Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (Questions 320-339)

Dr Mark Levy, Dr Susan Leech, Dr William Egner and Dr Pamela Ewan

17 JANUARY 2007

  Q320  Chairman: Thank you. Is there a separate curriculum anywhere—and it sounds from what you have said, Dr Levy, that there is not—for GPs who want to develop a special interest in allergy or for those people coming up through other specialties, such as chest medicine, who want to develop a specialist interest in allergy?

  Dr Levy: At the moment, it depends very much on personal interest and personal drive, with GPs cobbling together different courses and educational facilities that are available. For example, if a general practitioner wanted to learn about allergy or specialise in allergy, they would have to do various courses and then find clinical attachments, which are quite difficult to find. They might get some theoretical training but the clinical part is very difficult to access.

  Dr Ewan: Talking about the other medical specialities, allergy is mentioned in their training curricula. It is mentioned in the respiratory medicine one, it is mentioned in the dermatology one, but it is really a very minor part of these and most people training in those other specialties would go through their training with virtually little or no exposure to allergy. It is possible, of course, for people through their own personal interest to gain more training. A small number have indeed done that and have become competent in allergy, but that is very much self-driven rather than available. I suppose the exception is respiratory medicine, in that, in allergy, we do have a tradition of having been linked to respiratory medicine. However, this is centre-driven rather than curriculum-driven and there are some centres of excellence. Most of the allergy major centres have strong links and a strong background in respiratory training.

  Q321  Lord Taverne: You have told us what you are doing separately but how far do you cooperate? Is there any overview by any one establishment?

  Dr Ewan: Not really, in that these committees operate relatively independently. The difficulty is that the integration might come at practice level rather than training level, I think, where one tries to network services. A major part of what is done through allergy centres is networking with GPs in their area and other consultants who have an interest in their area, but this is not at the training curriculum level, this is in practice.

  Q322  Lord Taverne: Is there any point in having more cooperation and some more coordinating effort? Or does it not matter? Is all that matters that people should cooperate in practice?

  Dr Ewan: I think it matters a lot that they cooperate in practice. That probably enables a larger number of people to become involved. But there is certainly a very major need in primary care for more training and for all GPs to receive some training in allergy. Currently GPs can go through their training with really no exposure to allergy.

  Q323  Lord Taverne: That is the worst gap, is it?

  Dr Ewan: It is a huge gap and it comes about because there are very few consultant allergists in teaching hospitals, so it is possible to be a medical student and have one or two lectures on basic principles that might relate to allergy and that is it. No clinical exposure at all because there are no doctors to provide that training.

  Dr Egner: I think it is important to clarify that the immunology and the allergy curricula are devised and established by the same committee in collaboration, balancing the needs of the different specialists about what each of those curricula should contain with regard to immunology components and allergy components. For those two curricula there is a balancing mechanism with regard to their content but there is not, as far as I am aware, any interaction between the Joint Committee on Higher Medical Training that oversees immunology and allergy and that which oversees respiratory training or dermatology training and so on. Furthermore, we are in a period of rapid change with regard to medical training and modernising medical careers, and the perhaps unintended adverse consequence of that is that you can no longer train jointly in a specialty. You have to be on the specialist register for a single specialty. The irony of that is that a lot of practising allergists in major allergy centres have strong links and perhaps have even come through respiratory medicine or other curricula training. With respiratory medicine in the past, there was a curriculum which allowed you to train jointly in respiratory and allergy but that has now gone. Ironically, you can now no longer train jointly in immunology and allergy, which one would have thought was both logical and a way of introducing flexibility into the system. All of these things are introducing difficulties.

  Q324  Chairman: What is going to happen in the future to the person who then develops a specific interest as a clinician in an area with patients, who has been trained, for example, only in immunology without being trained in allergy?

  Dr Egner: The immunologist's view would be that the immunology curriculum contains a large component of allergy. If one looks at European practice, there is not a standard model. Some are joint training programmes, where you do immunology and allergy; others are stand-alone allergists; some have stand-alone immunologists; and a few countries lack one or the other. We do not know what the best model is. It is now up to Trusts to appoint the people that they wish to appoint to perform a function. It is up to that individual and the Trust to be clear that that person is re-validatable, maintains professional development and is fit to practise in that speciality and it is up to each individual doctor to know the limits of their competence and to refer on. One of the major problems is there is no formalised structure, no referral guidelines, no mechanism for referring on and no access to the service because both immunology and allergy are rare breed specialities.

  Q325  Lord Rea: Dr Ewan, you mentioned the intercollegiate committee. How does that operate in coordinating the activities and curriculum development between different colleges?

  Dr Ewan: There is a joint committee, an immunology and allergy committee, which controls those two curricula, with representatives of each speciality on it, but, beyond that, the other committees are separate. One could perhaps have some input into them but in reality they operate as distinct entities.

  Q326  Viscount Simon: My question overlaps the first question but goes a bit further than that, in that paediatricians and other specialists, such as dermatologists, chest physicians and ENT surgeons, have to deal with allergic diseases within those fields. Is the training of these specialists in allergic diseases sufficient?

  Dr Ewan: No, it is not. The reality is that they mostly treat these diseases symptomatically without considering allergy. For example, asthma or eczema can be adequately treated with medicines without considering allergy. Diagnosing means identifying the trigger for the disease and hopefully avoiding that or reducing it and so reducing disease episodes. In many children, eczema will be driven by food allergy. If you can identify the food and avoid it, the eczema can disappear. The alternative approach which would be taken by a dermatologist would be to treat it with creams or other drugs. For the most part these other specialists lack allergy training and have their own approach to the disease. That is perfectly acceptable for a considerable chunk of patients with asthma and patients with eczema. From the allergy point of view, we would not be arguing all these diseases should be seen by an allergist—certainly not—but there have been efforts to calculate the percentage of those people with these diseases where an allergy opinion is important. That still is a considerable number, although it is a minority of the total. That is where allergy comes in. Whilst it would be helpful to have some allergy training for dermatology and respiratory medicine, it is still going to be a small part of their whole remit. The other point to be made is that much of allergy is multi-system and another advantage of an allergist, assuming you need an allergy opinion, is that you sort out food allergy, drug allergy, asthma, eczema, rhinitis in a single consultation, so not only do you give the allergy diagnosis and management but you also save sequential referrals and therefore you reduce the burden on these other specialities, all of whom have their own waiting list problems.

  Dr Levy: This is further compounded by the problem from the general practice aspect, where the GP refers a patient with eczema to a dermatologist and does not recognise that this patient may also have food allergy aggravating their asthma. That referral will result in a dermatological opinion, the patient comes back to general practice and we need to re-refer the patient on to another organ-based specialist. Where the general practitioner is not trained in allergy, they might not recognise the need for multiple opinions, so the referral letter might not actually describe the problem very thoroughly. I agree with Dr Ewan 100 per cent that there is clearly a need for more allergy specialists or more widespread training of the generalists in allergy.

  Dr Leech: I would like to speak to that on behalf of paediatrics. I think it has to do with the quality of the consultation that is offered to the patient. A general paediatrician who sees a patient with allergies will usually manage the patient in a very superficial way; whereas in an allergy consultation you go a lot deeper into the patient's history and you address more than one of the patient's problems. It is a qualitative difference rather than a quantitative difference. That is not always appreciated by a lot of paediatricians who see patients with allergies. Part of the general paediatric training would cover things like respiratory medicine and gastroenterology and part of that would include allergy, but they do not go into allergy in any great depth and as a consequence of that there are fairly fundamental misunderstandings amongst paediatricians about allergy; for example, the use of the terminology is slightly incorrect and can cause confusion. Therefore, even within paediatricians there is a lack of proper understanding of what constitutes allergy.

  Dr Egner: This is perhaps reflected in the guidelines written by professional organisations regarding the management of organ-specific diseases. If you look at guidelines, such as SIGN guidelines for management of asthma or other respiratory diseases, the allergy component and how to select those patients who would benefit from additional investigation and how to go about that is often not there. I think that this is one of the problems that may reflect this lack of awareness.

  Q327  Lord Broers: Could you give us an overview of the training courses that are available in allergy and tell us who attends them, please.

  Dr Ewan: Are you talking about training now outside of the allergy curriculum for specialists?

  Q328  Lord Broers: All courses.

  Dr Ewan: If we start at the top, there would be the allergy specialist training, which is a five-year training. That is an excellent training but we have very few people undertaking that because there is a limited number of places funded nationally. Eight places only.

  Q329  Lord Broers: Eight places a year?

  Dr Ewan: Eight places in total, not a year. It takes five years to go through the programme, so every five years these places become available.

  Q330  Lord Broers: We produce 1.6 places per year!

  Dr Ewan: That is the full specialist. Then we have paediatric allergy specialists with their similar courses and then immunologists will do some allergy in their training. We have talked about dermatologists and the respiratory physicians having virtually none. Apart from that, there are courses which people could undertake at the post-graduate level. The biggest is run by Education for Health (which used to be called the National Respiratory Training Centre). It puts on allergy courses. They are primarily distance learning. They have a few sessions at the centre. They are theoretical, with a little bit of practical when they go into the centre. They are mostly taken up by nurses, especially nurses from primary care, but there are some nurses from the hospital sector. A small number of doctors go on these, mainly GPs, but it is very heavily nursing. These are good value but they lack the clinical experience and so often these nurses want to have some sort of clinical attachment so they can put their theory into context and have a better understanding. I think the other difficulty is that these nurses then go back into primary care and they are isolated. They might try to start putting something into practice but, because they have no doctor to communicate with or colleagues to communicate with, it is very hard for them to maintain what they have learned or really properly put it into context. There are some other courses around. There are some MSc courses.

  Q331  Lord Broers: What is the impact of these courses on the allergy services? Inadequate?

  Dr Ewan: Yes. It is better than nothing, clearly, to have them but we lack a sufficient network. GPs and practice nurses can be very well maintained in an area if you have specialist centres. If you have adult and paediatric allergy in a major centre, it is known that where these exist the GPs and practice nurses in the penumbra can be better supported and can be enabled to do more.

  Q332  Lord Colwyn: I imagine there must be a terrific delay between seeing a patient at the primary care level and seeing a specialist. Also, if there is a delay, surely the treatment might have already started, in which case it is difficult for a specialist to make an informed diagnosis.

  Dr Ewan: Yes.

  Dr Levy: We published a survey of general practitioners throughout the country and we sent invitations to 500 GPs to respond, of whom 50 per cent did. The delay in access to allergy consultations ranged from three to six months. The overall delay, if you looked at the extremes, was much longer. There were a few other points that came out of that survey, one of which was that about 50 per cent of these GPs had had some sort of training in allergy. We do not have much on the detail of what training they received but more than 50 per cent of them felt that their partners needed additional training. The worrying thing was that although they had not had much training in aspects of allergy, like, for example, food allergy which could be life-threatening, they felt competent in dealing with these conditions.

  Dr Leech: We have two training centres for paediatric allergy. We recruit an average of one trainee a year: one into one centre and then, the following year, one into the other centre, and it is a two-year programme for them. There is an allergy MSc which is run out of Southampton which is very good, and a number of people go on that. I think what is needed are a lot of local initiatives to support this requirement for increased knowledge in primary care. We find that areas where there are paediatric allergy centres or places where there are groups of people practising paediatric allergy can then develop local initiatives to increase the knowledge of their local general paediatricians about allergy in general.

  Dr Egner: The two major issues are that there is actually quite a lot of ad hoc training in allergy available through web-based modules, through drug company sponsored roadshows, through college activities, through professional societies, but not a lot of it is practically based with regard to clinical management. Much of it is theoretical and virtually none of it is quality-assured in any way. The other issue is that immunology and allergy centres where people have an interest in allergy and a large service will often provide local educational activities out of their own initiative, but, again, there is no standardisation of this. For example, in my centre I lecture to local general practitioners, both by invitation and through their GP training scheme. We have taught nurses. We teach colleagues. All of these are very important activities but, again, they are fragmented. They are only available if someone locally has the interest, because there is virtually never any time to do it routinely. It is all a question of making the time and seeing the need. There is no funding.

  Q333  Lord Taverne: In 2003 the Royal College of Physicians recommended that there should be clinical allergy training courses as part of the undergraduate medical curriculum. Has no progress been made on that at all?

  Dr Egner: I do not have the data but I could guess that very little has happened. We do know that the pathology component of undergraduate training has diminished over years and there is some data to show that and immunology will be part of that. It has been a concern that basic immunology (which obviously underpins allergy), as well as autoimmunity, primary immunodeficiency and other diseases which involve disease of the immune system is therefore not being recognised because it is simply not being brought to their attention and does not form part of the thought processes of trainees because they have not really grasped or been taught the basic science.

  Q334  Lord Soulsby of Swaffham Prior: In view of the difficulties that you are all identifying, is there a case for videoconferencing? I know in dermatology in the Royal Society of Medicine this was a very popular form of postgraduate education. It seems to me that many of the problems in allergy lend themselves visually to a videoconference up and down the country and in fact elsewhere than within the United Kingdom. Has much attention been paid to this?

  Dr Egner: I do not think videoconferencing has been used in the same sort of way as it is used in radiology work, where people can sit around and look at something; or perhaps in dermatology look at a rash and have a case-based discussion about the diagnosis. There are web-based modules provided by all sorts of providers, including the European Academy of Allergology and Clinical Immunology and the American Academy and so on and so forth, which invariably do this by presenting either videos or still pictures together with additional information that people can evaluate. But they are of variable quality. They operate in different modules. There was an e-learning initiative by the Royal College of Radiologists sponsored by the Department of Health. I know the College of Pathologists is very keen to be involved in the next round of that, which may well address some of the basic science and undergraduate issues, but we are unlikely to have the resource to turn that into a clinical module in the way that you can get off some of the commercial websites that target medical practitioners.

  Q335  Lord Broers: Dr Ewan, do the eight candidates taking this full course have clinical attachments during that course?

  Dr Ewan: Yes, it is almost exclusively clinical. They are in clinical practice all the time. Just to augment the answer to the last point, all these courses are fine but there are two key problems. One is the lack of specialists/lack of trainees to generate the future consultants. Another problem is doing something fundamental in primary care—not just having courses but including allergy as a key component of all GPs' education.

  Q336  Lord Taverne: My next question has been largely answered, which was whether GPs do receive any basic training in allergy. It seems that the answer is no. However, in so far as they do get training, who is likely to provide it and at what stage in their career?

  Dr Levy: There is some undergraduate training. The only evidence we know is from Edinburgh University, where about 26 per cent of the 46 modules include an aspect of allergy, but it is the theoretical aspects and not focusing on diagnosis and investigation. Where the GPs get their training is determined by self-interest and self-drive. If you are lucky enough, you can spend some time with a specialist in their clinic but most of the training is theoretically based, like the Education for Health and the courses that Dr Ewan has mentioned.

  Q337  Lord Soulsby of Swaffham Prior: There is a deficiency amongst general practitioners, I suspect, from what you say, but what are the incentives for GPs to undergo specialist training in allergy diagnosis and management?

  Dr Levy: There is virtually none. If we look at central drivers from the Department of Health or the Quality and Outcomes Framework, it includes asthma, which could include an aspect of allergy, depending on the expertise of the GP looking after the patient, but invariably asthma management would not focus on allergy. Local incentives are driven by the primary care organisations and based very much on savings at the moment. Allergy does not feature at all. A patient with cardiovascular disease or diabetes would get a lot of attention but not someone with allergy. As far as I know, there was only one general practitioner with a special interest in allergy in the whole country—and that was myself—employed by a primary care trust and that was for only nine months on an experimental basis. Despite demonstrating benefit for the patients and savings, allergy is not one of the primary care trust priorities and the clinic closed down.

  Q338  Lord Soulsby of Swaffham Prior: Could the postgraduate medical centres with the postgraduate deans stimulate an interest amongst GPs?

  Dr Levy: Obviously GPs will try to provide the best care for their patients, so if there is a talk or a lecture on allergy and they do not know much about it they will attend, but the key driver at the moment is work and availability of work. If you want to do general practitioner special interest work, a lot of GPs will focus on areas where there is work; that is, dermatology and cardiology.

  Dr Egner: I am sure there will be many general practitioners who would want to update. Adding an additional specialty to your practice provides professional interest and clinical development. I have two general practitioners who work for me. Just to illustrate that these posts are few and far between but entirely dependent on local initiatives: they work as clinical assistants because I do not have access to any formal programme for the development of GPs with specialist interest—and nor does any allergist or immunologist have access to that, although they are established in dermatology and rheumatology. One of those has done the Southampton MSc course, as a result of which she had to undertake 18 hours, I think, of practical training in a clinic and that is how she came to me, and stayed, and has developed expertise in allergy. The other is probably about to do that on one of the other courses and again is developing expertise. But there is no formal basis for this. They will not achieve a qualification for this, there is no mechanism to give them one, but they will and have already gained specialist expertise which no doubt will be of use to the service in the future.

  Q339  Lord Soulsby of Swaffham Prior: Is allergy, as opposed to asthma, part of the Quality and Outcomes Framework for GPs? If it is not, should it be?

  Dr Levy: It should be. Those of us who made proposals for the last Quality and Outcomes Framework did recommend that allergy was included. It was not accepted, unfortunately.

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