November This submission focuses on the following areas:

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1 November 2014 Arthritis Research UK response: Centre for Policy on Ageing and Local Government Association call for evidence on local government s response to an ageing society 1. Arthritis Research UK welcomes the opportunity to respond to the Centre for Policy on Ageing and Local Government Association call for evidence on the role of local authorities in preparing for the opportunities and challenges of an ageing society Arthritis Research UK is the charity dedicated to stopping the devastating impact that arthritis has on people s lives. Everything that we do is focused on taking the pain away and keeping people active. Our remit covers all conditions which affect the joints, bones and muscles including osteoarthritis, rheumatoid arthritis, back pain and osteoporosis. We fund research into the cause, treatment and cure of arthritis, provide information on how to maintain healthy joints and bones and to live well with arthritis. We also champion the cause, influence policy change and work in partnership with others to achieve our aims. We depend on public support and the generosity of our donors to keep doing this vital work. 3. This submission focuses on the following areas: Musculoskeletal conditions Key challenges of an ageing population Prevention Multimorbidity Frailty Musculoskeletal health data Musculoskeletal conditions 4. Musculoskeletal conditions are primarily long term conditions causing pain and disability. Around 20% of the general population consult their GP about a musculoskeletal problem each year. 2 That amounts to over 100,000 consultations a day, the majority of which are for osteoarthritis and back pain, accounting for a substantial attendance and demand for resource in primary care The impact and burden of musculoskeletal conditions is recognised by the World Health Organisation, which describes them as leading causes of morbidity and disability, giving rise to enormous healthcare expenditures and loss of work. 4 Indeed, UK analysis of the Global Burden of Disease 2010 identifies musculoskeletal conditions as the largest contributor to the burden of disability in the UK in 2010, such conditions accounted for 30.5% of all years lost due to disability. The study also showed the rising prevalence of musculoskeletal conditions over time, suggesting the area requires urgent policy attention Musculoskeletal conditions interfere with people s ability to carry out normal activities. Common symptoms include pain, stiffness and loss of mobility and dexterity. Pain and disability caused by musculoskeletal conditions can significantly impact quality of life, limiting independence and people s ability to participate in family, social and working life Broadly there are three groups of musculoskeletal conditions. Group one includes rheumatoid arthritis and comprises systemic inflammatory conditions which attack joints and other organs, requiring specialist treatment to suppress the immune system. These conditions are common for example, around 400,000 adults in the UK have rheumatoid arthritis. 7 Group two conditions such as osteoarthritis and back pain are conditions of musculoskeletal pain which affect millions of people and are generally treated by GPs in primary care through physical activity and pain management, though some people require surgery 8.75 million people in the UK have sought 1

2 treatment for osteoarthritis. 8 Group three is osteoporosis, a painless weakening of bone where the first sign of a problem may be when a fragile bone breaks causing pain and disability Fragility fractures affect large numbers of people and are commonly caused by osteoporosis. Around 300,000 fragility fractures (including 89,000 hip fragility fractures) occur each year in the UK. 10 Treatment of those at risk of a fragility fracture takes place mainly in primary care where medication can be prescribed. Fractures however need hospital treatment which can include surgery. 9. Over a third of the population aged over 50 have arthritic pain that interferes with their normal activities. 11 In terms of the most common form of arthritis osteoarthritis a survey found that 71% of people with the condition report some form of constant pain, while one in eight describe their pain as often unbearable. 12 Back pain is a major cause of working days lost, with one in six adults over 25 reporting back pain lasting over three months in the last year. 13 Around 4.7 million people in the UK have sought treatment for osteoarthritis of the knee, including a quarter of those aged 75. Over 1.5 million people in the UK have sought treatment for osteoarthritis of the hand and wrist At 5 billion, musculoskeletal conditions account for the fourth largest NHS programme budget spend in England. 15 The high cost of such conditions reflects the very large numbers of people affected, the cost of healthcare interventions including medications, and the substantial levels of joint replacement for severely damaged joints. Over 89,000 hip and over 91,000 knee replacements are performed each year 91% of primary hip replacements and 97% of primary knee replacements are due to osteoarthritis. 16 Key challenges of an ageing population 11. The risk of developing a musculoskeletal condition increases with age so an ageing population represents a growing challenge. The burden of musculoskeletal conditions is rising largely because more individuals are living into the age groups at highest risk. Present trends suggest that musculoskeletal conditions in the population will only increase further. The number of people aged over 65 with a musculoskeletal condition in England and Wales is predicted to increase by over 50% by Musculoskeletal conditions are much more common in older age. For example, 42.5% of people aged 65 and over have sought treatment for osteoarthritis. 18 As more people live longer the adverse effects of these conditions on those living with them, as well as health services and wider society, will increase Healthspan the number of years spent in good health is lagging behind life expectancy. On average women today have poor health for the last ten years of life and men for the last seven years. 20 Much of this morbidity is caused by musculoskeletal problems including osteoarthritis, back pain, falls and fragility fractures Muscle mass and bone strength gradually decline with age. Older people experience 2-4% loss in muscle strength each year. 22 After the menopause, women lose bone twice as quickly as men, at a rate of around 1% each year. 23 A quarter of women aged 80 will have osteoporosis, compared with only 2% aged These twin vulnerabilities weaker muscles and fragile bones are major threats to the musculoskeletal health of older people. Weaker leg muscles make it more difficult to remain physically active; destabilise joints leading to injury, damage and pain; and increase the likelihood of falls. Fear of falling can reduce older people s confidence, leading to loss of independence. 25 For people with osteoporosis, a simple fall from a standing height can result in a life-changing fracture. 2

3 16. Social isolation is also a significant risk. Many older people have mobility problems as a result of a musculoskeletal condition, which can impact on their ability to remain socially connected. A vicious cycle can emerge: musculoskeletal problems leading to pain, which can lead to low mood and social withdrawal. This sense of social isolation further reduces quality of life. Prevention 17. Given the very high prevalence of musculoskeletal conditions, the substantial consequences for those affected and the impact on health and care services and wider society, a public health approach is required to make effective, lasting and meaningful improvements in the musculoskeletal health of the population. 18. An ageing population, alongside rising levels of obesity and physical inactivity will increase the number of people living with a musculoskeletal condition. In 2012 the Chief Medical Officer acknowledged that osteoarthritis, the most common musculoskeletal condition, is a generally unrecognised public health priority. 26 The tools of public health can and should be used to create an environment where musculoskeletal health can flourish, where fewer people develop musculoskeletal conditions, and where those who do have a musculoskeletal condition are able to take steps to reduce the impact it has on their lives, and where possible can restore their own health. 19. Healthy ageing is at the core of a public health approach to musculoskeletal health. Keeping physically active and maintaining a healthy weight can markedly reduce the risk of developing a musculoskeletal problem. For those who have developed a musculoskeletal condition, lifestyle changes can substantially reduce the impact of the condition, at every stage and at every age. It is never too late to start taking steps to improving musculoskeletal health. 20. Tackling poor musculoskeletal health is a significant challenge posed by an ageing population that local authorities must address as part of their public health responsibilities. Approaches must be targeted and multidisciplinary, involving not just interventions targeted at older people now, but also preventative interventions designed to promote good musculoskeletal health throughout the lifecourse, with healthy ageing messages embedded to reduce the risk of people developing a musculoskeletal condition at all. 21. When designing programmes and interventions, local authorities must also take into account barriers to access or participation. For example, musculoskeletal pain can be a significant barrier to physical activity. A common misconception is that persistent joint and back pain requires rest while, in reality, physical activity is one of the best things anyone can do for their musculoskeletal health. Given the high prevalence of musculoskeletal conditions, particularly among older people, local authorities must target and tailor messaging for these hard-to-reach groups, to challenge the myth that pain equals rest. Multimorbidity 22. All strategies for addressing the opportunities and challenges of an ageing society must consider multimorbidity. Multimorbidity becomes more common with age and a significant proportion of those with a long term condition are multimorbid. 27 For example, 82% of people with osteoarthritis have at least one other long term condition such as cardiovascular disease, hypertension or depression, which can exacerbate the impact of osteoarthritis Local authorities must recognise the realities of multimorbidity the pain and disability caused by one condition may well have an equal or greater impact on someone s quality of life than any other condition they have. Interventions for older people must take into account the high likelihood of multimorbidity by taking an holistic approach, addressing the needs of the whole person rather than any one specific condition in isolation. 3

4 Frailty 24. Frailty presents a considerable risk to people as they get older. Musculoskeletal problems are a major contributing factor to frailty, particularly in terms of diminished bone density, joint and muscle weakness which accounts for many falls and fractures and the subsequent need for urgent and expensive secondary care. 25. Falls and fractures among older people is a pressing public health issue. Falls are the second greatest contributor to the burden of disability in the UK, and a major cause of mortality. 29 Falls are very common one in three people aged over 65 fall at least once each year. 30 Problems with balance and mobility, gait and muscle weakness all increase an older person s risk of falling. NICE recommends that those at risk receive a multifactorial falls risk assessment, a highly personalised intervention looking at functional limitation and environmental factors Around 300,000 fragility fractures occur each year in the UK, including over 89,000 hip fragility fractures. 32 Long term pain and loss of independence are common, and sometimes older people may not survive the trauma of a major fracture. Hip fractures are the most common cause of accident-related death in older people, resulting in nearly 14,000 deaths a year in the UK This is a growing problem. Between 1990 and 2010, the number of falls in the UK rose by 32% and with an ageing population, this burden is set to increase further. 34 Projections suggest that by 2036, hip fractures could account for up to 140,000 hospital admissions in the UK each year, with care and treatment costs rising to 6 billion Frailty, falls and fractures have a substantial impact on the lives of older people, resulting in the loss of independence, mobility and confidence. Local authorities must play their part in preventing falls and subsequent fragility fractures by ensuring that falls prevention interventions are available and accessible such interventions include exercise programmes and the provision of aids and adaptations. Local authorities should also ensure that people are supported across health and care settings, to smooth the transition between acute and community settings. Vital to this is the use of reablement services in the community to help people regain and maintain independence, confidence and quality of life, reducing the need for further support in the future. Musculoskeletal health data 29. Musculoskeletal health is a data poor area. There is a need for greater granularity in data collection relating to the incidence, prevalence and geographical distribution of musculoskeletal conditions in the UK, as well as the health status of people with such conditions. An ageing population and rising levels of obesity alongside rising demand for health and social care services means that the need for high quality data in musculoskeletal health is pressing. 30. This lack of reliable, high quality data is a significant limitation for local planning: musculoskeletal conditions are often overlooked when local authorities are planning the commissioning of services. We know that some musculoskeletal conditions are often not routinely included in local planning such as joint strategic needs assessments (JSNAs). In particular, conditions of musculoskeletal pain such as osteoarthritis and back pain are often not included. As JSNAs describe the health needs of the local population, the non-inclusion of some musculoskeletal conditions could result in the needs of people with musculoskeletal conditions not being considered in planning, resulting in a lack of service provision. 31. Our forthcoming report, a fair assessment, analyses JSNAs and joint health and wellbeing strategies (JHWSs) produced by 152 local authorities looking at the number and quality of mentions in relation to musculoskeletal conditions, and rating each local authority accordingly To help address the musculoskeletal data gap, Arthritis Research UK is developing a musculoskeletal (MSK) calculator to provide local estimates of the number of people with 4

5 musculoskeletal conditions in England, for use in the planning of healthcare services and public health programmes for local populations. 33. The MSK calculator is an online tool to provide healthcare planners with accurate and up-to-date musculoskeletal health data estimates of the incidence and prevalence of hip and knee osteoarthritis, rheumatoid arthritis, back pain and high risk fragility fractures. Estimates for each condition will be modelled at the national, regional and local level (including clinical commissioning group and local authority boundaries) so planners can analyse and include these local data estimates in JSNAs. 37 For further information on this submission, please contact: Amy Forbes Policy Officer Arthritis Research UK Registered charity in England and Wales No , Scotland No. SCO41156 A Company registered in England and Wales and Limited by Guarantee No

6 1 2 Arthritis Research UK Primary Care Centre (2009), Musculoskeletal Matters. 3 J Hippisley-Cox (2009), Trends in Consultation Rates in General Practice 1995/6 to 2008/9: Analysis of the QResearch database, NHS Information Centre for Health and Social Care. 4 World Health Organisation (2013), Chronic diseases and health promotion: chronic rheumatic conditions: accessed 23 Apr C Murray et al. (2013), UK health performance: findings of the Global Burden of Disease Study 2010, Lancet 381:9871, Arthritis Research UK (2014), Musculoskeletal health: a public health approach. 7 D Symmons et al. (2002), The prevalence of rheumatoid arthritis in the United Kingdom: new estimates for a new century, Rheumatology 41: 7, Arthritis Research UK (2013), Osteoarthritis in general practice. 9 Arthritis Research UK (2013), Understanding Arthritis: a parliamentary guide to musculoskeletal health. 10 National Osteoporosis Society (2011), A fragile future: 25th anniversary report. 11 E Thomas et al. (2004), The prevalence of pain and pain interference in a general population of older adults: cross-sectional findings from the North Staffordshire Osteoarthritis Project (NorStOP), Pain 110:1-2, Arthritis Care (2012), OA Nation. 13 AM Elliott et al. (1999), The epidemiology of chronic pain in the community, Lancet, 354:9186, Arthritis Research UK (2013), Osteoarthritis in general practice. 15 Department of Health (2011), England level data by programme budget: National Joint Registry for England, Wales and Northern Ireland (2014), 11th Annual Report. 17 Public Service and Demographic Change Select Committee (2013), Ready for Ageing?, HL Paper 140, Report of Session Arthritis Research UK (2013), Osteoarthritis in general practice. 19 Arthritis Research UK (2014), Musculoskeletal health: a public health approach. 20 Office for National Statistics (2012), Health expectancies at birth and at age 65 in the United Kingdom Christopher J L Murray et al. (2013), UK health performance: findings of the Global Burden of Disease Study 2010, Lancet 381:9871, WR Frontera et al. (2000), Ageing of skeletal muscle: a 12 year longitudinal study, J Appl Physiol (1985) 88:4, N Emaus et al. (2006), Longitudinal changes in forearm bone mineral density in women and men aged years: the Tromso study, a population-based study, Am J Epidemiol 163:5, G Holt et al. (2002), Prevalence of osteoporotic bone mineral density at the hip in Britain differs substantially from the US over 50 years of age: implications for clinical densitometry, Br J Radiol 75:897, SW Parry et al. (2001), Falls and confidence related quality of life outcome measures in an older British cohort, Postgrad Med J 77: 904, SC Davies (2012), Annual report of the Chief Medical Officer 2011 volume one, on the state of the public s health. 27 Karen Barnett et al. (2012), Epidemiology of multimorbidity and implications for health care, research, and medical education: a crosssectional study, Lancet 380:9836, FC Breedveld (2004), Osteoarthritis: the impact of a serious disease, Rheumatology 43:1, i4-i8. 29 Christopher J L Murray et al. (2013), UK health performance: findings of the Global Burden of Disease Study 2010, Lancet 381:9871, AM Tromp et al. (2001), Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly, J Clin Epidemiol 54:8, National Institute for Health and Care Excellence (2013), CG161 Falls: assessment and prevention of falls in older people. 32 National Osteoporosis Society (2011), A fragile future: 25th anniversary report. 33 J Roche et al. (2009), Effect of Comorbidities and Postoperative Complications on Mortality after Hip Fracture in Elderly People: Prospective observational cohort study, British Medical Journal 331:7529, Christopher J L Murray et al. (2013), UK health performance: findings of the Global Burden of Disease Study 2010, Lancet 381:9871, Steven Allender et al. (2007), The burden of physical activity-related ill health in the UK, Journal of Epidemiology and Community Health 61:4, Arthritis Research UK (forthcoming), A fair assessment?