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NHS: Osteoporosis Services

My Lords, this has been an excellent and long-awaited debate and I thank my noble friend Lady Quin for enabling it to take place. I am grateful to all noble Lords who have spoken, and I am especially grateful to the noble Baroness, Lady Cumberlege, not only for her expertise but for being the catalyst in many ways of some of the pioneering work that has taken place over the past few years. My noble friend spoke eloquently about osteoporosis and the devastating effect that it can have on people living with the condition, their families and those who care for them. Here I must declare an interest in that my mother had chronic osteoporosis before the wonderful new drugs had been developed. She was a wonderful, gentle, long-suffering woman who shrank swiftly. In the end, after years of suffering, she fell out of bed in hospital, broke her hip and died in a month—because, basically, she did not want to live. She did not want to be immobile with a broken hip. I, too, have low bone density, so I have a vested interest in all this and am acutely aware of the problems. I am a proud member of the National Osteoporosis Society and thank it for its brilliant work in raising awareness, raising money for research and providing invaluable advice and support to those who suffer from osteoporosis. While osteoporosis affects some younger people, together with falls it has important implications for the older population and we recognise that they represent a significant and growing burden on our health and social care system. Just this week we learnt that there are now more pensioners than children in this country, and we all want to remain as healthy and independent for as long as possible. I thank the noble Lord, Lord Addington, for raising awareness of the often-overlooked fact that men as well as women suffer from osteoporosis. In 2001, the Government published the National Service Framework for Older People, the first ever comprehensive strategy to ensure fair, high quality, integrated health and social care services for older people. Among other things, it highlights the importance of services for key conditions, including osteoporosis, and acknowledges that falls are a major cause of disability, and the leading cause of mortality resulting from injury, in people aged over 75. Osteoporosis is closely linked with falls prevention, as the risk of fracture after a fall increases with age. Prevention and effective management of osteoporosis has a significant effect on both the numbers and the social and economic cost of fractures. The development of integrated falls services was a key objective of the NSF and support for the local development of those services has been provided through guidance published by the Department of Health and through a co-ordinated approach with other national organisations with an interest. The noble Baroness, Lady Masham of Ilton, referred to Standard 6 of the NSF. There is a lot more to be done to ensure that Standard 6 is being respected throughout; however, I draw the noble Baroness’s attention to a national audit of falls services for older people, which was undertaken by the Royal College of Physicians in January 2006, which confirmed that 74 per cent of trusts had part of a co-ordinated, integrated, multi-agency service for falls. Overall, the audit results suggested that most areas have the infrastructure with the potential to identify need and provision of specialist fall assessment and treatment. That is not enough but we are getting there. There are many innovative and effective projects around falls up and down the country. For example, in the north-east the ambulance service works in partnership with local councils, using computer programmes to identify ““fall hotspots”” such as uneven pavements or ungritted paths in winter in areas with a high concentration of older people. Such schemes should be commended. The National Director for Older People’s report, A Recipe for Care, highlights that a modest investment by the NHS in developing falls and bone health services in line with NICE guidelines would produce significant benefits in reduced mortality, increased quality of life and savings through a reduction in hospital admissions—spend to save, as my noble friend said. We know what needs to be done. The policies are there but we have to ensure that they are translated into firm action by the NHS and councils. Local commissioners must decide how these things can be achieved but the Department of Health has a role in improving the way in which this commissioning is undertaken. I am, of course, aware that Falling Short, the APPG report on osteoporosis services, recommended the inclusion of osteoporosis in the Quality and Outcomes Framework—something of which many Lords have spoken. Clearly there is good evidence for the efficacy of multi-professional falls interventions in reducing the risk of a fall and osteoporotic fracture. Work in other clinical areas such as coronary heart disease, asthma and diabetes has shown that both the quality of data recording and the level of care for these conditions can be greatly improved by incorporation in the Quality and Outcomes Framework. The QOF is part of the General Medical Services Contract. It is a voluntary incentive scheme that rewards practices for achieving quality indicators across a wide range of clinical and organisational areas. It is a ““living”” document that is subject to a process of change and improvement over time. Recommendations on priorities for new areas in QOF, for negotiations regarding the 2008-09 contract, are being considered at the moment but it would not be appropriate for me to comment or to speculate. However, if osteoporosis is not included in 2008-09, we will certainly consider including it in QOF for 2009-10, and I will follow that up. However, in the mean time I am sure that much more could and should be done to raise awareness of osteoporosis among GPs to ensure that they see the telltale signs, diagnose accordingly and that the correct treatment can be prescribed. I note the point made by the noble Lord, Lord Addington, that men especially should have their awareness raised because so many GPs are not aware that this affects men as well as women. In the 21st century there is no reason why it should be undiagnosed in primary care. I will write to the Chief Medical Officer suggesting that he should draw GPs’ attention to osteoporosis in one of his forthcoming CMO updates. We must do more to raise awareness and diagnosis especially for people with long-term disabilities. I am very grateful to my noble friend Lady Wilkins for drawing our attention to that. I will, of course, draw it to the attention of my colleagues in the ministerial team. Kamran is clearly an extraordinary young man who is suffering from a fragmented system—the sort of system that the noble Baroness, Lady Cumberlege, rightly spoke of—and needs better access to integrated services for osteoporosis. I am sure that that is one of the things that my noble friend Lord Darzi will look at in his review. The noble Earl referred to the QResearch and the fact that patient computer records need to be improved. This is something that the Department of Health is looking at and I will come back to the noble Earl in due course. He also highlighted the importance of a better flow of information from primary care to acute care and between local authorities and the health service. That again is something that my noble friend Lord Darzi will look at, although, of course, his review cannot be a panacea. As many have said, DEXA scanners are vital in identifying those at high risk of developing osteoporosis, enabling the appropriate advice and treatment to be given so that the number and severity of fractures can be reduced. DEXA scanning has long been regarded as the gold standard procedure in determining whether treatment is appropriate. In 2005, the department announced that a cash injection of £20 million would be invested into bone density scanning to improve access to DEXA scanning and reduce waiting times. An initial £3 million was allocated to those areas with longest waits for the purchase from the independent sector of additional scans in 2005-06. A further £17 million has been allocated to SHAs as strategic capital for 2006-07 and 2007-08 to improve NHS capacity through investment in new DEXA scanning equipment. I note the concern about the patchy availability of DEXA scanners and I do understand that because the additional investment is not ring-fenced, it could potentially be used for a purpose for which it was not intended. But the reduction in waiting times clearly demonstrates that there are now many more DEXA scanners. Since January 2006, the Department of Health has been collecting waiting time and activity data for 15 diagnostic tests or procedures, including DEXA scans. The latest data show that the number of patients waiting more than 26 weeks—which is outrageous—for a DEXA scan has been cut from nearly 4,000 to just 61. Only 800 patients are now waiting more than 13 weeks for a scan, which is down from nearly 9,500, and the total number of patients waiting for a DEXA scan is down by nearly a third. That is all very good news, but more needs to be done. For example, at a local level we need to ensure that scanners are working to maximum capacity. I am sure that most people would not mind if their scan was outside the 9-to-5 ““normal”” time for scanning. NICE guidance and its recent appraisal have been a key focus of this debate. The National Institute for Health and Clinical Excellence has been carrying out two technology appraisals on a number of treatments for the primary and secondary prevention of osteoporotic fragility fractures in post-menopausal women. The treatments that have been appraised are alendronate, etidronate, risedronate, raloxifene and strontium ranelate for both the primary and secondary prevention of osteoporotic fragility fractures. Teriparatide has also been appraised in the secondary prevention of osteoporotic fragility fractures. As noble Lords have said, NICE’s recommendations on those drugs are the subject of an appeal and the outcome will be announced in due course. I am afraid that I do not have the date at present, but as soon as NICE informs the Department of Health, I will inform noble Lords. I could speak about NICE at length, but I am running out of time. I well understand the concern expressed, especially about those people who may have some adverse reaction to alendronate. I cannot make detailed comments, and I certainly would not wish to undermine the excellent NICE guidance in any way. I simply note the current clinical practice whereby patients who are unable to take one drug are offered another. I cannot see that situation changing. Through the Musculoskeletal Services Framework, we have also taken steps to improve assessment, diagnosis and treatment for osteoporosis and other musculoskeletal conditions in England. The goal is to ensure better outcomes for patients through a more actively managed patient pathway, with explicit sharing of responsibility agreed between all stakeholders; all health and social care clinicians and managers, the voluntary and community sector, patients and the public. Notwithstanding the many real concerns that have been expressed today, the initiatives that I have described clearly demonstrate that the Government are doing much to support NHS organisations to improve osteoporosis services. There is greater awareness, better diagnosis, waiting time for scanning is at a record low and more services are now in place for older people who have fallen. We are also doing much on the preventive front, with general lifestyle messages around diet, exercise, reducing smoking and avoiding excessive consumption of alcohol, which are all important in the prevention of osteoporosis. I do not underestimate how disabling, painful and debilitating this silent epidemic is for those who suffer, or the impact on their families, or the impact on health and social care services. I am confident that real advances have been made and will continue to be made. I assure noble Lords that the Government are absolutely determined to support the development of good services.