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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