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.
It has also been estimated that 3-6% of 13-14 year olds suffer
from sleep loss as a result of eczema or asthma.
Many children with allergic disorders also suffer from bullying
and social segregation at school.
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
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.
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.
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
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.
92. The estimatethat with each new birth cohort,
a potential 40,000 children with allergy will be added to the
problem each yearwas made by the NASG, in the document
An NHS Plan for AllergyMaking a Start.
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.
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.
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".
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
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.
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
- 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
Most districts carried out skin prick tests, some performed challenge
tests, and most dispensed adrenaline injectors, but with "a
hugely varied incidence".
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
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
- 55% had no training on dealing with allergic
- 67% would like to receive training.
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, preferablywell essentiallya
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.
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. 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.
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,
 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".
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".
In the view of Dr Philip Doré, independent sector clinics
offering alternative medicine "often manufacture illness
and rarely treat allergic disease adequately".
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.
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
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".
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.
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.
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.
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.
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
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
Ev 30-31 Back
Ev 28 Back
Ev 124 Back
Ev 34 Back
Ev 72 Back
Ev 166 Back
Ev 1 Back
Allergy: the unmet need, p22 Back
Ev 58 Back
Allergy: the unmet need, p13 Back
Allergy: the unmet need, p14 Back
Ev 194 Back
Ev 112 Back
Ev 160 Back
Ev 116 Back
Department of Health (2000) The NHS Plan: A Plan for Investment,
a Plan for Reform Back
Department of Health/NatPaCT (2003) Practitioners with Special
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Department of Health and Royal College of General Practitioners
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Sanderson, Diana (2002) Evaluation of the GPs with Special Interest
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Health Economics Consortium) Back
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For example, Department of Health (2003) Guidelines for the appointment
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Jones R and Bartholomew J (2002) 'General practitioners with
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Ev 106 Back
Ev 54 Back
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HC Deb, 14 October 2003, col 63WH Back
Ev 166 Back
Allergy: the unmet need, pp 24-25 Back
Ev 39 (NASG/BSACI) Back
Ev 40 Back
Allergy: the unmet need, p xiv Back
Ev 151 Back
Ev 92 Back
Ev 35 (NASG/BSACI) Back
Q73 (Professor Holgate) Back
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Allergy: the unmet need, p10 Back
Ev 109 Back
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See Ev 36ff Back
Allergy: the unmet need, p9 Back
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Available from http://www.teachernet.gov.uk Back
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Health Which?, December 1998, pp13-15 Back
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Ev 74 Back