Examination of Witnesses (Questions 40-56)
PROFESSOR MARTIN
MARSHALL, PROFESSOR
SALLY DAVIES,
DR KEITH
RIDGE AND
MR ALAN
BELL
22 NOVEMBER 2006
Q40 Lord Colwyn: We hear, that levels
of allergy have soared in recent years and that GPs, perhaps,
do not have an ideal training and cannot always cope with it and
specialists are few and far between. Having said that, I do want
to put a word in for my own profession, that of dentists, because
in fact I recall having a fairly comprehensive training on allergy
and certainly continuing professional education. It is something
that we have to be very careful with; dentists are providing more
invasive treatments, and it is a problem that we have to be aware
of. So patients tend to go to high street counters for their treatments.
Is there any evidence that treatments of no particular value are
being offered over the counter in high street shops?
Dr Ridge: In terms of the tests that are available
over the counter, the regulation of that, as you will see from
the memorandum, is largely based on whether the product is a medicine
or whether it is a medical device. For actual medicines, those
that are classed as medicines—creams, and those types of
things that are classed as medicines—those are regulated
in the normal way. For pharmacy itself there are professional
standards in place which are currently being revised as pharmacy
undergoes, if you like, a revolution in terms of how care is provided
on the high street, and a new regulatory framework for pharmacists
should be with us next year in terms of professional regulation.
For other professionals we are likely to bring forward regulation
of acupuncturists and herbal medicine as soon as possible. We
have also asked the Prince of Wales' Foundation for Integrated
Health to develop voluntary self-regulation amongst a range of
other currently unregulated professions. As far as pharmacy is
concerned, can I say a word around pharmacists in terms of their
training? The pharmacy undergraduate course contains elements
on allergy and conditions associated with allergy. Allergy is
also in postgraduate training which is well taken up. Therefore,
I would expect a pharmacist, from a professional point of view,
to be recommending medicines or medical devices which have a proven
use.
Q41 Lord Colwyn: I may be wrong but
I recall that the prescribing of antihistamine had to be done
on the script and now you can get it over the counter. Has that
changed? That must make a lot of difference to the products that
are available.
Dr Ridge: Absolutely. There are a range of products,
licensed medicines, which are available over the counter. I think
in the memorandum there is a figure which states that about £60
million a year is spent on over-the-counter therapies associated
with allergy.
Q42 Lord Colwyn: Can I come back
to the problem of the complementary therapies, because this is
something of great interest to me. Of course, many of the complementary
therapists are, actually, regulated (you mentioned the ones who
are looking for regulation). Is there any evidence that treatment
in a complementary way is harmful in any way?
Dr Ridge: I am not aware of any evidence that
it is harmful. I guess we could look further at that. However,
homeopathy, for example, as I guess you will be aware, is a recognised
system of medicine and regulation, and in fact we have just brought
forward new regulations around homeopathy in terms of the requirement
for products to satisfy a safety and quality test, and those regulations
came in on 1 September this year.
Q43 Lord Colwyn: The treatment of
allergy is all about arming one's immune system. That is the aim
of complementary therapies. I do not know if you would comment
on that.
Dr Ridge: In terms of whether complementary
therapies cause any harm? Is that the question?
Q44 Lord Colwyn: Yes.
Dr Ridge: I am not aware that they cause any
harm.
Professor Marshall: May I just add to that?
In terms of direct harm from complementary therapies, there is
not a lot of evidence, but Professor Edzard Ernst's team in Exeter
has done some interesting work looking at indirect consequences
of using complementary therapies, particularly in terms of delayed
diagnosis and delay in receiving evidence-based therapies. So
there is some interesting evidence here but it is contested, I
think it is fair to say.
Lord Colwyn: I think it is very minor
evidence on that.
Q45 Lord May of Oxford: You must
be aware that recently in the House of Lords, in the debate in
fact sponsored by Lord Taverne on the regulations on the labelling
of homeopathic medicines, a variety of people of expertise in
various relevant walks of life—the kind of expertise you
find in the House of Lords—voiced very strongly the belief
that the regulations had confused anecdote with established canons
of controlled scientific evidence in what was allowed on labelling.
In the light of that, can we have confidence that if you are going
to move to produce regulations for these alternative things they
will be done with a bit more thought and rigour?
Dr Ridge: As you may be aware, there are two
existing reviews of healthcare professional regulation, at the
moment. One is associated with the medical profession and one
with non-medical professionals. Consultation on that has just
finished and the principles associated with both of those reports,
I would imagine, would apply to certainly the herbalists and the
acupuncturists in terms of their statutory regulation forthcoming.
As for the others, if it is a self-regulatory system then I would
hope to see similar principles apply, but it is still a self-regulatory
system.
Q46 Lord Taverne: You will be aware
that when it came to the homeopathic regulations introduced on
1 September concern was expressed by nearly all the professional
societies—including the Royal Society, the Academy of Medical
Sciences and the Pharmacological Society—that for the first
time regulations were being introduced which allowed claims of
efficacy to be made which were not scientifically tested. Is that
something which is going to be part of future regulation or not?
Some concern was expressed to us at the seminar which was held
before we started hearing witnesses that there was some misdiagnosis
or delayed diagnosis, and the Royal College of Pathologists seems
to have expressed concern that the regulation of non-NHS clinics
is not adequate and that misleading advice can be harmful and
costly for patients. I hope these representations are being taken
seriously, and that we are not going to resort to non-scientific
approaches to medicine on something as important as allergies.
Dr Ridge: You are right in terms of how the
regulations are set up and in terms of their requirement or not
to demonstrate efficacy. I think that you are right to be concerned.
However, there is clearly a need for complementary therapies,
and the regulation of the professionals associated with those,
I think, is in the process of being enhanced.
Q47 Lord Taverne: Enhanced but not
in the way in which it was enhanced to promote the homeopathic
industry in the recent regulations. I hope that the regulation
will be based on scientific tests. Can we have an assurance on
that one?
Dr Ridge: I would need to go back and talk to
people about that assurance. I am sure we will provide you with
a note.
Q48 Lord Broers: May I ask whether
there have been studies of the effects of prolonged allergic disease
and the consequences of that? It would seem to me that severe
asthma puts great strains on one's heart. I am not an expert on
this, I am an engineer, but it would seem rather obvious; I have
watched people with sustained asthma and it seems to put great
strain on their system, so anything that delays treatment would
seem to be harmful.
Professor Marshall: There is evidence that untreated
asthma can lead to long-term lung disease. So there is certainly
evidence about that. Whether there is evidence in other areas
of allergy, I am not sure.
Professor Davies: No, I am not sure. Of course,
long-term bad lung disease can have an impact on the heart, but
you go through the lung disease before you impact on the heart
long term. There is evidence that we all recognise as clinicians,
of the allergic skin conditions it can lead to, lichenification,
thickening, and itching and unpleasantness. So we are all aware
of long-term consequences. Have I seen a study that tells you
the magnitude of that problem? No, but this is not my speciality
area; I am a haematologist.
Q49 Chairman: Dr Ridge, could I follow
up on the line of questioning that was directed at you previously?
If we look at the patients who go into their local chemist shop
and ask to see the pharmacist because they have symptoms that
they believe to be allergic in nature, what training does that
pharmacist have to give the advice and recommendations that are
given?
Dr Ridge: Pharmacists now undergo a four-year
training programme at undergraduate level. I have confirmed with
the Royal Pharmaceutical Society of Great Britain, who are the
regulators of the pharmacy profession, that the components of
allergy and treatment are within the indicative curriculum at
the undergraduate level. It is also within the pre-registration
year. At postgraduate level, the Department of Health funds the
Centre for Pharmacy Postgraduate Education based at the University
of Manchester, and they provide a series of learning materials
associated with allergy, and looking at the figures in terms of
uptake it seems reasonable.
Q50 Chairman: Do they have any input
from the clinical experts in allergy?
Dr Ridge: In terms of the Centre for Postgraduate
Pharmacy Education and how those packs are constructed, yes, is
the answer to your question. I think it is also worth mentioning
that as roles change within pharmacy (and, for example, pharmacists
with a special interest will be with us quite soon, clinical specialists
associated with a particular speciality working alongside and
within a network associated with specialists in a hospital environment),
then I expect to see that those people will be accredited in terms
of how their training will take place. That is a requirement.
Q51 Chairman: It seems to me there
is an enormous training load that is emerging in this session:
training of the GPs, training of nurses and training of pharmacists.
Yet that requires a body of specialist knowledge to be informing
that training process otherwise you will have constant repetition
of what was the level of knowledge at one time but without integrating
all of the research and, indeed, being involved in modern clinical
practice, that will eventually become increasingly out of date.
So there is a concern, I think, about the number of specialist
services and specialists that will be brought forward if they
are going to undertake the amount of training that is going to
be demanded of them with these changes you propose.
Professor Davies: Perhaps I could give you some
good news. As you will know through the UK Clinical Research Collaboration,
we went through a process which acquired the name of Walport,
from Mark Walport, of looking at the training of clinical academics
and agreed with Modernising Medical Careers a schema for training
clinical academics which would be clinical fellowships and clinical
lectureships. We are, at the moment, looking at the bids from
university/NHS partnerships for training these people and accrediting
those training programmes. We have agreed 11 programmes in allergy,
which is not insignificant.
Q52 Chairman: That is not insignificant,
and thank you for bringing some good news to the table, Professor
Davies. Could I move back to government policy and just ask you
how the policy is formed in terms of giving advice to patients?
For example, if we take the report from the Committee on the Medical
Effects of Air Pollutants, does the Department now advise the
public that air pollution is an important factor in allergic disease?
Mr Bell: If I may answer this one, obviously
in any area of government policy we would want to be informed
by the available evidence. We believe that having done the review
of allergy services we have done a lot to provide evidence for
further development of policy on allergy. Referring to the particular
report from COMEAP, my understanding of it is that that report
showed that exposure to air pollutants does not in itself cause
asthma but it may produce a worsening of the symptoms. Our colleagues
at Defra provide an air pollution service on behalf of the UK
Government and the devolved administrations. That air pollution
service for the public involves making hourly updates available
to the public through the Internet, a freephone helpline and TV
teletext, and those updates show the current levels of air pollution
and air quality forecasts. Defra also issues hourly updates to
the media and other subscribers. So there is that information
which we make available to the public about the levels of air
pollutants. There is also a free booklet which you can get through
the Defra website, which was produced by Defra in collaboration
with us and some other government departments, which will give
you advice as a member of the public on what particular levels
of air pollutants may mean for you and your health.
Q53 Chairman: What about advice to
pregnant and lactating mothers over diet?
Mr Bell: I am not an expert on that area. I
know the Department of Health has issued advice on that area.
I think that may be something we would need to follow up in writing
to you.
Chairman: It would be helpful because
there are questions over the evidence base for it and indeed,
if it is no longer underpinned by the evidence base, whether it
has been made quite clear that that advice should no longer be
given to women who are pregnant or lactating.
Q54 Viscount Simon: You talk about
air pollution, which is a very, very wide term. By what is air
being polluted?
Mr Bell: I would have to look at the COMEAP
report to narrow down which pollutants are being talked about.
There are all sorts of different things in the air, and I would
need to check what the details are and what the Government's air
pollution service therefore gives you information on. I am sorry
I cannot answer that.
Q55 Chairman: Thank you. We are just
about at the end of our questioning. I have one thing, but you
may want to supply this as a supplementary later, and that is
who is actually responsible for determining the coding with the
disease codes? The coding issue emerged early in our questioning.
Professor Marshall: A combination of Connecting
for Health, and that is directly through the clinical lead for
Connecting for Health, a gentleman called Michael Thick, and the
Chief Medical Officer's team, and I would take direct responsibility
for that. So it is a combination of the two of us.
Q56 Chairman: Perhaps you might like
to take away our concern about the current coding system. Is there
anything else you would like to tell us about that you feel that,
perhaps, you have not had a chance to explain adequately in the
questions we have put to you?
Professor Marshall: No, we are happy, thank
you.
Chairman: Can I thank you for coming.
If there is anything else that comes to mind, please feel free
to send it in and it will be published with your evidence. Thank
you all for coming and giving evidence today.
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