Complex Regional Pain Syndrome

Debate between Ruth George and Caroline Dinenage

Tuesday 19th June 2018 Commons Chamber

[The Minister for Care (Caroline Dinenage)]

I congratulate the hon. Member for High Peak (Ruth George) on securing this debate on such an incredibly important issue. She has articulated quite beautifully the hell that people suffering from complex regional pain syndrome go through. The only thing that I can even slightly identify with is the pain of childbirth, but even after that it is unimaginable for us to conceive of the sort of day-by-day endurance and the relentless pain that people suffer. It is a devastating condition and can lead to an overwhelming impact on sufferers and their families, so I thank the hon. Lady for bringing this subject to the House.

The potentially extreme nature of the condition and its symptoms, some of which the hon. Lady described—the excruciating pain, burning, swelling and skin discolouration —can be totally disruptive to everyday living and destroy a person’s quality of life. She spoke very movingly about her constituent Victoria Abbott-Fleming, whose story is incredibly upsetting. I very much forward to meeting Victoria and assuring her that I will do everything I can to move forward on the issues that the hon. Lady mentioned. In circumstances in which extreme decisions have to be considered, high-quality care and support can sometimes make a huge difference to someone’s experience of our health and care services.

I hope that, as I am sure the hon. Lady intended, this debate will help to raise awareness of this very debilitating and extremely painful condition. It has actually been recognised as a medical condition for around 150 years, but problems remain with the diagnosis of CRPS in its very earliest stages. Diagnosis involves excluding a lot of other more common conditions—such as infection or things like rheumatoid arthritis—that can have similar symptoms, and the causes remain largely unknown. Precipitating factors can include injury or surgery, but there is no relationship to the severity of trauma and the development of the pain. In some cases, there is no precipitating trauma at all. It is considered likely that because of the complex nature of the condition, there is absolutely no one single cause. That means that it is difficult to estimate how prevalent CRPS is, as many cases may not have been correctly diagnosed in the first instance.

To improve public awareness, the NHS Choices website provides comprehensive advice on the causes, symptoms and treatment of CRPS. In addition to that, various charities work in this area. The hon. Lady mentioned Burning Nights, which was set up by her incredibly brave constituent; if someone is in unimaginable pain, I can only imagine what a comfort it is for them to be able to speak to or hear from somebody who has experienced it themselves. The charities do great work to support not only the patients who have the condition but their families.

As the hon. Lady says, general practice is where patients with CRPS are most likely to be seen in the first instance. CRPS is a key part of the GP curriculum; it is identified as a key area of clinical knowledge in the Royal College of General Practitioners’ applied knowledge test content guide. The test is a key part of GPs’ qualifying exams, and it ensures that they have the knowledge needed to work as a GP in the NHS.

To improve identification and management of the condition, in 2013 the Royal College of Physicians published best practice guidance for clinicians on the diagnosis, referral and management of CRPS. This guidance was developed with the involvement and endorsement of 21 key organisations involved with the care of people with CRPS, including the Royal College of General Practitioners, the British Orthopaedic Association, the British Pain Society, the British Society for Rehabilitation Medicine and so on.

The guidance, as the hon. Lady says, recommends prompt diagnosis and early treatment. This is to avoid the secondary physical problems associated with disuse of an affected limb and the incredible psychological consequences of living with undiagnosed chronic pain. It has been shown that an early referral to physiotherapy, for example, and encouraging gentle movement as early as possible, may prevent progression of the symptoms. Patients with CRPS are generally best managed in specialist pain management clinics.

[Ruth George]

Will the Minister look at the proposal to set up protocols in fracture clinics and clinics where carpal tunnel surgery is performed? Prevalence of CRPS following such surgery or an injury is particularly pronounced.

[Caroline Dinenage]

I will certainly look at that.

The hon. Lady mentioned delays in referral to a pain clinic, which is something that concerns me. Waiting times should be about 13 weeks once a GP has referred someone, but, as she says, some people wait longer. NHS England commissions the highly specialised pain management services for adults and children, and we will raise the issue with it. The National Institute for Health and Care Excellence has also published guidance for the pharmacological management of neuropathic pain, which includes CRPS. The guidance was updated earlier this year to reflect the latest available evidence.

Patients with CRPS will usually be managed through routine access to primary or secondary care. For patients with the most chronic and intractable pain, a referral can be made to a highly specialised pain service, commissioned by NHS England. Here, patients can receive multidisciplinary expert care and specialised treatment. Once diagnosed, patients can expect access to a range of other healthcare professionals for support and on-going treatment. This includes physiotherapists, occupational therapists, neurologists, a psychologist to help with the associated psychological problems caused by living with CRPS, and other healthcare professionals trained in pain relief.

The hon. Lady spoke about research. The National Institute for Health Research welcomes research funding applications for any aspect of human health, including CRPS. The CRPS UK clinical and research network was established in 2006. It is a research collaboration between a number of UK NHS trusts and academic institutions with an interest in the disorder. Its primary aim is to raise awareness and understanding among health professionals, patients and the general public. This year it is 10 years since the network established the CRPS registry, which now holds over 500 records and contributions and has contributed to seven different national and international research studies.

I thank the hon. Lady again for bringing this important debate to the House. I have attempted to answer as many of her questions as I can, but I will come back to her with anything that I have not covered. I hope that the debate has been helpful in raising the profile of this very difficult and distressing condition.

Question put and agreed to.

Social Care Provision and the NHS

Debate between Ruth George and Caroline Dinenage

Thursday 3rd May 2018 Westminster Hall

[Caroline Dinenage]

The hon. Lady has a surprise coming—this action plan is signed by Ministers from across Government.

The hon. Member for High Peak raised cost pressures. We can all admit that local authority budgets have faced pressures in recent years. They account for about a quarter of public spending, so they have had a part to play in dealing with the historic deficit that we all know we inherited in 2010. That means that social care funding was inevitably impacted during the previous Parliaments. However, with the deficit now under control, we have turned a corner.

Thanks to a range of actions taken since 2015, the Government have given councils access to up to £9.4 billion of more dedicated funding for social care from 2017-18 to 2019-20. Local authorities are therefore now estimated to receive about an 8% real-terms increase in access to social care funding over the spending review. In Derbyshire, the hon. Lady’s local council has seen an increase of £33 million in adult social care funding from 2017-18 to £201.8 million, which is above the 8% figure—it is a 10.3% increase on the previous year. The Care Act 2014 places obligations on local authorities and the extra funding is designed to help them meet those obligations.

[Ruth George]

I did not want to turn the debate into a political tit-for-tat, but I do not want my constituents in Derbyshire to think that suddenly there is a £33 million increase and everything is rosy for social care. The council has seen its funding cut by £157 million over the past seven years. Unfortunately, that increase is a drop in the ocean. In particular, the rise in the cost of the living wage impacts on care costs. What the council is getting back is nothing like what it has lost.

[Caroline Dinenage]

I have already recognised the fact that all local authorities have had to make some really tough decisions. We know it has been difficult for everybody. Taking that action to control the deficit and get the country’s finances under control has meant that we have turned a corner and we are now beginning to put that funding back in. I do not think we can deny that there were years that were very difficult for all local authorities. There is dedicated funding in adult social care; the funding goes to a specific cause, which is really important, and allows local authorities to support and sustain a more diverse care market. It also goes on to help relieve pressure on the NHS, including by supporting more people to be discharged from hospital as soon as they are ready.

The money is already beginning to have an impact. Delays of transfers out of hospital due to adult social care hold-ups have reduced by more than a third over the past 12 months, freeing up 820 beds. A key tool in developing more and better out-of-hospital services is the better care fund, which is a mandatory, national programme for integrating health and social care. It joins up services so that they are designed around people’s needs, enabling them to manage their own wellbeing and to live as independently as possible. By mandating the pool of funds, the better care fund has helped to join up health and care services and incentivise local areas to work better together with increasing amounts of funds being used in that process. Some 90% of local leaders have reported that the better care fund has helped them to progress integration in their areas.

We know that the burden of care cannot and should not continue to fall simply on hospitals. We need to move care into the home and into the community. There are great examples of how that is working in practice up and down the country. Public Health England, the Chief Fire Officers Association, the Local Government Association, NHS England and Age UK already have a joint working approach to establish how local fire and rescue services, for example, can be commissioned to check on people in their homes, to check on the safety of people’s homes, and to check on things such as trip hazards—all things that can lead to people being admitted to hospital or needing the support of social care services. They work together to encourage joint working around intelligence-led early intervention and, in doing so, reduce preventable hospital admissions.

Evidence has indicated that longer hospital stays for older patients can lead to worse health outcomes and an increase in their care needs on discharge. We know that for a healthy older adult, 10 days of bed rest leads to a 14% reduction in leg and hip muscle strength and a 12% reduction in aerobic capacity, which is the equivalent of 10 years of their life, which is a massive incentive to make sure we get people back into their own homes and active as quickly as possible, in the interests of their own wellbeing.

I am particularly interested in understanding how intermediate care—step-up and step-down services—can reduce the impact of health crises on individuals. A relatively minor infection or a temporary worsening of a chronic condition should never spiral into a prolonged hospital stay with a detrimental impact on long-term quality of life. The real goal of integrating health and social care is not simply a benefit to the system, but an emphasis on person-centred care. We need multi-disciplinary teams working around a person to maximise the effectiveness of interventions, and therefore minimise disruption to the individual.

The hospital to home programme brings together practitioners across health and social care to develop solutions for more patient-centred care, focusing on how to keep people at home. It shows how urgent and emergency care services, community services, primary care and social care can all work together to make sure that people get the right care at the right time and, crucially, in the right place. That partnership goes through everything that local partners do, whether providing interlocking services or commissioning the right pattern of services.

How can we push forward these aims and create a sustainable settlement for social care? In March, the Secretary of State for Health and Social Care outlined seven principles for the Green Paper on care and support and for adult social care reform, and he put a key focus on the need to integrate services around the individual for a seamless, whole-person approach to both health and care. We have committed to publishing the Green Paper by the summer, and when it is published there will of course be a full public consultation, through which we want to seek the broadest possible range of views. I look forward to the contributions of Members under that national discussion.