Memorandum by North of England Clinical
Immunology Audit Group (NECIAG) (AL 20)
A. SUMMARY
This memorandum of evidence is submitted by
Dr William Egner on behalf of the North of England Clinical Immunology
Audit Group (NECIAG).
The function of the group is to provide a supra-regional
Audit Facility for Clinical Immunologists within the North of
England and Northern Ireland. NECIAG's function is to survey laboratory
and clinical practice and workload in Immunology and Allergy,
to derive agreed clinical and Laboratory standards and to audit
practice against these. Currently there are 17 UK Immunology centres
participating in its audit activities.
Dr Egner is the Chair of NECIAG had been asked
to submit a memorandum to the Enquiry on behalf of NECIAG in order
to:
1. Re-iterate the full and unequivocal support
of the Immunology Consultants within NECIAG for the creation of
Regional Specialist Allergy Services led by Full-time Allergists
as detailed in "Allergy: The unmet need. A blueprint for
better patient care", and to re-iterate the urgent need for
additional centrally-funded SpR training posts in Allergy (and
indeed Immunology) as part of a long-term strategy to develop
supra-regional centres of expertise.
2. Alert the inquiry to a forthcoming audit
of Allergy service provision and workload within Clinical Immunology
units, planned since early 2004, and to be performed in conjunction
with the South West Clinical Immunology audit group. This will
provide the committee with additional and extensive evidence regarding
the availability and pressures on Allergy services within England.
This is due to report in October 2004.
3. Summarise the experience of Clinical
Immunologists in the development of specialist Allergy care via
local initiatives in the North of England and their difficulties
in obtaining funding, which emphasises the need for additional
Consultant Allergists and a centrally co-ordinated approach to
the provision of funding for such activities. These services include
those Allergy activities specified within:
— The National Specialised Services
Definition set for Specialist Allergy Services (Number 17).
— "Good Allergy Practice: Standards
of Care for Providers and Purchasers of Allergy Services within
the NHS" (RCP/RCPath 1994).
— "Allergy the unmet need"
(RCP, 2004).
4. Clarify that; while "Allergy: the
unmet need" states that "most organ-based specialists,
who have traditionally dealt with allergic conditions such as
asthma, allergic skin disorders and allergic rhinitis, have no
training in Allergy", Immunologists are an exception to this
in that they do have formal training in the diagnosis and management
of allergic disease as part of their current and previous training
curricula.
5. In addition to supporting the creation
of Specialist Regional Allergy Centres, NECIAG ask the committee
to also consider mechanisms for improving patient access to expert
care in the short to medium term, since the lead-time for the
development of allergists as envisaged in "Allergy the unmet
need" is the creation of eight Regional Allergy Centres in
England requiring 16 Consultant Allergists. There are currently
only six full time Allergists in the UK at present, with five
Allergy SpRs in training. If each of the eight centres trained
two SpRs (taking five years plus two to three year higher degree)
it is clear that sufficient Consultant Allergists are not likely
to be available for at least 10-14 years to service such an Adult
expert network. The situation for Paediatric Allergy specialists
is much worse. Consideration should be therefore be given in the
interim to potential solutions, perhaps including Immunologists
and Allergists working in tandem to provide the earliest improvement
to specialised services for patients, and make the most efficient
use of existing resources.
6. Alert the inquiry committee that the
short and medium term provision of improved and equitable access
to Allergy services for the whole of England will depend on appropriate
funding and development of relevant specialist services in Teaching
hospitals, including those currently developed by Immunology,
in parallel to the development of Regional Specialist Allergy
services.
7. To emphasise that access remains poor
to Allergy services of any description in the north of England,
and that obtaining funding for Allergy services from PCTs or Regional
Commissioning Groups is extremely difficult, and requires a national
initiative and direction. Pressure on the services that do exist,
continues to increase in line with the observations in "Allergy:
the unmet need".
B. TERMS OF
REFERENCE
1. Availability of allergy services
Geographical Distribution
NECIAG incorporates the following Immunology
centres all of whom provide Clinical and Laboratory Allergy services:
Nottingham, Leicester, Sheffield, Pathlinks (Scunthorpe, Lincoln,
Boston and Grimsby), Hull, Central Manchester, Salford, Belfast,
Newcastle, Sheffield's Children's Hospital, Liverpool, Leeds,
North Birmingham, Preston, Middlesborough. We also collect data
from New Zealand, where similar service models for Allergy provision
apply. Most of these Immunology centres are providing Allergy
services to a variable degree, many of which incorporate specialised
Allergy service components as defined in the National Services
Definition Number 17 for Specialised Allergy and several include
components of Regional Allergy Centres which are defined in "Allergy:
the unmet need". Namely; Expertise, management of multisystem
allergic disease, multidisciplinary support, infrastructure for
management of allergic disease which cannot be dealt with in General
Practice; Educational resource; Support at local level for GPs
and nurses in the management of common allergic problems in primary
care.
The services provided within NECIAG include
desensitisation therapy, allergen challenge procedures, training
in rescue medication use, school liaison, GP education and assessment
of complex drug allergies, as well as the usual angioedema, foods,
aeroallergens and other allergens. Many of the Immunology Centres
are carefully governed by guidelines, protocols and information
sheets and have formalised training programmes for the use of
rescue medications including adrenaline, utilising Quality Management
Systems similar to those developed for Specialist Primary Immunodeficiency
Services as defined in Specialist Service Definition number 16:
Specialised Immunology and necessary for accreditation against
the service standards produced by UK PIN (UK Primary Immunodeficiency
Network).
In addition, Sheffield's Children's Hospital
hosts a dedicated Allergy service staffed by a 0.8 WTE Consultant
in Paediatric Immunology and Infectious Diseases. A similar paediatric
arrangement exists in Manchester, and Newcastle (the largest centre).
These specialist Paediatric services are extremely rare indeed,
as most Paediatric services in the UK are supplied by general
physicians with no specialist training in Immunology or Allergy.
It is of note that, unlike other specialties, past and present
Immunology training programmes contain specific training in the
diagnosis and management of immune system disorders including
Allergy and that many Clinical Immunologists subsequently undergo
further training and extensive post-graduate experience in the
management of specialised Allergy, as a result of personal interest
or patient demand for the provision of specialized Clinical Allergy
services. In this respect these clinical services are quite different
from the limited part-time organ-based Allergy service provided
by physicians in other specialties such as Dermatology.
Some Immunologists have developed, or are attempting
to develop the widest range of Specialist Allergy services to
meet patient demands, in the face of lack of funding for such
developments, lack of central direction, and the acute shortage
of Allergists and Immunologists.
While the NECIAG audit data is not yet available
I can illustrate the extent of the provision of Specialist Allergy
Services by Immunology teams and the difficulties involved within
the NECIAG grouping from information supplied by colleagues and
myself.
Access to Allergy services is especially poor
in the North of England (as detailed in "Allergy: the Unmet
Need") In Sheffield there is a single Consultant Immunologist
(Dr Egner) with support from a GP Clinical Assistant. An SpR in
Immunology will join us later this year. We see approximately
500 new Allergy patients per annum, approximately 750 follow-up
patients and approximately 200 day cases attendances per annum
for desensitisation and allergen challenge. The Sheffield Teaching
Hospitals trust has actively supported the development of Specialized
Allergy services in parallel with Specialised Immunology services
and a new dedicated clinical day case unit is due to be built
on site within the next month. The Trust has invested in additional
Nurse Specialist support to develop the outpatient and day case
clinical services for both Allergy and Clinical Immunology in
parallel, since similar staffing and facilities are required,
the governance and management requirements are similar, and because
both activities are based predominately on day case procedures.
Facilities suitable for immunoglobulin infusion and review are
also suitable for allergen challenge and desensitisation clinics.
Nurse specialists skills such as resuscitation, training, cannulation
and the development of nurse-led services also cross over to a
large degree, such that one nurse can service both activities.
This sort of successful local intitiative is unusual and dependent
on local goodwill and specific opportunities, and has occurred
in only three of the 17 centres within NECIAG. Other units in
the North of England have not been so lucky, and gaining the interest
of PCTs or regional commissioning groups is very difficult, as
Allergy is very far from the top of their agendas. Designation
of Regional Centres with appropriate central funding will be necessary
to ensure equity of access and enhance the likelihood of equitable
access nationally. The paediatric service in Sheffield has so
far failed to obtain any significant dedicated funding for its
activity. Data on the situation in other units will flow from
the NECIAG/SWCIAG audit in summer 2004.
Like other units within the Northern audit group
we have been active in promoting the development of the service
in the face of acute shortages in central funding for the establishment
of new training posts, as effects of previous under-funding of
trainee numbers in Immunology work through the system. Newly qualified
Immunologists are an extremely rare breed at present (although
not as rare as Allergists) and many centres such as Sheffield
have vacancies, which cannot be filled in the current absence
of trained candidates. According to Phil Quirke, Consultant vacancy
rates in Immunology in the UK are now an appalling 16%.
In Sheffield we have therefore had to look to
the development of both Immunology and Allergy clinical services
using Nurse Specialist-led clinics, to free Consultant Medical
staff for more specialised and difficult caseloads and most of
our nurses are receiving training in both the care of both Immunodeficient
patients and Allergy patients, including immunotherapy and challenge
day case procedures under supervision from the medical Consultant.
This model is utilised in at least three of the major centres
in the North of England. It is a model which is also applicable
to Regional Allergy Centres, and is part of the recommendations
of "Allergy: the unmet need". These Immunology centres
within NECIAG have shown that it is a workable service model.
It is likely that over the next year our capacity to provide allergen
challenges with short waiting times, improved access to desensitisation
procedures through additional support of nurse-led services and
the use of clinical assistant staff will enable us to match one
of our sister units in the North, who currently also provide most
of the Specialist Services incorporated into Specialist Service
Definition number 17 using a similar arrangements. They are currently
seeing twice the number of new and follow-up patients as Sheffield
and four times the number of Allergy day case procedures utilising
approximately double the number of staff at all grades. In that
centre, as with my own, the amount of Allergy activity exceeds
the Immunology by a factor of four to one for new patient activity,
1:1 for follow-up activity and there is approximately twice as
much Allergy day case activity as Immunology day case infusion
activity. On the back of this, several centres aspire to be able
to offer outreach services in district hospitals throughout the
region to improve local access to patients over the next few years.
In a recent survey of Allergy clinics in the
North West, there were approximately four times as many Allergy
clinics provided by Immunologists than those provided by pure
Allergists, emphasising the need for increased numbers of Allergy
Consultants. This reflects the relative numbers of Immunologist
and Allergists currently available, but emphasizes the point that
any interim solution for the provision of Allergy services will
require the support of the government for the development of local
access to specialist services via a combined approach utilising
existing regional services, where much of the infra-structure
and expertise is either already in place or could be rapidly acquired
with the appropriate funding and support.
2. Priorities for improving services
1. Funding for the establishment of eight
dedicated Supra-Regional Allergy Centres, led by Allergists is
urgently required as detailed in "Allergy: the unmet need".
2. This should be accompanied by new centrally
funded Specialist Registrar posts in Allergy to enable to the
long-term development of Specialist Allergists with CCST's in
Allergy.
3. In the interim, improved Allergy services
cannot depend on increased provision of Allergists, as there are
so few available. Immunologist are also in short supply but are
already in a national network and there are a larger number of
Immunology trainees in training with approximately 21 currently
due to obtain CCSTs by 2008 (although not all will take up UK
NHS service posts and most will extend training by two to three
years to acquire a higher degree such as MD or PhD). Despite this,
additional central funding of extra Immunology trainees will also
be necessary if they are to fulfil a role in the additional development
of Allergy services outside of the Specialist Regional Allergy
units.
4. In view of the similarities in the physical
and organizational needs of both Immunology and Allergy out-patient
and day case services, the inquiry should give consideration to
whether it would be most efficient to develop Teaching Hospital-based
Regional Allergy and Immunology services in parallel, initially
developed utilizing the existing available infrastructure. This
would promote a win-win situation whereby patients have short-
to medium-term improved access to specialist Allergy services,
and enable the basic framework for improved Allergy services to
be developed prior to the availability of significant numbers
of Allergy trainees. As SpRs in Allergy become available for Consultant
appointment they will then have the choice of joining an existing
service with a view to professionally directing and developing
an expanded range of Regional Specialist Services across the country
or join one of the smaller number of Supra-specialist Regional
Allergy centres, to improve the training capacity and the academic
base of Allergy practice in the UK. This suggested arrangement
would potentially provide excellent clinical governance and the
best opportunity to provide increasing education and support for
Allergy care and education in primary care, reaching the widest
number of people in the shortest time in the most efficient and
cost-effective manner.
5. The government should urgently consider
adding Allergy and Immunology to the list of specialties for which
GP's with specialist interest (GpwSI) can be developed.
6. The government should consider the funding
of Nurse Specialist's or Nurse Consultants in Allergy or combined
Immunology and Allergy utilising the models detailed above.
3. Governance and regulation of independence
sector provided and links between the NHS and the independent
sector
NECIAG has no data or proposals to make on this
area.
C. CONCLUSION
The NECIAG and SWIAG survey of Allergy services
and workload should be available prior to our joint meeting in
October 2004 in Birmingham.
NECIAG will be happy to submit this data to
the health committee inquiry on request. I have little doubt that
it will provide further clear evidence of the growing need for
Allergy services, the current inadequate provision of Allergy
services in England (and Scotland, Wales and Northern Ireland),
service models that currently exist and the need to rationalise
the way in which specialist services are delivered both in the
medium and long term, to make the most effective use of a limited
Consultant Workforce, while investing for the future.
I would be happy to relate this evidence to
the inquiry in person, if required.
Whatever the final recommendations of the inquiry,
in view of the existing acute lack of appropriately qualified
Consultant Allergists or Immunologists which cannot be rectified
in the short term, it is clear that access to improved Allergy
will not be possible on a meaningful timescale without the creation
of Regional Allergy Centres, staffed by Allergists and without
also developing the existing infra-structure of Allergy services
which are currently inequitably distributed.
May 2004
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