Select Committee on Science and Technology Minutes of Evidence

Memorandum by the Royal College of General Practitioners

  1.  The College welcomes the opportunity to make submissions to the House of Lords Science and Technology Select Committee's Call for Evidence on Allergy.

  2.  The Royal College of General Practitioners is the largest membership organisation in the United Kingdom solely for GPs. It aims to encourage and maintain the highest standards of general medical practice and to act as the "voice" of GPs on issues concerned with education, training, research, and clinical standards. Founded in 1952, the RCGP has over 24,000 members who are committed to improving patient care, developing their own skills and promoting general practice as a discipline.

  Please find below a submission to the Committee's Call for Evidence questions as outlined below the four topic headings:


What is allergy? What is the difference between allergy and intolerance?

  3.  The term allergy has evolved in medical usage over the last century so whereas once it referred to any type of immunological response, it typically now has a much more specific meaning referring to an immunological response to an antigen mediated by specific IgE. These reactions are also sometimes known as Type 1 or immediate hypersensitivity reactions.

  4.  At the same time as its meaning becoming more restrictive in medical usage, the word allergy has also penetrated lay social discourse, where it is also rapidly evolving, but in a way that sees it being used in an ever more broad sense.

  5.  Intolerance reactions are common and can result in significant morbidity. Although the underlying pathophysiological mechanisms are often not clearly understood, it is clear that these reactions are not specific IgE mediated. Clinically, these are far more variable in onset, less predictable and typically more transitory than allergic reactions; they are not life-threatening.

What is and what is not known about the origins and progression of allergic disease?

  6.  Allergic disorders can affect people of any age, both genders and all ethnic groups. There are however considerable variations in prevalence of these disorders internationally. Allergic conditions often manifest first very early on in life, often beginning with eczema/dermatitis and food allergy in the first year of life, progressing onto the development of allergic rhinitis and asthma in early childhood, and other more systemic allergic disorders such as urticaria and angioedema typically manifesting more commonly in middle-age. Anaphylaxis is the most serious manifestation of allergy and occurs in children and adults.

Why is the incidence of allergy and allergic diseases rising? Why does the UK in particular have such high prevalence of allergy?

  7.  The reasons underpinning these dramatic recent increases are complex and as yet poorly understood. Whilst some of the observed increases are likely to be due to a combination of better recognition, changes in disease labelling patterns and a lowering in the threshold for diagnosis, there has almost certainly also been a genuine increase in the incidence and prevalence of allergic conditions over the latter half of the last century in the UK and elsewhere. The UK ranks highest in the world for asthma symptoms, with a prevalence 20-fold higher than that in Indonesia, it is also near the top of the world ranking for rhinitis and eczema.[1],[2]

  8.  The narrow time window in which these increases have occurred makes it implausible that these changes are due to genetic factors—rather, they are due to environmental and gene-environmental interaction factors, which are affecting large sections of the population, particularly in very early life (foetal development and/or infancy). Numerous risk factors have been suggested as being responsible for these increases, but as yet the reason(s) underpinning these increases remain elusive. Given the number of identified risk factors, it is likely that these increases represent complex interactions between a variety of environmental factors and genetic predisposition.

  9.  The epidemiological picture has become even more complex in recent years with indications that there may be diverging trends in the local and systemic allergic disease trends: the prevalence of the more local allergic disorders such as eczema, hay fever and asthma appears to have stabilised in the UK and may even be declining, although there are no signs of similar declines in relation to the more systemic allergic conditions such as food allergy, urticaria, angioedema and anaphylaxis.

What gaps exist in establishing the overall disease burden for all types of allergy and what are the barriers to filling these gaps?

  10.  We currently have no data on Accident & Emergency consultation rates, hospital out-patient consultation rates and hospital in-patient prescribing, which makes it difficult to assess overall disease burden from the point of view of the NHS. We also have no real idea of loss of time from work or school or understanding of the impact on day-to-day life, educational impact, career prospects and social activities of those suffering from most allergic disorders which renders it difficult to assess the disease burden posed to individuals who suffer from many of these allergic problems.

  Strategies to filling these gaps include:

    —  A more comprehensive range of disease codes and aetiological trigger factors for use in primary and secondary care (for example, there is currently no codes for peanut or kiwi allergy in ICD-10).

    —  Central database of out of hours contacts (NHS Direct).

    —  Central database of A&E consultations.

    —  Central database of out-patient consultations.

    —  Data linkage potential between different healthcare datasets to allow more meaningful analysis of overall disease burden to individuals and populations and also to allow the study of risk factors associated with disease development and exacerbations.

    —  In the light of such large variations, there is a need for on-going data surveillance, particularly for food allergy and anaphylaxis.

    —  Quality of life measures being developed for the full spectrum of allergic conditions.

In addition to the impact on the health service, what is the overall socio-economic impact of allergic diseases (for example, absence from work and schools)?

  11.  This is likely to be large, but cannot reliably be measured at present because of the absence of relevant data collection (see above).


What is the effect of current treatments on the natural history of allergic disease?

  12.  There are currently no cures for allergic problems—rather, what we have is an array of non-pharmacological and pharmacological approaches which can, in most patients, help achieve symptom control and possibly result in some modification of the underlying disease course.

What is the evidence-base for pharmacological and non-pharmacological management strategies?

  13.  Whilst the evidence-base for pharmacological treatment approaches is on the whole good for most commonly used preparations, there is less secure evidence for allergen avoidance approaches that are commonly recommended. There is also very little evidence in relation to important health services research questions about how best to structure care.

  14.  The shortage of capacity in allergy treatment capacity has led the public to look outside the NHS. This has resulted in the proliferation of questionable allergy practice in the field of alternative and complementary medicine, where unproven techniques for diagnosis and treatment are used. [3]

Is the level of UK research into allergy and allergic disease adequate?

  15.  There are currently no dedicated funding streams for allergies in the UK and there are also no charitable funding streams for researchers to draw on. Much of the existing generic funding available from the Medical Research Council and the Wellcome Trust has, for example, been directed towards basic sciences and translational research and there has as a consequence been very little dedicated health services research into allergy. This problem was highlighted in the recent Department of Health and Scottish Executive reviews into allergy services and the relative lack of evidence uncovered in relation to how best to provide care. In view of the scale of the problem, what is needed is provision of programme research grants to allow meaningful progress to be made.

What are the most promising areas of research into preventing or treating allergy?

  16.  There is a need for a dedicated Cochrane review group for allergy to allow relevant high quality evidence in relation to disease prevention, treatment and organisation of care to be systematically collated and periodically updated. Areas of research that need investing in include studying the role of dietary exposure in pregnancy and infancy, evaluating the role of prebiotics, probiotics, anti-oxidants, pasteurised milk and vaccination based strategies, amongst others, and various combinations of these, for preventing disease onset and progression. Research is also needed into educational initiatives aimed at primary care staff and also new models of delivering care such as General Practitioners with Specialist Interests in allergy.


How effective have existing Government policy and advice been in addressing the rise in allergies?

  17.  The number of allergy specialists is totally insufficient to meet the need. Improved links are required between primary and secondary care. Increasing specialist capacity in allergy practice would improve diagnostic and treatment advice and would allow primary care teams to draw on an existing specialist knowledge base.

  18.  The only specific government advice that we are aware of relates to high risk mothers modifying their diets and those of their infants, but there was no proactive attempt to assess compliance with this and evaluate its effectiveness.

How is current knowledge about the causes and management of allergic disease shared within Government?

  For example,

    —  Do housing policy and regulations governing the indoor environment pay enough attention to allergy?

    —  How effectively are food policy and food labelling regulations responding to the rise in food allergies?

  19.  Current housing policy has not really considered the issue of allergy in any serious detail. The recent EU directive about food labelling appears to have been helpful in allowing food allergy sufferers to better determine the contents of pre-packaged foods, but there has been no attempt empirically to evaluate whether food allergy sufferers have found this advice helpful or satisfactory. Furthermore, issues remain about the adequacy of current labelling approaches.


What impact do allergies have on the quality of life of those experiencing allergic disease and their families?

  20.  In some patients, allergic disorders are relatively short-lived and exert only a relatively minor impact on day-to-day life. There is however ample evidence that they can also be life-threatening, and in those with particularly severe allergy or substantial co-morbidity the concern is that they can impact on all aspects of day-to-day life. For those with food allergy, the whole household can be affected and impairment in quality of life for young people can be comparable or even greater than those with diabetes. Living with the threat of possibly life-threatening reactions can be very worrying for all concerned.

What can be done to better educate the public and to improve the quality of information that is available to patients and undiagnosed sufferers?

  21.  A number of measures need to be taken, including:

    —  Better undergraduate training for healthcare professionals which is based on an understanding of the needs of sufferers.

    —  Similarly, better postgraduate training opportunities, particularly for GPs and their teams.

    —  A national NHS e-library for allergy with a section also available to the public.

    —  Map of Medicine for allergies which patients also have access to.

    —  A dedicated patient helpline/website, linked to NHS Direct, for authoritative information being made available in a range of languages.

Are current regulatory arrangements, for example, those governing private clinics offering diagnostic and therapeutic services and the sale of over the counter allergy tests, satisfactory?

  22.  No, as there are a number of diagnostic tests available which do not have any sound scientific basis—these are therefore unhelpful, and potentially harmful, as they can result in considerable unnecessary restriction of diet etc. Better regulation would certainly be helpful, accompanied with far better access to scientifically sound tests in primary care.

  23.  I acknowledge the contribution of Professor Aziz Sheikh (Allergy & Respiratory Research Group, Chair; Professor of Primary Care Research & development, University of Edinburgh) towards the above comments; additional contributions were made by Dr Mark Levy (Clinical Research Fellow, General Practice Section, University of Edinburgh; Editor-in-Chief, Primary Care Respiratory Journal), Professor David Price (GPIAG, [4]Professor Primary Care Respiratory Medicine, University of Abderdeen) and Dr Dermot Ryan (GPIAG, Allergy Lead; Rhinitis Guidelines Working Party; Rhinitis Guidelines Committee; Royal College of Physicians, Allergy Working Party). While contributing to this response, it cannot be assumed that all of those named necessarily agree with all of the above comments.

9 October 2006

1   The International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee, Worldwide variation in prevalence of symptoms of asthma, allergic rhinioconjunctivitis and atopic eczema: ISAAC. Back

2   European Community Respiratory Health Survey. Variations in the prevalence of respiratory symptoms, self-reported asthma attacks and use of asthma medication in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1996; 9: 687-95. Back

3   Bielory L. "Complimentary and Alternative Medicine" Population based studies: a growing focus on allergy and Asthma. Allergy; 2002; 57: 6,455-8. Back

4   GPIAG: General Practice Airways Group. Back

previous page contents next page

House of Lords home page Parliament home page House of Commons home page search page enquiries index

© Parliamentary copyright 2007