Annex A
AN NHS PLAN
FOR ALLERGY—MAKING
A START
1. This paper sets out the options available
to the Department of Health on how to modernise NHS allergy services.
A summary is given in paragraphs 2 to 5 below.
2. Central Government initiatives are required
to give an effective start to the improvement in NHS allergy care.
The initiatives need only be small scale. They would be the precursor,
not an alternative, to close to patient developments which can
be the main driver for change once allergy services have become
part of the NHS mainstream. Central intervention to begin change
will give direction and leadership, will make it possible to address
the most serious gaps in service first, and will help to make
the overall process more effective and more efficient.
3. Mixing (supportive) central initiatives
with (mainstream) local developments would be the right way to
develop services for allergy. It need not create difficult policy
precedents for the Government, given its desire to make service
development a local health authority responsibility.
4. The initiatives which are needed would
help to create a core NHS allergy service where currently none
exists. This would eventually cost an additional £5.6 million
pa for the English NHS, building up over a number of years. Some
of the costs will be offset by necessary interventions to prevent
an imminent deterioration in allergy care. And—although
this cannot be quantified, given the information which is currently
available on the NHS—reduced calls on other parts of the
NHS would also result as provision for allergy becomes consolidated
around the new core.
The Analysis—Four Parts
5. Four aspects to the analysis are presented,
as follows:
A: Growing need and inadequate services:
There is a current epidemic of allergy in Britain. An estimated
30% of the population now have allergic disease; the proportions
for children are ten percentage points higher still; the numbers
with complex, severe or life threatening illness are growing disproportionately.
Faced with the unprecedented levels of need which result, but
with no effective service base from which to grow, the allergy
service of the NHS needs to be transformed if it is to provide
21st century care. A start must be made on doing this.
B: Achieving Change—the right response:
The core issue is how to create a health service capable of meeting
the needs of the 1/3 of the population who
have allergy—given the current, effective absence of any
national, clinical or commissioning infrastructure for such a
service within the NHS.
— While recognising there is a problem,
the Department of Health has said that it does not see any need
for central intervention. Additional general flows of funds into
the health service, combined with close to patient decision taking
within a devolved NHS, will—Ministers have said—be
sufficient to address any significant problems the service may
face from the epidemic.
— A consensus of clinical and patient
opinion, however—including the Department's own expert advisers
on the management of the NHS medical workforce—have concluded
that some central action will be required to respond to the situation
which is developing. Well managed, what has become necessary could
be the start of an effective change process resulting in the creation
of new services for people with allergy within the NHS.
— That said, the choices facing the
Health Department are not—as they have been presented—between
centralised or devolved decision taking. The advice being offered
to the Department—principally by the Royal College of Physicians—is
that strategic central investment in medical manpower will support
and complement, not cut across, locally driven change.
C: The NHS allergy workforce: The NHS
currently offers a vestigial allergy service across all sectors
of care.
— The small group of specialist, consultant
allergists is forecast to become even smaller in the coming decade
because not enough doctors are being trained to replace those
who will retire. This is an exceptional situation across virtually
all medical disciplines in the NHS.
— In consequence the Department's expert
advisers on the medical workforce are proposing that the balance
should be redressed. If their advice is accepted, the resulting
increase in centrally funded, specialist training would begin
a process of improvement in the way recommended by the Royal College.
— For paediatric allergy, where successive
birth cohorts of children are driving the epidemic, allergy doctors
face a very serious and growing imbalance.
— Ensuring the medical workforce is
appropriately trained—given the national information requirements
for planning, the very high premium on getting workforce numbers
right and the timescales and costs of delivery—is anyway
a responsibility of central government.
— Using a workforce intervention to
initiate change need not, therefore, be seen as cutting across
the preference for allowing local health decision taking to drive
change wherever possible.
D: Ends and Means: Government's plans
for the NHS promise a service which is there when its patients
need it, access which is timely and convenient to arrange and
which offers the best in modern medicine. Wide ranging change
will be needed if an NHS allergy service is to become part of
the mainstream NHS, delivering on this promise. With commitment
and imagination most of what is required can be developed within
a devolved service; but creation of the initial core group of
allergy doctors cannot. For this group to be recruited, trained
and located, Government must act using resources it controls centrally.
Doing this opens the way for other changes which can be driven
locally and within the medical profession.
A BREAKDOWN OF
THE PROBLEM
AND A
WAY FORWARD
The allergy epidemic and current services
6. In June 2003 a Royal College of Physicians'
expert committee(1) reported, having studied the emerging allergy
epidemic in Britain. The report contained new clinical and epidemiological
estimates of allergy prevalence—the latter based on official
data—an appraisal of the current state of allergy services
in the NHS and recommendations for improvement.
7. On allergy prevalence, the Royal College
found reliable evidence of an allergy epidemic in the UK.
(a) an estimated 30% of the population have
an allergic disease (15 million people in England); 10 million
people have active allergic symptoms in any year;
(b) at least 2.5 million people (one in six
of those with allergy) have sufficiently severe symptoms to require
tertiary level clinical help. A further group of people need more
specialist help than can be provided in primary care; it is difficult
to estimate the size of this group;
(c) these prevalence rates are among the
highest in the world;
(d) 40% of children have allergy—each
birth cohort increases the numbers of people needing help; the
epidemic continues to grow, making allergy a particular problem
for today's children, and their families, and for tomorrow's young
adults;
(e) there are no socio-economic class, ethnic
origin or geographic variations in the disease.
8. On NHS allergy service provision, the
College found widespread poor standards. There is insufficient
understanding, training and adherence to good clinical practice
within primary care, where major parts of a disease with such
widespread prevalence must ultimately be managed. NHS Commissioners
have inadequate information about allergy; and few of them seem
to have thought about the illness or the requirements for an allergy
service. In the hospital sector, the College found clinics providing
services for allergy patients mixed in with the management of
other conditions. And, in the absence of specialised alternatives,
doctors who are not allergists, some of whom have had little or
no training in allergy, are working to help to manage the epidemic,
as an add-on to their main role. It follows that patients are
not receiving adequate standards of care; children may be particularly
badly served.
9. As far as the specialised allergy services
are concerned, the College found gross under resourcing and an
inequitable geographic distribution. However, in six locations
across the country (three of these in London, with others in Southampton,
Cambridge and Leicester) the College found a significant concentration
of allergy expertise, and service and training capacity. For the
most part—although not exclusively—this national expertise
on allergy had been developed by doctors funded primarily in their
capacity as clinical academics and researchers.
10. Therefore, major improvements in the
hospital based services, combined with a significant "reskilling"
programme in primary care, are required to enable the NHS clinical
workforce to meet the challenges of the allergy epidemic.
11. An independent assessment of one aspect
of what will eventually be needed is available from the Royal
College of Physicians' report on NHS specialist workforce requirements
across all medical disciplines (2). Using a methodology common
to all specialities to take account of emerging need, the latest
Royal College assessment is that 520 additional consultant allergist
posts in England and Wales are needed in order to provide a competent,
reputable and fully fledged specialist allergy service within
the NHS. This is just one measure of how far commissioning will
need to drive the service once its basic infrastructure is in
place.
12. The patient's organisations, quite reasonably,
are asking for:
— convenient and timely access to the
health service; and appropriate and accurate diagnosis of allergy;
— treatment or referral; convenient
and timely access to a clinic in the case of referral;
— for evidence based information to
be provided to individual patients on how to manage their allergy;
— continuity of care to be available;
and
— for emergencies both to be well managed
by clinical staff who know about allergy and for the emergency
to be used as an event triggering an appropriate medical review.
13. Meeting these aspirations for allergy
patients from today's virtual standing start will require:
— the introduction into primary care,
more or less de novo, of competence to diagnose and manage allergy
(as opposed to the drug treatment of specific allergy driven diseases,
such as asthma);
— the parallel introduction into most
teaching hospitals of an allergy service, providing convenient
local access for people with more complex allergy;
— and the development of a regional
or tertiary level service which can manage the most complex cases
and provide overall leadership during a time when, however fast
the service grows, a serious imbalance between needs and capacity
will exist.
14. We have estimated the service gap which
exists. Estimation is inevitably imprecise because the NHS has
virtually no clinical information available on allergy. The most
complex cases will be appearing throughout the service classified
and managed as other, specific illness. We can make no estimate
of the gap in the case of primary care. But we have concluded
as follows for specialist services, for the UK as a whole
"The numbers of children with allergy in
need of specialist help are estimated to be increasing by over
40,000 each year across the UK. An estimated minimum of 2.7 million
people currently need specialist diagnosis and treatment for their
allergy. NHS allergy clinics are able to cope with a maximum of
50,000 new cases a year—less than 2% of estimated unmet
need assuming no annual increase in need. All current clinics,
working as they are, would take 50 years to clear the backlog,
if there were to be no new cases of severe or complex allergy".
See the annex to this paper for more detail.
Achieving Change
15. Department of Health Ministers have
agreed—in debates in the House, in answer to Parliamentary
Questions and in correspondence—that there is a need for
improvement. But they have also said that decisions on how great
a need, and on what priority should be given to this in relation
to other areas of need for service, are the responsibility of
local health authorities and trusts in partnership with other
local stakeholders—not of central government.
16. For allergy, this approach is bound
to result in inaction. The reasons for this are common to all
clinical areas not currently identified as a centrally determined,
national priority—even with the increases in health finance
currently in evidence, local priorities are being squeezed out
by the pressing urgency to deliver results on centrally driven
targets.
17. And in the case of allergy there are
additional considerations, namely
(a) clinical knowledge of allergy is poor
across all sectors. A primary care led approach, for instance,
would not be appropriate at this point for this reason1,3. This
does not rule out investment in a better prepared primary care
workforce—indeed the reverse—but expectations of what
can be achieved through such an investment must be constrained
until there is an infrastructure of clinical expertise within
which it could be fully utilised. And local clinical leadership
is precisely what is lacking.
(b) the NHS does not know, in any regular
and reliable way, where its allergy cases are, how many there
are and who is managing them. It needs to rely on estimates of
the kind provided through the Royal College, and in the annex
to this statement, in the absence (until recently4) of a recognised
way of coding allergy work within the NHS. Even then, because
allergy care is suffused across a wide range of NHS and private
health care, it will remain difficult to build a true picture
of the clinical workload for the foreseeable future. In this situation
local commissioners have, and will have, effectively no robust,
local clinical information base to work from.
(c) the seriousness of the developing workforce
situation explained in paragraphs 24-30 below, and local awareness
of the national picture, is a case in point. We are aware of no
Department of Health instructions, advice or information which
has been given to local service commissioners on how to decide
or predict local specialist workforce capacity or requirements.
And local commissioners seem unaware or at best unclear about
the appropriate investment levels for the future clinical workforce.
And in the circumstances, when juggling to meet cost pressures
from existing services, they can hardly be expected to take a
new situation seriously, and develop new services, unless told
to do so or unless local pressures build up in an unavoidable
way. It is then, of course, too late for long term investment
into having the right workforce in place to manage the new situation.
(d) not surprisingly, local commissioners
are paying little or no attention to the population's allergy
need. To give one example: in January 2004 Department of Health
Ministers and officials provided the names and contact details
of NHS officials in lead PCTs in England responsible for commissioning
allergy services. Thirty contact names and addresses were provided.
All were immediately contacted to ask what they had done with
respect to allergy services and what priority they attached to
the area. Five months later seven have replied. One has said they
attach importance to allergy. One has refused to answer the questions.
The others do not commission allergy services, so do not appear
to think allergy is important. The response from the authority
saying allergy is important in their area is difficult to interpret
as it is in a part of the country which relies on "block
contracting". Under this arrangement those who provide a
range of services receive a general guarantee and are trusted
to determine the mix they provide across clinical services. It
is difficult to see any scope for commissioner driven change in
this situation. And elsewhere commissioners clearly have other
things on their minds.
18. How, then, to start the changes required
beginning from this situation? It has been said that if allergy
patients were to become more vocal, and to make their voices heard
by local health authorities, then the prospects for change would
improve. Certainly patient's organisations in allergy are contacted
by very large numbers of people seeking help; the Royal College
Report documents the contact levels. But it would be perverse
if the only way to achieve change in a health service professing
to be sensitive to patient need was by turning patient's requests
for help into campaigns for service improvement.
19. There must be a better way. The Royal
College of Physicians have proposed a way. Other growth strategies,
it was thought, would demand substantially larger investment to
get them off the ground and, without clinical leadership, the
results across the country would be at best uncertain.
20. The College has, therefore, proposed
an initial concentration on tertiary allergy care for those in
the most need to give the earliest and most direct possible impact
on the provision of high quality allergy services across the NHS.
It has proposed that
(a) a core initial infrastructure of regional
allergy centres could be created, a minimum of one for each population
of five-seven million people and providing for both adult and
paediatric allergy;
(b) the centres might be centrally sited
within their local populations, or dispersed across the region—depending
on local service configuration;
(c) they would deal directly with the most
complex clinical cases; in doing so they would be addressing the
most serious need and would help to reduce service pressures,
making more effective the clinical management of the most complex
cases;
(d) they would also be an educational and
information resource for their areas—providing training
and clinical assistant opportunities, and path finding the clinical
management of emerging, complex allergy; and they would network
with others contributing to allergy care;
(e) in these wider roles they would support
the development of regional and local expertise among both service
commissioners and other providing units;
(f) and they would become the allergy champions
making locally driven service development a reality. The wider
roles would therefore be at least as important as that of direct
service provision.
21. The College judgement is that, with
this core in place, the essential initial impetus would exist
for more local developments to drive change. Implementation of
such a way forward requires training to be provided for an additional
32 specialist allergy consultant posts, covering adult and paediatric
allergy—four posts, two for adult allergy consultants and
two for paediatric allergists in each regional centre (numbers
of posts are calculated as whole time equivalents for clinical
care). The consultant posts themselves would not need to be resourced
until consultant training for them had been completed. But prior
commitment to create these would be needed to attract good young
doctors into the new core service structure for allergy. The costs
would build up to an additional £5.6 million pa when all
the trained consultants were in post.
22. Capacity exists to provide this amount
of additional training for specialist allergy. But new ways of
networking will need to be developed so that the new allergy doctors
have access to both specialised supervision and to patients in
parts of the country where new specialist services must be located.
While other parts of the country have allergy services run by
doctors from other specialities, and it is important that these
are recognised, there are currently no specialist allergy services
in England west of Bournemouth and north of Manchester. The current
specialist allergy centres will, therefore, need to find ways
of networking with clinics located in the north, west midlands
and west of the country.
23. It is perhaps relevant to set the additional
costs in context. Academics from three British universities have
very recently published estimates of the current cost of allergy
to the NHS5. They have estimated £1 billion across the UK;
and they have concluded that "the more serious systemic disorders
. . . are rapidly increasing". This will prove to be an underestimate.
It is based on historic NHS data; and, as the authors say, the
epidemic is escalating and the rates of serious and complex allergy
are growing disproportionately. Reality may well now have outstripped
this assessment. It is also relevant that
(a) expensive medical emergencies for allergy
are increasing. There was an eight fold increase in community
prescriptions for allergic emergencies in the decade to 20016.
Since the 1990s, hospital admissions for anaphylaxis increased
seven fold and more than doubled for other systemic allergic conditions
(6).
(b) adverse drug reactions account of 5%
of all hospital admissions and 15% of inpatients have a hospital
stay prolonged as a result of drug allergy7.
(c) Service pressures resulting from the
allergy epidemic which are currently experienced across the NHS
would be relieved if a dedicated allergy service were to be developed.
See annex—we have assumed a ten year period to clear the
current care backlog. In that scenario, and not taking account
of new cases, between 10% and 12% of clinic care provided for
allergy patients could be delivered by doctors with other specialities
providing allergy cover. These valuable services would need to
remain in place, working as they are. But pressures on them would
be correspondingly less.
Workforce Issues
24. There are currently only 26.5 whole
time equivalent specialist allergy consultant posts in the English
NHS, with a higher proportion than in other specialities being
filled by individuals supported by academic funding (42%) and/or
working part time for the NHS.
25. Tertiary services, once established,
will be required to provide training and education to undergraduates;
primary and secondary care education and support in establishing
allergy clinics; and very importantly, research and development
to inform clinical practice . Consultants in these centres will
have to deliver a mix of academic and service provision. The number
of consultants proposed (see 21.) is calculated on the basis of
whole time equivalent NHS funded service posts.
26. In total five NHS funded training posts
currently exist in allergy. Recently an additional training post
became available for 2004, in future making a total of six (five
of which are centrally funded) training posts.
27. With the extra post included, the most
recent forecast of the expert group set up by the Department to
advise on medical workforce planning (the Workforce Review Team9)
is that by 2012 the NHS specialist allergy consultant workforce
will have declined by 3%, taking into account predicted retirements,
the academic and service mix of the discipline and all current
and planned training. The advice, therefore, is that allergy will
soon fail to maintain even its current specialist service contribution
to the NHS. It will be one of only two medical disciplines which
will decline in size across the medical workforce planning horizon.
The allergy services available to patients will deteriorate in
consequence, from a mixture of increased need and reduction in
the size of the workforce.
28. The situation is considerably more serious
in respect of paediatric allergy. There are only six consultants
in paediatric allergy, four of whom receive academic funding.
Four of the six have been appointed in the last three years; so,
the paediatric allergy workforce is likely to decline slightly
in size in the next decade; but it is of course totally, inadequately
small. None of the six, because they have academic responsibilities
or are part-time, spend time equivalent to a full-time NHS consultant
on clinical care for children with allergy.
29. The Department's medical workforce advisers
are therefore saying that centrally supported training provision
in adult allergy should be increased by an additional 10 posts
for 2005-06, with a further 10 for 2006-0710. If implemented as
part of a national plan for allergy, this would both make up the
impending shortfall due to retirements and fully implement the
proposals of the Royal College as far as services for adults with
allergy are concerned. Initial training costs would be met from
the medical manpower training programme; and they would be contained
overall within the total cost estimates provided in the Royal
College Report. A Government decision is awaited on this latest
advice.
30. A way forward for paediatrics is different
because the training arrangements for doctors who work with children
are specific to that discipline. Regional Committees work with
training quotas for paediatricians from all the disciplines within
their region and may assign training numbers for sub specialities.
It is possible therefore to assign to paediatric allergy some
proportion of each region's general paediatric training quota.
A training programme for paediatric allergy but combined with
two other specialisms has just been developed, and one national
grid post created. However, a separate sub-speciality training
programme for paediatric allergy is needed; and the whole arrangement
is exposed to the catch 22 discussed in this paper. Without experts
and advocates for allergy within the planning and allocation arrangements,
the need for change cannot be registered effectively. As elsewhere,
the approach of the Regional Committees would change if the Department
of Health were to say that it is important to develop the service.
Ends and Means
31. Allergy commonly affects many organ
systems and it is common practice in the UK for such patients
to end up attending separate clinics for different problems, which
are often not recognised as allergic in origin. The burden of
disease in allergy patients is therefore unrecognised as well
as unmet, and current management is wasteful of NHS resources.
A comprehensive allergy service will not only improve the holistic
care of patients and remove this enormous burden on their quality
of life, but also has the potential to reduce costs and relieve
the load on other disciplines currently picking up these patients.
An improved allergy service would thus be cost efficient.
32. This paper has discussed the rationale,
context and options for making a start on the improvement of allergy
services in the NHS. It key recommendation is straightforward
and is in line with the recommendations of the Royal College of
Physicians. There needs to be an initial, central investment to
create a core workforce of allergy specialists. The investment
would be through the medical training programme in the first instance.
As such, it would not be in open conflict with a general desire
to devolve decisions into the NHS wherever possible. It would
need to be a followed up by commitments to finance subsequent
new consultant posts in allergy.
33. By taking this step, and by saying it
is important to do so, and why, a way would become open to move
forward discussion on other issues—like the training of
primary care doctors in allergy, within the structures being created;
and like improving the paediatric allergy training curriculum.
While these are not direct Government responsibilities, acting
on those issues which are its responsibility would help to create
an environment where other work can be orchestrated and progressed.
Subsequent developments, having created the new core for an allergy
service, could be locally and professionally driven.
34. The Department is being asked to bring
allergy care into the mainstream of the NHS and to let it be known
that this is the intention. To achieve this end a national plan
for allergy will ideally be needed, with both central and local
aspects.
At the start, a core specialist service is required.
For this, commitment by the Department to the following essentials
is needed.
— Intervention to provide for 20 additional
specialist training posts in adult allergy (CCST Allergy) by 2007;
and 18 additional adult and 18 additional paediatric allergy consultant
posts for trainees to move into;
— Support for the creation of a separate
paediatric allergy sub speciality and allocation of training posts
in this by 2007;
— Support for discussion with RCGP
on making allergy a more central part of training of tomorrow's
GPs;
— Development and distribution of an
action plan which would make clear who, within the devolved NHS,
is accountable for the allergy service locally and which would
provide the information and other means for the accountability
to be discharged.
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