Select Committee on Science and Technology Sixth Report


Members visiting Addenbrooke's Hospital were: Baroness Finlay of Llandaff (Chairman), Lord Haskel, Lord Rea, Viscount Simon, Lord Soulsby of Swaffham Prior, Lord Taverne. In attendance: Miss Sarah Jones (Clerk), Professor A. B. Kay (Specialist Adviser).

27 March 2007

The Committee was welcomed to the hospital by Mr Robert Winter, the Medical Director of Addenbrooke's Hospital. It was noted that allergy service provision in the United Kingdom was orders of magnitude behind that of other European countries, due to a shortage of specialist allergists and the small number of dedicated allergy clinics. The clinic at Addenbrooke's was very popular with patients, as staff could deal with the whole spectrum of allergic disease, ranging from the mild to the potentially fatal.

Mr Richard Sunley, Director of Operations highlighted the difficulties faced when developing allergy services. The importance of allergy as a specialty was not fully recognised, so it was a struggle to convince local commissioners to invest in allergy training and services. Because the clinic at Addenbrooke's had become well established, local GPs knew to direct referrals there, and the clinic received patients from the whole of the East of England region.

For many patients, the clinic aimed to diagnose their condition, prescribe a course of action, and then refer them back to their GP for treatment. However, this was not appropriate for all patients. For example, children who had suffered anaphylaxis were given follow-up appointments at the clinic every 18 months in order to reassess their condition. This was something that GPs should not manage.

Dr Pamela Ewan, Director of the allergy clinic, outlined the nature and extent of allergic diseases in the United Kingdom and the ways in which they were treated. In contrast to the large clinical burden, there was a relatively small specialist workforce, with only 26.5 full-time equivalent consultants, seven trainees and little knowledge in primary care.

The allergy clinic at Addenbrooke's was established in 1988 with one consultant. The high demand for the service had quickly become evident, but it had been difficult to find funding to increase the number of staff. Funding for a second consultant had not been granted until 2001, and a third consultant specialising in paediatric allergy began at the clinic in 2006. Two other consultants worked part-time at the clinic, but these posts were not permanent as funding again was a problem. In addition to the consultants, the clinic also employed one trainee, two specialist allergy nurses and three allergy trained clinic nurses.

The clinic trained specialist registrars in allergy and ran short training courses for local GPs once or twice a year. It was felt that an important part of GP education was provided during everyday work. For example, telephone conversations between GPs and staff at the clinic avoided unnecessary referrals, and follow-up letters written by consultants provided feedback and helped to educate GPs. It was noted that over the last 10 years, this dialogue between primary and secondary care had greatly improved the pattern and appropriateness of referrals the allergy clinic received.

The clinic also carried out research and maintained a large clinical database of the patients treated, including 2,000 with nut allergy, 760 with venom allergy and over 100 who had suffered anaphylaxis during general anaesthesia. The database included details of the allergens which caused patients' reactions, the severity of their reactions, and the results of any diagnostic tests. This enabled the clinic to monitor local trends and evaluate allergenic risk factors, as well as assess the effectiveness of diagnostic tests, management plans and various treatments.

The Committee observed patient consultations carried out by Dr Pamela Ewan, Dr Shuaib Nasser and Dr Andrew Clarke. Many of the patients seen at the clinic had severe allergies, or suffered from an allergy which caused multiple illnesses. Some had travelled considerable distances to receive treatment at the clinic and many had been unable to get help elsewhere in the NHS. The clinic had developed model systems for the diagnosis and management of a wide range of conditions. Children with nut allergies received a comprehensive management plan which included written guidance on avoidance, a written treatment plan and training in how to administer emergency medication. Model letters for schools had also been constructed, which could be personalised for each patient, to educate teachers and other staff about the child's condition.

For patients who suffered anaphylaxis during general anaesthesia, it was essential to carry out specialised drug allergy investigations to identify the culprit drugs and prevent future reactions. It was also important to exclude any drugs which did not cause a reaction and which would therefore be safe for future use. Dr Ewan noted that drug allergy patients who did not get referred to specialist allergy clinics were often given little information about their condition and were confused about how to protect themselves from further reactions. But at the allergy clinic, following the appropriate tests, the patients were sent a letter which clearly explained the substances to which they were allergic, and explanatory notes were also forwarded to the patients' GPs and other consultants.

Several anaphylactic patients told us that the information they received from GPs about their emergency medication was poor. Many patients who had been prescribed adrenaline autoinjectors did not understand under what circumstances to use them, or administered them incorrectly. The clinic therefore spent time educating patients and relatives about how to use the adrenaline autoinjectors correctly, and administration of the treatment was practiced using "dummy pens."

The importance of regular assessments was also noted, especially in children who could potentially outgrow allergies. If regular IgE antibody tests and skin prick tests indicated that an allergy was being outgrown, challenge tests were sometimes prescribed. These tests involved the administration of increasing amounts of allergen to assess whether the child was still allergic. If the allergy was found to have been outgrown, it would therefore remove a large burden from the parent and child who would otherwise have avoided the allergen unnecessarily.

Patients suffering from bee or wasp venom anaphylaxis were unable to effectively avoid the allergens, so desensitisation treatments were often offered at the clinic for these individuals. Subcutaneous immunotherapy courses took three years to complete, with intervals between treatments increasing over time. Due to the risk of adverse reaction, it was necessary to monitor patients for an hour after administering the treatment. Immunotherapy was therefore a time-consuming course of treatment, especially if the patient travelled a long distance to reach the hospital, but its effects could last for many years and might even last an entire lifetime. Patients' quality of life was also greatly improved once the fear of anaphylaxis was removed. Patients with severe hayfever and other allergies were also desensitised at the clinic if medication had not controlled their symptoms adequately.

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