Memorandum by Professor John Warner (AL
3)
1. INTRODUCTION
I am most grateful for the opportunity to make
a submission to the Inquiry. I am the Professor of Child Health
in the University of Southampton based at Southampton General
Hospital. My principal clinical and academic interest is in allergic
diseases of childhood. As such, I have been involved with allergy
research for the last 30 years. I am currently Editor-in-Chief
of an international medical journal, Paediatric Allergy &
Immunology. I am a Trustee of the Anaphylaxis Campaign and
a member of a number of national and international allergy societies.
My current research programme focuses on the early life origins
of allergic disease in order to identify targets for future prevention
strategies.
2. ALLERGY SERVICES
Southampton General Hospital is one of the few
Hospital Trusts in the country which is able to boast a fully
comprehensive allergy service for both adults and children. However,
it is entirely staffed by University employees. As such, there
is no guarantee of continuity in event of any one academic leaving.
Furthermore, the service has evolved without a proper business
case and is, therefore, not adequately funded. There is no dietetic
or specialist nurse input. This is also provided entirely from
soft money acquired by individual University clinical academics.
Thus the paediatric allergy clinic is supported by a research
dietitian and research nurses, myself as Professor of Child Health
and a senior lecturer, Dr Jonathan Hourihane. The adult allergy
service is provided by Professor Tony Frew and a reader in medicine,
Dr Peter Howarth, together with their research teams. If the University's
research agenda changes, this whole service would disappear overnight.
Furthermore, enormous waiting lists have developed over the years
because of the paucity of services. The only way this has been
controlled is by either the academics doing additional clinics
or the employment of past clinical allergy fellows to return for
limited periods. This is a wholly unsatisfactory way to run a
clinical service.
3. PRIORITIES
FOR IMPROVING
SERVICES
Notwithstanding the problems itemised above
in running a clinical allergy service exclusively with University
appointed academic clinicians, I believe that the structure we
have established is a working example which could be used throughout
the country. Because Southampton currently has a large research
programme in allergy, there are sufficient numbers of clinicians
and scientists to run a postgraduate training programme in this
discipline. This extends to a full MSc which has been running
for the last two years and has allowed us to train a cadre of
doctors, nurses and dietitians who I hope will form the core of
those who might be able to establish allergy clinics in their
own localities.
We have also established an allergy network
for our health region. We have regular meetings with our colleagues
from surrounding District General Hospitals. A website has been
set up, though only with input from a pharmaceutical company grant,
and protocols for management of specific disorders and for care
pathways are being formulated and agreed. However, our District
General Hospital colleagues are constrained by their Hospital
Trusts and are unable to establish appropriately staffed allergy
clinics themselves. Furthermore, they have found that once it
becomes known that they have an allergy interest, their own waiting
lists for new appointments very rapidly exceeds acceptable limits.
We are now also involving primary care within the network and
hope that appropriately trained general practitioners might be
able to handle more cases, thereby reducing the load on hospital
services. However such is the very high prevalence of allergic
disorders and the paucity of expertise in handling them, it will
be many years before adequate services will be in place.
I and my colleagues believe that the establishment
of allergy networks involving primary, secondary and tertiary
care with clinicians, nurses, dietitians and immunologists is
the way forward to improve services.
However, this can only be achieved if it is
resourced from within the Health budget. It cannot be sustained
by academics alone. Adequate resourcing of our service in Southampton
through the Hospital Trust would allow us to devote more time
to training, research and development and to supporting the evolution
of services in surrounding health districts.
4. GOVERNANCE
& REGULATION
I also have a role as the allergy expert on
the Advisory Committee for Novel Foods & Processes at the
Food Standards Agency. As such, it has become very clear to me
that there is a desperate need for a post-marking early warning
programme to be established, to review evolving allergies to new
foods. This will only be possible if there is an adequate network
of properly constituted allergy clinics around the country that
could act as the sentinels reporting new cases as they arise,
following a similar programme to the yellow card system for adverse
reactions to drugs. Currently the only agency providing any early
warning system to patients is the charity, The Anaphylaxis Campaign.
Without this organisation, many patients with acute severe and
life threatening allergies would be left undiagnosed, unsupported
and uninformed with the inevitable occasional disaster of severe
acute reactions which are increasing in prevalence, presenting
to hospitals and still tragically sometimes the cause of death.
We have recently completed a survey of attitudes
to allergic aspects of asthma amongst patients, families and health
professionals. This highlighted that patients and their families
are well aware that allergy contributes to their problems and
are desperate to obtain appropriate advice. Approximately one
quarter of the patients had had allergy tests. However, only 2%
had been organised by their general practitioners. The remainder
had come through the independent sector where there is no regulation
or governance. Many of the tests performed have been proven to
be of no value whatsoever and much exists within the so-called
complementary medicine sector. Sadly the response of the health
profession has been wholly inadequate to patient and families'
expectations. At primary care level, allergy avoidance advice
is given without doing any tests which, of course, is totally
inappropriate. At secondary and tertiary care level, there is
a great reluctance to do allergy tests at all. In my view, the
inevitable consequence of this is loss of confidence in the health
profession, reduced compliance with therapeutic recommendations
and, therefore, poor outcomes. This requires urgent attention,
and will only be addressed by establishing allergy services staffed
by appropriately trained staff uniformly across the country and
eventually in all District General Hospitals. The pattern of service
in our Region of a "hub and spoke" arrangement with
the tertiary centre providing the leadership, training and support
is likely to be the most effective arrangement.
5. RESEARCH &
DEVELOPMENT
Research and development must be an integral
component of the clinical service. Allergic diseases are currently
not curable, though they are imminently controllable. While clinical
services for allergy are rudimentary in the United Kingdom, this
country has provided a disproportionate number of the world's
leading allergy researchers. Dwindling resource is beginning to
take its toll. It is imperative that the expertise in allergy
research is sustained by ensuring adequate resourcing. It does
seem rather remarkable to me that the largest amount of funding
to support allergy research in the United Kingdom comes from the
Food Standards Agency. Why is the Department of Health not involved
in supporting such research, given the enormous prevalence and
health economic burden of allergic conditions?
June 2004
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