Examination of Witnesses (Questions 20-39)
PROFESSOR MARTIN
MARSHALL, PROFESSOR
SALLY DAVIES,
DR KEITH
RIDGE AND
MR ALAN
BELL
22 NOVEMBER 2006
Q20 Lord Soulsby of Swaffham Prior:
Pertinent to GPs and their knowledge of allergies, are there regional
differences that GPs should be aware of, that in the North of
England, for example, this is more common than something in the
South of England? If that is so, what special training and information
is given to GPs to be on the look out for issues that may not
occur in different parts of the country?
Professor Marshall: Do you mean regional differences
in the epidemiology of allergies or the provision of services?
Q21 Lord Soulsby of Swaffham Prior:
Regional differences in the causation of allergies, more than
the administration.
Mr Bell: Perhaps I could just comment on that.
The epidemiological data that we pulled together for the review
did not show any clear differences between different parts of
the country in the proportions of people who might develop different
allergic conditions. We do not think that really is an issue.
Q22 Lord May of Oxford: If I could come
back to the Review of services for allergy, it made
some recommendations and I would like to ask you about two of
the recommendations: what has been done towards implementing them
and on what timescale. The first suggested thinking about commissioning
the development by NICE (which I think is the National Institute
for Health and Clinical Excellence) of guidelines for allergy,
and the second recommendation was that there might be some work
with the Royal Colleges on guidance for referral and care. What
actually has happened and on what timescale do you see that happening?
Professor Marshall: Could I apologise for our
use of acronyms; it is a disease that we all have within the Department
of Health system.
Q23 Lord May of Oxford: I apologise
for not knowing it!
Professor Marshall: Yes, we regard the development
of guidelines as being one of the more important of our recommendations.
We have worked up proposals which have been submitted to NICE
in order to develop allergy guidelines. We have submitted them
to two of the NICE consideration panels, to the Long-term Conditions
Panel and to the Maternity, Children and Adolescents Panel, and
we understand that they are going to be looked at around about
now, certainly before the end of the year. If they agree that
it is important, and our understanding is that they probably will,
then it needs to be taken to a national committee in January,
which prioritises it alongside other demands for guidelines, and
then taken to Ministers to be signed off. If it is signed off
then the development of guidelines usually takes between 18 months
and two years. So, as far as NICE is concerned, we have taken
action. We did make a specific recommendation about involving
the Royal Colleges in developing further guidelines. We decided,
after discussions with NICE, that it would be better for the Royal
Colleges to feed into the NICE process, so we do not have parallel
processes going on. We have done some specific work with the Royal
College of Paediatrics and Child Health over developing care pathways,
and we have just started talking to them. They are apparently
very keen on working with us, and that work will be taking place
over the next few months.
Q24 Viscount Simon: Stephen Ladyman,
in evidence to the House of Commons Health Committee, said that
he was going to ask the Chief Medical Officer to oversee an allergy
"action plan", in effect to guide and support local
allergy commissioning. Do you know what has happened to that?
Professor Marshall: Yes. As a Government we
are very committed to ensuring that any policies that we make
or any action that we take is based as firmly as possible on research
evidence, and we felt there was insufficient research evidence
to take action immediately after the House of Commons Health Select
Committee. That is why the decision was made by the Chief Medical
Officer to undertake a further review, and hence the review that
we have submitted to you. Now that that review has been published
(it was published in July) you will see a series of next steps
or recommendations, many of which are in line with and address
the issues recommended by the House of Commons Health Select Committee.
Q25 Viscount Simon: Have any PCTs
commissioned any allergy services?
Professor Marshall: To our knowledge, not yet—to
our knowledge. We have sent them copies of the review and we are
going to be doing work with them, as we mentioned, on one of our
recommendations around commissioning.
Q26 Viscount Simon: Do the local
commissioners have the money, the expertise and other resources—and
I stress those words—to co-ordinate appropriate allergy
services?
Professor Marshall: This is the key question.
I think it is the right question because action needs to be taken
at a local level. Whether PCTs have the capacity or capability
at the moment to undertake commissioning of the quality that we
would like them to undertake, I think, is questionable, although
we are putting steps in place to support them and make sure that
they skill up much more rapidly. That is a general issue in terms
of commissioning. Specifically in terms of commissioning allergy
services, it is up to the local PCTs as commissioners to decide
on the priority of allergy services alongside the many other priorities
that they are going to have to look at. I would not be at all
surprised if PCTs decided that cancer services, cardiovascular
services, liver services and chronic obstructive pulmonary disease
are higher priorities for them than allergy services will be.
Q27 Chairman: You are asking them
to commission for services but without baseline data of the level
of need. All you have got is that perception of demand, which
may be quite different to need.
Professor Marshall: Commissioning is a complex
process; it is not just about, as you are well aware, contracting
for services. The first step of commissioning is needs assessment.
We are asking them to undertake the needs assessment first before
they then decide what their local needs are. That process is not
just about looking at the epidemiology in their local areas, it
is also about consulting with key stakeholders, of which we regard
the public as being an absolutely key one. If the public regard
allergy as being a priority then that is something that the PCT
will have to take on board.
Q28 Chairman: Without the coding
how can they collect the data, without doing an original research
project, which they do not have the resources to do?
Professor Marshall: They are going to have to
look at other codes that might be related to allergy services.
It is the weakness and a deficiency, as we have already identified.
Q29 Chairman: Can I go back to another
gap, possibly, that you have highlighted, which relates to training?
If you are wanting GPs to undertake the larger part of the services
and there are not adequate training courses for them (and indeed
they are not on them at the moment) then it seems that you have
got an enormous amount of training to do, and yet if specialist
services do not have the capacity to provide that training you
do not have anybody to provide the training which would be needed
to get them up to the level to be able to provide the service.
Professor Marshall: I agree that that is a particular
issue. What we are doing is working very closely with the Royal
Colleges and with the Deans to try to address that issue. I think
we are starting from a fairly low baseline in terms of allergy
services. One specialist allergist committed to teaching can teach
many hundreds of GPs over a period of time, and therefore what
we would expect is a cascade process. So I agree that there are
insufficient allergists to be able to move things on very quickly,
but we believe that action can be taken.
Q30 Chairman: However, you do still
need to have specialists coming up in the system particularly
to replace those who take time out to do teaching.
Professor Marshall: Yes.
Q31 Lord Taverne: The UK Health
Research Analysis carried out by the UK Clinical Research
Collaboration analysed spending on health research in the UK,
but because allergy is a multi-organ disease it fell across several
disease categories. What should be done to ensure that you get
a grip on the results of the research and that it does not suffer
from being compartmentalised?
Professor Marshall: Perhaps I could ask Professor
Davies to answer that question.
Professor Davies: Thank you. I am glad you have
seen this report. I chair the UK Clinical Research Collaboration
and I am very proud of the work we have done in this. It is the
first time anywhere in the world that we have looked at how research
funding is spent, and this takes in all the major public sector
funders and the major charities. It was a very intensive, 18-month
project and we split it down, as you have seen, into a number
of areas which did not include allergy—you cannot do everything.
Here, where the bits most relevant to allergy are respiratory,
what you will see was perhaps expected, but what was worrying
was that when we compared the research spend with the disease
burden there was an imbalance. However, we cannot do much more
in depth with the data because it is a limited data set that was
collected there. What we are doing with most of the major public
funders is continuing to categorise present and future spending
in this way, so we will collect that. I think the highlight around
the respiratory, much of which is COPD or asthma, is very important.
That shows that there is an imbalance that needs to be looked
at, but it is high level. We are clearly doing a lot to try and
make sure the funding goes where it should, and you will know
that at the end of January we launched the new government strategy
for health research in NHS, Best Research for Best Health,
that opens up a lot of funding opportunities in this area for
allergy or other diseases where they need to do clinical research.
Q32 Lord Taverne: What about the
cost of the research? Research is national and goes beyond PCT
boundaries. How will this be accounted for when you have practice-based
commissioning?
Professor Davies: Research is a national good,
so it is not money that we devolve down. Indeed we are, as part
of Best Research for Best Health taking money out that
was given historically to hospital trusts—over £500
million a year—being spent on research and supporting research,
and putting it back totally transparently over a three-year transition
period. Where necessary that will be competitive, but all transparently.
So in the future we will know much better where the money is going
and it will have been subjected to much stronger quality thresholds
and relevance thresholds than it is at the moment.
Q33 Chairman: I wonder, Professor
Davies, if you could tell us how much research is going on into
food allergies and anaphylaxis? You have referred to respiratory
problems.
Professor Davies: We do not know and it is not
data we can get at. When we look at what we know we are funding,
we fund a unit at Imperial for £2 million over four years
looking at allergy and asthma; we are funding five projects within
the Health Technology Assessment Programme for a total of £2.2
million and they are doing studies like comparing inhaled corticosteroids
with leukotriene receptor antagonists and, interestingly, a trial
of ion-exchange water softeners for the treatment of atopic eczema
in children. On reviewing the reports that we receive from hospital
trusts for those allocations that are historical we know that
there are five major programmes which are working in the allergy
field, including Guy's and St Thomas', King's College Hospital,
the Royal Brompton, Southampton and South Manchester. However,
to break it down further we cannot do at this stage.
Q34 Chairman: My understanding is
that the majority of those are respiratory-based.
Professor Davies: I can see from the data I
have that four out of the five are definitely respiratory-based.
The Southampton one we do not have data on.
Q35 Lord Broers: The indirect costs
of allergic diseases are potentially huge. How does absence from
work due to allergic conditions compare to that of other conditions,
for example back problems, mental illness and repetitive strain
injury?
Professor Marshall: The indirect costs are absolutely
potentially huge. We do not have any good comparative data comparing
issues related to allergy with the other conditions that you mention.
One of the problems with allergy is that it does not tend to be
a diagnosis that is put on sick notes, for example, in the way
that back pain might be. So we do not have any direct comparative
data here. I suspect and hope that colleagues from the Health
& Safety Executive might be able to give you more data than
we have available here.
Q36 Lord Broers: Do you think the
Department of Health response to the diagnosis and treatment of
these conditions is proportionate to their impact on work, education
and quality of life?
Professor Marshall: I think that is a difficult
question to answer in absolute terms. If all we are doing is looking
at allergy services then I would probably argue that our response
is not appropriate. If we compare it with other priorities then
I think it is appropriate.
Q37 Lord Soulsby of Swaffham Prior:
You may have answered, in part, this question: what is the level
of support given through grants under Section 64 of the Health
Services and Public Health Act 1968 to not-for-profit organisations
that support people with allergy?
Mr Bell: Perhaps I may answer that one. We looked
at that on the database and apparently over the last decade we,
in the Department of Health, have awarded grant funding under
Section 64 (the general scheme of grants) to voluntary bodies
in the allergy field totalling over £532,000.
Q38 Lord Soulsby of Swaffham Prior:
What are the criteria for receiving these grants?
Mr Bell: Essentially, the Section 64 general
scheme gives the Secretary of State for Health the power to make
grants to voluntary bodies in England whose activities support
the Department of Health's policy priorities. Needless to say,
the competition for available funds every year is extremely strong
and we give priority to applications with innovative proposals
of national significance that will complement statutory services
and so help to secure the provision of high-quality health and
social care and, by so doing, promote the nation's health.
Q39 Lord Soulsby of Swaffham Prior:
You mentioned approximately half a million in funding. To my mind
that does not seem an awful lot of funding for what we are talking
about. In answer to Lord Broer's previous question it is a major
problem, yet half a million seems an extraordinarily small amount
of money to put into this.
Mr Bell: You could certainly argue that. As
I say, it is always very competitive who is going to get grants,
but I could say that to my knowledge three organisations—Allergy
UK, Asthma UK and the National Eczema Society—have all had
grants in that period, and the main beneficiary out of the three
is Allergy UK, which has had four different grants totalling nearly
£400,000. Section 64 funding is very much regarded as pump-priming;
we do not look to fund, on the whole, the core administrative,
ongoing costs of these bodies; we are looking to help them with
particular projects.
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