging onto the end of their branch, hoping against hope that they don’t get swept onto the bonfire of autumn detritus.
So today, the first of the 10 days of debate allocated to mountain of H&SC bill amendments, it is to be hoped the Lords, and soon once more the Commons, do not forget the needs of this patient group and those in similar straits.
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• Losing the plot: How the Lords rubbished the NHS bill – then voted for it anyway – Jos Bell, October 15th 2011
• Lansley told to his face why his NHS reforms are wrong, wrong, wrong – Shamik Das, October 14th 2011
• Lib Dem MP tells Lords how the NHS bill needs to be changed – Andrew George MP, September 21st 2011
• Lord Owen: Government acting with “no authority” over NHS reforms – Jos Bell, April 4th 2011
• The truth behind the coalition’s NHS proposals – Jos Bell, January 25th 2011