Examination of Witnesses (Questions 1-19)
PROFESSOR MARTIN
MARSHALL, PROFESSOR
SALLY DAVIES,
DR KEITH
RIDGE AND
MR ALAN
BELL
22 NOVEMBER 2006
Q1 Chairman:
Thank you for coming. Can I welcome our witnesses today. This
is the first evidence session of the Select Committee inquiry
into allergy. This is a public hearing and it will be webcast.
There is an information note available to the public which states
the declared interests of all Members, so we will not be declaring
our interests each time. I just wonder if you would like to go
along the row, please, and introduce yourself to the Committee,
and then we will go through the questions. We have quite a lot
of questions for you within the hour that we were planning on,
so it would be helpful if you kept your answers concise, if possible,
so we can get through them. We can always return to things if
time allows.
Professor Marshall: Good morning. My name is
Martin Marshall, I am the Deputy Chief Medical Officer and I am
heading up the team.
Mr Bell: Good morning. I am Alan Bell, and I
led the recent review of allergy services by the Department of
Health.
Professor Davies: Sally Davies, Director General,
Research, for the Department of Health and the NHS.
Dr Ridge: Good morning. I am Keith Ridge; I
am the Chief Pharmaceutical Officer at the Department.
Q2 Chairman: I wonder if I could
start off by asking you how the different government departments
communicate with each other on allergy issues, including issues
around education and training. Indeed, when was the last time
they did?
Professor Marshall: Perhaps I could take that
question, thank you. We clearly see collaboration between government
departments as very important, particularly in an area like allergies
where there are very clear interests from departments other than
the Department of Health. We relate to each other in a number
of different ways, some of which are formal, through standing
committees, some of which involve joint memoranda and some of
which involve informal working at the policy officials' level.
If I could just give a couple of examples: in terms of a formal
level, at memoranda level, the Department of Health has worked
very closely with Defra on air pollution and the impact that might
have on allergies. The second example would be our very close
working with DfES on developing guidance for medication for school
children, particularly around treatment of anaphylaxis. So we
regard collaboration as very important, and I think it is fair
to say that the process that we have been through in developing
this review has highlighted the importance of collaboration for
all of us.
Q3 Chairman: Who leads on those meetings?
Professor Marshall: Whoever is relevant to the
particular area, usually at policy official level, for example,
Alan's level.
Q4 Chairman: Just picking up on what
you said about atmospheric pollution, if there is a conflict of
interest between departments I wonder if you could give us an
example of how it might be handled, such as things like airtightness
of buildings; when energy conservation would suggest that the
building should be as airtight as possible but that might be detrimental
to allergy sufferers.
Professor Marshall: I do not have any personal
specific experience of any conflicts of interest happening, but
in an example of the sort you have given what I would expect is
close collaboration and negotiation between the two areas and
then trying to find common ground.
Q5 Chairman: My next question is
probably for others at the table. We do have the highest prevalence
of asthma and allergy sufferers in the world, and I wondered what
explanation the Department has for this phenomenon. Perhaps you
would like to take it?
Professor Marshall: Yes, if you do not mind.
I am sure the others will have an opportunity to answer some other
specific questions in their areas. I am sorry, could you repeat
the main gist of the question?
Q6 Chairman: We wondered how you
could explain why the UK has such a high prevalence of asthma
and other allergic conditions.
Professor Marshall: It is very difficult to
know how the prevalence of allergy conditions in the UK compares
with other countries. We think it is high. We also think it is
high in countries like Australia, New Zealand and Canada as well.
The problem is having good quality comparative data. I think we
need to accept that the prevalence is high in the UK, but how
high it is relevant to others we do not know. The exact causes
of the high prevalence, again, are unclear; there is not good
evidence in this area. So whilst the scientific evidence is very
good at talking about the underlying mechanisms causing allergy,
the actual aetiology—the causes of it—are less clear.
There are a number of different hypotheses; some of them relate
to environmental factors like pollutants and smoking, some are
related to genetic factors and infective factors, but probably
the most popular theory relates to the hygiene hypothesis that
suggests that, particularly, children are not exposed to the dirt
and specific allergens that they might have been exposed to in
the past, and therefore their immune system is not primed to deal
with them appropriately.
Q7 Lord Taverne: Other countries
have high standards of hygiene, many other countries smoke more
than we do, so it does not explain why we should have a higher
incidence than others.
Professor Marshall: You are right, although
I come back to my original answer that we do not know whether
we have a higher incidence than others, but you are right absolutely
that we cannot explain the high incidence. Certainly the incidence
seems to be increasing over the last 30 years, although there
is some evidence over the last 10 years that some specific allergies,
specifically asthma, might actually be reducing in prevalence
now.
Q8 Chairman: The Department of Health
review on services for allergies, commented that there is a lack
of information on the extent of untreated allergic conditions.
I wonder what you can tell us about what the Department is doing
to improve on its data and, in fact, have appropriate data collection
to know about distribution of severity and unmet need.
Professor Marshall: There are very real problems
with the quality of data in this area and, indeed, in some other
areas as well. We are doing a number of things to try to improve
it, but the principal problem, I think, is that some allergies
are treated in other organic-specific areas. So, for example,
data about asthma are more likely to be found in respiratory areas,
or data about eczema are more likely to be found in dermatological
areas than it is classified specifically as allergy. The main
thing we did in 2002 was introduce an allergy National Code. I
have to say that that introduction has not been entirely successful
and I do not think we have seen particularly better quality data
as a result of it because people are still classifying within
disease-specific areas. We are hoping that the introduction of
Connecting for Health, and particularly the introduction of a
new nomenclature system called SNOMED, will help us to then classify
the allergy in a much more specific way, actually in a semi-automated
way, when clinicians enter data on to patient records.
Q9 Chairman: Would that classification
separate out allergic from non-allergic, so that as there is a
classification you will be able to capture better those which
are thought to be allergic versus non-allergic causes?
Professor Marshall: At the moment it does not,
but I think it would be desirable if it did. The problem, of course,
is that allergy is not a label that hangs over a patient when
they are first seen. So it would have to require entry into patient
records at a later stage when the allergic component becomes clear.
Q10 Lord Colwyn: Does the Department
make any assessment of the, I would have thought, hundreds of
thousands of patients, who never actually get to see a doctor,
a specialist or anybody, but who treat themselves?
Professor Marshall: The Department of Health
itself has not. We are very aware that there are potentially a
huge number of people with allergies out there who come nowhere
close to formal health services. The extent to which that matters
is unclear, from the epidemiological data that is there at the
moment. All of us will know of people who have allergies who self-treat,
perhaps who go to pharmacies, who actually do not want to get
even close to the formal health services in order to treat them,
so we do not know how important that is.
Q11 Lord Broers: The Government evidence
notes that the Department of Health's A review of services
for allergy "identified good practice in the NHS, across
the wide range of services available for people with allergies"
but also acknowledged many "gaps" in the skills of clinical
staff, planning of services, baseline data and research. Are these
two statements contradictory?
Professor Marshall: Perhaps I could ask my colleague,
Mr Bell, to answer that question.
Mr Bell: On the face of it they may look contradictory,
but I do not think they are. I think what the review showed is
that allergy services are provided in different ways around the
country by a range of clinical staff. There are examples of excellent
practice, we believe, in allergy care provided by all those professions.
There is no conclusive evidence that we found that establishes
that one particular model of service delivery outstrips others.
Nevertheless, although there are these pockets of good practice,
undoubtedly, the evidence, including the views of the many stakeholders
with whom we engaged on the review, does suggest that there is
scope for improvement in the areas that you have highlighted.
There are undoubtedly, as we have found, gaps in current knowledge
around issues like service configuration, the best skill mix,
the best balance of generalist against specialist services and,
also, in data on cost-effectiveness. We believe that the next
steps that we have set out in the report of our review will help
to address some of these issues.
Q12 Lord Broers: There does seem
to be a problem with the data, does there not? The review concluded
that the absence of baseline data on allergy services made it
difficult to develop a strategic national view of how and where
services could be developed. What steps have been taken to combat
this?
Professor Marshall: We think that improving
the data is an absolutely fundamental thing that we have to do.
We think that the best way of collecting data is at a local level.
This is why one of our key recommendations, which perhaps we will
come back to, is around improving commissioning. What commissioning
involves is a very clear needs assessment, so we would regard
PCTs as taking the lead in assessing the needs by performing formal
epidemiological assessments of the needs within their local communities
as well as prioritising those things alongside others. We hope
that that, in conjunction with the other issue that I mentioned
of a properly promoted National Code through Connecting for Health
and SNOMED, will help improve the quality of the data that we
have.
Q13 Lord Broers: Do you think this
will allow us to collect basic demographic data in a standardised
form? The thing that interests me here is your statement that
we do not really know how we stand with respect to other countries.
Is there an effort to get together, for example, across Europe
at least, to standardise these data?
Mr Bell: We are aware of initiatives such as
the Global Allergy and Asthma European Network which is busy,
amongst other things, collecting data on allergies across different
countries in Europe. Certainly the data that they have suggests,
as Martin said earlier, that we are up there near the top of the
table (or bottom of the table, depending on which way you look
at it). There have been other research studies done, some of which
are still ongoing, such as the International Study of Asthma and
Allergies in Childhood, which has looked at data from children
in, I think, something like 56 countries, which again is suggesting
that certainly for asthma—less clearly for other allergic
conditions—it is the UK, Australia, New Zealand and the
Irish Republic which are, again, up there at the top. So there
is some international research effort going on to collect relevant
data on prevalence and incidence.
Q14 Baroness Platt of Writtle: Do
General Practitioners have adequate training in allergy?
Professor Marshall: Perhaps I could take that
question because, as a General Practitioner myself, I am acutely
aware of it. I would say across the board probably not, is the
answer. If I just give an example of my particular training: we
had good training at undergraduate level in basic immunology and
in applied immunology, and that has clearly got better in the
last 20 years: very good training in taking history, in making
a differential diagnosis, and good training in specific disease
areas like asthma or like dermatology. I think the areas of weakness,
where they exist, are, first of all, an awareness of allergy as
a potential diagnosis—I do not think that is as good as
it could be—and, secondly, understanding some of the second
line issues around diagnostic procedures and treatment procedures.
So I think General Practitioners are very good at first line,
simple symptom control but perhaps not in the more complicated
cases of allergy.
Q15 Baroness Platt of Writtle: Who
is doing the training locally for them?
Professor Marshall: For General Practitioners,
perhaps I could divide between higher specialist training, before
somebody becomes a GP, and post-specialist training. In terms
of higher specialist training, the main people responsible for
setting the standards are a group called PMETB a regulatory body
with responsibility for setting standards of training. They work
very closely with the Royal Colleges, and with the Postgraduate
Deans. So they are responsible also for providing the specialist
training. Once somebody has qualified and in independent practice
then, again, the Postgraduate Deans play a role and there are
a number of specialist allergy courses that General Practitioners
can attend around the country, particularly one in Southampton
and one in Warwick, that have been around for some years and are
very highly regarded.
Q16 Baroness Platt of Writtle: But
not necessarily over all the country.
Professor Marshall: No, I think that is true,
although people are very willing to travel to high-quality courses
like the Southampton and Warwick ones, so I do not think they
have to be in each locality.
Q17 Baroness Platt of Writtle: There
are 13 million patients with allergic disorders, 7 million of
whom would benefit from specialist care. To whom can the patient
be referred in the absence of a specialist in the area?
Professor Marshall: It is an important issue,
and I think it is, perhaps, where our allergy review came out
as rather different from the recommendations in the Health Select
Committee report and, prior to that, in the Royal College of Physicians
report in 2003. They called very strongly for much larger specialist
services, particularly a much larger number of specialist allergists.
We could find no evidence that that was going to be a cost-effective
way of using limited resources, and our argument is that what
we need to do is skill-up the primary care services far more.
So our argument is that if primary health care teams, which include
General Practitioners, practice nurses and community dieticians
as well, were working well then actually the need for specialist
services would be far less. Having said that, there very clearly
is a need for specialist services, and I think it is absolutely
clear that there are inadequate specialist services at the moment.
Q18 Baroness Platt of Writtle: If
you are going to rely on the GPs and the practice nurses, which
I think is a good idea because it is local and near the people
who have the problem, where are they going to get their specialist
training, if it is not available locally? They are busy people.
Professor Marshall: That is a key issue, and
I would agree with you that it is something we need to look at.
Q19 Chairman: Can I pick up on that
and follow on, because you cite the courses in Southampton and
Warwick, but my understanding is that most of the people on those
courses are nurses, they are not GPs, and they are not actually
providing clinical experience on those courses; they are not monitoring
the practitioner's clinical practice either even back at base.
Professor Marshall: You are certainly right
about most attendees being nurses rather than General Practitioners,
and I think in many ways that reflects the nature of the skill
mix and delivery of primary care over the last 10 or 15 years.
I think you are correct that in terms of assessing the quality
of services at a local level I do not think that happens adequately
at the moment.
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