Memorandum by The British Society for
Allergy, Environmental and Nutritional Medicine (BSAENM) (AL 59)
SUMMARY
The BSAENM, a society of doctors, presents evidence
that a large number of chronic conditions improve when treated
as if they were allergies. Very few of the small number of NHS
allergy clinics are prepared to treat these cases, which are presently
left to GPs who try to suppress the symptoms with drugs. These
conditions make a substantial contribution to the large numbers
of the population with chronic complaints and to the poor morale
of doctors.
1. The BSAENM
1.1 The British Society for Allergy, Environmental
and Nutritional Medicine is a Charity whose aim is to promote
the study and good practice of allergy, environmental and nutritional
medicine for the benefit of the public. Full members are doctors
or dentists. This method of practice sets out to identify the
environmental influences provoking chronic and recurrent illhealth,
and arranging management by avoidance and/or desensitisation.
As a result, the patients usually attain control of their symptoms
and greatly increased wellness. We use the initials AEN to indicate
this approach.
1.2 The logic of the AEN view of medicine
was cogently expressed by Rapp in 1988 "Basically, if you
have a sore on you foot caused by a nail in your shoe, the answer
is to remove the nail, not to put a bandage on the sore".
2. Allergy Services
2.1 When a large number of chronic complaints
are treated as allergies the patients get marked relief, stop
deteriorating, and are able to keep themselves more or less well.
This is common even when there is a long history of symptoms and
consultations with many different doctors, whether they have previously
been given another firm diagnosis or have medically-unexplained
symptoms.
2.2 The provoking exposures are commonly
certain foods, low concentrations of volatile organic chemicals
and biological inhalants. This is documented in many publications,
and supported by symptom provocation on double blind challenge
(see background paper and data pages A-G).
2.3 Allergies of this sort tend to get worse
and spread to involve other factors unless they are controlled.
Avoidance and/or desensitisation are effective managements for
these conditions: well-managed, the tolerance of most patients
improves.
3. Availability of Allergy Services
3.1 There are very few NHS allergy clinics
to service the 30% of the population now suffering from allergies,
and few of these are prepared to consider that chronic conditions
may be provoked by food intolerance or chemical sensitivity. At
the time the BSAENM published its report Effective Allergy
Practice (enclosed), there were a number of BSAENM members
in other specialties running clinics dedicated to this aspect
of allergy but most have now retired and the clinics have been
discontinued.
3.2 As a result, patients with these conditions
who have noticed they are made worse by foods or chemical exposures
tend to be dismissed as not allergic, and subsequently managed
by symptom suppression by drugs, usually deteriorating gradually.
However, most patients are not aware that they could be helped.
3.3 AEN methods need a prolonged first consultation
and are not easily incorporated into standard NHS situations.
In the longer term they give excellent results and are very cost
and time efficient.
3.4 The BSAENM has 130 doctor members but
most of these are struggling to do a little AEN as they find they
are able, many of them already overworked in general practice.
The others are practising privately because there are no NHS jobs
in which they can practise this constructive medicine.
3.5 The environmentally-controlled inpatient
facility (ECU) in Yorkshire which helped the more severely-affected
patients was forced to close after the last reorganization of
NHS funding because the Primary Care Trusts delayed approving
funding for individual patients for one to two years because they
were unsure how far their funds would go. An ECU is an essential
facility for making a firm and complete diagnosis in patients
with multiple allergies, and a prerequisite of good research in
this area, particularly in respect of multiple chemical sensitivity.
4. Priorities for Improving Services
4.1 Financial support for training in AEN,
currently funded only by the Trainees themselves.
4.2 Inducements to GPs to recognise patients
whose chronic complaints would respond to AEN management, and
to investigate and treat them using AEN methods.
4.3 Funding of the training and employment
of specially-trained nurses and dieticians to work with GPs in
helping these patients.
4.4 Establishment of posts for allergists
interested in food intolerance and chemical sensitivity as well
as traditional allergy in medical schools and in other hospitals,
with some ring-fenced research money.
4.5 Pressure from the GMC to insist that
AEN management is included in the medical school timetable, and
that students are not taught that medically-unexplained symptoms
are psychological in origin without evaluating the positive evidence
to the contrary.
4.6 Establishing a comprehensive environmentally-controlled
inpatient unit with a dedicated and specially-trained staff for
the investigation and short-term management of the severely-affected
and those with serious medically-unexplained symptoms, perhaps
initially one unit with 10 to 20 beds but with the intention of
expanding to one associated with each teaching hospital.
5. Governance, Regulation and Links
5.1 The BSAENM has set up a semi-autonomous
Board of Registration to run an accreditation scheme for doctors
which includes applicants attending a training course, doing clinical
audit and preparing written case histories: the names of accredited
doctors are entered on the newly-instituted Register of AEN Physicians,
held for us by the Institute of Biology. There is no other training
or qualification available in this discipline in the UK.
5.2 The BSAENM Board of Registration registers
such members as apply for inclusion on the Register when they
have satisfied the accreditation criteria. An entry implies that
the Board is prepared to recommend the registrant to doctors and
patients. Those who do not wish to be on the Register are free
to continue to practise, and most, probably all, are thoroughly
competent.
5.3 The Board of Registration has been provisionally
accepted by the GMC to contribute to the revalidation of members
practising AEN. This is similar to the role to be played by the
Royal Colleges. Those of our members who are not on the Register
will presumably take another route to revalidation.
6. Other Matters
6.1 The premises and staff of some of our
members is being deemed to come under the National Care Standards
Directive: if this is applied to them all, some will stop practising
altogether because the heavy costs of complying with the regulations,
and registering, will make part-time practice uneconomic. There
are so few doctors practising this way that that would be a disaster.
7. Enclosures [Not Printed]
A Background Document including a brief
survey of the evidence that this method of practice is effective,
illustrated by data pages A-G.
Effective Allergy Practice: a document on
standards of care and management for the Allergy Patient.
Report of the BSAEM/BSNM 1994. 200 references.
Multiple Chemical Sensitivity—Recognition
and Management: a document on the health effects of everyday chemical
exposures and their implications Report of the BSAENM 2000.
285 references.
The Lancet review of the Textbook Environmental
Medicine in Clinical Practice.
May 2004
NB. The initials AEN are used to indicate allergy,
environmental and nutritional medicine
1. INTRODUCTION
1.1 Approaching chronic illness using the
concepts of AEN is a demanding but very rewarding way of practising
medicine. This document summarises the methods we use and briefly
surveys the evidence.
1.2 The chronic conditions caused by allergy/intolerance
have been given the name Toxicant-Induced Loss of Tolerance (TILT),
recognising them as sharing patho-aetiologic mechanisms. In the
future this concept is likely to prove at least as important and
influential as the germ theory of disease. A key characteristic
of this group of illnesses is that the link between exposure to
the provoking agent and the development of symptoms is frequently
obscured until after a break in exposure which relieves the symptoms,
often after an initial worsening.
1.3 There are four main elements in the
management:
— using elimination diets to expose
the effects of hidden food allergy;
— using avoidance of everyday exposures
to chemicals to uncover hidden chemical sensitivities (including
those to cleaning materials, gasses given off from synthetic materials,
combustion products, food additives, food and water contaminants,
medication etc);
— considering whether allergies to
biological allergens (pollens, moulds etc) may be having chronic
effects in other systems as well as causing recognised allergies;
and
— looking for, and correcting, deficiencies
of vitamins and minerals which predispose to, and result from,
allergic reactions, and which are an additional cause of chronic
symptoms and of poor pregnancy outcome; deficiencies of vitamins
and minerals are worryingly common (Block and Abrams. Ann NY Acad
Sci 1993; 678: 244) and MAFF data shows intakes of zinc and selenium
that are inadequate even for the healthy.
1.4 Many patients with chronic illness,
including those with "medically-unexplained" illness,
become virtually symptom-free without requiring medication if
the environmental triggers of their symptoms are detected and
avoided. This should be the bedrock of all medical treatment,
but has been ousted by pharmaceuticals which are quicker and easier
to prescribe although commonly less effective. Wider training
and implementation of this constructive approach to chronic and
recurrent illness would decrease drug bills and improve outcome,
but most NHS consultations, both in primary care and in hospital
clinics, are too short for the approach to be initiated, although
in the longer-term the patients who benefited would consume much
less medical time if treated this way. This form of management
(which we term AEN) has been assessed in the short-term using
double-blind randomised trials, but such trials cannot be used
to assess the long-term efficacy of therapies in chronic illness.
Other methods are more suitable for the assessment of treatments
for chronic and recurrent illness, and of any therapy which is
based on the need to correct deficiencies or manage idiosyncratic
reactions.
1.5 Patients get lasting relief after finding
the triggers of the symptoms of irritable bowel syndrome (IBS),
migraine, hyperactivity, depression, arthritis, eczema, asthma,
rhinitis and other conditions using an elimination diet. Others
find relief if they take rigorous action to reduce their exposure
to house dust mite allergen, or moulds or volatile organic chemicals.
Chemical sensitivity is particularly likely to give rise to psychological
and cognitive symptoms, for instance varying difficulty with sleep,
memory, word-finding and mood, and is responsible for some aggression
and violence.
1.6 On the pages attached, the first page
(Annex 1) [Not printed] shows references to papers which demonstrate
that a wide range of symptoms can be provoked by food challenge
(after symptoms have been relieved with an elimination diet),
all confirmed by double blind challenge. The studies tended
to choose patients with symptoms which could be confirmed objectively,
so other symptoms are under represented.
1.6.1 On Annex 2 [Not printed] outcomes
are illustrated by the changes in scores for hyperactivity (the
higher, the more severe) which fell during the elimination diet
and rose again with blind test food challenge but not with placebo.
The lower half of Annex 2 shows changes in peak flow rate (high
is good) illustrating similar effects in asthma, and showing that
bronchospasm in reaction to a food may be prevented by Nalcrom,
an anti-allergy drug.
1.6.2 Annex 3 [Not printed] shows the amount
of Life Disruption reported by a series of severely-affected
patients before AEN treatment and at long-term follow-up in a
two-centre study. In half of these patients symptoms had got worse
for at least 10 years before referral: one had seen 11 consultants
in other specialities first. The darker, the more serious.
1.6.3 Annex 4 [Not printed] shows the percentage
of these patients who reported each of 64 symptoms on presentation
(top bars) and at follow-up (lower bars). The frequency and severity
of each symptom were reported separately and combined to give
a single grading. Again, the darker, the more serious. There was
a statistically-significant improvement in almost every one of
the symptoms.
1.6.4 Annex 5 [Not printed] shows some other
long-term results in asthma and in rheumatoid arthritis, in each
case involving diet studies in which the foods most likely to
cause problems were omitted at first, and avoided long-term if
they provoked a worsening of symptoms later. Over half the asthma
cases were better at a year. As is shown, both symptoms and signs
of rheumatoid arthritis were significantly improved after a year
on the regime.
1.6.5 Annex 6 [Not printed] (top) shows
the percentages of patients who benefited in a number of long-term
studies, and (bottom) some data about cost effectiveness.
1.6.6 Annex 7 [Not printed] shows the medical
costs of two patients before, during and after AEN investigations.
2. IS IT
ALLERGY?
2.1 At present most of the patients with
these complaints are being treated with symptom-suppressant drugs,
or seeking help from complementary therapists, or from books,
although a few find their way to the doctors who practice AEN,
a mere 130 or so for the whole country, most engaged primarily
in another field of medicine, mainly general practice.
2.2 The mechanisms by which foods and environmental
factors cause such symptoms as hyperactivity and lBS are uncertain,
and most of the conditions cited above are not due to IgE-mediated
allergy (atopy), although many of the patients also suffer from
allergic rhinitis. The hypothesis which currently best fits the
data is that most are due to non-atopic types of immune reaction
and probably involve Types II, III and IV of the Gell and Coombs
mechanisms of tissue damage. Calling these reactions "allergy"
raises objections from some conventional allergists, but allergists
who fail to recognise these adverse reactions fail to help this
type of patient.
2.3 The evidence is primarily clinical—that
there are a lot of different symptoms which can be prevented by
treating them as if they were allergies. This is practical experience
supported by good clinical trials (see Annex 1). Acceptance has
been slowed by the absence of reliable routine laboratory tests
for non-IgE-mediated allergy. It would, in particular, be helpful
to have a good laboratory test for hidden food allergy. None of
the tests available to date shows sufficient reliability to be
used as a basis of a long-term diet, though they may provide a
useful starting point for exclusions. Although it would be more
satisfactory to have established the mechanism, the absence of
an accepted mechanism cannot negate the clinical findings.
2.4 The lergic hypothesis for these conditions
is supported by their association with IgE-mediated allergy, by
the fact that there have been parallel increases in prevalence,
and by the role that desensitisation plays in each. Uncovering
hidden food allergy can, on rare occasions, lead to acute allergic
reactions on challenge (for instance anaphylaxis has been described
in boys with a food-related eczema), and care is needed during
the investigation of patients with severe asthma. Because of this,
it is important that the medical profession takes responsibility
for investigating the role of environmental and food reactions
in the aetiology of the wide range of chronic and recurrent illnesses.
If not, patients will continue to get help from books, or from
complementary therapists not trained to recognise or treat severe
allergies, putting some patients at risk.
2.5 In practice, our members also use nutritional
medicine because we have found that the best results may not be
achieved unless the nutritional state of the patient is also considered;
many allergic patients are deficient in essential nutrients such
as B vitamins, zinc and magnesium. This has led us to study the
nutritional literature and recognise that marginal deficiencies
may also cause chronic symptoms, delay recovery from infections,
operations and trauma, and contribute to infertility and poor
pregnancy outcome. A balanced diet is clearly an essential preliminary
to keeping well, but may not be sufficient for some. Patients
who are markedly deficient, or are having repeated allergic reactions
(which use up nutrients), or need an idiosyncratically high intake
of some essential nutrients, will not achieve repletion unless
they take additional supplements, often needing many times the
recognised daily requirement. Shorter hospital stays could be
achieved if the importance of replenishing levels of deficient
nutrients were to be more widely recognised, making an important
contribution to medical treatment and to the finances of the NHS.
In particular, more use should be made of essential micro-nutrients
in combating infections and aiding repair.
2.6 A textbook for doctors and other health
professionals [Environmental Medicine in Clinical Practice]
was published in 1997 and reviewed in the Lancet 1998; 35 1: 221-2.
It covers the evidence that this approach is effective, the practical
aspects about how to do it, and the social implications. A copy
of the Lancet review of this book is enclosed.
3. BENEFITS OF
AEN TO PATIENTS
(a) Relief of previously intractable symptoms,
some labelled medically-unexplained or wrongly attributed
previously to psychological causes.
(b) Coming to understand the causes of their
symptoms, which takes away much of the fear and distress.
(c) Ability to avoid provoking their symptoms.
(d) Increased general well-being: partly
from reduced medication but also because both adverse reactions
and nutrient deficiencies cause malaise.
(e) The power of choice: patients who suffered
from severely-disabling symptoms usually choose to be very careful
to avoid incitants, but others make day to day choices about where
to go and what to do; with care, many recover their tolerance
with time (months/years).
(f) Relief at having their experiences listened
too, tested, and often confirmed and extended: before referral
to AEN many patients have been almost persuaded that they were
psychologically disturbed.
4. BENEFITS OF
AEN TO THE
NTIS
(a) Reduced burdens of consultations and
investigations, after the initial period (see Annex 7).
(b) Reduced drug bill (see Annex 6 bottom).
(c) More satisfying practice: AEN patients
whose sensitivities are ignored tend to get worse; they develop
many different symptoms and need repeated prescriptions and repeated
referrals to different consultants without much benefit; they
are a severe drain on doctors' morale.
5. BENEFITS OF
AEN TO SOCIETY
(a) Reduction in chronic illness burden,
shown by the General Household Survey to involve 20-40% of the
adult population (depending on how it is ascertained).
(b) Reduced sickness benefit and care and
disability allowances.
(c) Reduction in crime. A police officer
co-operated in a study using AEN in boys involved in repeated
criminal activity; criminal activity was reduced and most of the
boys continued to avoid their incitant foods even after the end
of the study (Bennett P. Yorks Med 1992; 4: 19); vitamin deficiency
is a common cause of psychiatric symptoms and linked to crime
(Schauss A. Diet, Crime and Delinquency. Berkeley, CA:
Parker House 1980).
(d) Healthier babies born to mothers who
would otherwise have had allergic reactions during pregnancy and
been depleted of essential nutrients.
6. WHY AEN IS
NOT WIDELY
ACCEPTED IN
SPITE OF
EVIDENCE
(a) There is very little teaching about allergy,
about chronic or recurrent effects of chemicals or about nutritional
medicine in medical schools, or during postgraduate training.
(b) It is only recently that allergy has
been recognised as a specialism and there are very few allergists
in the country in spite of at least a third of the population
being allergic. Almost all of the few allergy posts concentrate
on atopy. Over the last 20-30 years a number of other consultants
(mainly general physicians, chest physicians and paediatricians)
started to practise AEN; in each case these clinics have had good
results, been heavily used, and had long waiting lists, but have
reverted to standard medicine when that consultant retired.
(c) Allergy and nutrition are regarded as
difficulty: allergy because of its inherent nature, nutrition
because it requires more biochemical expertise than most doctors
possess.
(d) Doctors are taught as students that multiple
symptoms are of psychological origin and so a psychological aetiology
is generally assumed for conditions which are not understood.
There is no evidence for this, and a lot against it.
(e) Doctors have misplaced confidence in
negative results of tests. Even when the appropriate test is used,
a negative may not be capable of ruling out a condition; if the
wrong test is used (for instance IgE testing in hidden food allergy
or magnesium from serum levels), the results are totally misleading.
(f) AEN patients have to take more responsibility
for their own health than doctors are used to, making doctors
feel threatened. Most doctors are used to, and happy with, a more
paternalistic relationship in which they have a secure place,
such as ranging laboratory in estigations and prescribing medication
which only they can do. AEN requires individual medical detective
work and close co-operation with the patient.
(g) Very little research money is available.
Most medical research money either comes from the pharmaceutical
companies or is distributed by committees whose members rely on
such funds for their own department's research output. The pharmaceutical
companies see AEN as a threat.
(h) The pharmaceutical companies fund a lot
of postgraduate training; AEN training has to be paid for by those
attending it.
(i) The blacklisting of nutritional supplements
for NHS prescribing implied to doctors that they are of no use,
which is contradicted by the evidence. When a DHS committee concluded
that Vitamin B6 was dangerous, on very poor evidence, this discouraged
doctors further from using supplements. In contrast to drugs (which
cause thousands of deaths each year) nutritional supplements are
extremely safe; the most serious adverse reactions (to tryptophan
and to germanium) occurred with manufacturing failures.
(j) Many doctors are now too overworked and
disheartened to be thinking creatively or reading anything new
or demanding.
(k) The report published by the Roy College
of Physicians in 1992 entitled Allergy: Conventional and Alternative
Concepts dismissed environmental approaches without ex ining the
published literature in the scientific fashion that would be expected
of such a prestigious body. This report has been repeatedly cited
as indicating that there is no scientific basis for the types
of management the BSAENM advocates, although it was selective
and biased in its coverage. A critique of the report was published
the same year (Downing D, Davies S. J Nutr Med 1992; 3: 331-49.),
and the evidence has been considered in the three reports published
by the BSAENM.
7. LIMITATIONS
ON RANDOMISED
CONTROLLED TRIALS
IN CHRONIC
ILLNESS
(a) In long-term illness the patient has
effectively acted as his own control for 10 years or longer: if
they suddenly get better, and stay better, this is highly unlikely
to be due to a placebo effect.
(b) Long-term improvement is the prime endpoint
in assessing the effectiveness of the treatment of chronic illnesses.
It is difficult to maintain the integrity of intended treatment
arms of RCTs long-term, particularly among patients doing poorly
who will be tempted to t anything else; drop-outs and protocol-breakers
introduce bias, whatever decisions are made about the inclusion
of their data in the analysis.
(c) RCTs compare two (or more) treatment
regimes in randomised groups from a homogeneous patient population;
women and the elderly tend to be under-represented, excluded because
they often suffer from more than one recognised illness which
is the norm for the characteristc AEN patient.
(d) RCTs test uniform treatments; this is
not appropriate for patients in whom there is a need to identify
and correct individual nutrient deficiencies or identify individual
intolerances so that the incitants can be avoided; the treatment
plan must be valid for each p ient and for AEN this requires person
ised management.
(e) The results of RCTs are generally disbelieved
unless they have been carried out double-blind; blinding is impossible
with hands-on treatment, and with all management which relies
on the patient to modify their lifestyle or diet. For maximum
clinical effectiveness, exclusion diets must exclude all
food incitants; investigatory elimination diets must therefore
first check all likely food incitants in order to identi control
foods, which obviously cannot be done double-blind; double-blinding
results in false negative results to some challenges.
(f) Randomised referral trials are an adequate
alternative.
8. WAYS IN
WHICH WIDE-RANGE
ALLERGY SERVICES
COULD BE
ENCOURAGED
8.1 Overcoming the barrier of disbelief.
In our view, this is not primarily a matter of research—there
are good research results published already—but of getting
the evidence assessed impartially. We would be delighted if an
influential, independent, unbiased individual (or small group
of individuals) were to be asked to report to you, to the DHS
and to the Royal Colleges after examining the literature and talking
to clinicians, researchers and patients and, if necessary, examining
trial notes, and patients' clinical notes, and/or following prospectively
some patients treated in this way. The group would probably need
to be able to appoint some independent staff to help them.
8.2 A randomised referral trial, in which
patients are randomly assigned to standard medical management
or AEN management, and then managed individually within those
disciplines. This must be organised from somewhere outside AEN,
as Dr Tom Meade did for the chiropractors. The patients might
be a random sub-sample of patients with certain chronic symptoms
identified either from a routine hospital department, or from
a population survey.
8.3 Establishing clinical posts for allergists
concerned about hidden food allergy and multiple chemical sensitivity
in all the teaching hospitals, with provision for auditing their
results and their workload, and a commitment to expand the service
if or when effectiveness and demand are both recognised. Some
of the last few NHS clinics of this sort for adults experienced
very high referrals, and political pressure to keep down waiting
lists contributed to the limitations imposed on them and ultimately
to their closure. It would currently be impossible to fill posts
in all teaching hospitals with experienced doctors recognised
as being of consultant quality, and it might be necessary to appoint
some temporarily at lower status. However, providing that the
conditions were right, and facilities for training were developed,
doctors with experience would be encouraged to get the necessary
training, and others be attracted into the discipline. The BSAENM
is looking at the possibility of introducing a diploma scheme
for which the accreditation scheme running at present could be
one introductory qualification.
8.4 Research Funding Although investigations
of mechanism are needed, it would be important that clinical research
had at least as high a profile, and that funds are available for
professional studies of cost effectiveness. Since most medical
research funding comes from (or is administered by groups indebted
to) the chemical companies (to whom AEN is understandably anathema),
ring-fencing research funds would be necessary to attract researchers
to this area.
8.5 Establishing a comprehensive environmentally-controlled
inpatient unit (ECU) and subsequently extending provision to provide
an accessible service for patients from all over the country.
The Airedale Allergy Centre (AAC) was the first purpose built
ECU in the world. It was forced to close when the re-organisation
of NHS finances left the primary care trusts uncertain about how
far their money would go. Nearly all of them delayed agreeing
to fund patients for investigations at the AAC, saying that they
would reconsider in one or two years. This was a body blow for
a small concern depending on staff who had to be trained specially.
During the 14 years in which it functioned, it solved medical
problems that were regarded as insoluble (Maberly and Anthony
J Nutr Med 1991; 2; 83.) and converted hundreds of patients from
chronic invalidism to more or less normal life (see Annexes 3
and 4): a number of these patients would undoubtedly have died
without this. For some severely and chronically ill patients the
role of the environment in provoking their illness can only be
identified, or ruled out, by admission to an ECU. Admission (usually
for three weeks) is only necessary for small minority of patients,
but speeds up recovery in many other patients compared with even
the best outpatient practice and makes the management of patients
with anaphylaxis and severe asthma safer. ECUs make an important
contribution to teaching AEN, make possible valid research into
the problems of multiply-allergic patients, and are an essential
facility for research into multiple chemical sensitivity.
9. COMMENT
9.1 We believe that the evidence available
now is quite sufficient for the NHS to make AEN generally available.
A rate of improvement as high as 60% (see Annex 6) has never been
achieved by placebos, even in the short-term, and most placebo
effects are of very limited duration. We see it as quite inappropriate,
and very sad, that the few NHS facilities for AEN treatment for
adults have been allowed to decline further. Most doctors seeing
patients at private clinics have previously been in the NHS and
have only left because they found it too difficult to practise
this constructive medicine within it; few of them prefer to be
private practitioners.
9.2 Before the changes in funding were introduced,
patients were being referred under the NHS to the special inpatient
facility and for outpatient management at a number of different
private clinics; this funding almost dried up and is only slowly
increasing again.
9.3 The spread of AEN management would be
helped by the employment of specially-trained nurses and/or dieticians
to work with these patients in general practice, under the supervision
of GPs, but both ancillary staff and the GPs would need special
training. The BSAENM is currently training our doctor members
and we would hope to be able to extend this to the ancillary workers
if funds were available. Because AEN practice is both tiring and
time consuming initially (although it saves time, money, effort
and heartbreak in the longer-term), doctors would probably need
financial incentives at first to undertake training and to supervise
ancillary staff. The advantage of having a specially-trained nurse
to advise patients about reducing exposure to aeroallergens and
to do prick tests has already been demonstrated (Brydon M. Clin
Exp Allergy 1993; 23: 1037). With more training, nurses could
also do much of the history taking and play a part (with specially-trained
dieticians or nutritional therapists if available) in supervising
elimination dieting and subsequent exclusion diets.
9.4 The primary care teams would benefit
from specialist allergists to whom to refer difficult cases, preferably
with access to an environmentally-controlled inpatient unit (see
paras 8.4-8.6).
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