Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 40 - 59)



  Q40  John Austin: In terms of being able to identify the allergens which are the triggers, a lot of the written evidence we have had suggests that people have waited a very long time until they could discover what the triggers were. It has been said that apart from the extreme ends, where desensitisation is needed, risk can be reduced by avoidance of certain things if you know what you are allergic to. Is the basic skin test for identifying the allergens one which has to be carried out in the specialist allergy centre, or is it one which could be done fairly easily in primary care with appropriate training of staff?

  Dr Nasser: Skin testing, on the whole, is fairly safe, but there are cases of very severe allergic reactions as a result of skin testing. It is important that the person who carries out the skin tests recognises this and is prepared to deal with the consequences, and is able to resuscitate the patient if required and has the facilities to do so. I think a lot of general practitioners are reluctant to do this, especially as we have a history of severe allergic reactions in primary care during desensitisation. So there is a natural reluctance to do this. A better way would be for there to be a readily accessible clinic in secondary care, that patients would have ready access to and they could just go along and be skin tested by nurses. GPs would have access to this. It is important, though, that the skin tests are appropriately interpreted because a positive skin test does not necessarily mean you are going to have an allergic reaction to something. It is important to interpret it in the light of the clinical history. So there are some more complex aspects of this. Sometimes you have to undertake higher dose skin tests, which are more technically demanding and need even greater skill in interpretation. Although in theory they could be done in primary care, a better way would be for them to be readily available in secondary care and that the general practitioners had ready access to this and ready access to someone who could interpret them.

  Q41  Chairman: One of the issues in which we as a Committee have taken an interest is what is generally known as tele-health and e-health, where you can electronically connect, so your primary care setting with a secondary or tertiary setting. In terms of dermatology, I have seen this working quite successfully. Bearing in mind we are never going to get, certainly in most of our lifetimes, the kind of level of tertiary provision that we would want to kick on the kind of provisions that obviously are necessary, are there any possibilities within health, if you follow me, in terms of your area?

  Dr Nasser: Do not be so pessimistic about not being able to get this. We should not start from that premise. We should say, "Look, we have really got to go for this"!

  Q42  Chairman: I am considering myself completely ticked off!

  Dr Nasser: I think dermatology is very different. With dermatology, you have a rash and you can recognise it. This is a challenging subject. This is multi-system. It is not just the illness itself, it is the burden of anxiety that patients talk about. They need to be able to talk to someone who understands their problems.

  Q43  Chairman: What I am trying to say to you—and I have seen this done with psychiatric patients—is why is it not possible for a patient to go to a GP and talk on a camera to you in your hospital and you interview that patient with the GP sitting beside them about managing their care and looking at what they need to do. I take your point that if they are doing testing that could result in a reaction that needs specific medical treatment that is not available there, but are there not things that could be done to enable you to reach out to more people further afield? I am particularly conscious—as I was remarking earlier on—that, looking at the map, from Yorkshire we have to go miles to get anywhere. Yorkshire is bigger than Wales and Scotland virtually. We have no provision in the tertiary sense at all according to the map we have and our information. Is there not a potential to do something to connect you down the line to people, where we could do more than we are doing now?

  Dr Nasser: Ultimately the patients have to be tested. Otherwise, we will remain in a situation where children are told, if they have had an allergic reaction to, say, milk from a very young age, "You are much more likely to be allergic to nuts, you are much more likely to be allergic to eggs," and we will end up with a lot of malnourished children who are avoiding many more things than they need to. Allergy is not just about identifying what you are allergic to but identifying what you are not allergic to, to allow the child to be able to lead a much more normal life. This is something that is fraught with stigma. These children grow up with stigma.

  Q44  Chairman: I think the answer to my question from what you say is e-health has a limited use in addressing the problems we have at the present time. I think that is what you are saying.

  Dr Nasser: It is probably useful in the support stages. After the initial diagnosis has been made, it is probably useful there and I am sure that something could be done. But initially they need to see someone who can explain the problem to them.

  Q45  John Austin: You have mentioned milk. What evidence is there to link the early feeding of cows' milk to young infants with later problems in terms of allergic reactions?

  Dr Nasser: That is a difficult question. We know that breast milk protects from allergic disease. Breast milk is good. The early feeding of any type of allergen, be it eggs or nuts or milk may be a problem during either lactation or pregnancy or in very early infancy, but we don't fully understand this. There is probably a susceptible time when the child is likely to developing desensitisation, but we do not fully understand what that susceptible period is. That is not a question that I think anyone can easily answer.

  Q46  John Austin: But you are saying that there is evidence of showing a very clear correlation on the reduction of risk if the child is breastfed.

  Dr Nasser: Yes.

  Q47  Mr Amess: When Mr Reading told us he had lost a daughter as a result of peanut allergy, I think that more than emphasised how serious the problem is. We are hoping that by having his inquiry minds will be concentrated, and we hope to draw up recommendations which will be relatively easily obtainable, given that there is not a bottomless pit of money that is available. We have already touched upon the evidence we have received from people saying that allergy is not taken seriously enough. GPs are very busy. They are each day receiving a pile of new products from the pharmaceutical companies. How on earth can they keep on top of it? We cannot necessarily blame the GP that they get the diagnosis wrong, etcetera. Would the three of you just give us a layman's guide of how you really think the primary care sector for the treatment of allergies could improve relatively quickly in some tangible way, because, let's be honest about this, we cannot say, "Right, allergies on hold. No one is going to have any of these allergies for the next six months/two years." People need help now. Is it better communication? Is there something we can do with the primary care sector?

  Ms Simmons: We would definitely like to see more training. The ideal situation, yes, is to have centres where from those leading centres training could go out, but that is expensive and it is not going to happen quickly. We know this. There is a very real wish for education at primary care. We run training courses. I have two master classes that are happening very shortly. Both are oversubscribed, all from GPs wishing to learn more about how to help their patients in allergy. If money could be directed into educating the GPs and also increasing the funding to encourage them to deal with allergy. Unfortunately, we know at the moment the daily grind—which is really what I am concerned about. When somebody has an anaphylactic reaction, they have to be dealt with and it is all systems go. It is the people who are trying to cope every day with an illness that is downright debilitating. It affects their family life, their social life, their working life very importantly, and these are the people who are not getting the help. That is why we feel the education should be put into primary care. We have some wonderfully knowledgeable people in the world of allergy—many of them are sitting behind us. We should be providing a lot more training for primary care to enable people to be dealt with.

  Q48  Chairman: In the work you do with GPs, do you get any impression that the younger, more recently trained GPs have any more awareness of this area than the older ones? Is there any indication that their training is reflecting the trends that we are seeing here of this hugely growing problem?

  Ms Simmons: Yes, with all due respect to the gentleman. They are probably rather more broadminded and they are also more up to date in the latest science.

  Chairman: Richard is very broadminded!

  Jim Dowd: It did take him three days to work out he had broken his arm!

  Q49  John Austin: That is because he has been desensitised!

  Ms Simmons: Unfortunately there is still a lack of training within their main training as a doctor, and that definitely needs addressing, but we also desperately, desperately need to do something about the GPs that are out there now. They do want to learn, and that is the main thing.

  Q50  Chairman: You basically provide for this need, but do you draw from all over the country or just the immediate area where you are located?

  Ms Simmons: No, we deliberately put our master classes in various parts of the country.

  Q51  Chairman: So you move around.

  Ms Simmons: Yes, we do. I would say that it is not actually right that charitable funds should be used in that way.

  Chairman: We understand the point you are making.

  Q52  Mr Amess: As far as the waiting times are concerned for this area, we have been given a table that indicates that in the last quarter of the year 2003/2004 only one patient waited between 21 and 25 weeks and a further one waited 26 weeks or over from receipt of the GPs written referral until first out-patient attendance. What is your feeling about the waiting times?

  Ms Simmons: I have to say I am somewhat surprised at those. The feedback we are getting—and I hate to stress this, but I will say it again—is, number one, these are the lucky people who are getting a referral. But we are hearing on the helpline that there is a big gap between the time the doctor refers and the time the patient gets the appointment. That is what we are hearing on the helpline. Instead of it being at that end, so it is a true reflection of the time they are waiting, they are not being given the appointment very quickly. That is what we are hearing.

  Q53  Chairman: Have you seen the Department of Health submission, the figures to which David has referred?

  Ms Simmons: Yes, I have.

  Q54  Chairman: You are sceptical, quite clearly, about the accuracy of those figures.

  Ms Simmons: Yes, I am.

  Mr Reading: I am too. Well, I cannot deny that those figures are possibly true, but we hear a different story. I must say, being at the extreme end, if a child does have a severe allergy to peanuts or kiwi fruit or sesame seeds or whatever and there is that anxiety—and Mr Amess mentioned my daughter, and a lot of other parents think they are in the same situation as I am—they are going to find any wait of, say, more than 12 weeks an absolute nightmare, if a child is believed to be at risk of a fatal reaction. Often the truth is different and it is manageable, most certainly manageable, but it is only manageable when you have that proper care and proper information and guidance. To wait probably even more than a month for some of these parents is to them an absolute nightmare. Realistically, the tales we hear are of 11 months/12 months between the time they first see the GP and when they actually get to see the consultant, and then sometimes there is a wait to get the test results back, so it can be many, many months. Whilst not denying those figures are true, it is a different story that we are hearing.

  Q55  John Austin: You mentioned a couple of foods. I am also wondering to what extent a change in diet and an alien diet may have some influence. Kiwi fruits and sesame seeds have only been in this country within the lifetime of those of us in this room. Peanuts did not really arrive here in numbers until the '40s and the groundnut scheme. There has been a significant change in our diet and the eating of things which are not natural in this part of the world. Is there any evidence that dietary change is a contributory factor?

  Dr Nasser: Certainly for allergy to occur you need exposure in a susceptible individual. Peanuts, for example, are very high in protein and protein is what causes an allergic reaction. Having said that, we know, for example, that people in different parts of the world eat large numbers of these. For example, the Chinese eat lots of peanuts but they do not get a lot of allergy, but when they move to this country they do. It is not just the food itself, it is to do with the environment and a genetic background. It is a mixture of a number of things. After all, egg and milk allergy occur, and we have been eating those for a long time. We are seeing increasing amounts of fruit allergy, apple allergy, and certainly those things have been eaten for many years in this country. It is not just a simple explanation of foreign proteins, no.

  Q56  Jim Dowd: Is this mirrored across comparable societies, other parts of Europe, North America, those in similar states of development?

  Dr Nasser: Absolutely. The increase in allergy is being seen right across the developed world. The highest incidence of allergy is probably seen in New Zealand/Australia and in this country but also in the US and certain other parts of Europe.

  Q57  Jim Dowd: New Zealand is often held up as an idyll of healthy lifestyle.

  Dr Nasser: Enormous numbers of them are allergic to house-dust mite.

  Q58  Mr Amess: Why do so many people have a wheat allergy now? That is a basic part of diet. The supermarkets are producing things to help people with coeliac disease. It seems extraordinary.

  Dr Nasser: Yes. Again, we cannot answer why we are getting increase in allergy, we can only speculate. But, again, it is the broad increase and it is a true increase. Although we are getting better at recognising it, it is a true increase. As I mentioned previously, the hygiene hypothesis is a good one. There are different types of wheat allergy. There is a type of wheat allergy that causes similar reactions to, say, nuts; there is a type of wheat allergy that only manifests after exercise; and there is a coeliac type of wheat allergy. There are so many different types of problems that you can get with wheat and it is important, again, that you go to see an allergy specialist to be able to sort out what type you have.

  Q59  Mr Amess: You were both concerned about the waiting time figures and you will be pleased to know that in a later session the minister will be giving evidence to us and that will give us the opportunity perhaps to clarify some of these points you are concerned about. Dr Nasser, I wanted you to say something about hospital allergy services. This is not to knock you down at all but I was fascinated when you were saying, "Go along and get these desensitising tests." When I had personal experience of this process many years ago, it took a long while. I think I was given 26 tests and I was positive to everything, including eating strawberries, and I came to the conclusion life is not much worthwhile living if I am going to fiddle about with different things. It just seemed one long drawn out procedure, where we live in a climate where you just want to take a tablet hoping that will cure things, etcetera, and the hospitals are under such strain that if you say that is the only way to fix things, so be it. So I am not going to have an argument about the veracity of what you said, but how do you think we could improve the position of hospital services to treat these allergies?

  Dr Nasser: I am sorry you had such an awful time. If you were to go to see a specialist in this field you would probably find you would have a different experience. Come and see us up in Cambridge, if you like, and I suspect we will probably change things a little bit and improve your quality of life.

  Jim Dowd: He is allergic to Cambridge, unfortunately!

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