Annex B
CORRESPONDENCE WITH DEPARTMENT OF HEALTH
MINISTERS AND OFFICIALS
1. DR
STEPHEN LADYMAN
AN ALLERGY
PLAN FOR
THE NHS: MAKING
A START
Treat Allergy Seriously
At the beginning of the year you kindly met
with some of our colleagues to discuss how to improve NHS allergy
services. You and your fellow Ministers had agreed that there
needs to be improvement—that allergy patients are not receiving
an adequate standard of care. The meeting discussed how progress
might be made.
You agreed at the meeting to consider what might
be done to improve the level of investment in training the allergy,
clinical workforce and you said you would ask the CMO about drafting
a possible "action plan" to support and guide local
NHS work on allergy service development. Subsequently Pam Ewan
wrote to you, on behalf of all of us, offering our help and saying
that we would write to you again.
Since then, as you will be aware, interest has
grown within Parliament about the need for something to be done
to improve allergy services.
However, in correspondence which we have seen
and in answer to questions in Parliament, you have maintained
a line that only change driven by the local health service can
be contemplated and that a sustained, general increase in health
expenditure will be all that is required from the centre to begin
to affect the availability and quality of allergy services.
We thought that we should write in a rather
different way from that contemplated immediately after the January
meeting; and we attach a paper. We have particularly wanted to
ensure that the advice in the June 2003 Royal College Report,
and an assessment of its merits given the framework of Government
health policy, was fully explained.
You may know that academics from three British
universities have very recently published estimates of the current
cost of allergy to the NHS (Clinical and Experimental Allergy,
volume 34, number 4, April 2004). They have estimated £1
billion across the UK; and they have concluded that "the
more serious systemic disorders . . . are rapidly increasing".
For that reason, and for other reasons outlined in the attached
paper, £1 billion will prove to be an underestimate. And
the allergy care that is delivered as a result will be neither
as effective nor as efficient as it should be because there is
currently no proper infrastructure for its delivery (the paper
describes the care that is available for allergy patients currently
as being "suffused" across a wide range of services
and arrangements; what is lacking is a clinical focus).
So, the challenge that the allergy epidemic
presents is how to create service arrangements capable of meeting
the needs of the 1/3 of the population who
have allergy, with an increasing proportion having severe and
complex allergy, when the NHS currently lacks any national, clinical
or commissioning infrastructure for such a service? How is progress
to be made from this base?
Following the advice to you of the Royal College
of Physicians, our answer is to invest first in the creation of
the base.
The allergy epidemic, although it has been developing
in scale for over a decade, is presenting the NHS with new challenges
(these are ones not foreseen when Government built a consensus
around its current 10 year NHS Plan for the NHS; certainly one
with dimensions not fully understood until the work of the Royal
College Committee; and possibly one requiring some flexibility
in the evolution of clinical priorities for the NHS going forward).
If the delivery of allergy care through the NHS is to realise
its potential in the face of the current epidemic, wide ranging
changes will be required. The attached paper explains these.
But our immediate concerns are with making a
start; and we strongly urge you to do the following.
First, create an initial, national clinical
structure for allergy services based on tertiary regional centres.
This is the most cost effective immediate action which can be
taken. It involves central commitment to the creation of 32 new
specialist consultant posts across the English NHS. It will cost
£5.6 million per annum in England, building up over a number
of years as adult and paediatric allergy doctors are trained to
the appropriate standard. It will deliver both a service for those
most in need of help and clinical leadership for other developments
which must follow.
Two further points about this first step. Something
needs to be done to stop the situation getting worse. Not enough
doctors are being trained in allergy to replace those who will
soon retire—your own specialist advisers are telling you
this—so training levels need to be increased. Also, given
both the scale of investment to train doctors, and the timescales,
this must be considered a central Government responsibility even
in a devolved NHS. Initial central investment in the development
of an allergy service through a training route could therefore
take place, if you wished it, without major disruption to the
general thrust of the policy to rely on the initiative of local
health services.
Second, help and support local allergy service
planning. Only six of the 30 officials specifically responsible
for commissioning allergy services whose names you gave us in
January have found the time to reply to our contact with them.
Only one has said they attach any importance to allergy; and,
for reasons spelt out in the paper, we find this reply incredible.
By themselves these figures can easily be dismissed; and we refer
to them only because they illustrate the indifference to the needs
of people with allergy which exists, comprehensively, across many
parts of the NHS. If serious service development is to take place,
focused help will need to be provided. We hope that meaningful
"action planning" can come about following your discussions
with the CMO.
Lastly, if any aspirations for change are to
be acted on, Health Ministers need to say that it is important
that the NHS responds to the allergy epidemic by building appropriate
allergy services, and by indicating how this is to be done. Unless
you add your voice and authority, messages to the NHS about allergy
care will not be heard or taken seriously.
17 May 2004
2. DR
STEPHEN LADYMAN
MP
DEVELOPING ALLERGY
SERVICES
Thank you for agreeing to meet with us on 28
January. It was encouraging for us to be able to put our case
on the need for improved allergy services directly to a Health
Department Minister.
You explained to us the nature of the relationships,
under the NHS Plan, between central government and the devolved
health service, and the ways in which these constrain the types
of central initiative which can be taken.
Equally, we explained—and you agreed—that
the current allergy epidemic faces the service with significant
and new challenges and, as matters stand, the service response
has not been adequate. Across the country there are serious inequalities
in access; for much of the country the services available are
vestigial; and in only a few centres are we up to the standards
routinely achieved for the treatment of allergy in comparable
health care systems.
We discussed the prospects for sustained improvement
in allergy services led by PCTs and Strategic Health Authorities.
We put it to you that, without informed local leadership in allergy,
with no one to make bids for allergy services, without an identifiable
information base, with many other pressures on time and resources,
the prospects are not good. This applies to the majority of the
country.
As so much depends on the local capacity to
deliver change—for allergy as for so much else—we
shall now do all we can to help local commissioning.
However, we see little prospect for improvement
without direction from the centre to take allergy seriously and
to plan for services appropriate to need. We hope that you remain
open to further discussion of what is being achieved, and what
is needed, therefore.
Two points for action from the Department of
Health were identified in our discussion. You offered to write
to the CMO to ask whether he would be prepared to produce an Action
Plan for the development of allergy services which could be used
to inform and guide local service change. You also said that you
would look yourself at the quotas that operate around the central
funding of specialist doctor training posts. (Specifically, more
centrally funded SpR posts in allergy are essential for service
development; and this has not been addressed despite powerful
arguments being put to the Medical Workforce Review Team and the
Workforce Numbers Advisory Board over several years.)
We see the two possible areas of work to be
linked—as the Royal College Report on allergy spelt out,
putting specialist clinical leadership in place is the most cost
effective way of getting local change under way.
We should like to offer our help in taking both
action points forward. We can contribute knowledge and skill and,
if it were needed, some secretarial services to put together a
first draft an Action Plan. Would that be helpful?
In the first instance, you might care to see
some costed analysis on the specialist training situation in allergy.
We shall aim to send you a note on this for the end of February.
Thank you again for your time. We look forward
to hearing from you.
3 February 2004
3. RT
HON JOHN
HUTTON MP
We are writing to you as chairs respectively
of the recent Royal College of Physicians committee on allergy
in Britain and of the National Allergy Strategy Group (NASG)—an
alliance of health organisations working together to support the
development of effective NHS based allergy care. We are writing
with the active support of our colleagues on NASG: Professor Andrew
Wardlaw, President of the British Society for Allergy and Clinical
Immunology, as well as those from Allergy UK and the Anaphylaxis
Campaign, the principal patients' organisations in the allergy
field.
The Royal College committee produced a report
in June this year entitled Allergy: the unmet need. The
report documented the significant public health problems being
faced from the epidemic in allergy which has arisen; and it provided
a blue print for how to respond to the epidemic, one which the
committee concluded was the most cost effective approach available.
The information your Department is using to
respond to enquiries from Members of Parliament and the public
about Government's response to the Royal College report contains
factual errors, and gives a misleading impression about what is
happening and what is possible for the care of people with allergy.
We write to begin to set the record straight.
Your 21 August letter to Michael Ancram (copy
attached) contains paragraphs being used in other letters. We
shall refer to the Ancram reply below.
A number of facts are wrong. The correct information
is detailed below.
(i) ALLERGY
AND IMMUNOLOGY
ARE DIFFERENT
CLINICAL SPECIALTIES
Your letters combine information on
these two differing areas of medicine. In fact they are different
specialities, with very different training and skill requirements.
Immunology is predominantly a laboratory based discipline, whereas
allergy is totally bedded into the clinical management of patients.
Some immunologists provide care for
people with allergy, and this is to be welcomed as the alternative
would be no NHS service for many more people. However, their expertise
is in another branch of medicine; specifically they are not specialist
allergy doctors. In consequence, the service they provide is limited
leaving people with other allergy symptoms, which they are not
able to provide for, to find help where they can elsewhere.
Combining data about the numbers of
doctors working in the NHS from the two disciplines is therefore
misleading and gives people the wrong information about what is
happening.
(ii) THE
NHS HAS FAR
FEWER ALLERGISTS
THAN YOU
IMPLY, AND
MANY AREAS
OF THE
COUNTRY ARE
DEPRIVED OF
A SPECIALIST
SERVICE
Your letters say there were 80 consultants
in "immunology (including allergy)" in 2002.
In fact—using data from the Medical
Workforce Review Team Reports, which we take to be your source—there
are 26 whole time equivalent NHS allergy posts (and not all of
these are NHS funded) across the whole United Kingdom.
There is no specialist service west
of Bournemouth or north of Manchester; and no service in the whole
of Scotland, or Wales or Northern Ireland.
We believe this exposes people with
allergy to the unacceptable consequences of post code lottery
in access to care.
(iii) THERE
HAS BEEN
LITTLE GROWTH
IN THE
SERVICE FOR
ALLERGY SINCE
1999
Your letters say there has been an
increase of up to 58 posts or 264% since 1999, taking allergy
and immunology together.
Of these only six have been in allergy,
two of which were part time posts.
This is offset by the fact that earlier
two allergy consultant posts vacated by retirements were not replaced.
(iv) CENTRAL
FUNDS FOR
FUTURE GROWTH
IN SPECIALIST
TRAINING CONTINUE
TO OMIT
ALLERGY
Your allocation of funds for 400 additional
specialist doctor training posts from 2003-04 allow for one additional
immunology post but none for allergy.
The additional immunology training
post will add to the seven training posts in this discipline which
are currently unfilled.
There are at least seven allergy centres
prepared to take responsibility for a new trainee should funds
be made available.
The letter contains misleading information.
The correct position is shown below.
(v) GENERAL
WAITING TIMES
INFORMATION DOES
NOT REVEAL
WHAT IS
HAPPENING FOR
ALLERGY
Your general statements about success
in reducing waiting times, implying a specific benefit for allergy
from the general improvement, do not take account of the following.
— For very large areas of the country there
is no specialist allergy service at all—for anybody to be
referred to. A survey of GPs carried out by the Royal College
committee revealed that 80% of GPs thought that NHS services were
poor in respect both in access and in quality. The situation is
especially serious in paediatric allergy, where there are only
three specialist centres and a total of five clinicians for the
whole country.
— Where there are specialist clinics, the
gap between potential use and available capacity, given the imperative
to meet waiting time targets, faces clinicians with choices which
we believe patients should know more about.
— Some clinics have so far remained open
to all allergy referrals. The result has meant "efficiency
improvement" of the kind intended by the waiting times initiative.
But our colleagues are increasingly concerned at the risks to
patient safety as we see patients less often and for shorter periods
in order to keep up with an increased throughput. It should be
emphasised that the allergies being managed in these clinics are
not trivial; some patients have serious or life threatening conditions.
— Other clinics are restricting access
by narrowing the range of allergic symptoms they will admit. A
clinic might only accept referrals from local PCTs—increasing
the disparity between those fortunate enough to live near an appropriate
quality service and those who do not. Alternatively, a clinic
might only admit certain cases of confirmed allergy. GPs might
be informed about the restricted criteria being used. A patient
referred with allergy outside the restricted list will not be
contacted.
— Requiring confirmation of allergy in
primary care before accepting a referral, of course, presumes
competence in primary care to make the diagnosis. Our committee
found that the overwhelming majority of GPs have no training whatsoever
in the management of allergy; less than one in four have any knowledge
of a clinical guideline for the management of allergy; and you
will find there is a general reluctance among untrained GPs to
test for allergy and make a clinical diagnosis in the first place.
We believe these observations begin
to expose further dimensions to the pressures building up over
access to allergy care. The situation is sufficiently serious
to warrant more investigation.
(vi) THE
NHS IS UNPREPARED
TO BENEFIT
FROM CURRENT
RESEARCH AND
DEVELOPMENT
Your letters point to the contribution
being made by British research towards the international R&D
effort in allergy.
The problem this exposes is that the
state of clinical services in this country is so far behind what
is considered acceptable standards elsewhere that we are unprepared
to benefit from new allergy treatments which will become service
opportunities over the next decade.
New treatments are going to be effective
and expensive. They will rely on an accurate diagnosis and good
clinical management. People with allergy receive this only exceptionally
from the NHS now. We see no sign of a commitment to improve matters.
(vii) LEAVING
ALLERGY SERVICES
TO "FIND
THEIR LEVEL"
WITHIN A
PATTERN OF
GENERAL IMPROVEMENT
ACROSS THE
NHS IS NOT,
BY ITSELF,
AN APPROPRIATE
RESPONSE TO
THE ALLERGY
EPIDEMIC
Your letters say that there are "a
wide range of services to which people with allergies have access",
that allergy patients can be seen "within a wide range of
hospital specialities", and that it is for Strategic Health
Authorities (SHAs) and Primary Care Trusts (PCTs) to decide what
services are appropriate for "people in their care".
We are unsure of the status of the
statement in your letter that this duty of care "would also
include any increase in the number of speciality clinics".
Given the known distribution across
the country of these clinics, and the inequality in access to
care which results, are you saying "it's totally up to them",
the SHAs and PCTs?
Or does your statement that they are
close to the people they serve and best placed to respond "sensitively"
to need, imply any judgement about consequences of failures in
duty of care? Is there to be no other body for patients to resort
to if no specialist service is available locally?
We should perhaps point out that in
a visit to your officials in March 2003 we said there was uncertainty
about precisely who was responsible for specialist commissioning
and for leading PCT work in this area. An action point was recorded
to find out and let us know who was accountable. We still do not
know.
Melanie Johnson said in the House of
Commons on 14 October that NHS allergy services are starting from
a low base, that the Government takes the need for improvement
"very seriously indeed" and that the need to improve
the numbers of consultant allergists in the NHS was a specific
issue. While falling far short of recognising the need for any
kind of national priority for allergy, this statement leaves open
the possibility for dialogue. The standard letter currently in
use offers no such prospect.
We look forward to your response, especially
to learning how you intend to inform the public of the true situation
about allergy services in the UK.
6 November 2003
4. DR
JOHN REID
MP
THE STATE
OF ALLERGY
SERVICES IN
THE NHS
I am writing to you as chairman respectively
of the recent Royal College of Physicians committee on allergy
in Britain and of the National Allergy Strategy Group (NASG)—an
alliance of health organisations working together to support the
development of effective NHS based allergy care. I am writing
with the active support of my colleagues on NASG: Dr Pamela Ewan,
its co-chair, and Professor Andrew Wardlaw, President of the British
Society for Allergy and Clinical Immunology, as well as of Allergy
UK and the Anaphylaxis Campaign, the principal patients' organisations
in the allergy field.
The Royal College committee produced a report
in June this year entitled Allergy: the unmet need. I attach
with this letter a copy of the Executive summary of the report.
Following publication, there has been correspondence
between people with allergy, and their representatives, and your
Ministers and officials. And there has been a debate in Westminster.
Our purpose in writing is to let you know what we have done to
help to ensure a correct public understanding of the facts on
allergy and to ask you to look personally at the central issues
to be faced.
First what is being said. The Department is
answering enquiries about allergy services in the NHS through
the use of a general letter which contains factual errors, and
which we believe gives a misleading impression about what is happening.
We have written to John Hutton about this. We attach correspondence.
In the debate on paediatric allergy in Westminster
Hall on 14 October Melanie Johnson outlined the Government's policy
on allergy services. She accepted that current levels of NHS provision
are not adequate and are working from a low base. She emphasised
that the Government was taking this "very seriously indeed".
She referred to the Royal College of Physician's report, Allergy:
the unmet need. And she said that general improvements in
funding levels and in the delivery of patient sensitive services
across the NHS would raise general levels, bringing benefits to
allergy services.
She nevertheless recognised a "specific
issue" in respect of the need to improve the numbers of allergy
consultants at work within the service—currently 26 whole
time equivalents across the whole UK, and none west of Bournemouth
or north of Manchester; and none at all in Scotland, Wales or
Northern Ireland.
Government's recognition of the problems being
faced by people who experience allergy is an important step forward.
And Melanie Johnson's offer in the Westminster debate of a meeting
with Stephen Ladyman is welcomed. But it is quite unclear to us
how general health improvements by themselves will benefit allergy;
and we shall need to be convinced.
We believe there is a central issue which Ministers
as a whole must take into account. Might we ask that, as Secretary
of State, you consider this. If we can be of any help, we are
at your service.
The issue is that the current devolved approach
to service improvement, outside the overriding national clinical
priorities, cannot succeed in an area like allergy. For most parts
of the country there are insufficient people with adequate knowledge
about what is required to commission or provide effective services,
and no local champions. Without central help, allergy simply has
an inadequate service infrastructure to build on. Something therefore
needs to be done to put in place enough grass roots leadership
to allow local service planning and priority setting to work.
The recommendations of our Royal College working
party were designed to achieve precisely that—at a full
eventual cost in England, covering adult and paediatric services,
of £5.8 million, building up over a number of years. Service
improvements will offset some of these costs. For example, 5%
of hospital admissions result from adverse drug reactions; avoiding
drug-induced allergy would make a big dent in these largely avoidable
consequences of inappropriate care. Multiple referrals of an allergy
patient to non-experts and continued use of NHS resources because
illness has not been prevented would be reduced.
Some details follow:
In primary care
With one in three of the population suffering
from allergy; and one in five receiving treatment in any year,
primary care ought to be in the front line of an allergy service.
Yet the overwhelming majority of GPs have received no training
in allergy; and we found less than one in four have any knowledge
of a clinical guideline for the treatment of allergy. With less
than eight in 100 of the GPs surveyed for our committee believing
they had access to a fully comprehensive allergy service, we might
expect service improvements currently in place to be addressing
the need for change. Yet there is no reference to allergy in the
new GP contract. And we are not aware of any plans coming forward
from within primary care for the introduction of GPs with a special
interest in allergy into the service.
Specialist care
A central finding from the Royal College work
was that allergy has become more challenging clinically over recent
decades. It is now more often severe, expresses itself in complex
ways and involves multiple organ systems. Specialist allergy care
is needed for these cases. Particularly if we want to help people
to manage their allergy as well as possible, we need to help them
to identify and isolate the causes of any allergic response and
not just respond to presenting symptoms.
Yet the specialist services are, if anything,
in a worse state than primary care. There are serious and dramatic
variations in access to appropriate services. Large parts of the
country have no specialist allergy service. People have to travel
long distances to find a specialist allergist able to treat their,
or their child's, illness. Often the nearest allergy service is
provided, because no alternative is available, in a chest or eczema
clinic or because an immunologist has developed an interest in
allergy. But these are not specialist and clinically comprehensive
services. While welcome because the alternative is no service
at all, limited care provided by experts in other clinical disciplines
cannot be the right basis for a modern and reliable health service.
Starting change
Our proposed solution is to commit to fund 32
consultant posts across the country, covering paediatric and adult
allergy, and to gear training to secure the eventual supply of
sufficient specialist allergy doctors to do this. The dual commitment
to training now and to an adequate number of posts over time,
as qualified allergists become available, is necessary to attract
good quality young doctors into the discipline. While they are
training the young doctors will begin to enhance the service.
The new posts, when added to what already exists, will give an
infrastructure for devolved leadership, allowing the service then
to grow through its own momentum.
Yet recently, when your Department funded 400
extra training posts, none were made available for allergy. And
when we raised this with CMO, Sir Liam thought that "we may
not be able to do anything directly at the moment given the majority
of the NHS funds are allocated for the next five years".
If we may say so, five years seems a long time for one third of
the population to have to wait for service improvement to even
begin to get underway.
We put it to you Secretary of State, and ask
for your help. Ministers have accepted a need for something to
be done. But relying on local priority setting will not be an
adequate response to the challenge posed by the current allergy
epidemic. And waiting until well into the next Parliament before
any new approach can be considered is indefensible.
What's needed and what could be done
The country is facing a significant public health
problem from the epidemic in allergy. The evidence for this is
in the Royal College report and international medical literature.
Distinctively in the UK, our service response has been delayed.
We believe that what is ideally needed is to
make allergy a national priority for the NHS and to direct resources
to build an appropriate service infrastructure to tackle it. We
think that we must continue to call for this, and we shall do
so.
However, there are some pragmatic steps which
could be taken, with your help and support, which would not challenge
the whole thrust of your policies and priorities for the NHS—but
which would help to get important work on allergy underway.
First: primary care
We need to introduce primary care to allergy
in a meaningful way. We are planning through the NASG to mount
a series of "road shows" aimed both at executive and
management and clinical staff—to show what is involved in
delivering a good quality allergy service in primary care. These
will provide material for publication and discussion with the
other Royal Colleges whose help will be needed to change overall
responses to the epidemic—general practice, paediatrics,
pathology and so on.
Viability depends on money and on attracting
the attention of primary care leaders to the initiative; we have
the expertise. Would you consider helping us to get "on the
road"? Would you consider a Ministerial involvement in the
road shows, to give them authority and a sign that the Government
is seriously interested in a build up of capacity to manage allergy
within primary care?
Second: commissioning
Government has already agreed and published
a protocol for specialist commissioning of allergy. There are
two problems we face:
(a) we simply do not know who the specialist
commissioners or lead PCTs on allergy actually are. We do not
know, across the whole country, who is specifically responsible.
(b) PCTs do not understand the need to commission
allergy services. It is likely that in the large parts of the
country where there is no allergist, PCTs have ignored this speciality.
This would be helped by government support for the road shows
(above).
Third: funded training and consultant posts in
allergy
No progress can be made without an increase
in funded SpR posts for allergy training. Current funding arrangements
contain "slack". A central commitment of funds for a
training post may take several years before the finance is actually
used, as no doctor or training location may be forthcoming. Across
all disciplines there are currently workforce resources not actively
deployed for their intended purpose—so called unfilled posts.
Within such a system it must be possible to find funds centrally
for a handful of allergy training posts. Allergy is able to provide
training locations if the finance were to be released.
More consultant posts in Allergy are also needed.
The Royal College committee has identified a
moderate and pragmatic way forward. This letter sketches out some
moderate steps which could begin to move along that path. We hope
and trust you and your Ministerial team are able to respond to
the challenge in like terms.
6 November 2003
5. SIR
LIAM DONALDSON,
CHIEF MEDICAL
ADVISER DEPARTMENT
OF HEALTH
ALLERGY SERVICES
Thank you for finding time to meet me and Andy
Wardlaw to take forward the Royal College Report on allergy.
It was encouraging to know that you support
the analysis in the report. Growth in the incidence, complexity
and severity of allergy over the past two decades, together with
the emergence of new disorders, have caused a significant public
health problem—made all the more serious by a general failure
to recognise what has been happening. Within the NHS, poor management
of allergy is leading to unnecessary suffering and health service
costs and to many patients seeking help outside the service, often
through resort to unproven therapies. And we have an inappropriate
service base from which to exploit the allergy therapies which
are in development.
The situation is unsatisfactory; and a key step
towards turning it round—as the Royal College report says
in its primary recommendation—is to set in place a core
group of allergists who could themselves take the more complex
cases and who would orchestrate the work of others who are prepared
to help. This requires the development of at least one specialist
centre, allergist-led, for each region. We shall need to encompass
the work of immunology and other organ specialist colleagues who
are prepared to use their clinics to support the management of
allergy cases and to provide local clinical leadership to growing
a capacity within primary care. We need to cover both paediatric
and adult allergy.
The Royal College committee was unanimous that
this is the most appropriate and least costly way forward (the
committee costed its proposal for the establishment of regional
centres with paediatric and adult allergy consultants at £350,000
per annum per centre for an adult allergy service (£2.8 million
for England) and less than double this to include paediatric allergy.
The cost is low for a valuable service to five million population
served per centre; costs would be phased in; and would be off
set by cost savings in other parts of the NHS, now dealing inadequately
with the problem. The challenge before us is to turn these sound
principles into a practical programme of service development.
Specialist Commissioning
We need to set up capacity for specialist allergy
leadership in those parts of the country where none exists currently
and sustain it in those areas where NHS support is fragile. Encouragement
to implement the agreed plans for specialist commissioning (produced
by the Department of Health in 2001) would support this and we
discussed whether you could highlight this to Strategic Health
Authorities and lead PCTs, or in other ways. Allergy is simply
not on the agenda of commissioners in large areas of England.
It needs to be.
Allergy doctors
In parallel we need to offer good young doctors
a secure career pathway if they embark on a career in allergy
as an NHS speciality. Their leadership can then become the driver
for local service development and the dynamic they set in train
can become self sustaining. To do this we need to establish a
small number of NHS funded consultant posts, in paediatric and
adult allergy. Additional funded SpR training posts are also essential
to support the programme.
As we discussed, however, it is exceptionally
difficult to see how any of this can be achieved in the current,
devolved NHS, and it may be impossible to do so, without central
leadership of some kind. The problem is simply that devolved developments
require the pre-existence of local capacity with the knowledge
base and authority to be the local champion. In large parts of
the country that precondition is not met for allergy. We nevertheless
plan among other things to spend the remainder of the year trying
to stimulate local activity in selected areas and to encourage
local commissioners to resource new consultant posts for allergy
if we may, we shall let you know how we get on.
Patient's organisations active in allergy are
working closely with us to establish a case for action behind
the Royal College recommendations. But central and local pressure
of the kind which patient's organisations can put on the service
merely add to the pressures which colleagues are anyway under—unless
a practical way forward can be found.
You kindly suggested some things which you might
do to help. You said that you would talk with your colleagues
to see whether there is anything which can be done from the Department
at this stage about the provision of central funds for consultant
posts. Central funding of consultant posts would of course be
the most straightforward way of resolving the dilemmas faced by
the allergy services.
You said you will see whether some funded SpR
allergy posts could be obtained to increase our allocation in
the current round from zero towards the needed figure of an additional
seven (by creating additional posts or by re-badgeing those not
used). I append the relevant contact details of those I deal with
for Allergy on the Workforce Review Team and WNAB.
You suggested that it might be possible to add
allergy into SHO training schemes, which could be used to provide
primary care doctors with exposure to allergy. This would be a
helpful supplementary development; but it needs proper infrastructure
to relate it to and it could only happen in the few major centres
that can provide training.
You said that you would be very happy to see
a chapter on allergy in CMO's Annual Report. We welcome this and—both
as individuals and as from the BSACI—will give any help
needed in writing the chapter.
The main need, however, is to recognise the
importance which allergy now has to the health of the society
and to give it the appropriate priority in NHS ratings, both locally
and centrally.
If you are able to identify any help that can
be given centrally we would be delighted to hear from you. We
are proposing to write to the Secretary of State later in the
year; perhaps we might copy you into that correspondence.
Before then it would be most helpful if we could
talk to you again to review developments.
21 July 2003
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