Select Committee on Health Sixth Report


1  INTRODUCTION

1. Allergies affect around 30% of the adult population, and 40% of children, making these amongst the commonest diseases in England.[1] Approximately 15 million people in England now suffer from allergies, of whom 10 million will experience symptoms in the course of a year. Allergy in the population is rapidly escalating, especially in children. Until 1990 peanut allergy was rare. By 1996 the prevalence amongst children was one in 200. The figure may now be as high as one in 50—almost a quarter of a million children.[2] Whereas in 1979 only two cases of latex allergy had been recorded, now some 8% of healthcare staff suffer from this condition.[3] According to the Royal College of Physicians' (RCP's) working party on the provision of allergy services in the UK, "international comparisons show that the UK population has the highest prevalence of allergy in Europe and ranks among the highest in the world". [4]

2. Despite the high prevalence of allergy in the population, expert or specialist allergy treatment is very difficult to access within the NHS.[5] The great majority of GPs have received little allergy teaching as students and no extra postgraduate training. There is approximately one specialist consultant per two million of the population, as opposed to one per 100,000 for a mainstream specialty such as gastroenterology.[6] Specialist clinics are very few and are largely concentrated in the South East. Everywhere there is an enormous gap between the need for allergy services and their provision.

3. We announced our intention to hold this inquiry on 29 April 2004 with the following terms of reference:

    The Committee will inquire into the provision of care and treatment for allergies by the NHS and the independent sector.

    In particular the Committee will examine:

    Availability of allergy services (including issues such as geographical distribution, access times and patient choice) and specialist services for patients with severe allergies;

    Priorities for improving services;

    Governance and regulation of independent sector providers, and links between the NHS and the independent sector.

    The scope of the inquiry will not extend to issues relating to clinical treatment of specific allergies and levels of incidence of allergies.

4. On 17 June we took oral evidence from: Muriel Simmons, chief executive of the charity Allergy UK; David Reading, director of the Anaphylaxis Campaign; Dr Shuaib Nasser, consultant allergist, Addenbrooke's Hospital; Professor Stephen Holgate, Chair of the National Allergy Strategy Group (NASG); Professor Andrew Wardlaw, President of the British Society for Allergy and Clinical Immunology (BSACI); Professor John Warner, paediatric allergist, Southampton University; and Dr Lawrence Youlten, consultant allergist at The London Allergy Clinic. On 1 July we took evidence from Dr Stephen Ladyman, MP, Parliamentary Under-Secretary of State for Health and officials from the Department of Health (hereafter 'the Department').

5. In addition we received around 80 written memoranda from a variety of professional bodies, pressure groups, charities and clinicians. We also received well over 300 memoranda from individuals, either sufferers of allergy or parents/carers of people with allergy. These indicated some of the problems faced by those affected by allergy, and we append an analysis of these submissions to this report. We are most grateful to all who provided written or oral evidence.

6. In the course of the inquiry we undertook a visit to the Children's Asthma & Allergy Centre, Llandough Hospital, Cardiff. Dr Mazin Alfaham, a general paediatrician with an interest in allergy, and his team, described their experiences of running a paediatric allergy clinic and shared with us their views on the prevalence of allergy and the provision of allergy services. We are most grateful to them for finding the time to see us.

7. Our specialist adviser in this inquiry was Dr Pamela Ewan, consultant allergist at Addenbrooke's Hospital, Cambridge. We wish to thank Dr Ewan for giving us the benefit of her extensive knowledge of the provision and treatment of allergy care, and for the enthusiasm and expertise with which she assisted us at each evidence session.

What is allergy?

8. Allergy is a 'hypersensitivity' reaction, or exaggerated sensitivity, to substances which are normally tolerated. Such substances are known as allergens.[7] Examples of common allergens include peanuts, milk, cats, horses, medicines and grass pollens. These allergens trigger the production of a harmful antibody, immunoglobulin E (IgE). In an allergic reaction, the interaction between the IgE and the allergen causes the release of inflammatory chemicals such as histamines and leukotrienes. These cause symptoms such as sneezing, itches, rashes and falls in blood pressure; they may also cause airway narrowing, which leads to shortness of breath and wheezing, and swelling which, if in the mouth, throat or airway, causes severe difficulty in breathing. Sometimes symptoms are caused by other mechanisms, where IgE is not involved. These are often described as 'intolerances' to, for example, foods or medicines.[8] Allergy practice deals with both IgE-mediated and non-IgE-mediated reactions.

9. People commonly react to a number of allergens causing different symptoms in several parts of the body. Symptoms may be mild or severe. Reaction times may vary from immediate, to hours after exposure. Some people recover after a period of illness; others remain at risk for the rest of their lives. Some allergies vary according to the season. Many, such as those related to food or drugs, are avoidable if identified properly.

10. Allergic symptoms vary greatly. An individual may have a single symptom (for example, asthma) or multiple reactions (for example, asthma, eczema and hay fever); swellings on the skin; or sickness. The most extreme reaction of all is anaphylaxis. During anaphylaxis, the blood pressure drops, breathing becomes difficult and an individual may collapse and become unconscious. Symptoms include swelling in the throat and mouth and severe asthma.[9] In extreme cases those suffering anaphylaxis will die; and many more will believe during an attack that they will die. Anaphylaxis is a very frightening experience and the fear of a further reaction—particularly when a child is involved—creates great anxiety.

11. Allergy is a complicated and sometimes confusing branch of medicine. As the seminal RCP report Allergy: the unmet need noted, in some conditions IgE-mediated allergy plays a role in some patients but not in others. [10] This is especially the case for asthma, rhinitis (chronic nasal symptoms), eczema and urticaria (itchy skin blotches or hives). Seasonal allergic rhinitis, or hay fever, is entirely caused by allergy. Chronic allergic rhinitis may be caused by allergy to the house dust mite. But other forms of rhinitis are not IgE mediated. Similarly, in respect of asthma, "allergy may be just one of many triggers of an attack; others include virus infections, air pollutions or stress".[11] To complicate matters further, the manifestations of allergy may alter with time: eczema and milk allergy are more prevalent in children but may abate in adulthood or be replaced by other allergies, particularly if not identified and treated at source. Finally, allergy may present in a very complicated way. Professor Stephen Durham, a consultant in allergy and respiratory medicine at Royal Brompton and Harefield NHS Trust, noted:

    A major problem is that the typical allergic patient has diseases affecting the multiple organ systems including eyes, nose, chest, skin, gastro-intestinal tract with or without the risk of potential life-threatening anaphylaxis.[12]

12. The following diagram, from the RCP report, well illustrates the role of allergy in various diseases:


Figure 1: The role of allergy in various diseases.[13]

THE ROLE OF AN ALLERGIST

13. An allergist deals with a wide range of allergic disorders which cross the conventional disciplines within medicine and also with disorders specific to allergy. Since allergy commonly presents with disease affecting different parts of the body, disorders often co-exist. Therefore, as well as having knowledge of a number of different medical specialties (which will be less comprehensive than that of specialists in these other areas), an allergist also needs to have a wide knowledge specific to allergy. This includes knowledge of allergens, causes of disorders, diagnostic methods and the natural history of disease and treatments. Thus the expertise of an allergist has to be distinct from that of organ-based specialists or immunologists. With growing numbers of people today being subject to allergic disease, the expertise and added value which comes from a proper focus on this, we believe, needs to be seen as a part of mainstream healthcare.

14. Specialist allergy nurses and dieticians are an important part of an allergy team. Nurses have a variety of roles, including supporting the accurate diagnosis of allergy through skin testing, giving advice on allergen avoidance, and training patients in the use of self-injectors. In addition, nurses will monitor patients during procedures which carry the risk of anaphylaxis—for example, immunotherapy (where increasing doses of an allergen are injected under the skin over time as a treatment to allow the patient to develop resistance to the allergen) and challenge testing (where the patient is exposed to the suspected allergen under controlled circumstances). Paediatric and adult dieticians provide valuable support when patients are on long term dietary exclusion or need to exclude foods for diagnostic purposes.

15. Allergy is treatable and manageable; often one or two visits to a specialist allergist will be sufficient. Accurate diagnosis, including identification of allergic or other triggers, is essential. Management involves avoidance of the allergen or trigger, as well as drug treatment. Avoidance may completely relieve the symptoms of the disease. For example, if a drug or food is the trigger, or if asthma is caused by a specific allergen, avoidance strategies can be identified and assembled for the individual patient. Even when allergens cannot be avoided completely, reduced exposure ameliorates chronic symptoms. An allergist needs to have expertise in controlling problems unresponsive to standard drug therapy, such as some types of asthma, rhinitis and angioedema (swelling under the skin or of the mucous membranes), as well as conditions not normally recognised or managed by others, such as food, drug and insect-sting allergies, and the prevention and planned self-management of anaphylaxis. An alternative management strategy is immunotherapy, which alters the underlying immunological abnormality and may 'switch off' disease. Other types of allergy vaccine are being developed and new treatments are expected: allergists will have an important role in patient selection and administering therapy. Allergists also need to have experience of treating acute allergic reactions, including anaphylaxis, as these can be induced by some types of allergy testing or immunotherapy.

Trends in prevalence

More allergy

16. Levels of allergy in the population have soared in recent years. Whereas, as we have noted, allergies are present in around 30% of the adult population, the figure is higher for children, with 40% of children having some form of allergy. In England, around 15 million adults and children will suffer from some form of allergy, with 10 million showing symptoms in any one year.[14] A recent survey in the London schools area suggested that 2% of children aged 5-18 suffered peanut allergy, 2% were allergic to other nuts and 1% suffered sesame seed allergy.[15] Adverse drug reactions account for 5% of hospital admissions in the UK, and drug allergy is one cause of such reactions that is becoming increasingly common.[16] Asthma, rhinitis and eczema have increased in incidence two- to three-fold in the last 20 years.[17] Dr Shuaib Nasser, a consultant allergist at Addenbrooke's Hospital, Cambridge, told us:

    In an allergy clinic 10 years ago, if we saw a patient with a fruit allergy or a latex rubber allergy, we would call everyone in the clinic round to talk to the patient. All the doctors, all the nurses would come round and we would talk with great enthusiasm with the patient because this was such a rare disorder. Now we see these patients two or three times a week and there is nothing surprising about it. The health service has to evolve with the changing pattern of illness.[18]

17. Approximately 20% of the population now suffers from allergic rhinitis (hay fever, with varying degrees of severity). Alan Edwards, clinical assistant at the David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Isle of Wight, provided evidence on the incidence of common manifestations of allergy using data gathered from two birth cohorts, which demonstrated the growth in allergy in the population.[19]

Table 1: Manifestations of allergy, asthma, allergic rhinitis and eczema compared in two birth cohorts

Newborns
Asthma
Rhinitis
Allergic eczema (%)

1989-90
8.64%
15.54%
12.55%
2001-02
21.58%
25.03%
24.04%
Data source: Ev 145 (Alan M Edwards)


18. A table showing the prevalence of some common allergies is given below:

Table 2: Prevalence of some allergic disorders in adults and children in UK and other EU countries

 
Children prevalence %
Adults prevalence %

Asthma
 
 
Wheeze in past year
32
19
Ever wheezed
49
32
Allergic rhinitis
 
 
Rhino-conjunctivitis in past year
19
19
Hay fever ever
35
19
Eczema
 
 
Eczema ever
24
16
Food
 
 
Peanut and/or tree nut
2
Not known
Peanut
1.4
Not known
Egg
1.6
Not known
Milk
1.1-3
Not known
Data source: See footnote[20]



19. Demand on allergy services is growing. Guy's, King's, and St Thomas' School of Medicine runs a specialist allergy service which took on 1,090 patients in 1997-98, but 1,922 patients in 1999-2000. Dr Gideon Lack, a consultant in paediatric allergy and immunology at St Mary's Hospital, London, noted that at least 6% of paediatric admissions to Accident and Emergency (A&E) at his hospital over the last year were "directly attributable to an acute allergic problem".[21]

20. The causes of the striking growth in the prevalence of allergies are not thoroughly established. One possible explanation has been termed 'the hygiene hypothesis'. This argues that a lack of exposure to microbes in early life appears to encourage the development of allergy. The hypothesis is supported by evidence to suggest that the oldest child in a family has increased susceptibility to allergy. This child is more likely to be spared infections early in life, giving less opportunity for what one witness described as the "kick-starting of the immune system".[22]

21. Professor Stephen Holgate, Chair of the National Allergy Strategy Group (NASG), suggested that factors potentially involved in the increased prevalence of allergy included: diminished exposure to bacterial products; dietary changes (in particular, those altering the micro-flora in the intestines); and the introduction of new allergens in the form of chemicals and 'foreign' proteins entering the environment and increasing sensitisation. There is also a growing debate as to whether exposure to antibiotics early in life might be a factor, by altering the bacterial flora and therefore damaging the ability of the immune response to self-generate its protection.[23]

MORE SERIOUS ALLERGY

22. In its memorandum the Department noted that "the majority of people with an allergy experience mild or moderate symptoms".[24] Nonetheless, the rise in allergy has been most marked in respect of serious allergy. According to the British Society for Allergy and Clinical Immunology (BSACI) and the NASG, numbers with "complex, severe or life-threatening illnesses" are growing "disproportionately".[25] The chief executive of Addenbrooke's NHS Trust, which provides an allergy service widely recognised as a centre of excellence, commented that the case-load the service in his hospital dealt with had changed, and that the majority of patients seen now had severe or complex allergies.[26] The RCP similarly noted:

    A number of severe and potentially life-threatening disorders which were previously rare, are now common. As part of the increase in incidence, more children are now affected, particularly by previously little-known food allergies, such as peanut allergy. These are also among the most serious allergies, and accurate diagnosis, advice and treatment are vital.[27]

23. Hospital admissions for anaphylaxis have increased seven-fold over the last decade, according to the Department's figures. The number of deaths caused by anaphylaxis is extremely difficult to ascertain. Dr Richard Pumphrey, a consultant immunologist at St Mary's Hospital, Manchester, has maintained a register of anaphylactic deaths since 1992, and reported that it had been possible "to confirm only 20 acute allergic fatalities each year", but that there were "reasons to believe that this is an underestimate".[28] It is likely that many deaths are recorded as being caused by asthma. A 1994 study of patients coming into an A&E department found that a severe anaphylactic reaction occurred in approximately one in 3,500 of the population each year in the community.[29] This also is likely to be an under-estimate, as the figures only included those being treated in A&E, and those whose anaphylaxis arose in the community. Anaphylaxis induced by, for example, intravenous drugs or latex in hospital settings is not included.

24. The impact of serious allergy is considerable. It is well illustrated by an account we received from a mother whose child had life-threatening anaphylaxis due to milk allergy:

    At 3 months he had a bad reaction to something in the Welcome Pack, which contained baby rice. At one point epilepsy was diagnosed (wrongly) because he was unconscious from a crumb of biscuit. At seven months he was in hospital for three days, reacting to something in a jar with milk in it. Almost immediately he had another reaction and was in hospital for 10 days. We were then fairly sure and were avoiding milk. He had another attack at about two and a half when he got hold of something; we were very lucky that time.

    Then we got a proper diagnosis of anaphylaxis … If it's not clear what the problem is then it's not safe.

    I myself had anxiety attacks. I still do. It changes life for the family ...

    People don't know the difference between allergy and severe allergy. And you don't know how a reaction will develop. They know the tingling in the throat and lips; but … it's not clear what's going to happen next …

    Nobody should underestimate the effect this has had.[30]

25. As this example suggests, serious allergy often causes distress to families and carers, as well as to those directly affected. The Department itself acknowledged that three million people suffer from serious allergies in the UK.

MORE COMPLEX ALLERGY

26. As well as growing more prevalent and more serious, allergy is becoming more complex in the population. The RCP report noted patients now often had disorders affecting several systems, or parts of the body, or the whole body, as in anaphylaxis:

27. Allergic problems frequently co-exist. The RCP estimated that 10% of those with allergy aged below 45 have been diagnosed with more than one allergic condition, a figure which falls to 5% for older adults. For children the figure is 11%. A study of patients with nut allergy found that 96% also had one or more of the conditions: allergic asthma; allergic rhinitis; and atopic eczema.[32] Nut allergy is a relatively new manifestation of allergy, and its effects and effective treatment are still being investigated and understood by allergy clinicians.

28. Complex allergy is harder to diagnose and to treat, and requires correspondingly greater expertise on the part of health professionals This particularly applies to the newer diseases such as nut allergy and fruit allergy, where experience of seeing many cases allows a more informed approach to diagnosis and management. But it also applies to such conditions as drug allergy, where there is currently a lack of consensus on diagnostic methods, or where tests are harder to interpret. In all these areas considerable experience is essential, but there are immense benefits to patients when their clinical care is effective. Patients with severe or complex allergy will benefit from referral to a specialist allergist.

A crisis in allergy?

29. In a Westminster Hall debate on NHS allergy services in October 2003, the Public Health Minister, Melanie Johnson MP, acknowledged that these services "needed improvement" and that "we are starting from a very low base indeed".[33] According to a survey cited by the Royal College of Paediatrics and Child Health, more than 80% of GPs thought that NHS hospital-based allergy services were "of poor quality".[34]

30. Numerous memoranda attested to serious deficiencies in the current service. Professor Stephen Durham, a consultant in allergy and respiratory medicine at the Royal Brompton Hospital, described allergy services as "grossly inadequate in the face of this serious public health problem that affects around 30% of the UK population".[35] For Professor Adnan Custovic and Dr Andrew Bentley of the North West Lung Centre the current lack of any specialist service in their area was "highly unsatisfactory".[36] Dr Chris Corrigan, a reader and consultant in respiratory medicine and allergy at Guy's, King's, and St Thomas' suggested that the "availability, geographical distribution and access times for NHS allergy services" were "woefully poor countrywide".[37] The BSACI/NASG joint submission used the word "vestigial" to describe allergy services.[38] Dr Gideon Lack said that the sharp growth in allergy in the population, coupled with enormous pressures on scant services, constituted a "national catastrophe".[39] The RCP described allergy services as "totally inadequate", contending that NHS services could not cope with the rising amount and severity of allergy.[40] Dr Nasser, in written evidence, suggested that the NHS had been "wrong footed" by the epidemic. Patients were only rarely tested for allergy and many were told that there were no allergy clinics and that they would simply have to "cope with their symptoms".[41] Professor Andrew Wardlaw, President of the BSACI, summed up the view of the great majority of health professionals giving evidence when he told us:

    For a disease which is one of the commonest diseases in the UK, which … causes so much morbidity and a certain amount of mortality, the service is utterly derisory, and if you compare it, there are something like 26 full-time allergists in the UK, and really we should be able to have the same as chest physicians and dermatologists, where there are 500. Quite honestly I think it is a disgrace.[42]

31. The general picture of provision reflected in our evidence from a wide range of health professionals, points to a service which is under-resourced and overstretched, one where the basis for improvement and growth only exists in a limited number of locations across the country, and in which specialist care is provided largely by consultants in other clinical specialties developing an interest in allergy to cover the gap. This account was reinforced by the correspondence we received from patients and the evidence of the allergy charities. We were told in graphic detail of the many problems experienced by those seeking help from the services, which were caused by a lack of provision for allergy and a lack of understanding of the clinical need, including access restrictions, withdrawal of services, inequality of service provision by location, people being driven into unregulated assessments and service use, poor and inappropriate diagnoses being given and inadequate treatment and advice for patients.

32. When the RCP assessed allergy services, in Allergy: the unmet need, published in 2003, it found strong evidence of deficiencies in the delivery of care in the primary care sector, and a lack of specialist care in the secondary and tertiary sectors. Specialist care was completely absent in large parts of the country. The RCP also found a dearth of both training places for new consultants and of funded posts for any who were trained. It was their considered judgement that the best starting point for meeting the growing need for allergy services was to establish specialist centres of excellence in each region; use these to act as a focus and point for training primary care; and train a whole generation of specialist allergists for whom posts should be created to give allergy equivalent status to other specialties.

33. In this report, we analyse the evidence we have received to see how convincing the arguments are for a major reorientation within the NHS to create a high-quality allergy service. In chapter 2 we assess the quality of allergy services in primary, secondary and tertiary care and in the independent sector. In chapter 3 we look at the capacity of the NHS to deliver services. We turn in chapter 4 to possible levers for change to address the problems we found.



1   Royal College of Physicians, Allergy: the unmet need-A blueprint for better patient care, 2003, p7 [hereafter cited as 'Allergy: the unmet need]; Ev 110 (Dr Chris Corrigan) Back

2   Ev 125 (Dr Gideon Lack)  Back

3   Ev 169 (Royal College of Physicians) Back

4   Allergy: the unmet need, p7 Back

5   Ev 35-36 (British Society for Allergy and Clinical Immunology/National Allergy Strategy Group); Ev 53 (British Society for Allergy and Clinical Immunology) Back

6   Allergy: the unmet need, p7 Back

7   Allergy: the unmet need, p3 Back

8   Allergy: the unmet need, p3; Ev 145 (Alan M Edwards) Back

9   Ev 2 (the Anaphylaxis Campaign) Back

10   Royal College of Physicians (2003), available from http://www.rcplondon.ac.uk/pubs/books/allergy/allergy.pdf  Back

11   Allergy: the unmet need, p5 Back

12   Ev 106  Back

13   Allergy: the unmet need, p6 Back

14   Ev 52 (BSACI) Back

15   Ev 125 (Dr Gideon Lack) Back

16   Allergy: the unmet need, pxiv Back

17   Allergy: the unmet need, pxiv Back

18   Q7 (Alan M Edwards) Back

19   Ev 145. The figures are for the cumulative prevalence of reported asthma, allergic rhinitis and eczema among parents and siblings of the newborn infants. Back

20   Sources: ISAAC (the International Study of Asthma and Allergies in Childhood), Lancet 1998, 351:1223-32; Gupta R, Strachan D P, Anderson H R, Clinical & Experimental Allergy, 2004, 34:520-26; Lack G, (personal communication), Avon Longitudinal Study of Parents and Children; Grundy J, Matthews S, Bateman B et al, Journal of Allergy &
Clinical Immunology 2002, 110:784-9; Eggesbo M, Allergy, 2001; Host A Ann, Allergy Asthma Immunology, 2002; Allergy: the unmet need, Appendix 1; Avery N J et al, Paediatric Allergy and Immunology, 2003 
Back

21   Ev 125  Back

22   Q70 (Dr Lawrence Youlten) Back

23   Q66 Back

24   Ev 71  Back

25   Ev 36  Back

26   Ev 150  Back

27   Allergy: the unmet need, pxiii Back

28   Ev 116-17  Back

29   Stewart AG and Ewan PW, "The incidence, aetiology and management of anaphylaxis presenting to an Accident and Emergency department," QJM 89 (1996): 859-64 Back

30   Ev 209 (This account was taken from a survey of patient experiences conducted for our inquiry by Dr Shuaib Nasser and colleagues at Addenbrooke's Hospital, Cambridge.) Back

31   Allergy: the unmet need, pp xiii-xiv Back

32   Allergy: the unmet need, pp 7, 53; Ewan, PW and Clark AT, Lancet 2001, 357: 111-15 Back

33   HC Deb, 14 October 2003, Col 65WH Back

34   Ev 130  Back

35   Ev 106  Back

36   Ev 94  Back

37   Ev 110  Back

38   Ev 36  Back

39   Ev 126  Back

40   Ev 168  Back

41   Ev 27  Back

42   Q79 Back


 
previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2004
Prepared 2 November 2004