Memorandum by Dr Adrian Morris (AL 50)
1. AVAILABILITY
OF ALLERGY
SERVICES (INCLUDING
ISSUES SUCH
AS GEOGRAPHICAL
DISTRIBUTION, ACCESS
TIMES AND
PATIENT CHOICE)
AND SPECIALIST
SERVICES FOR
PATIENTS WITH
SEVERE ALLERGIES
With increasing public awareness of allergy
related diseases, the inadequate provision of National Health
Service (NHS) allergy diagnostic and treatment clinics has become
apparent. Even the few available NHS allergy clinics found mainly
in and around London have waiting lists in excess of 12 months.
In their desperation to seek alternate allergy services (after
failing to get General Practitioner (GP) referral to NHS allergy
services) many genuinely allergic people will end up in the hands
of fringe allergy practitioners, where they receive poor advice
regarding their allergies. They then endure years of unnecessary
dietary restriction, inappropriate treatments and wasting income
on costly and unnecessary food supplements.
This obvious under provision of specialist allergy
services in the NHS is highlighted in the Royal College of Physicians
(RCP) Report and leaves no doubt that allergy specialist services
in England are grossly inadequate.
1. Royal College of Physicians, Allergy-the
unmet need: a blueprint for better patient care: London RCP 2003
2. PRIORITIES
FOR IMPROVING
SERVICES
Long-term solutions for improved services include:
Better undergraduate allergy education as part of basic medical
training, increasing General Practitioner allergy awareness during
Registrar training and encouraging GPs to acquire better allergy
diagnostic skills as part of ongoing Professional Development
Plans (PDP). Central funding for more NHS specialist and nurse
driven allergy clinics in community hospitals and regional hospitals
is necessary. Creation of more Senior Registrar and Consultant
posts for Clinical Immunologists and Allergists over the next
few years will only have a positive clinical impact in five or
more years' time.[2]
Certain short-term strategies can implement
immediate improvement in services. Many NHS allergy diagnostic
services and allergy courses are available but this is not common
knowledge.
A number of organizations already offer accredited
allergy training courses for GPs and Practice Nurses including
National Respiratory Training Centre in Warwick, Allergy UK Allergy
Days, Southampton Hospital MSc Course and the British Society
for Allergy and Clinical Immunology (BSACI) Basic Allergy courses.
Allergy testing is readily accessible at NHS
pathology laboratories in the form of improved versions of the
RAST (Radio-Allergo-Sorbant-Test) known as a CapRAST or UniCAP
test—this blood testing facility is currently available
to most private and NHS Specialists and General Practices in England.
The GP simply has to complete a standard request
form for the specific RAST test and send a clotted blood specimen
in the usual way (as simple as requesting a cholesterol check).
Utilising this facility, a GP would immediately be able to confirm
the cause of suspected life-threatening food anaphylaxis and not
have to wait one year for a specialist consultation in London
or perhaps never be able to confirm the diagnosis if in North
England (where no referral allergy clinics exist). Allergy self-test
kits marketed by certain supermarket and pharmacy chains for home
testing provide rather "hit and miss" results and are
of debatable value.
There are over 450 individual UniCAP RAST tests
available for anything from Almond to Yeast. There are about 90
NHS pathology laboratories in the UK that offer these UniCAP RAST
tests and those that don"t can refer the tests to reference
laboratories. This has been confirmed by personal communication
with the UK suppliers of UniCAP RAST to these 90 NHS Hospitals
(Sweden Diagnostics (UK)).[3]
RAST tests are relatively expensive at approximately £8 per
allergen, but essential for allergy confirmation prior to a life-time
of specific allergen avoidance and prescribing of expensive Epipen
(or Anapen) adrenaline auto injectors (£72 as two are issued
annually) for suspected anaphylaxis.
As most NHS pathology departments provide fixed
rate services to Primary Care Trusts (PCTs), it is currently not
be in their budgetary interest to encourage the use of these little
known tests. Most GPs are not aware that these tests are indeed
widely available. The short-term solution to inadequate allergy
clinic provision is to encourage use of existing test facilities
in a controlled and responsible manner. To achieve this, GPs would
need "information algorithms" on how to request the
most appropriate RAST tests for each specific allergic condition.
Recent reports indicate that many GPs are of
the view that allergy testing is a futile and unreliable exercise,
and are uncomfortable interpreting test results. Many feel ambivalent
and lack confidence in (or have any interest in) Allergology.
But simple management protocols and algorithms can be designed
by organisations such as the National Institute for Clinical Excellence
(NICE), BSACI and RCP. This simple strategy could facilitate large
numbers of allergic conditions being adequately treated in the
primary care General Practice setting. In this way existing allergy
diagnostic services would be better utilised and the burden on
specialist allergy clinics reduced.
3. GOVERNANCE
AND REGULATION
OF INDEPENDENT
SECTOR PROVIDERS,
AND LINKS
BETWEEN THE
NHS AND THE
INDEPENDENT SECTOR
The unregulated private allergy sector is 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 usually have no scientific
basis nor have been validated. These pseudo-diagnostic tests usually
designed to identify multiple "sensitivities" include
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 are growing at
an alarming rate. These practises provide no useful role in allergy
diagnosis as they confuse the public about their allergies and
put individuals onto unnecessary and sometimes dangerous diets.
This leads to social deprivation, unnecessary anxiety and occasionally
death from misdiagnosis of a severe underlying allergy.
There is an urgent need to introduce regulatory
bodies to act as gatekeepers to and check on unconventional practices.
This should involve utilising reputable complementary health practitioners
in a regulation process to ensure registration of all complementary
practitioners purporting to diagnose and treat allergies. In this
way only trained ethical practitioners would be allowed to practice
independently and standards of service would improve. The public
would then be protected in a similar way to which the General
Medical Council operates in protecting the public from unscrupulous
practitioners masquerading as allergy experts.
1. "Which" Report: Allergy
Testing 1998.
2. Allergy: Conventional and Alternative
concepts. A Report of the Royal College of Physicians Committee
on Clinical Immunology and Allergy 1992.
3. Health shops stoke up fake allergy
fears (page 8) Sunday Times Newspaper 29 December
2002.
4. Morris AJ Complementary medicine and
allergy—a review of the facts Current Allergy and Clinical
Immunology 1996:Vol 9 No 3.
May 2004
2 Levy ML et al: Inadequacies in UK primary
care allergy services: national survey of current provisions and
perceptions of need. Clinical and Experimental Allergy; 2004:
34; 518-519. Back
3
MacLachlan K, Manager. Sweden Diagnostics (UK)Ltd, CBX2
West Wing, 382-390 Midsummer Boulevard, Central Milton Keynes
MK 9 2RG. Back
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