Select Committee on Health Sixth Report


2  QUALITY OF NHS PROVISION FOR ALLERGY SERVICES

34. According to the Department's memorandum, when patients present with allergies, they may follow different pathways of care, depending on the type and severity of the problem:

  • Most patients with simple allergic disease will be dealt with in general practice.
  • Some patients will be seen by organ-based specialists with an interest in allergy—eg in local hospitals.
  • More complex cases should be seen in specialist allergy centres. Consultants in specialist centres have important links with organ-based specialists and GPs providing allergy care. Allergy care is best provided as a network, co-ordinated by specialist allergy centres.[43]

35. The Minister, Dr Ladyman, described the way services were currently provided:

    First of all there will be a huge body of people who will be self-medicating, who will use the advice of pharmacists, NHS Direct, and will be perfectly happy controlling their allergy through self-medication processes. Then there will be those who go to their GP and the GP will feel competent to deal with their issues. Then there will be a smaller number where the GP feels that it is necessary to make a referral and the GP will make a decision as to whether that person should be seen by a generalist or by a specialist in a particular type of physical function, or by sending them to a multiple allergy specialist. In a much smaller number of cases the person will end up with a multiple allergy specialist.[44]

36. This benign and evidently theoretical explanation of how the NHS currently deals with allergy was directly contradicted by most of the evidence presented to us. We received over 300 submissions from individuals that detailed the experiences they, as people with allergies or as carers for people with allergy, had encountered. It is apparent to us that very many individuals have experienced poor response and treatment for their conditions and that many continue to battle against an insufficient service provision. For many people with allergy the patient pathway is blocked or frustrated at all stages. In consequence there is a direct and stark mismatch between what the Minister said should happen and the reality as reported to us. Two examples from a survey of patient experiences conducted for our inquiry by Dr Nasser and his colleagues at Addenbrooke's Hospital, Cambridge, illustrate the nature of this mismatch (patients' names have been changed, and comments by medical staff at Addenbrooke's are included):

'Dr Edmonds', aged 26.

    Clinical summary : Aspirin sensitive asthma; treated without allergy diagnosis since a small child; now controlled for the first time.

    "I wasn't referred at all for allergy.

    I had asthma from age 5, which was GP and chest clinic treated. My asthma was difficult, with numerous A&E admissions. I was in an undergraduate seminar, and my asthma was bad, when a tutor said that he was working with a doctor who was interested in my type of asthma. They were in the same laboratory, so I went to the Addenbrooke's Allergy Clinic.

    I did my post-graduate in Oxford. The GP there said that there was no equivalent place in Oxford for me to be referred to, so I commuted to Cambridge for treatment.

    Now I haven't had an attack for over a year. I have to avoid fruit.

    Comment: Lottery of care. Poor control of asthma for many years because of failure to recognise allergic triggers and treat appropriately. Inappropriate referrals led to costs to patient and the NHS. It was luck that got this patient to an allergist.

    'Mr Halsey', aged 47.

    Clinical summary: Severe hay fever; 14 years of long-acting steroid injections; 90% improvement on immunotherapy.

    "I have been a hay fever sufferer for over 20 years. After I was 27 it got progressively worse; the season went on from April to November; it was terrible; attacks might last 2-3 days; my nose was running; I was sneezing constantly; I couldn't sleep and finally couldn't work.

    The GP prescribed all the over-the-counter drops and sprays. They made some difference, but not enough. In the end he realised that I was not an average case; and he prescribed corticosteroid injection in April each year, which would last until July, then again in July. The treatment was effective on the same day and was welcome.

    That lasted for 11 years. In summer 1997 I had had the July injection and was playing with the children in the park. I began to limp. I didn't take much notice. But it went on for 2-3 weeks and got worse. I went to the doctor in August and he said wait, it might be a muscle sprain.

    When it hadn't cleared by December we began to realise that it was the side effects of the steroid treatment. I was diagnosed with avascular necrosis. Nobody admits it. Nobody accepts. They say the dose I was getting is not big enough to cause it. But the accumulation must have been a factor.

    Now I have avascular necrosis. Both my hip bones are damaged. The right is at stage 5, total collapse and needs replacement. And avascular necrosis is now present in the left hip bone.

    I was referred to the orthopaedic department at a hospital in London in April 1998. I still go there. I am putting the operation off as long as possible; I don't want to have a series of hip replacements over the years. But it's serious discomfort ...

    Then came the problem with what to do about the hay fever. They referred me to the Allergy Clinic at Addenbrooke's. They gave me skin tests and began desensitisation. That was 4 years ago. It seems to work. Yesterday (30 May) I sneezed once. Today is fine. I've known nothing like it before.

    I have friends from France. In 1992 they said that desensitisation was commonly available in France; and they were surprised that I couldn't get treatment. I wish it had been available from Day 1. I have missed work and all this could have been prevented."

    Comment: Delayed referral for 14 years despite desperate quality of life in the summer. Serious life-long side-effects of inappropriate treatment and failure to refer to an allergy clinic. Heavy costs to the patient and to the NHS.[45]

37. The key conclusions reached in the Addenbrooke's survey illustrate the problems faced by patients with allergy who have a severe and dangerous disease:

  • Allergy makes its presence known in very different ways.
  • A common experience is that people felt they were working on their own to manage a persistent, wearing, often unpredictable and sometimes dangerous illness.
  • Many people were anxious; this was more so if a child was involved.
  • In every case very substantial health gain was achievable with proper medical care.
  • When care was effective this came about through recognition of the needs of the whole person and of all aspects of the illness.
  • The search for help through the NHS was all too often blocked at some point, often at several points, and sometimes for long periods of time, by a health service ill prepared to care appropriately for severe allergy.
  • Considerable resolve (or luck) was often required to negotiate or find a way through the system of front line care and referral.
  • Experiencing lack of understanding and help, people were frustrated and sometimes frightened by what they needed to face.
  • People had to, and were prepared to, face long journeys to get the right help.[46]

Primary care

38. A patient suffering from allergy is likely to seek access to the health service through their GP. Nobody who gave evidence to our inquiry disputed that it was appropriate for the great majority of those patients suffering from allergy to see GPs in the first instance. Nor is there any serious disagreement that GPs will treat the majority of allergy patients. Maureen Jenkins, writing on behalf of the major allergy charity, Allergy UK, argued that "most allergic disease is better managed in primary care".[47] She contended that primary care clinicians were likely to be the first port of call for most problems. Allergic symptoms that are not readily controlled often lead to inflammation and chronic symptoms, resulting in repeat consultations and high costs for medication over a long period of time. If patients have access to good treatment in primary care, that allows for quicker diagnosis and management of conditions, given the paucity of specialist treatment centres. Ms Jenkins pointed out that allergy often runs in families (and even where it does not, often involves other family members in the management of the condition) and that the primary care team was best placed to offer care for a group of family members. However, because of the lack of knowledge of allergy in primary care, accurate diagnosis including the identification of allergic triggers is rare.

39. Specialists in allergy treatment nevertheless concur with the necessity to treat much allergy within primary care. The BSACI/NASG joint submission, drew attention to many shortcomings with current provision in that area, but acknowledged that "major parts of a disease with such widespread prevalence" must be treated in this sector.[48] Dr Nasser, from Addenbrooke's, agreed that "five out of six [patients] can almost certainly be treated in primary care".[49] This represents an ideal, and one which we believe could be realised if primary care were playing its part within a comprehensive service. But at present the knowledge-base across the whole of the NHS, including primary care, is inadequate. The Department's memorandum made no reference to any deficiencies in the treatment of allergy in primary care. It noted the inclusion of a specific quality indicator for the treatment and care of people with asthma in the new General Medical Services contract. More generally, it pointed to the growth of investment in primary care, and the potential of this additional investment to improve the quality of care for patients.[50] However, we received powerful evidence to suggest that general measures are not going to tackle the specific problems of allergy in primary care, and that nothing effective is being done to correct the situation.

40. Our sample of 201 (out of 338) allergy sufferers submitting evidence, analysed in the Annex, is clearly not necessarily representative. Nevertheless, we find it very disturbing that only 23% of patients received a correct diagnosis of allergy when they first presented to their GP. The majority received an incorrect diagnosis and many visited their GP on numerous occasions over a period of years before a correct diagnosis was made. In the survey, many patients (58%) had not been referred to any type of allergy service. Sometimes they had only been referred to one after they had consulted an allergy charity and armed themselves with the names of relevant consultants and units. A lack of knowledge of allergy in primary care was noted in our analysis as being one of the principal causes of distress to patients. In addition, many patients reported a response of scepticism, ridicule and disbelief on the part of GPs when confronted by patients with suggestions over their symptoms. This confirms a point made by Dr Penny Fitzharris, consultant in allergy at Guy's, King's, and St Thomas' Trust, London, that "in the past there has been a perception amongst poorly informed medical practitioners that much allergy is in the mind and without clearly defined causes and thus services are unnecessary".[51]

41. Allergy UK told us that people with allergy had reported that GPs evinced little understanding of the impact of allergy on a patient's life or the potential seriousness of an "on-going allergy problem". They cited a survey that they had conducted for their 2003 report, Stolen Lives. Of 6,000 helpline callers questioned, almost three-quarters said they had never been asked by their doctor or nurse how allergy affected their quality of life.[52]

42. Allergy UK and the Anaphylaxis Campaign suggested that the commonest calls to their help-lines related to difficulties patients experienced in obtaining help with allergies in primary care. This is also clear from the patient pathway chart in the RCP Report, based on information from patients given to the Anaphylaxis Campaign.


Figure 2. Allergy Pathways[53]

43. We also received evidence from clinicians to support the patient experiences we have had reported to us, that the primary care treatment of allergy is poor. This indicated a general absence of both willingness and expertise to diagnose, treat and refer allergy appropriately in primary care. As Professor John Warner noted, "at primary care level, allergy avoidance advice is given without doing any tests which, of course, is totally inappropriate".[54] For too many patients the GP is part of the problem, not the route to a solution, as the Addenbrooke's survey made clear, where many patients reported that the GP had not been able to treat them satisfactorily or refer them appropriately. Professor Stephen Holgate, for the NASG, painted a worrying picture when he told us that one of the most important findings of the RCP report into allergy services was that "general practitioners, across the country, were very poorly informed about allergy and generally they just reached for the anti-histamines or steroids to treat patients instead of establishing a diagnosis, which all doctors should really do as a primary move".[55] A survey of 240 GPs commissioned for the RCP report revealed that the majority had "received no training in the management of allergic disorders" and that fewer than a quarter reported that they were "familiar with any guidelines for the management of an allergic condition".[56] The survey revealed that:

  • Fewer than 8% of respondents said they had access to a fully comprehensive NHS allergy service
  • 59% felt that the quality of care in primary care was poor
  • GPs felt most confident in treating the most common allergies eg asthma, allergic rhinitis and eczema and less confident about managing allergy in children, food or insect-sting allergy
  • Skin prick tests were available in only 4% of the practices sampled
  • Half of the GPs sampled had received some training in allergy theory, mostly minimal, at undergraduate level and not in clinical application. Only 10% of partner GPs and 17% of practice nurses had received any clinical training in allergy.[57]

44. Professor Aziz Sheikh, Professor of Primary Care Research and Development at the University of Edinburgh, pointed out that: "There is an increasing body of evidence to suggest that primary care provision of allergy services is frequently sub-optimal … particularly with respect to the rarer (and often more severe) allergic conditions such as anaphylaxis but also in relation to milder conditions such as hay fever". He concluded by providing a possible rationale for this situation: "Key underlying reasons for this sub-optimal care are the dearth of training opportunities—at both an undergraduate and postgraduate level—in the management of allergic problems and the lack of appropriate diagnostic facilities (eg skin prick testing) in primary care".[58]

45. Dr Nasser told us that: "General practitioners are not educated in allergy. Medical students are not educated in allergy. They do not understand the concept of multi-system disorder which is becoming increasingly more severe". He continued:

    Many general practitioners in this country do not know that there are allergy services and they deny their patients because they say, "Look, we do not know where we can refer you." And locally they may not have allergy services. They do the next best thing and, after a lot of cajoling —because they often deny the patient any referral at all—they may refer the patient to a dermatologist who may then refer them on to an ENT [Ear Nose and Throat] surgeon who may then refer them on to a chest physician or a paediatrician. This means a very tortuous journey for the patient and it is only the very determined few … who can navigate their way through the jungle.[59]

46. For Muriel Simmons, Chief Executive of Allergy UK, GPs were failing to refer patients effectively to appropriate secondary or tertiary care. She told us that:

    The major problem is getting a referral. … The general practitioner, because they do not have training in allergy, are either very dismissive or they will try to find out where an allergy clinic is but then it is often down to a funding issue or a distance issue.[60]

47. With an inadequate service available in both primary and secondary care, the relationship between primary care and the secondary and tertiary sectors is highly problematic. Our evidence suggests that the primary care sector is not referring patients to secondary and tertiary care other than in areas where specialist clinics operate, and even then only patchily. In the view of the RCP, and many others submitting evidence to us, the lack of awareness and expertise in the primary care sector could only be addressed effectively after specialist care expertise was first developed across the country. This would allow primary health care professionals the opportunity to observe and learn from best clinical practice and would also act as a resource to which primary care professionals could turn for guidance and support. Dr Chris Corrigan at Guy's, King's, and St Thomas' NHS Trust argued forcefully that the lead had to come from the specialist sector:

    Although the front line of allergy management will be in primary care, with no primary care skill base from which to work, clinical leadership must come initially from specialist centres.[61]

48. Dr Nasser, from Addenbrooke's, supported this:

    I think the important thing here is that we have to say, "Who is going to train the GPs?" first. You do need a hospital base. In every region there has to be a hospital base in order to provide the training for general practitioners.[62]

49. We believe that primary care should be the frontline provider of allergy care, but the skill base from which to build an adequate primary care service is lacking. In order to develop an appropriate primary care service, an infrastructure of specialist allergy services is therefore first required. As we propose below, it is imperative that specialist clinics for the treatment of allergy should be developed across the country, so that these can become centres of local networks of competent practice in allergy care, and facilitate the training and professional development of staff in primary care. It will, however, take several years for these centres to be fully operational. So we recommend below a number of measures intended to have a more immediate effect on the capacity of primary care to deal with the growing problem of allergy in the population.

50. We believe a national primary care allergy network should be created to support those working in primary care to allow them to access second opinions, to offer peer review of services and to provide ongoing education and professional development. The active involvement of current and developing specialist centres is crucial to the existence of such a network. We recommend that the Department takes steps to draw to the attention of GPs the directory of allergy services produced by the British Society for Allergy and Clinical Immunology.

51. We recommend that in its next review of the clinical incentives in the current GP contract, the Department should introduce clinical quality markers for allergy.

52. Primary Care Trusts should consider how to ensure that people with allergy in their area know who is appropriately trained and who is clinically accountable for providing a service. We recommend that a named person in each PCT should be identified. This process should be overseen by Strategic Health Authorities as a regional overview will be important.

53. We recommend that the basic training curriculum for GPs should be reviewed, and modified as required, to take account of the need to have allergy as a basic component in the initial training for general practice.

54. We note the evidence presented by Dr Adrian Morris, a GP with particular interest in allergy, who explained that a number of organisations already offered accredited training courses for GPs and Practice Nurses, including the National Respiratory Training Centre in Warwick, Allergy UK (who hold Allergy Masterclass Training Days), Southampton University (which offers an MSc course, attended mainly by GPs) and the BSACI.[63] Such courses appear to be very popular. Muriel Simmons, for Allergy UK, told us that her organisation would shortly be holding two masterclasses: "Both are oversubscribed, all from GPs wishing to learn more about how to help patients in allergy".[64] By taking a role in the provision of these courses, the Department would give quality assurance.

55. We recommend that the Department should disseminate information to all PCTs on training provision in their area. Given the general level of ignorance of allergy in primary care we recommend the Department should provide some financial support to provide access to initial in-service training for a wide range of health professionals. We recommend that the Department assesses the quality of the various training courses on offer to GPs.

GPS WITH SPECIAL INTEREST

56. As a way of improving the capacity of primary care to deal with allergy, Dr William Egner, a consultant immunologist at Sheffield Teaching Hospitals Trust, suggested that the Department should urgently consider adding allergy and immunology to the list of specialties for GPs with special interest (GPwSI).[65] Professor Holgate, for the NASG, agreed that such a change would be beneficial:

    Allergy is a discipline that would lend itself very nicely to the GPwSI system and specialists within groups of general practices that could concentrate effort and involve some nurses working in primary care … We have GPwSIs in diabetes and other areas. So one step government could take is to recognise this as an area [in which] they might be able to support allergy specialists in the secondary care sector.[66]

57. GPwSIs were introduced to the Health Service in The NHS Plan (2000), which envisaged that by 2004, up to 1,000 GPwSIs would be "taking referrals from fellow GPs for conditions in specialties such as ophthalmology, orthopaedics and dermatology" and undertaking some diagnostic procedures such as endoscopy.[67] It is estimated that there are now at least 1,250 GPwSIs in the NHS.[68]

58. GPwSIs are general practitioners with a specific interest and competence in what are normally hospital-delivered services. They may deliver services for one or more PCTs beyond the scope of normal general practice, undertake advanced procedures or develop a service. Where GPwSIs are available, other GPs can refer relevant patients to them rather than to a hospital consultant. GPwSIs will often have shorter waiting times than hospital consultants and provide care within the familiarity of a community setting. They may refer patients with more serious conditions on to hospital. GPwSIs continue to be primarily generalists, with the specialist role only supplementing the duties of a regular GP.[69]

59. The role of GPwSI has the potential to break down some of the barriers between community and hospital-led care, enabling a more 'joined-up' system from the patient's point of view. The Action on ENT Programme, which piloted GPwSIs in ENT in Ealing, demonstrated some of the benefits of GPwSIs, including:

  • 30-40% of referrals to secondary care could have been seen by a GPwSI with appropriate training, support and equipment;
  • a GPwSI seeing 10 patients in an established once-a-week clinic can perform up to 500 consultations a year, seeing between 320-400 new patients annually;
  • GPwSIs discharged around 70-80 % of patients back to the care of their GPs;
  • GPwSI clinic consultations were significantly less costly than consultant consultations.[70]

60. GPwSIs are potentially beneficial to patients, but the effectiveness of a scheme may depend heavily upon implementation, accreditation and monitoring of standards, which is mainly the responsibility of PCTs. GPwSI programmes have been most successful where they are a joint PCT and Acute Trust initiative[71] as GPwSIs require direct access and support from consultants and the diagnostic provision sometimes only the acute sector can provide. Again, this points to the necessity of first developing specialist allergy services to support the primary care sector. In addition, established guidelines state GPwSIs should be expected to undertake at least one session a month working in the acute sector.[72]

61. The GPwSI National Development Team has developed a number of frameworks for the appointment of GPwSIs, laying out their responsibilities, and defining what level of qualification, formal and/or experiential, is appropriate and necessary and what evidence is required to prove this. Currently, these guidelines cover under 20 specialties; a survey of GPs has shown that there is interest in many more, including specialised allergy services.[73] The prioritisation of development of GPwSI guidelines for certain services over others is based upon services with national programmes such as those with National Service Frameworks, for example coronary heart disease and diabetes, or services that present access problems for many patients, such as drug misuse or mental health provisions. However, even within some of the more specific guidelines, much of the detail of individual GPwSIs is to be determined locally by the PCT holding the contract.

62. We conclude that, while GPs with Special Interest could make an important contribution to service development in allergy care, a precondition of their successful introduction is the prior availability of specialist care to underpin standards and provide clinical training and case management guidance. Nevertheless, the curriculum for GPwSIs could be developed with allergy consultants now, and we recommend that this should be done. The pace of change can then be set taking account of the overall programme required to modernise allergy care within the NHS.

63. We recommend that the GPwSI National Development Team begin work on a framework for GPwSIs in allergy services, working with the current specialist allergy centres (and with additional regional centres once these are established) to identify the core activities of an allergy GPwSI, and the qualifications and/or experience that would make a GP eligible for such a position.

64. To show that it is genuinely committed to this planning phase, the Department should indicate that it wishes to see (and is prepared to finance) the creation of a first generation of GPwSIs in allergy on a sufficient scale to ensure there is a GP with a special allergy interest in each PCT, once sufficient consultants in allergy are available to train them.

Secondary and tertiary care

65. For some time to come, the majority of patients referred to secondary care will not be treated by an allergy specialist. As the RCP report explained:

66. Professor Stephen Durham, a consultant in allergy and respiratory medicine at the Royal Brompton and Harefield Trust, outlined some of the limitations of using organ-based specialists to treat allergy:

    The current piecemeal service provided at secondary care by individual organ specialists is inadequate. For example, a chest physician may be competent to evaluate the allergic component of asthma. He may or may not recognise that the patient has associated distressing allergic rhinitis requiring separate management. Almost certainly, he would not be equipped to investigate and diagnose associated food allergy. Neither could he deal with associated urticaria or difficult eczema. Such a patient requires one consultant allergist with a multi-disciplinary approach to diagnosis and treatment rather than the alternative, namely 4-5 organ specialists to deal with multiple allergic problems.[75]

67. Overall, the BSACI described national capacity to manage allergy in secondary care as "derisory" and noted that such capacity as was available was "provided in large part by specialists in other disciplines".[76] They suggested that when care was provided by non-specialists, the allergic basis of the disease would not be addressed, and the clinics would not be equipped to deal with several different expressions of allergy, leading to "sub-optimal management". Apart from consultant allergists, the two main specialties seeing patients with allergic diseases in roughly equal numbers are clinical immunologists and respiratory physicians. The BSACI noted that both these specialties did include the management of allergic disease as part of their training (though this was more the case with immunologists than with respiratory physicians). While some immunologists regarded patients with allergy as their main interest, in the view of the BSACI:

    The majority of clinical immunologists and respiratory physicians have a considerable workload caring for patients with diseases relevant to their main interest (managing the immunology laboratory and immunodeficiency in the case of clinical immunologists and chest disease for respiratory physicians) and do not have the time or often the inclination to develop allergy services.[77]

68. In evidence to us, Dr Ladyman questioned whether there was in fact a clear consensus that patients requiring specialist allergy treatment ought to be referred to an allergy specialist:

    What I would counsel you about is that I think there was an implication from some of your earlier witnesses that there was a consensus view about the benefit of specialist centres. I do not believe that there is that consensus view; I believe, for example—and I think that you have had written evidence to this effect from some of the other specialist areas—that dermatologists take the view that if you have a skin condition or eczema you should start off with a dermatology specialist rather than going to a multiple allergy clinic. Dieticians take the view that you would be better off seeing a dietician first. There are some specialists in respiratory diseases who think that if you have asthma you ought to start off with lung specialists and respiratory specialists. The impression I got from some of your earlier witnesses was that what they would like to see was a direct referral of people from their GP to their allergy specialists, and I think that is probably appropriate where there is clear evidence that the person is suffering from multiple allergies, but it is not necessarily the best thing to do if it is clear that the allergy they are suffering from is more specific than that.[78]

69. However, our evidence was almost uniform in calling for specialist allergy treatment for people with severe or complex allergy. The British Association of Dermatologists in their memorandum, which the Minister referred to, did not argue against the creation of specialist allergy centres, but merely remarked on the limitations in allergy services which some departments of dermatology were able to provide.[79] Dermatology was one of the disciplines represented on the RCP working group that produced the report Allergy: the unmet need, which the Council of the College as a whole sanctioned. If, as the Minister claimed, there is a serious debate about whether allergy should be dealt with by allergists or organ-based specialists, we find it surprising that only one or two of the 400 or so memoranda we received had anything at all to say about this and none argued directly against it.

70. Our evidence indicates therefore that the RCP analysis and recommendations are not contested, as Dr Ladyman suggests. A need for specialist allergists is recognised and accepted within the medical profession. Nor does there seem to be any serious disagreement about the way allergy overlaps with other specialties, especially respiratory medicine and dermatology. The complementary nature of the relationships seems to be recognised and, for example, it seems generally accepted that it is appropriate for asthma and eczema to be dealt with primarily by these specialists. There seems also to be a professional consensus, unfortunately one not acknowledged by the Minister, as to the added value provided by an allergist. For patients where allergy is a driver of the illness, an allergist can identify the trigger; and a clinical judgement that there is, or may be, such a trigger, or that this needs to be ruled out, determines when an allergy specialist is needed. This is usually either for severe disease, or when there is multiple system involvement, or for diseases that do not sit in any other specialist's territory, for example food, drug and insect-sting allergy, anaphylaxis and some types of angioedema. But it can sometimes be appropriate to refer to an allergist for a single system presentation if there are specific clinical presentations. We consider that the RCP were right in identifying the need to provide increased specialist capacity in allergy care given the (undisputed) growth in allergic diseases.

71. We asked the Minister how the conflict of views he had depicted as existing between organ-based specialists and allergy specialists could be resolved. We did not find his answer especially reassuring, given that there is a consensus and none of the evidence demurred from it:

    Ultimately these things, I suppose, get resolved. If there is no growing consensus on the way forward then these things do get resolved by national guidance, like National Service Frameworks being produced in order to say, "Here is the model that we think is the best evidence-based way forward". How these things normally get resolved is through processes like the one we are undertaking today, the publication of the Royal College's documents and a review of services by local commissioners and discussions with clinical specialists in order to come to something that approaches the consensus of the best way forward. I know that does not sound terribly clean but the alternative is something which I think would be less effective … and that is for me to sit in my office in Whitehall and make these decisions for you all.[80]

72. International comparisons suggest that the UK is out of step with other countries in terms of the numbers of its doctors specialising in allergy. For example, while there are only four NHS paediatric allergists in the UK, in Sweden, there are 96 trained paediatric allergy specialists and, in Germany, there are 500. Compared with the UK, there are five times the number of paediatric allergists in Greece and four and a half times the number in Switzerland.[81]

73. When giving evidence to us Dr Nasser told us:

    We are seeing here that there is a lack of allergy specialty. This is something that is available and many of the other developed countries in the world, throughout Europe, the United States, have very well developed allergists who can treat multi-system disease. In this country we need to get education, starting from medical school upwards. We need to train doctors to become allergists and we need to develop centres of excellence where allergy is a recognised specialty.[82]

74. The lack of development of allergy services in the NHS in comparison to other European countries was illustrated to us by Professor Holgate, for the NASG, who suggested that "we should be able to lift the whole thing up, as has happened in every single country in Europe, apart from Great Britain; even Estonia, Latvia and Lithuania have allergy practitioners".[83] Dr Penny Fitzharris, a New Zealander recruited to the NHS, noted the absence of UK-trained candidates to take over her role as consultant in allergy at St Mary's Hospital in Paddington in 1993 and at Guy's Hospital in 2004, and argued that allergy services were "much better developed in Continental Europe, North America and Australasia" than in the UK.[84]

75. As other countries have discovered, for allergy as it is now presenting, the best and most efficient referral path is often not, as the Minister suggests, GP to another specialist and then to an allergist, but often GP straight to an allergist. Where specialist services exist, GPs appear to recognise this: approximately 85% of referrals to such centres are made direct from primary care. At the moment, however, an unusual situation prevails in the NHS. There are very few allergists, and nearly all are acting in both a tertiary and secondary capacity (for the most part, providing a local specialist service for their geographical area). But some patients travel very long distances out of area to obtain care. In the rest of the country, secondary care is mainly being provided by other types of consultants, who have other work to do and who are either limited in their expertise of allergic conditions, or have expertise limited to one part of the body, or both. We are not convinced that this is an efficient or an effective model. Even when they eventually find their way to appropriate specialist care, the journey for many patients has to be through the hoops of partial or, to varying degrees, inappropriate care. And for the majority not even this possibility is available. They have no choice; effectively they have no access to any kind of adequate NHS allergy care.

76. Turning to the specialist centres that do exist for the treatment of allergy, what is immediately striking is the absence of geographical equity in provision. There are only six full-time allergy clinics in England and none in Scotland, Wales or Northern Ireland. The six clinics in England are located at:

  • Guy's Hospital, London
  • Royal Brompton Hospital, London
  • St Mary's Hospital, London
  • Addenbrooke's Hospital, Cambridge
  • Southampton General Hospital
  • Glenfield Hospital, Leicester.

77. These six centres provide expertise in all types of allergic disease, including complex problems, and provide a comprehensive allergy service with a multidisciplinary approach. The clinical service provision is complemented by an international reputation for research in allergic disease. There are nine part-time services run by specialists and 86 part-time services offered by consultants in other specialties (these are generally part-time clinics).[85]

78. The map below, taken from the RCP report, indicates the distribution of full- and part-time specialist centres, and the specialist allergy clinics:


79. The Department, in its memorandum, acknowledged the existence of these six full-time and nine part-time specialist centres but we find it surprising it chose not to discuss how what they represent could be developed into a fairer national system of care. We also find it most surprising that the Department nowhere in its evidence acknowledged what Professor Holgate described as the "tremendously poor distribution and inequality of allergy service provision", which had contributed towards a "tremendous mismatch between clinical provision of services and the clinical need".[86]

80. The RCP in its report Allergy: the unmet need recommended that all of the former eight NHS regions in England, serving populations of around five to seven million, should have a minimum of one specialist allergy centre. They recommended minimum staffing levels for each centre of:

  • two adult allergy consultants
  • two paediatric allergy consultants supported by paediatric nurse specialists
  • two full-time nurse specialists
  • one half-time adult dietician and one half-time paediatric dietician with specialist training in food allergy
  • facilities for training of two specialist registrars (in some centres only).

81. The cost of such an expansion has been estimated at £5.6 million per annum.[87] We believe that much of this cost would be offset by the introduction of more effective and efficient treatment of allergy. Better care which tackled the cause of the disease would lead to a reduction in the long-term prescription of drugs which treat symptoms, reduced hospital admissions and A&E attendance, and fewer GP consultations for ongoing poorly controlled disease. It would relieve the pressures on other specialist services. As the BSACI/NASG in their submission suggested, the current management of allergy, where patients often attend separate clinics for different problems, is "wasteful of NHS resources".[88]

82. Allergic disease currently accounts for 6% of general practice consultations, 0.6% of hospital admissions, and 10% of the GP prescribing budget. Allergic problems are responsible for an estimated 12.5 million GP consultations a year (with an estimated cost of £211-311 million). The cost (in primary care, excluding hospital services) to the NHS is £900 million per annum.[89] Hospital admissions have been costed at over £68 million per year, but none of the outpatient work, which is the main hospital cost of allergy, has been determined.

83. The chief executive of Addenbrooke's Hospital, which maintains a major allergy clinic, suggested that more specialised treatment of allergy would be "a cost effective system for the NHS at large, preventing ongoing illness and reducing further acute reactions".[90] Dr Michael Tettenborn, a consultant paediatrician at Frimley Children's Centre in Camberley, contended that: "Our current approach of simply prescribing anti-histamines and steroids in most instances is not cost effective and is associated with significant problems with side effects. An investment in this area could save the NHS money as well as reducing mortality and significant morbidity".[91] Further, the cost is more than a service saving. It represents a service development investment. Developing specialist allergy services will lift the service in the whole region and the capacity of all providers by having expertise 'on tap'.

84. It seems to us to be manifestly inequitable that there is no comprehensive allergy service in England north of Manchester or west of Bournemouth.[92] The current provision in fact owes nothing to the geographical spread of allergy in the population. Rather, it comprises those centres where specialist research in allergy has taken place, on the back of which clinical services have developed ad hoc.[93]

85. We endorse the proposal of the Royal College of Physicians that a minimum of one specialist allergy centre should be established in areas equivalent to each of the former NHS regions, serving populations of five to seven million, to offer at least some local expertise for allergy sufferers. More provision may well be needed in less densely populated areas. We also endorse their recommendations for staffing levels both for adult and paediatric care, that is to say that each centre should have as a minimum two adult allergy consultants, two paediatric allergy consultants supported by paediatric nurse specialists, two full-time nurse specialists, one half-time adult paediatrician and one half-time paediatric dietician. This is our key recommendation and the one on which all other elements to develop a national allergy service within the NHS will depend.

86. The specialist allergy clinics, other clinics capable of providing allergy services and hospital trusts need to develop new ways of working, or adapt old ways, to provide for a national network of interim care while a new cohort of allergists who will run these new centres is trained. Through these networks, the information could be gathered to locate new consultant allergist posts where unmet need is greatest as new doctors emerge from training. We believe that Strategic Health Authorities should play their part in co-ordinating such activity.

87. In the longer term, we would like to see allergy provided with a full specialist consultant workforce. The Royal College of Physicians' medical workforce projections indicate this would eventually require the creation of around 520 consultant allergist posts. This is clearly an ambitious goal and unachievable even in the medium term when starting from such a low base, even if the resources were available. We recommend that an important more intermediate target would be for most major teaching hospitals to have a consultant allergist-led service, covering adult and paediatric allergy, with appropriate support staff.

Services for children

88. As we have noted, prevalence of allergy in children is higher than it is in adults. Allergy poses particular problems for children. It can, for example, disrupt their school lives. A regime of anti-histamines to combat hay fever is not the ideal preparation for exams. The need for constant vigilance on the part of those allergic to nuts is not assisted if schools cannot treat anaphylaxis or cannot adequately protect children against allergic triggers. One study has suggested that children with peanut allergy are more anxious about their condition than are those with insulin-dependent diabetes.[94] It has also been estimated that 3-6% of 13-14 year olds suffer from sleep loss as a result of eczema or asthma.[95] Many children with allergic disorders also suffer from bullying and social segregation at school.[96]

89. There is evidence to suggest that early diagnosis and treatment of allergy can reduce the disease burden in later years. Professor Tak Lee, of King's College London, informed us that:

    Early treatment of paediatric allergy with, for example, immunotherapy may reduce the progression of disease and reduce new allergic sensitisations. There is therefore a real opportunity to halt the epidemic of allergic disease if the appropriate services and resources are provided.[97]

90. As a practical example of this, Dr G K Scadding, a consultant allergist and rhinologist at the Royal National Throat, Nose and Ear Hospital told us that rhinitis was a risk factor for asthma development, and that treatment of childhood rhinitis by immunotherapy could reduce progression to asthma.[98]

91. Professor John Warner, a paediatric allergist at the University of Southampton, indicated the scale of the problem. He felt that allergy in childhood required the same network of specialist tertiary centres supporting other health professionals with specific training as should be present for allergy in adults. He told us that the potential demand for specialist treatment was enormous:

    We estimate about a sixth of the total number of cases require special attention. In childhood now 40% of all children have some allergy. Of those, about a sixth require specialist referral, and that means we are talking, based on the current birth rates, about 40-45,000 new cases a year for specialist referral.[99]

92. The estimate—that with each new birth cohort, a potential 40,000 children with allergy will be added to the problem each year—was made by the NASG, in the document An NHS Plan for Allergy—Making a Start.[100] This document made proposals to improve allergy care, and was sent to Dr Ladyman in May 2004. Professor Warner only quoted one aspect of the estimate. The other is the gap between provision (including all providers, not just allergy specialists) and need. Taking all measurable factors into account, it was estimated that hospital provision can only deal with about 2% of the need (all ages). With current capacity for allergy referral (to all types of consultant) it would take 50 years to clear the backlog. Even taking account of the inevitably rough and ready nature of these estimates, the orders of magnitude they expose are exceptionally worrying and point to an unacceptable situation.

93. In the UK, a high percentage of both inpatient and outpatient paediatric workload is related to allergic disease. In a recent survey of paediatric A&E admissions at St Mary's Hospital, London, almost 7% of children seen as emergencies were diagnosed as having allergy disorder. These children required twice the rate of admission and twice the rate of specialist tertiary referral compared to other children attending as emergencies.[101]

94. Notwithstanding the scale of the problem, our evidence suggests that services for children are even more scant than they are for adults. Dr Gideon Lack, a consultant in paediatric allergy and immunology at St Mary's NHS Trust, London, argued that children were suffering the consequences of not seeing paediatric allergy specialists in three ways:

    Firstly, they are denied proper diagnosis and care. These children are at risk of anaphylactic reactions (one in 50 children in the UK are allergic to peanut and similar numbers of children are allergic to tree nuts).

    Secondly, these children suffer nutritional consequences in the absence of adequate nutritional advice. They exclude multiple foods and have compromised diets. We have seen children with rickets, growth failure, developmental disorders and severe psychological problems all because they failed to receive proper specialist advice at the right time.

    The third way in which these children suffer damage is that their parents are unwillingly forced into the hands of dangerous alternative practitioners who run private clinics where non-validated and often dangerous practices are used. I know of instances where patients have been morally blackmailed to receive expensive treatments that are potentially life threatening. The situation is analogous to the days when young pregnant women were forced into the hands of back-street abortion clinics.[102]

95. According to the Royal College of Paediatrics and Child Health (RCPCH), the majority of care for children with allergies is provided by organ-based specialties, ENT surgeons and dermatologists, with no allergy training. This, in their view, leads to "inappropriate care, bizarre and poor practice".[103] Only four centres, St. Mary's Hospital and King's College Hospital in London, Southampton General Hospital, Glenfield Hospital and Royal Infirmary Hospitals, Leicester, offer a full range of paediatric allergy services. As we have noted, Sweden, a country with a population less than a sixth that of the UK, has 96 trained allergy specialists. Against this, the UK has six paediatric consultants. In the view of the RCPCH, provision in the NHS is "totally insufficient" to meet the need. The situation seems unlikely to improve in the near future, since there is currently only one trainee in paediatric allergy.[104]

96. The RCPCH also recommend the creation of a new cadre of general paediatricians with an interest in allergy in teaching hospitals and district general hospitals to deal with local needs, and the designation of one community paediatrician in each PCT to co-ordinate the management of children in schools and nurseries at risk of severe allergic reaction. Dr Vibha Sharma, a consultant paediatrician in the Royal Albert Infirmary, Wigan, called for the appointment of a consultant with special interest in allergy in each district general hospital, linked to a regional tertiary centre to provide expertise and support. She noted that when she had taken over an embryonic paediatric food allergy clinic she had found it very difficult to obtain expert clinical support and training for her work.[105]

97. Such provision as is available is usually patchy, poorly co-ordinated and under-resourced. Dr Julia Clark and Professor Andrew Cant, consultants in paediatric immunology at Newcastle General Hospital, recently undertook an assessment of paediatric allergy work carried out in the Northern Region. Their survey of all clinical directors revealed that:

  • all were carrying out some allergy work, though none could quantify it;
  • 40% had no paediatrician with an interest in allergy;
  • 70% had no paediatric allergy dietician; and
  • 60% had no nurse with an interest in allergy.

98. Some areas with a paediatrician with an interest in allergy lacked nurse or dietician support; some nurses and dieticians with such an interest worked in areas with no trained paediatrician.[106] Most districts carried out skin prick tests, some performed challenge tests, and most dispensed adrenaline injectors, but with "a hugely varied incidence".[107] According to Dr Clark and Professor Cant, children with eczema and asthma were well served by respiratory paediatricians and dermatologists, but children with food allergy or recurrent chronic urticaria were very poorly served. Despite the fact that food allergy was by far the commonest reason for people seeking advice, few local hospitals could offer an appropriate range of professional expertise to advise patients on management of the condition, on an appropriate diet or on the use of adrenaline auto-injectors.

99. The RCPCH also commented that many children were currently being treated in adult clinics. This contravenes the tenor of the Department's National Service Framework for Children, which states that all young people should have access to age-appropriate services which are responsive to their specific needs as they grow into adulthood.

100. Childhood allergy presents problems which are in some respects identical, but in others distinct from those experienced by adults. What is most noticeable is that the gap between need and service performance is wider and growing faster in the case of paediatric allergy. We do not find it acceptable that children are being treated in adult settings and that there are only half a dozen consultant specialists in child allergy, given the prevalence of allergies amongst children.

101. We endorse the suggestion of the Royal College of Paediatrics and Child Health and the Royal College of Physicians that there should be a parallel development of paediatric allergy services to those for adults, with the creation of regional centres, each staffed with a minimum of two paediatric allergists and support staff.

102. Schools have a key role to play in dealing with children who have allergy. We received evidence of some good practice in many schools but also much disturbing evidence, not least in some personal accounts, of ignorance and ineffectiveness in the monitoring and treatment of children. Dr Philip Doré, a consultant immunologist from the Hull and East Yorkshire Trust, cited a survey conducted in October 2003, which showed that, of 280 local schools surveyed (59% response rate):

  • 82% had no policy on allergic reactions;
  • 55% had no training on dealing with allergic reactions; and
  • 67% would like to receive training.[108]

103. The RCP called for community paediatric nurses, working with specialist allergists, to carry out school and nursery visits so as to train staff. We asked witnesses whether school staff were reluctant to become involved in this area of care. David Reading, for the Anaphylaxis Campaign, told us he thought that this problem was diminishing, but that it was crucially important that teachers were properly supported:

    First of all, you need the teachers to volunteer … but you do need somebody, preferably—well essentially—a medical person to go into the school to seek out the volunteers and to train them in the use of injection. I know in good areas like Southampton and parts of London and Cambridge you will get excellent systems set up where people train to go in and train the staff, but this is patchy. Around other parts of the country teachers will understandably be very frightened at being asked to inject an adrenalin pen.[109]

104. There is evidence to suggest that, where a specialist allergy centre does exist, good allergy care in schools follows. In Cambridge, where many children are treated, allergists set up links with the community paediatric teams and this has led to the development of high-quality care in schools. School staff feel confident to deal with allergic emergencies and anxiety amongst patients and children has been reduced. There has been a substantial reduction in further allergic reactions. Gradually all local schools have developed allergy policies and undertaken annual retraining. This system has spread through the region, and led to recommendations for good practice in schools. But these systems need leadership and ready access to advice from an allergist, lending further support to the desirability of establishing a major centre in each region.[110] Regional allergy centres can extend their services into the community and give parents and staff in playgroups, schools and elsewhere the knowledge and confidence to manage allergy well. They can provide guidance for good practice in the care of children at risk of anaphylaxis in schools.

105. The Anaphylaxis Campaign highlighted the importance of careful management of severe allergy within schools, stating that with communication between parents, staff and medical representatives, and with planning and precautionary measures in place, children with severe allergies should be able to experience school normally.[111] Emphasising the importance of teachers working with parents to agree basic and emergency procedures for children who suffer from anaphylaxis, the Campaign endorsed the use of a protocol, developed by parents and the school, in consultation with the school nurse, the child's treating doctor and the education authority. They suggested this should cover such issues as symptoms, emergency procedures, medication, food management, staff training, precautionary measures and professional indemnity.

106. The Department for Education and Skills encourages all local education authorities and schools to adopt the guidance Supporting Children with Medical Needs: a good practice guide, [112] which includes advice on dealing with children with anaphylaxis and suggests the use of protocols for children with severe allergies, although schools are not obliged to develop such policies.

107. It should be recognised that with a specialist allergy service linked to a community paediatric team, help and support for school staff can be offered and children at risk of anaphylaxis can be managed. The creation of regional, specialist paediatric centres across the country, making expertise available to the schools through community paediatric teams, is the key to giving school staff the confidence that this can be done. This should be implemented as a matter of urgency.

108. We recommend that until a regional paediatric service can be established all local education authorities and schools should be guided by the Supporting Children with Medical Needs: a good practice guide and Anaphylaxis Campaign guidance. In addition, Strategic Health Authorities should ensure that community paediatricians liaise with the major allergy centres for advice on management of at risk children in schools until they have a consultant paediatric allergist in their region.

Provision outside the NHS

109. The lack of provision of specialist allergy treatment in the NHS leads many patients to pursue treatment in the independent sector, either through the use of private sector clinics offering diagnosis and/or treatment, or through the purchase of tests claiming to diagnose allergy and treatments, some of which will be herbal or homoeopathic. Muriel Simmons, for Allergy UK, told us that people turned in desperation to the independent sector. Her organisation had encountered "more than one case where people have lost their life-savings and have been told to sell their homes".[113]

110. We received a very large and worrying body of evidence both from health professionals and from patients to suggest that much of the 'diagnosis' of allergy conducted outside the NHS, and some of the treatment offered, was ineffective, expensive and in some cases dangerous. While it was widely accepted that in a small number of centres good advice and treatment were available, often provided by staff either working or trained in the NHS, there was a huge amount of unvalidated testing taking place.

111. Given the lack of expertise relating to allergy in the primary care sector it is probably unsurprising that many people feel it worthwhile to have themselves tested in the independent sector. However, most such testing is, in the words of Professor Warner, "of no value whatsoever".[114] In the view of Dr Philip Doré, independent sector clinics offering alternative medicine "often manufacture illness and rarely treat allergic disease adequately".[115] For Dr Adrian Morris, a GP with an interest in allergy working both at the BUPA hospital in Farnham, Surrey and as a clinical assistant at the allergy clinic at the Royal Brompton Hospital, the unregulated private allergy sector was a source of great concern:

    Allergy sufferers, despondent that they cannot get access to an NHS allergy diagnostic service then approach the unregulated private sector. Often practitioners are not even medically qualified and the testing methods have no scientific basis nor have been validated. These pseudo-diagnostic tests usually designed to identify multiple "sensitivities" included VEGA testing (black box), applied kinesiology (muscle test), hair analysis and the leucocytotoxic tests (marketed as Nutron or ALCAT tests), all of which have been discredited over the years. Unfortunately the plethora of these tests and pseudo-diagnoses is growing at an alarming rate. These practices provide no useful role in allergy diagnosis as they confuse the public about their allergies and put individuals onto unnecessary and sometimes dangerous diets.[116]

112. In 1998, the Consumers' Association evaluated four different allergy testing services, advertised in magazines, available on the high street, by post or from independent practitioners. They concluded that "none of the tests reliably diagnosed allergies"; in one case, a researcher who was allergic to peanuts was categorically told he was not allergic, by a practitioner of 'applied kinesiology', a form of complementary therapy which claims to detect changes in muscle strength so as to provide an insight into underlying causes of health problems. Generally, the tests listed very long lists of foods to be avoided, although these were not based on credible evidence. Nevertheless, exclusion diets based on these lists would have led to people eating very unbalanced diets.[117]

113. Although the Consumers' Association report is not recent, we received plenty of evidence to suggest that problems still prevailed. Dr Jonathan Hourihane, a paediatrician in the Southampton allergy clinic, described paediatric allergy services as being "plagued by the interventions of practitioners who are not qualified in what could be considered medical allergy".[118] The dangers of such interventions were stark:

    I certainly have personal experience of individual children who have had testing by homoeopaths and other practitioners, which have demonstrated the 'safety' of 'safe foods'. These children have gone on to suffer severe allergic reactions on exposure to that 'safe' food. Conventional testing in our clinic with the foods turned out to be positive showing the food to be unsafe.[119]

114. Professor Holgate, for the NASG, told us of his experience as part of an RCP team sent, at the request of the Chief Medical Officer, to visit a private hospital in England that undertook a range of diagnostic and therapeutic procedures:

    This hospital had seen 12,000 patients over a period of six years, had used a very wide range of diagnostic and therapeutic procedures, none of which had been validated. Not only that, they were seeing children and there was not a single practitioner there qualified in child health, they were using treatments that had never been properly tested using established procedures and, in fact, the whole activity they were engaged in was very alarming and worrying.[120]

115. Dr Katherine Sloper, a consultant paediatrician at Ealing Hospital NHS Trust, reported that a significant proportion of creams prescribed for eczema from some alternative health workers in London had been shown to contain a high level of corticosteroids. Patients had not been made aware of this, and there were potentially severe long-term side effects.[121]

116. The Department's submission noted that in April 2004, the Healthcare Commission took over responsibility for regulating and inspecting the private and voluntary healthcare sector, which was previously the responsibility of the National Care Standards Commission. The duty to regulate and inspect private and voluntary healthcare is laid out in the Health and Social Care (Community Health and Standards) Act 2003. The Department acknowledged that not all allergy screening services would come under the regulatory arm of the Healthcare Commission, as only those providing medical treatment are registerable. Therefore all those allergy screening centres that screen, but do not treat, are not required to register.[122]

117. Dr Ladyman told us that individuals should have the right to use alternative medicine if that was their wish, but that he was concerned about the lack of evidence for some of the claims made. He used the word "poppycock" to describe the quality of diagnostic tests being sold through supermarkets, and indicated that he would give careful consideration to any recommendations we might make in the area of regulating diagnostic services.[123]

118. We are concerned that the current arrangements for inspection of the independent sector by the Healthcare Commission only cover facilities providing medical treatment. Evidence submitted to our inquiry has illustrated that the use of expensive, and often useless tests, creates considerable unnecessary expense and worry for patients and also may place them at risk. We therefore recommend that the Healthcare Commission should be required to inspect organisations providing diagnostic services in allergy, as well as those offering treatment.



43   Ev 72  Back

44   Q145 Back

45   Ev 30-31  Back

46   Ev 28  Back

47   Ev 124  Back

48   Ev 34  Back

49   Q32 Back

50   Ev 72  Back

51   Ev 166  Back

52   Ev 1  Back

53   Allergy: the unmet need, p22 Back

54   Ev 58  Back

55   Q72 Back

56   Allergy: the unmet need, p13 Back

57   Allergy: the unmet need, p14 Back

58   Ev 194  Back

59   Q8 Back

60   Q12 Back

61   Ev 112  Back

62   Q32 Back

63   Ev 160  Back

64   Q47 Back

65   Ev 116  Back

66   Q120 Back

67   Department of Health (2000) The NHS Plan: A Plan for Investment, a Plan for Reform Back

68   Department of Health/NatPaCT (2003) Practitioners with Special Interests: bringing services closer to patients Back

69   Department of Health and Royal College of General Practitioners (2002) Implementing a scheme for General Practitioners with Special Interests  Back

70   Sanderson, Diana (2002) Evaluation of the GPs with Special Interest (GPwSI) Pilot Projects with the Action on ENT Programme (York Health Economics Consortium)  Back

71   Department of Health/NatPaCT (2003) Back

72   For example, Department of Health (2003) Guidelines for the appointment of general practitioners with special interests in the delivery of clinical services: diabetes Back

73   Jones R and Bartholomew J (2002) 'General practitioners with special clinical interests: a cross-sectional survey'', British Journal of General Practice 52: 833-34 Back

74   Allergy; the unmet need, p21 Back

75   Ev 106  Back

76   Ev 54  Back

77   Ev 54  Back

78   Q130 Back

79   Ev 102-103  Back

80   Q209 Back

81   HC Deb, 14 October 2003, col 63WH Back

82   Q6 Back

83   Q72 Back

84   Ev 166  Back

85   Allergy: the unmet need, pp 24-25 Back

86   Q72 Back

87   Ev 39 (NASG/BSACI) Back

88   Ev 40  Back

89   Allergy: the unmet need, p xiv Back

90   Ev 151  Back

91   Ev 92  Back

92   Ev 35 (NASG/BSACI) Back

93   Q73 (Professor Holgate) Back

94   Cited Ev 4  Back

95   Cited Allergy: the unmet need, p7 Back

96   Allergy: the unmet need, p10 Back

97   Ev 109  Back

98   Ev 183  Back

99   Q115 Back

100   See Ev 36ff  Back

101   Allergy: the unmet need, p9 Back

102   Ev 125  Back

103   Ev 130  Back

104   Ev 130  Back

105   Ev 123  Back

106   Ev 147  Back

107   Ev 147 Back

108   Ev 108  Back

109   Q24 Back

110   See Vickers et al, "The management of children with potential anaphylactic reaction in the community", Clinical & Experimental Allergy, 1997, pp 898-903; Ewan et al, "Long-term prospective observational study of patients with peanut and nut allergy after participation in a management plan", The Lancet 2001, 357:111-15. Back

111   See the Anaphylaxis Campaign's Allergy in Schools website on http://www.allergyinschools.org.uk/  Back

112   Available from http://www.teachernet.gov.uk Back

113   Q64 Back

114   Ev 58  Back

115   Ev 108  Back

116   Ev 160  Back

117   Health Which?, December 1998, pp13-15 Back

118   Ev 193  Back

119   Ev 193  Back

120   Q112 Back

121   Ev 162  Back

122   Ev 74  Back

123   Qq219-23 Back


 
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