Memorandum by Dr Chris Corrigan (AL 17)
SENDER DETAILS
This report is submitted by Dr Chris Corrigan
MA, MSc, PhD, FRCP, Reader and Consultant in Respiratory Medicine
and Allergy at Guy's, King's and St Thomas' School of Medicine,
King's College London.
I submit the report both in a personal capacity,
running a busy and comprehensive allergy service at Guy's Hospital,
and as Secretary of the British Society for Allergy and Clinical
Immunology, the professional body representing NHS clinical and
academic allergists in both primary and secondary care in Great
Britain, and as secretary of the Joint Committee for Higher Medical
Training in Allergy, the Royal College Committee responsible for
the training of new doctors as specialist allergists.
EVIDENCE BASED
ON TERMS
OF REFERENCE
Availability of allergy services (including issues
such as geographical distribution, access times and patient choice)
and specialist services for patients with severe allergies
The availability, geographical distribution
and access times for NHS allergy services are woefully poor countrywide.
The full details are set out in a recent publication from the
Royal College of Physicians: Allergy, the unmet need: a blueprint
for better patient care (London: Royal College of Physicians,
2003). For accurate appraisal of the situation, the Committee
should be thoroughly familiar with this document. In brief:
We are in the middle of an epidemic increase
of allergic diseases. Allergic diseases are by far the commonest
diseases today in the UK. In any given year, 12 million people
in the UK (one fifth of the population) are likely to be seeking
treatment for allergy. Peanut allergy, which may in some cases
produce fatal anaphylaxis, now affects one in 70 children (that
is, one child in every year of every school in the UK). Asthma
and allergic rhinitis (hay fever) rank top of the list of causes
of loss of time from school and work in the UK. Approximately
20% of the population, both adults and children, suffer from hay
fever in the UK. Although this disease does not have the glamour
of cancer or heart disease, it must be taken seriously. About
one third of the 12 million people who suffer report that the
symptoms adversely affect their work, home and social lives. Among
children and teenagers in particular, hay fever can cause learning
difficulties caused by fatigue and inability to concentrate, with
poor examination results. Hay fever at exam-time is so troublesome
that it is cited as one reason for considering a change in the
traditional three-term school year. In the USA, which has a similar
prevalence of hay fever to that seen in the UK, two million lost
working days, three million lost school days and 28 million days
of decreased productivity annually are attributed to this disease
alone.
The Royal College of Physicians report notes
that there are only six fully staffed allergy clinics in the UK.
These have developed around centres with an interest in allergy
research, and do not represent the product of NHS planning or
support. They are located mainly in London and the South East,
creating a marked geographical inequality in service provision.
Allergy barely features in the undergraduate training curriculum
for medical students, and the lack of specialists means that virtually
no clinical training is available, Consequently, most medical
practitioners are ignorant of the practice of allergy, and have
no idea of the diagnostic and therapeutic benefits potentially
open to these millions of sufferers.
What other allergy services do exist in the
UK are run part-time by consultants in other disciplines (immunology,
dermatology, paediatrics, respiratory medicine, ENT). While excellent
in their respective fields, these clinics do not have the capacity
to cope with the rising tide of allergy or with the increasing
complexity of allergic disease (for example, a child with peanut
allergy who also has eczema, hay fever, asthma and glue ear).
Allergy is increasingly a multi-system disorder and must be managed
accordingly.
Patients with severe allergic diseases simply
do not know where to turn. As evidence of this I present a selection
of pleas reproduced verbatim from (anonymised) patients
received on the BSACI web site (www.bsaci.org) between January
and April of this year. During this period the web site received
1,117 "hits" on the section providing information on
what allergy services are available in the UK.
From South Wales:
My son has severe eczema I would like to know
if you could help. I have tried almost everything he is six and
is getting very aware of his appearance.
Nearest clinic Cardiff, 20 miles away, staffed
by consultants whose primary speciality is not allergy.
From Cleethorpes, Lincolnshire:
I would appreciate a list of allergy clinics
in the UK, particularly in Lincolnshire, Nottinghamshire and Yorkshire.
I live in Cleethorpes, North East Lincolnshire.
Clinics in Scunthorpe, Leeds and Sheffield,
nearest 25 miles away, all staffed by consultants whose primary
speciality is not allergy.
From Kent:
My name is __________, I am 30 years old and
I am from Italy. I moved to England in 2000 and since I have had
problems in finding a doctor specialised in Allergology. Unfortunately,
since I can remember, I have always suffered of severe forms of
allergy, including anaphylaxis, and I had a specialist in Rome
who used to take care of me. At the moment, and after a couple
of year of apparent calm, I am experiencing high discomfort due
to some "minor" forms of allergy/intolerance—urticaria,
rashes, vomiting/diarrhoea—I forgot to mention that most
of my allergies are related to food (legumes, maize, most fruits
and vegetables, shellfish, porc etc), even though I badly suffered
in the past from insect stings, pollen and dust (I had very bad
asthma in my childhood). After a serious reaction to asparagus—which
ended up in hospital—my GP referred me to a dermatologist,
however, this doctor could not do anything for me, apart from
prescribing some adrenaline to carry. At this moment in time I
would like to have a more thorough investigation of my allergies,
possibly with some more tests to be carried out, in order to find
out which are my allergies now—I am under the impression
that they have slightly changed in time and that I am now avoiding
the wrong food and eating something that is actually "poisoning"
me. For these reasons, I would like to ask you if you can kindly
give me some information on a specialised clinic/doctor in my
area (south-east of England) or, worst case scenario, in the whole
country, who could help me better understand my condition. Thank
you in advance for your understanding.
Nearest clinics Southampton or London.
From Aberdeen, Scotland:
I have had 10-15 allergy attacks in last two
years with two x anaphylaxis emergencies. I cannot connect with
any pattern of food or exercise and waiting list in Aberdeen to
see a consultant is two years. Any help would be appreciated very
much. I am prepared to travel anywhere in the UK and pay for the
help.
No clinics in Scotland run by consultants
whose primary speciality is allergy.
From Chaddesden, Derby:
I am particularly interested in finding out where
I can get my children food intolerance tested due to behavioural
problems. Please can you contact me as soon as possible as this
is now of an urgent nature.
Nearest clinic Nottingham, staffed by consultants
whose primary speciality is not allergy
From Lyme Regis, Dorset:
I live in Lyme Regis and I am curious if there
are going to be any clinics near us—the Devon/Dorset border?
Thank you.
Nearest clinic Plymouth, staffed by consultants
whose primary speciality is not allergy
Priorities for improving services
These are set out in the RCP report referred
to above. I earnestly and urgently request, on behalf of the existing
allergy specialists and the 12 million suffering patients, that
the government consider and implement these.
The provision of allergy care in the NHS must
be led by specialists trained in allergy, so that appropriate
standards of care can be achieved and maintained. 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.
Consequently, the NHS needs to move forward
on two fronts. As a first step, more consultant posts and funded
training posts in allergy are required. These will provide the
basis for a national training and clinical development initiatives,
as well as the basis of a genuinely national allergy service for
NHS patients. This will require recognition of need, and then
appropriate action from the Department of Health, the Workforce
Numbers Advisory Board, Primary Care Trusts, Regional Commissioners
and Trust managers. Allergy is also recognised for regional specialist
commissioning, and this must be implemented.
More specifically, the RCP plan envisages that
each of the eight NHS Regions in England (as configured in 2001,
each with a population of five to seven million), as well as Scotland,
Wales and Northern Ireland, should have an absolute minimum of
one specialist allergy centre staffed by a minimum of two whole
time equivalent consultant allergists, a minimum of two full time
allergy nurse specialists, one half time adult dietician and one
half-time paediatric dietician with specialist training in food
allergy, two consultants in paediatric allergy supported by paediatric
nurse specialists and facilities and funding for training for
two specialist registrars in allergy.
The regional centres would provide specialist
expertise for adult and paediatric allergic disease, manage allergic
disease which cannot be dealt with in primary care, act as an
educational resource for the Region and facilitate local training
in allergy for non-allergy specialists, GPs and practise nurses.
In addition, further consultant allergist posts
need to be created in other teaching hospital and district general
hospitals in each Region to deal with local needs. All teaching
hospitals should have an allergy service provided by a consultant
allergist. One model might be for a shared appointment between
Trusts.
The training of GPs and practice nurses in allergy
must be improved. A key part of this will result from interaction
with consultant allergists, and the inclusion of clinical allergy
training in the undergraduate curriculum.
Governance and regulation of independent sector
providers
Although some qualified allergists work in the
private sector, these are very few and far between. It is understandable
that patients, in their desperation to receive help, have turned
to less orthodox techniques of allergy diagnosis, often with no
proven merit. For example, many High Street health food and other
stores, fitness centres and similar establishments advertise diagnostic
tests for "allergy" which in many cases are of unproven
scientific worth. There appears to be little regulation or national
governance of these tests and practises. They often cost considerable
sums of money. The failure to make a proper diagnosis and offer
rational management can add to patient suffering, for example
by enforcing inappropriate or unnecessary dieting or other changes
of lifestyle. Quite apart from the loss of productivity this entails,
not to mention the chance of significant illness and even death,
these patients will eventually come back to the NHS, adding further
to the NHS healthcare burden.
Additional comments on training issues
Training of new specialist allergists is one
of the cornerstones of the priorities for improving allergy services
referred to above. Speaking as secretary of the Royal College
of Physicians Joint Committee on Higher Medical Training for allergy,
which is responsible for setting the training curricula and standards
for trainee allergy specialist registrars across the UK, I must
voice concern on behalf of the Committee about the paucity of
centrally funded allergy training posts made available in the
UK since allergy was recognised as a unique speciality.
The Department of Health Workforce Numbers Advisory
Board has recommended 20 new, centrally funded National Training
Numbers for trainee allergists between 2005 and 2007. Our experience
shows, however, that there is no certainty that these recommendations
will become reality, as the quota was reduced from seven to nought
last year. The specialty eventually received one new NTN following
rigorous appeal. In the previous year, just one post was funded.
Excellent training centres hotly contest these posts, and it is
a constant source of frustration that so many applicants are disappointed.
At present, the JCHMT estimates that there is immediate capacity
in existing allergy centres to commence training of 12 new specialist
allergists. Allergy is predicted to show negative growth by 2012
according to the Department of Health's own estimates; it is one
of only two medical specialities in this situation. The speciality
cannot grow unless more trainees are provided. On behalf of the
BSACI, JCHMT and as a personal plea, I respectfully request that
the government intervenes directly to make more allergy training
posts available as a matter of urgency.
The appointment of new trainees must progress
in concert with the establishment of new allergy centres with
specialist trainers and suitable training facilities. This will
happen if, and only if the recommendation by the Department of
Health that regional centres of excellence for allergy should
be established, which was reiterated in the recent Report of the
Royal College of Physicians Working Party referred to above, is
implemented. There are grave concerns, however, as to whether
the current arrangements for health care commissioning at regional
and national levels are sufficiently robust to cope with the financial
pressures and service aspirations of specialist allergy centres.
In short, it seems possible that many of these commissioning bodies
simply do not appreciate the size and urgency of the problem.
At best there will be inevitable debate on priorities for funding
of specialist services nationwide as opposed to addressing local
issues and initiatives. It is also understandable that regional
funding and commissioning bodies look inwards, rather than outwards,
no matter how inappropriate this may be. It is therefore important
for the commissioning process to understand the need to provide
care for larger populations by specialist teams. This is essential
not only to guarantee the quality of patient care, but also to
allow time and space for the training of specialists, promoting
innovation and research. For these reasons we respectfully repeat
our earnest and urgent request that the government take direct
action in this matter to ensure that the needs of 12 million UK
citizens are met by their National Health Service in a timely
and equitable fashion.
May 2004
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