House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

Annex

A FRAMEWORK FOR AN ADULT ALLERGY NETWORK IN THE NORTH WEST:
THE NORTH WEST INTEGRATED CLINICAL ALLERGY SERVICE (NWICAS)

1. WHAT IS ALLERGY?

1.1 The specialty of Clinical Allergy involves the management of a wide range of conditions that cross the organ-based disciplines. Allergic disease is increasing in prevalence at the rate of 50% per decade [1-3]. Most allergic disorders are chronic and they may be debilitating, involving periods off work or school (eg asthma, urticaria and angioedema). Furthermore, some of the conditions may be life threatening (eg nut anaphylaxis).

1.2 Allergy is a clinical speciality in which investigations are important but, as sensitisation may not always indicate disease, the clinical history is paramount. The most common clinical conditions managed by Clinical Allergists include asthma, eczema, rhinitis (seasonal and perennial), bee and wasp venom allergy, food allergy, latex allergy, urticaria and angioedema, drug allergy, anaphylaxis and food intolerance.

1.3 The Department of Health has included Specialist Allergy in the national list of services that require specialised/collaborative commissioning arrangements (see section 11).

2. CHILDREN

2.1 This document does not specifically refer to allergy services for children. However, some of the staff working with adults also have clinical sessions in children's facilities. This would suggest that a broadly similar model to that proposed for adults (see paragraphs 12.5-7 and the table following) would be appropriate for children. The foci for this might be Alder Hey Children's Hospital and/or the Manchester Children's Hospitals.

3. PREVALENCE OF ALLERGIC DISEASE

3.1 There has been a considerable increase in the prevalence of the common allergic disorders (asthma, eczema and rhinitis) in the last two to three decades [1-3]. Recent data from the North-West of England suggest that one third of the population now suffers from allergic disease and that almost half of the population has allergic sensitisation to one or more common allergens (eg house dust mite, cat, dog, grass pollen) [4]. Superimposed on this there has been a rapid rise in serious, life-threatening allergic disease.

3.2 Anaphylaxis has become increasingly common, occurring in one in 3,500 of the population per annum in 1994, and is rising [5, 6]. Peanut and nut allergy affects over 1% of children [7-9] and latex allergy, which was extremely rare before 1980, now affects up to 8% of health care workers [10, 11].

4. PATIENTS' PERSPECTIVE

4.1 The current situation is highly unsatisfactory, with long waiting times exacerbating discomfort and distress. There is no allergy service in many parts of the country (source: British Allergy Foundation) and patients are not being appropriately identified and treated.

4.2 There is little or no provision for primary care allergy testing in the community and no community care for allergy sufferers. This results in patients not knowing where to go for advice. Furthermore, patients often want to take control of their disease by, for example, using allergen avoidance procedures rather than drugs but there is no provision for the assessment of their allergic status and a lack of appropriate guidance.

4.3 Patients with severe, multi-system conditions, such as allergy, need to see one person who can deal with the cause of the condition. The current system is too reliant on organ-based specialists with, for example, a patient seeing an ENT specialist, an immunologist, a respiratory physician and/or a dermatologist, as well as their general practitioner and various Accident and Emergency doctors. It should be possible, at secondary care level, for them to see a single clinician with a recognised qualification in allergy.

5. TRAINING IN ALLERGY

5.1 The management of allergic conditions requires appropriate expertise. Unfortunately, little training is given on this subject in medical schools. Before the Calman changes in training, allergy was part of the Clinical Immunology and Allergy training programme, distinct from Immunology related to Pathology. Training programme changes and the delay in Clinical Allergy being included on the Specialist List have resulted in uncertainty and a loss of potential SpRs. A new, objective-based, Royal College of Physicians approved, Allergy training programme, leading to the Certificate of Completion of Specialist Training (CCST), was recognised for the first time in June 1999.

5.2 Clinical Allergy is currently a small speciality, with a great need for more SpRs and consultants if it is to meet the need.

6. CURRENT PROVISION OF SERVICES

6.1 Most patients with asthma, eczema and rhinitis should be able to be managed adequately by primary care and district hospital organ-based specialists. However, allergy testing, which is necessary for the planning of allergen avoidance, is often unavailable in district general hospitals. As a consequence, advice on allergen avoidance is frequently inadequate. In addition, immunotherapy and specialised bronchial challenge in suspected occupational asthma are not generally available in district general hospitals.

6.2 Acute and chronic urticaria and angioedema are difficult conditions to manage and, whilst the majority do not have an allergic basis, the more severe cases need to be carefully investigated to exclude an allergic cause.

6.3 Anaphylaxis is becoming increasingly common and is potentially life threatening. Although acute attacks are managed in accident and emergency departments, the full evaluation of patients to identify the cause and then the availability of appropriate advice on allergen avoidance are essential. In addition, training in the use of the Epipen (self-administered adrenalin injection) can be life saving.

6.4 Despite the obvious need, the current provision of allergy services across the UK is extremely poor [12]. The British Society for Allergy and Clinical Immunology (BSACI) held discussions with the Department of Health (Allergy Task Force) to highlight the need and to press for improved services. This initiative is being taken forward by the National Allergy Strategy Group (NASG) launched at the Royal College of Physicians in May 2001. Current services and proposals for allergy care have been outlined [13]. There is a shortage of consultant allergists. Full-time services led by consultant allergists are virtually restricted to London and the South of England.

7. FULL-TIME SERVICES LED BY CONSULTANT ALLERGISTS ACROSS THE UK

7.1 The six centres in the UK currently providing a full-time allergist-led NHS service are located mainly in the South of England. These comprise:

— Addenbrooke's Hospital, Cambridge—Dr Pamela Ewan

— Glenfield Hospital, Leicester—Dr Martin Stern

— Guy's Hospital, London—Professor Tak Lee, Dr Christopher Corrigan

— Royal Brompton Hospital, London—Professor Stephen Durham

— St Mary's Hospital, London—Dr Douglas Robinson

— Southampton General Hospital, Southampton—Professor Anthony Frew.

8. SERVICES IN THE NORTH WEST OF ENGLAND

8.1 There is no full-time allergist-led NHS service provided in the North West. The provision of services in the North West is inadequate as evidenced by the long waiting times of patients referred to the patchy service that does exist. Most patients with allergic disease in the North West never see an allergist.

8.2 The only consultant allergist-led (part-time) services for adults in the North West are based at the Royal Liverpool and Broadgreen University Hospitals and at Wythenshawe Hospital in Manchester.

8.3 A detailed list of clinical services provided by organ-based specialists and immunologists with an interest in allergy can be found in the British Society of Allergy and Clinical Immunology booklet [16].

8.4 Patients and GPs have difficulty in accessing the currently available services and, as a result, desperate patients seek help from non-validated sources (eg Vega test, homeopathic immunotherapy, hair testing) [14].

9. ACADEMIC ALLERGY IN THE NORTH WEST

9.1 In the North West Lung Centre at Wythenshawe Hospital in Manchester there is a large Allergy and Asthma Research Group led by Ashley Woodcock, Professor of Respiratory Medicine, and Adnan Custovic, Professor of Allergy. This group produces original research to a high international standard and is a world-leading centre in the area of indoor allergen research (70 peer-reviewed allergy publications; more than 100 invited presentations at national/international meetings; more than £2.5 million research funding, in the last five years). Dr Richard Pumphrey, Consultant Clinical Immunologist (Manchester Royal Infirmary), actively researches and publishes in anaphylaxis.

10. MODEL OF ALLERGY CARE

10.1 An ideal model of allergy care has already been developed [12] and is presented in a modified form below:

Tier 1

Tier 2a

Tier 2b

Tier 3

10.2 Currently in the North West there are considerable deficiencies in all the proposed tiers:

— The majority of general practitioners have little or no training in the diagnosis and treatment of allergy.

— The network of organ-based specialists with an interest in allergy is small and insufficient to deal with the demand.

— No local allergy services are provided by a district-based allergist.

— There is no Regional Allergy Centre.

10.3 The immediate aim is to develop a Managed Clinical Network in Clinical Allergy for the North West to provide expertise, improve geographical equity of access to care and act as an educational resource and training centre.

11. SPECIALISED COMMISSIONING DEFINITION

11.1 Clinical Allergy is designated under specialised commissioning arrangements where services to support patients with rarer health conditions are planned and developed to meet the needs of an appropriate population. A national review, on behalf of the Department of Health, has been undertaken to identify and define services that are deemed to be specialised. The aim is to develop a consistent approach to the commissioning (both planning and procurement) of specialist services at national, regional and local levels. In total 36 specialist services are identified, including "Allergy Services, Definition No 17".

12. CHARACTERISTICS OF A MANAGED CLINICAL NETWORK IN ALLERGY FOR THE NORTH WEST

12.1 The development of managed clinical networks in clinical specialties has been progressing over a number of years. There are a number of key issues which need to be addressed including the role of the "hub" or "centre" in leading the network and setting the culture, the clinical governance issues of providing services or linking with services at other locations and the management of staff and physical assets.

In Scotland, a significant amount of work has been undertaken to progress managed clinical networks. Details of this are published in the Scottish health circular MHS MEL(1999)10.

The circular suggests the following requirements:

— Clarity about network management arrangements is essential with one individual as overall lead. Networks would produce a written annual report.

— A defined network structure indicating service delivery points should be developed.

— It should have clear clinical and service outcomes to be able to evaluate its effectiveness.

— It should use a documented evidence base and be committed to research and development.

— It should be multidisciplinary and include patient representation in its management arrangements.

— It should have a clear policy of dissemination of information to patients including those in primary care settings.

— All representatives in the network should sign up to explicit principles of working.

— It should have a quality assurance programme to ensure consistency of standards.

— It should develop links with universities and colleges and promote education and training.

— Audit data should be produced for open review.

— It should enable staff rotation to occur as part of the programmes of continuous professional development.

— It should be examined for the potential to achieve better value for money.

The regional centre(s) will have a crucial role in ensuring that effective links across the different sectors of care are established and maintained.

The establishment of managed clinical networks enables small and highly specialised services to be provided across a range of organisations, by a multi-professional team guided by clear reporting and accountability structures and working to agreed protocols and policies.

12.2 A North West managed clinical network would be comprised of a group of health professionals and organisations from primary, secondary and tertiary care, working in a co-ordinated manner to ensure the equitable provision of high-quality clinically-effective services in allergy in the North West of England. The name proposed for the network is the North West Clinical Allergy Service (NWICAS).

12.3 To meet the expected workload, a NWICAS would require a minimum of:

— three whole-time equivalent (WTE) consultant allergists;

— three WTE specialist allergy nurses;

— two WTE dieticians; and

— appropriate technical support.

12.4 Initially, given the geography of the North West (for this clinical network probably also including North Wales) and its population distribution, it is suggested that the NWICAS should have three foci. The need for any additional centres should be considered after the first few years of its establishment.

12.5 Therefore, a model of service is proposed for the North West based on three Specialist Allergy Centres. They should be developed in parallel, with the commissioners for the population of North Wales deciding to which of the three that population should look. This service should ideally be based on hospitals which can provide excellent out-patient, pulmonary function and radiology services, with easy access to full immunology testing. Furthermore, a strong academic basis would be a significant advantage.

12.6 The intention is to create a multi-disciplinary/multi-professional network and ensure representation from patients' organisations (eg those included in the "Allergy Umbrella"—the Anaphylaxis Society, British Allergy Foundation, National Asthma Campaign, National Eczema Society). A chain of interconnected people and processes, working in partnership to maximise the benefits for all patients, would deliver care. Elements of the service would be delivered on an outreach basis from the centres (eg the immunotherapy service, with a specialist allergy nurse attending satellite clinics, with appropriate local medical support and facilities, to administer maintenance doses and thereby minimise the patients' need to travel).

12.7 To ensure clarity about the network management arrangements, the NWICAS would:

— Identify a person with overall responsibility for the operation of the Network.

— Have a defined structure setting out the points at which the service will be delivered to the patients (initial development needs are outlined in the following table).


Level	Service Offered	Development Needs

Living at home, not using GP services	Advice	Community pharmacists trained to give advice, in particular in the use of over-the-counter allergy medication
Local GP surgery	GP consultation, screening for allergic conditions (eg allergic rhinitis, asthma) and onward referral	Joint protocols for managing allergic disease (eg anaphylaxis) with defined referral criteria agreed with network consultants
Specialist GP surgery	GP specialist undertaking allergy testing (eg skin-prick testing, spirometry) and nurse-led clinics held by visiting specialist allergy nurse	Training in procedures; defined referral criteria; specialist allergy nurse exports expertise from the Regional Allergy Centre
Community hospital/ district general hospital/diagnostic and treatment centre	Organ-based specialists with an interest (dermatologists, respiratory physicians, ENT and immunologists) to provide a district-based framework. In the long term, development of a local allergy service including outreach allergy clinics, skin-prick testing, anaphylaxis clinics and immunotherapy clinics.	Agreed operating procedures and consultants with a major interest in allergy. In the long term, the appointment of a consultant allergist, core nursing staff with specialist allergy interests and skills and links to dietetic services. There are minimal equipment needs.
Specialist Allergy Centre (3 for the North West)	More complex and severe disorders (asthma/rhinitis, anaphylaxis/acute allergy, food allergy, urticaria, angioedema, drug allergy*) and provide "tier 2b" for the local catchment area	Specialist allergist, specialist allergy nurses and dietician with good communication networks enabling the transfer of patients to local services for the continuation of care (eg immunotherapy service)

*Although it was envisaged, in Good Allergy Practice [17], that patients with non-specific/ polysymptomatic illness, which would include patients with chronic fatigue syndrome and multiple chemical sensitivity syndromes, would be assessed at allergy clinics, this would have considerable implications in terms of time, personnel and physical facilities.

13. THE PATIENT PATHWAY

13.1 Primary care would continue to deal with the simpler allergic diseases (such as mild hay fever). For more difficult-to-manage diseases, the general practitioner would refer the patient to either an organ-based specialist with a special interest or a local consultant allergist for secondary care. The most complex cases should be referred to the Specialist Centre from secondary care. The Specialist Centre should also provide secondary care for its local population.

13.2 Primary care

Primary care has a record of successfully managing chronic conditions through the use of agreed protocols of care. In terms of the provision of allergy care, the successful model of asthma care could be extended to the extremely common diseases like allergic rhinitis and angioedema/urticaria. Most patients with allergic diseases should be able to be treated in primary care.

A more coherent approach to modifiable risk factors (eg allergen exposure, environmental tobacco smoke exposure) will be encouraged and protocol-driven direct access to hospital-based investigations (eg specific challenge procedures) will be provided. Health professionals (eg specialist allergy nurses), working at the interface between primary and secondary care, will have an increasing role in implementing treatment protocols (eg for rhinitis, asthma, urticaria) and patient education and training (eg in the use of self-administered adrenaline for the treatment of anaphylaxis).

13.3 Secondary care

Integrated multi-disciplinary/multi-professional care for the patients with allergic disease, characterised by improved collaboration between primary and secondary care, should bring major benefits to patients. For example, it is now clear that the appropriate use of the adrenalin self-injector saves lives. Appropriate training has to be given not only to patients and/or members of their family but also needs to be available to appropriate individuals in schools and other high-risk environments.

13.4 Local collaboration

Primary Care and Hospital Trusts will be encouraged to collaborate in the establishment of local allergy services. This will be achieved either by utilising a consultant allergist and allergy specialist nurse practitioner from the regional centre, on a sessional basis, or by identifying an existing organ-based specialist with an interest in allergy and enabling them to receive training in general allergy to supplement their organ-based knowledge (the allergy nurse could support the service on a sessional basis, eg by providing a local immunotherapy service). Further support will be provided from the specialist centre by a combination of liaison meetings, consultant-to-consultant referrals and education meetings and by the development and implementation of agreed protocols. Thus the local allergy network will act as a source of advice to GPs, as a basic specialist service for those aspects of allergy in which the local specialist is acknowledged as being competent and as an access point to the centre.

14. SPECIALIST ALLERGY CENTRES IN THE NORTH WEST

14.1 Out-patient service:

— A core multidisciplinary/multi-professional team of clinical allergists, specialist nurses and liaison psychiatrists, physiotherapists and dieticians will provide the out-patient service; a suite of consulting rooms is necessary to allow the team to work together. A special room with skin-prick testing facilities and for the administration of immunotherapy, with full resuscitation facilities (drugs, IV lines and fluids, oxygen, nebulised bronchodilators, a tilting couch and a cardiac arrest box) should be available.

— Radiology, pulmonary function testing and immunology and other blood tests should be readily available.

— Allergy patients are usually complex and the taking of a detailed history is essential. Realistically, a minimum of 45 minutes per new patient is required and 20-25 minutes per follow-up. A reasonable plan for a consultant allergist would be to see four new and one follow-up, three new and three follow-up or two new and six follow-up patients per clinic session. Consultants would train doctors (specialist registrars, GPs and other consultants) and nurses in the out-patient clinics. One consultant can supervise one person per clinic but must allocate extra time to review the patients and teach trainees/students.

— Specialist allergy nurses will perform skin-prick testing and allergen immunotherapy, and in appropriate circumstances take clinical histories, examine, and assess patients in the clinic under the supervision of the doctor. In addition, they will explain the literature for the diagnosed condition (eg allergen avoidance) and how to use peak flow, food and symptom diaries. They will be equipped to train patients in the use of an Epipen, and inhaler devices, including those delivering adrenaline. They will also deal with telephone enquiries from patients, guided by the doctor, and give patients information on support groups (eg the Anaphylaxis Campaign).

— Dieticians are essential to the service as much of the work deals with food allergy/suspected food allergy. The dietician is needed to establish if a diet is nutritionally adequate and to provide advice on exclusion diets.

— Written management advice for a range of conditions should be available for the patients to take away.

— Waiting time for a routine out-patient referral should be no longer than 13 weeks (currently patients in this region wait up to three years).

— Urgent referrals (particularly for anaphylaxis patients) should be seen within one month (currently one to two years).

— Follow-up appointments should be available within three months of the initial consultation to convey results and their implications to patients in person. Some patients, having had a definitive diagnosis made at their initial appointment may collect the results of their confirmatory tests from their general practitioner or be sent them directly by post. Although many patients with anaphylaxis attend for annual (or bi-annual) review, most other patients will be discharged after a single follow-up visit.

— Pharmacy services are necessary to supply drugs for skin testing, prepare capsules for challenge studies and to give drug information to patients.

— Adequate secretarial support must be provided to aid communication with GPs.

It is likely that the spectrum of clinical conditions that would present to the Specialist Allergy Centres in the North West would be similar to those presenting to the service provided in Southampton. However, our numbers would be larger due to a bigger catchment area. The NWICAS would serve Cheshire and Mersey (2.4 million people), Greater Manchester (2.6 million people), Lancashire and South Cumbria (1.6 million people) and North Wales (c0.5 million people). In Southampton, the large Allergy and Asthma Research Group currently provides two NHS out-patient allergy clinics per week, plus a severe asthma clinic and a fortnightly medical immunology clinic. The case mix is roughly asthma/rhinitis 20%, anaphylaxis/acute allergy 10%, food allergy 15%, urticaria/angioedema 30%, drug allergy 5%, the remaining 20% being immunological problems, chronic fatigue and bowel disturbance. They also run an immunotherapy service in parallel with the clinics, managing approximately 300 patients at any one time.

14.2 In-patient and day case service

— Facilities for day cases will be available (this may be in the out-patients department) where patients undergoing challenge tests can remain all day (with appropriately trained nursing staff).

occasional

— Allergists will also be expected to provide a consultation service for other specialists, particularly in respiratory medicine, ENT, dermatology, cardiology and general medicine, as patients with allergic conditions will be admitted under these specialties (eg a patient with an anaphylactic reaction may be admitted overnight on the acute medical take).

14.3 Network co-ordination and leadership

The Centres, in collaboration with each other, will lead the development of clinical guidelines and protocols for all levels of care in the network and will co-ordinate the audit of their use.

15. TEACHING AND TRAINING IN THE NETWORK

15.1 The education and training potential of the network will be used in full through exchanges between those working in the community and primary care and those working in hospitals/the specialist centres. In particular, Consultant Allergists will be expected to co-ordinate and undertake multi-professional teaching including:

— Educating undergraduate medical students.

— Provision of training for Specialist Registrars in allergy.

— Training of Senior House Officers (particularly in the A&E department) must be a regular commitment, as many patients with allergic reactions present to A&E.

— Training of other professionals, especially practice and specialist hospital nurses, but including pharmacists, dieticians and others.

— Postgraduate teaching for General Practitioners and organ-based specialists in DGHs.

16. ACADEMIC ALLERGY IN THE NETWORK

16.1 There are many areas of allergy that need further research. Some of this research needs to be laboratory based but much is also clinical and involves following the natural history of environmental allergies, many of which are relatively new (eg latex allergy). It is important, therefore, to keep a database of diagnosed cases to facilitate this and to increase the clinical knowledge base. In addition the regional centre will co-ordinate clinical trials of new therapies.

It would be essential for the Specialist Allergy Centres in the North West Integrated Regional Clinical Allergy Service to have a strong academic presence. This would provide the opportunity to increase the clinical knowledge base, improve treatments for the population of the North West, with its relatively poor health status, and to begin to address the deficit in trained clinicians in this area and should not be lost.

17. STAFFING THE CENTRES IN THE NETWORK

17.1 The Specialist Allergy Network would need to have three WTE Consultant Allergists. In addition, three WTE specialist nurses and two WTE experienced dieticians and, possibly, a liaison psychiatrist and physiotherapist, would need to be employed as part of the team. A Secretary/Administrator would also be required. The hospital pharmacies would each need to identify a member of staff with an interest in allergy to help prepare capsules for challenge tests and for information on the ingredients of drugs and on drug reactions.

18. OPPORTUNITY FOR PREVENTION

18.1 There are currently several cohort studies of the effects of allergen avoidance on the development of allergies in childhood being undertaken around the world and, in particular, based on the North West Lung Centre at Wythenshawe Hospital in Manchester[15]. The results of such clinical trials should have a major impact on public health policy and the Specialist Allergy Centres would have an important role in disseminating information and guiding the implementation of such policies. Successful allergen avoidance in childhood could significantly reduce morbidity in later life.

18.2 There are many claims being made by manufacturers regarding the efficacy of their products in aiding allergy sufferers, much of which is unsubstantiated. The Specialist Allergy Centres should provide advice and clear information on what is of proven benefit, what is of potential benefit and what has been shown to be of no benefit, based on the best available scientific evidence.

19. NEW DEVELOPMENTS

19.1 There is a range of novel, immunotherapeutic treatments, currently undergoing clinical trials, which will probably enter clinical practice over the next two to three years. These treatments are likely only to be suitable for a carefully selected group of patients with particular conditions. The Specialist Allergy Centres would play a key role in selecting patients and delivering treatments in a safe and cost-effective manner.

20. COLLEGE ADVICE

20.1 The Allergy CCST was only recognised in June 1999. Currently there are very few consultant allergists and, consequently, very few specialist registrars in training.

20.2 A conference took place at the Royal College of Physicians (Allergy Services Conference, 15 May 2001) to discuss the demand for allergy services, the unmet need and to examine ways to improve service delivery. The recommendations included the development of Regional Specialist Allergy Centres (two allergy consultants, two nurses, one dietician, one secretary/administrator) and a further expansion in the number of allergy consultants to support the wider network. In addition, it was felt that more research was required fully to identify the burden of allergic disease.

21. COSTS

21.1 These will be identified when there is broad agreement that Clinical Allergy is an area of deficiency that should be addressed and that the model proposed in this paper is to be introduced. The "centre" components of the model currently envisaged would require funding for staff, in total, of the order of £400,000 per annum.

References

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SUB-GROUP MEMBERSHIP AND PROCESS

The then North West Regional Specialised Commissioning Group, at its meeting on 6 June 2001, decided to obtain advice on the current and future provision of allergy services in the Region. I was asked to convene a sub-group.

As relatively little was widely known about the current state of this service and the desirable future model of provision, it was decided to adopt a rather different approach from that used for other services. The following people were asked to meet to prepare a draft paper to be circulated to providers and commissioners across the Region:

Adnan Custovic, then Reader in Allergy and now Professor in Allergy, Wythenshawe Hospital.

Roy Dudley-Southern, then Deputy Director of Clinical Strategy, Manchester Health Authority, and now Strategic Planning Manager and Acting Director, Greater Manchester PCTs Collaborative Commissioning Programme.

Rosalind Jones, then Business Manager, North West Region Specialised Commissioning Team, now Assistant Service Development Manager, Cheshire and Mersey Specialised Commissioning Team.

Bridget Simpson, Clinical Nurse Specialist in Allergy, Wythenshawe Hospital.

Ashley Woodcock, Professor in Respiratory Medicine and South Manchester Clinical Academic Group Leader, Wythenshawe Hospital.

Miriam Woodman, then Consultant in Public Health Medicine, Manchester Health Authority (until October 2001), now Consultant in Public Health Medicine, Walsall Primary Care Trust.

Not unexpectedly the draft produced a range of responses. These were mainly supportive but there was also some criticism from those who felt their contribution had not been sufficiently recognised. A range of meetings and discussions took place across the Region, although diary difficulties made this a longer process than had been expected. It proved possible to incorporate or otherwise address most of the comments and this paper is the result.

I would like to express my appreciation for the time and effort that has been committed by the members of the sub-group to this endeavour and my thanks to those who took the trouble to respond to the consultation and to meet us.

January 2003



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