Examination of Witnesses (Questions 167-179)
PROFESSOR STEPHEN
DURHAM, PROFESSOR
PETER BARNES,
PROFESSOR ANDREW
WARDLAW AND
PROFESSOR ANTHONY
FREW
18 DECEMBER 2006
Q167Chairman: Could I start by welcoming you
and thanking you for coming to give us evidence today. I am Lady
Finlay. I am the Chairman of this Committee. The meeting will
be webcast on the internet. There is an information note for the
public which declares the interests of members of the Committee,
so we will not be declaring them during this session. We have
a lot of questions we would like to ask you so if you are able
to keep your answers as concise as possible that will allow us
to get through more and be able to come back to you with supplementary
questions as we go. Perhaps I can ask you to introduce yourselves
and then we will get into the question session.
Professor Frew: I am Tony Frew. I am President
of the European Academy of Allergology and Clinical Immunology,
and a consultant in allergy and respiratory medicine in Brighton.
Professor Wardlaw: I am Andrew Wardlaw. I am
an allergist and respiratory physician in Leicester and until
recently was President of the British Society of Allergy &
Clinical Immunology.
Professor Barnes: I am Peter Barnes. I am a
pulmonologist, Head of Respiratory Medicine at Imperial College
London.
Professor Durham: I am Stephen Durham. I am
an allergist at the Royal Brompton Hospital and President of the
British Society for Allergy & Clinical Immunology.
Q168 Chairman: Thank you. It has
been evident from the way you have introduced yourselves that
you describe yourselves as having an interest in allergy. Would
you describe yourselves as allergists and I wonder if you could
also outline for us the route by which people become allergists
and quite what is meant by this term?
Professor Frew: I trained as a respiratory physician
and a general physician and then did additional specialist training
in allergy in London and also in Canada. I practise as an allergist
and would describe myself as such. I do other things as well but
I would certainly accept the term.
Professor Wardlaw: My route into allergy is
through my academic interest. My research is into the pathogenesis
of allergic mechanisms. My clinical practice is about 50 per cent
allergy and 50 per cent respiratory medicine, and my training
in allergy was undertaken in a fairly ad hoc fashion.
Professor Barnes: I am not an allergist; I am
a pulmonologist, but I see a lot of patients with asthma and many
patients with asthma are allergic. I have done no specific training
in allergic diseases.
Professor Durham: I describe myself as an allergist.
Looking backwards, the dilemma is that there was previously no
formal training for allergists until five years ago and therefore
unavoidably my training was ad hoc, so I have been grandfathered
into the term "allergist" on the basis of 20 years'
experience. I think we should be looking forward, not backwards,
as to the best way to train allergists, which is probably not
through specialist training but through training allergists.
Q169 Chairman: As specific allergists,
so allergy training as outlined by the College of Physicians?
Professor Durham: It is our priority, certainly
in the British Society of Allergy & Clinical Immunology, to
equip all practitioners to become aware of, recognise and treat
allergy appropriately. There are different levels that one must
address. There is the specialist allergist in a tertiary centre.
We see it as our role to train chest physicians and other secondary
specialists in allergy, and also to increase awareness in general
practice, and I think we should be looking at a multi-layered
approach in terms of equipping us. From the patient's point of
view I think that is an important benefit.
Q170 Lord Taverne: Is there a proper
career structure for people who are allergists? There is a new
system now for training them but is there a proper framework for
creating posts for people as allergists, because I have heard
a suggestion that this is a lack in the present set-up?
Professor Durham: I think it is a chicken and
egg situation. We need regional centres to train allergists and
then when the specialist trainees become allergists we need to
create posts for them to practise in allergy. The way to look
at this is to look at the needs of the allergy sufferer rather
than individual specialist training. You are quite right to raise
the issue that if we train allergists at the present time will
there be posts for them to move into, but I think that is something
that needs to be addressed centrally.
Professor Wardlaw: Allergy was created a speciality
only five or six years ago and it has been a major effort by the
BSACI to try and establish this as a viable speciality. That has
been through a lot of lobbying of the Department of Health to
try and do that because we need sufficient training numbers and
sufficient consultant posts at the end of it to make a viable
speciality which will provide a network of allergists around the
country. At the moment that struggle still goes on and it is far
from being successful.
Q171 Lord Colwyn: Although it was
a long time ago I seem to recall that the only sketchy medical
training I had in allergy was how you dealt with emergencies.
That was it.
Professor Frew: Certainly within the two medical
schools I have worked in allergy has a definite place in the curriculum.
It is small but it is there and we try to make sure that everybody
coming through nowadays is given some basic knowledge of allergy.
At the same time, as has been said, we are trying to provide retrospectively
some training for people at postgraduate level so that everybody
is aware of the mechanisms and clinical aspects of allergy as
they relate to their chosen branch of medicine.
Q172 Earl of Selborne: I would like
to follow up the concept of a viable speciality. How well co-ordinated
is the process whereby new treatments for allergy and/or their
various allergic conditions are assessed and approved for use
given that the term "allergy" describes a generic immunological
response and the effects may be manifested in a range of linked
diseases?
Professor Frew: The problem is that allergy
is a mechanism rather than a disease in itself and many of the
treatments that come forward are looked at in terms of the organ-based
speciality to which they relate, so treatments tend to be thought
of in terms of treatments for eczema or treatments for asthma
or treatments for rhinitis. A lot of the companies producing these
compounds are relatively small compared to some of the large pharmaceutical
companies dealing with, say, hypertension, and so it has been
difficult to get some of the trials pushed forward. There are
also some barriers in place, particularly for new approaches to
this. For example, recombinant allergens, which look a very attractive
way of treating people by specifically targeting the problem of
that individual, come up against really quite strict regulations
about individual components of the vaccines that you might want
to use, which make it extremely difficult under current regulations
to test and consider how you might get a product licence for them,
and I think in general the co-ordination is not terribly good.
Q173 Lord Rea: What provision is
there currently in the National Health Service for specifically
treating allergy as opposed to the range of conditions affecting
particular organs that come under the general heading of allergy?
Of course, now these are largely handled in primary care or by
other specialities.
Professor Wardlaw: It is very poor, is the answer.
There are very few trained specialist centres or departments dealing
with allergy specifically. There are perhaps half a dozen well
established allergy clinics in the UK and there is a certain amount
of provision from clinical immunologists treating general allergy,
which in some areas is excellent and in other areas is more variable.
The problem is that for a number of reasons allergy has always
been a Cinderella subject and specialist allergy training, as
we have heard, is very poor at undergraduate and postgraduate
level. Organ-based specialists, I have to say, tend to be rather
protective of their patch, as we all are a little bit, I guess,
and I think they feel that their allergy training is better than
we as allergists feel it is, so we feel generally that provision
of NHS training is very poor in the UK now.
Q174 Lord Rea: Do you think there
is a strong case for training nurses and doctors in primary care
to a higher level for recognising allergy and so guiding their
more appropriate treatment?
Professor Wardlaw: Absolutely. The majority
of allergy is seen in primary care and a lot can be effectively
treated in primary care or in the community, but the problem is
that the knowledge of allergy in primary care is very poor and
there is no mechanism for training primary care doctors because
there is such an inadequate critical mass of people to train the
GPs. What you need first, we think, as an allergist is to have
a critical mass and then train the GPs, but it is very important.
Professor Frew: There is an additional issue
here, which is that there are some conditions that patients have
which are fairly easy to map onto the current NHS speciality map.
For example, if you have asthma there is going to be somebody
in your patch who will deal with it at an adult or paediatric
level. If you have a food allergy it can be quite difficult to
identify who in the area should be dealing with it. If you look
at it from the point of view of the patient's problem, if it maps
on to the organ-based specialities it is easy to find somebody
who at least ought to be able to address it, but if they have
a more general problem—anaphylaxis, peanut allergy—it
can be quite difficult to try and find your way through the system
to get specialist advice if you cannot get that at the primary
care level.
Q175 Lord Rea: What short courses
are available for practitioners in primary care or in some other
specialisms to get some improved skills for these things?
Professor Durham: If I may address that on behalf
of the British Society for Allergy and Clinical Immunology, this
is a very big priority for us. The way we are addressing this
is that we are having a primary care day or two days dovetailed
into our annual national meeting. We have organised a series of
regional training days in allergy for general practitioners and
nurses and we have a clinic list of NHS allergy clinics which
is open and available to general practitioners and nurses so that
they may attend those clinics in order to gain experience in allergy.
It is really a more general approach to increase awareness of
allergy, to inform general practitioners when to refer to secondary
care level and also, for a smaller proportion of general practitioners,
to encourage them to develop a specialist interest and support
them through our NHS clinics.
Q176 Lord Rea: Do you think there
is a good case for specialist nurses working in primary care to
handle the allergy component of the workload?
Professor Durham: I would emphasise that I think
that is a very important component. We have the Education for
Health in Warwick that has trained some nurses from some 9,000
general practices throughout the country in the management of
asthma. The same group have also encouraged training in allergy,
so nurses are an important component, but we must bear in mind
that this is what we are dealing with in terms of the common allergic
conditions. What is even more important is to encourage and make
people in general practice aware of when to refer. To give examples,
food allergy, drug allergy, venom allergy, latex allergy, occupational
allergies, the patient with multiple problems, difficult paediatric
problems are all just the sorts of problems that need to be recognised
and referred on. I think it is our role also to empower general
practitioners, and I believe the Government's role to support
not only increased awareness of allergy in primary but also the
facilities at secondary care level to deal with the current epidemic.
Q177 Chairman: How much supervised
clinical experience is contained within the Warwick course?
Professor Durham: At the present time not a
lot, but then I think the objectives of the Warwick course are
to increase awareness of allergy and to empower general practitioners
and nurses to recognise allergic conditions. It is very important
for treatment to have a little knowledge disseminated widely to
increase awareness of the subject at the first base, but you are
quite right: in terms of the need to train GPs to more effectively
manage allergic conditions it requires more specialist services
at secondary and tertiary level.
Q178 Chairman: I just wonder whether
such short courses are appropriate to provide GPs in particular
with the skills that they would need to manage patients with complex
conditions and multiple manifestations.
Professor Durham: May I say that that is not
at all possible. That is why we need to increase allergy awareness
and training at all levels.
Q179 Baroness Perry of Southwark: My
question follows on very much from that discussion. We were told
by the Department of Health that they had proposed to NICE that
they should develop guidelines for allergy, and I understand they
are doing that now. What guidelines would you like to see?
Professor Durham: Two obvious examples in terms
of generic allergy treatment as opposed to organ-based treatments
would be to look at anti-IgE therapy, which is a novel therapy,
and subcutaneous and sublingual immunotherapy for those patients
with IgE mediated disease and a very focused spectrum of problems.
Anti-IgE and immunotherapy would be two appropriate areas.
| 
