APPENDIX 9: VISIT TO THE ALLERGY CLINIC,
ADDENBROOKE'S HOSPITAL, CAMBRIDGE
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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