Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (Questions 340-359)

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

17 JANUARY 2007

  Q340  Lord Soulsby of Swaffham Prior: If we were to make a recommendation—

  Dr Levy: That would be a key driver to stimulate GPs to know more about allergy. It would drive courses; it would drive increase in quality of care; and I think it would generate a lot of savings in the Health Service. It will reduce referrals and benefit patients and general practice generally.

  Q341  Lord Rea: Are there easily identifiable criteria on which you could allocate the points that form part of the Quality and Outcomes Framework with regard to allergy? Have these been worked out, as to how you would assess whether the doctor qualified for a point if it were included in the Quality and Outcomes Framework?

  Dr Levy: There are various ways of addressing this. One of the ways that we suggested was quality of clinical care. For example, patients with asthma who also have food allergy are at very great risk, the risk of dying, from allergic crises. GPs were asked to record the proportion of patients who had asthma and food allergy as being assessed. That could generate a useful indicator of quality of care. Unfortunately a lot of the Quality and Outcomes Framework points are derived by ticking boxes and there is very little evidence that quality care lies behind that. There is some research going on in Manchester at the moment which will hopefully enlighten us.

  Q342  Lord Rea: Do you think it would be a help for allergy to be included in the Quality and Outcomes Framework, even though the measurement of useful activity in that field is difficult to measure?

  Dr Levy: If diagnosis confirmed by investigations was one of those criteria, you would need to provide evidence that investigations were done and that could be a useful example of a good outcome. There are numerous steps that could be provided. The key thing is to get the word "allergy" into the Quality outcome Framework.

  Q343  Earl of Selborne: Could you tell us what strategies, if any, are in place to monitor allergy training at the primary care level.

  Dr Levy: Unfortunately, none.

  Earl of Selborne: I think we know the answer.

  Chairman: Yes, we have heard that loud and clear. Thank you for confirming it to us.

  Q344  Lord Taverne: The picture we have is of terrible mess. Is it right to say that this is probably the weakest aspect of medical training in this country?

  Dr Ewan: Yes, I should think it is. You have to put it in context in relation to the clinical need. What is quite shocking about allergy is that we have this very small service on the specialist side, we have virtually no knowledge in primary care, and yet we have a huge patient burden. It is almost as if this has caught up and the NHS has been caught on the hop and has not realised what is happening. There has, indeed, been a big change in allergy in terms of patient need, not only in numbers, which have increased very substantially, but also in severity and complexity. There is this major need and patients are really being very poorly served by the Health Service. We are back in the Middle Ages trying to think about it. We have had a series of inquiries about it, nothing much happens, and unfortunately now the whole process has got caught up in the financial problems of the NHS and it is difficult to see local PCTs having any hope of sorting this out.

  Dr Leech: Allergy was not recognised as a sub-specialty by the College of Paediatrics and Child Health until 2000 and it affects 20 per cent of the population.

  Q345  Countess of Mar: How often is it that your patients come to you and say, "I think I have an allergy and it is this"? Is it more frequent than the training you get?

  Dr Levy: Most of the time the patient gives guidance to the GP on where the problem lies. We are taught at a very young age: If you want to know what is wrong with somebody, you listen very carefully to what they tell you.

  Q346  Lord Colwyn: I remember some of my training—it was a long time ago now, in the sixties—and the allergy part of the training was related to dealing with emergency procedures and reactions to drugs and various things, particularly as a dentist, that you inject into people or do to people. Would you consider that a part of the training?

  Dr Levy: Anaphylaxis is certainly—

  Q347  Lord Colwyn: Not necessarily anaphylaxis but even less serious reactions.

  Dr Ewan: Yes, drug allergy is a very big part of allergy now. It is mostly processed in the specialist centres. Unravelling drug allergy is very complex and difficult and it is an increasing problem.

Lord Colwyn: If you inject some local anaesthetic into a patient and they pass out, you have to know what to do about it.

  Q348  Baroness Perry of Southwark: I am turning to the training of consultants now. Given that you have eight coming out every five years, how has the number of allergy consultants changed overall in recent years?

  Dr Ewan: There has been an increase, although it is a small increase in a small total. In the last five years we have had about five additional consultants, which is not very much but there is some growth. Part of that has been by recruiting doctors from overseas and some of it has been generated from our own trainees. Another change which is perhaps beneficial is that, of these recently appointed consultants, most have been NHS funded—which is a change. Of the existing number—we have 34 consultants in allergy—a considerable proportion are academically funded. Whilst that is excellent in one way, in another it means the service may not continue beyond the life of the head of department. Recently there was a big problem at Southampton when the Professor of Paediatric Allergy left and it was not sure if the service would fold. So far it has managed to limp along, and it may survive in fact. Having some NHS funding in the system is good. I think we have had more growth in paediatric allergy than adult allergy.

  Dr Leech: We have eight consultants in paediatric allergy. Two of those were appointed prior to 2000. Six of those have been appointed post 2001. Of those six appointments, three of them are academic appointments. Two that pre-dated 2000 are also academic appointments.

  Q349  Baroness Perry of Southwark: Are those figures UK wide or England?

  Dr Leech: This is England. And we have had one paediatric allergist who has emigrated to Ireland.

  Dr Egner: Yes, I totally endorse the fact that, in terms of appointments of allergists, whole time allergists specifically, there has been a shameful lack of posts created. We need to address that. We should not forget, however, that immunologists do practice allergy as a core part of their practice and there have been 23 of those appointed in the last 10 years—on a small base as well, because there is only a total of 61 according to the RCP census in 2005. Most of the trainees would look to practise allergy in some way, some as specialists, involving most of their clinical activity, and others as a smaller part of their general activity. Knitting those into the picture of allergy service provision and getting a network that enables appropriate referral pathways, care pathways and guidance, is critical to making a better use of what we have got, whilst also supporting the development of pure allergists as a specialty and paediatric allergists particularly.

  Q350  Baroness Perry of Southwark: What is the evidence that it is an attractive specialism? Do you have difficulty attracting people into the course? If there were more training places provided, would it be easy to recruit people?

  Dr Ewan: So far it has not been difficult to recruit people but we have had a small number of places. I think one of the difficulties is the small number of consultant posts and really what is needed is a planned, coordinated development, creating more training posts but also with a promise of more consultant posts for them to move into. Equally, there are problems. For example, I have funding for an additional consultant post and I cannot see a suitable trainee to take it because there is nobody coming out at the moment. It is very difficult to balance this when you have a small specialty. You are trying to argue the case for funding for a new post and getting trainees to come through. One thing perhaps we should add to this discussion about the numbers is that the way you get more people is having champions for the cause. You only get more money—because money is short everywhere—by having somebody there who is pushing for the case, and we have too few of these. So it is a slow growth.

  Q351  Baroness Perry of Southwark: Are the consultants spread widely across the country or do you have a concentration in a few centres?

  Dr Ewan: With the allergists, they are concentrated in a relatively small number of centres. There is not a geographical spread, so patients are therefore disadvantaged.

  Dr Leech: The paediatric allergists are concentrated in four centres in Britain.

  Q352  Lord May of Oxford: Do you think the NHS monitors sufficiently and thinks as carefully as it ought to about the cost-effectiveness of consultant-led allergy services against other forms of service delivery? I also have a couple of follow-up questions on alternatives. One is turning to services, as it were, out in the community and the other is turning to the academic basis of understanding immunology.

  Dr Ewan: No, I do not think they monitor what is going on. One of the problems is that the NHS centrally has not had allergy on its radar until quite recently. They do not record properly what goes on with allergy in the NHS because it is a Cinderella subject, it is a new speciality. There is now an allergy code, which was introduced into the NHS in 2005, but that has only been implemented by the specialist centres. They are now recording their work, and it could be pulled out centrally by the Department of Health as numbers of allergy patients seen, but, for much of the rest of allergy, which is diffused through other areas, there is no proper recoding of what goes on. The department does not have a good handle on even what is happening in allergy. In terms of cost-effectiveness, no, I do not think they have begun to be able to address this.

  Dr Egner: I do not think there is any good data at the moment. I think it is going to be very difficult to generate good data until we have standards of care, agreed referral guidelines and care pathways and an effective and equitable network of services which allow local access to people in a geographically equitable distribution around the country. For example, we have heard how the adult allergists and the paediatric allergists are very much concentrated in the South East, whereas the immunologists are spread out over the North and South West and Wales. That all needs to knit together and we need to standardise care before we can look at the different models that are out there, before we can compare them and know what is cost-effective. The other thing is that many of us who are attempting to demonstrate leadership are trying new models of service. I am a single-handed immunologist—I will not be for much longer, thank goodness, but have been for the last five years—yet we have managed to develop services using multidisciplinary teams, nurse specialists, clinical assistants, and those are all strategies that need to be modelled and costed as a way of improving services for patients.

Lord May of Oxford: Are there any community care programmes which monitor the patients that have been referred to specialist services, so that you get an idea of what is going on in different parts?

  Q353  Chairman: Dr Levy, did you want to say something on the previous question?

  Dr Levy: The problem relates to diagnosis and then coding of the diagnosis. When general practitioners refer the patients, most of them are using computer-based systems and coding was one of the issues communicated to this Committee by the College of Child Practitioners' report. If we refer patients into secondary care or, for example, a patient with allergic rhinitis to an ENT specialist, the code will be "ENT consultation" not "allergy consultation" so the information is not really there.

  Dr Egner: We have forgotten how the Health Service is funded—or I had—until this question came up of tariffs. We cannot generate a tariff until you have some reasonable model of care and care pathways that are roughly similar throughout the country; otherwise you are going to end up with a cost in one centre that does not reflect the cost of the service in another and that will cause all sorts of problems.

  Q354  Lord May of Oxford: It seems to me that this is much more broadly an area, like so many in medicine, where one is looking at the balance among the basic academic advances, the clinical application of them and somehow the specialist things like immunological training programmes to deal with it. I am really struck in this inquiry more generally at the contrast between this and HIV (which is something I know quite a bit about). I can understand why there is such an emphasis on understanding the dynamics of the immune system and the interaction and what is going on because of the magnitude of the global problem, but, if you were actually to do some weighted sum of the impact on health in the UK, you would probably find there ought to be more on allergy, and yet, compared to the sophistication of the understanding at the molecular level and not at the pathogenesis of HIV that we have and the number of ace people working on it, I am struck by the rudimentary nature still in our understanding of the immunological dynamics of much of allergies. Do you think this is just intellectual fashion? Do you think it is because there are things in other areas of immunology that lend themselves to more prestige or more to the solution? Why is it that this is so much more rudimentary than other areas? Or am I wrong in my impression?

  Dr Ewan: I would have to disagree with you. We have excellent science and understanding of the basic immunology and mechanisms of allergy but we have—

  Q355  Lord May of Oxford: It is still not generally agreed that peanut allergy comes from not being exposed to it younger. That is a pretty fundamental question.

  Dr Ewan: Yes. We have very good basic science about the mechanisms and understand the allergic process. We lack, downstream of that, the clinical side. There are big gaps in clinical research. You have highlighted one very fundamental question. The other gap is clinical service. We do not have enough people who are looking at the clinical side, either research aspects or providing clinical service—and the two are interlinked—but we have international leaders in basic allergy research in this country.

  Q356  Lord Taverne: I thought there was still a lot of contradictory evidence and uncertainty about the causes of certain allergies.

  Dr Egner: The immunologist tends to have a finger in many pies but we are supposed to have mastery of the basic science of the immunological components of lots of diseases, from autoimmunity, through to allergy, through to primary immunodeficiency. There have been massive advances in the understanding of allergy but, without wishing to understate the point, it is not quite as simple as some of the other single gene defects that we have been able to isolate to understand the immunology of, for example, primary immunodeficiency. We can isolate a single pathway and the consequences of disruption of that pathway, following, particularly, through individuals who inherit it in an X-linked form, so that males in the family are involved. Those are all areas of the immune system in which we can gain a fairly rapid understanding of the key pathogenesis of that disease. Allergy is different. One, not only is it multi-system, the susceptibility is related to both genetics and environment and the complex interplay of those, and that is much more difficult to unravel. The other problem, as Dr Ewan points out, is that we do not have the network of services working in a standardised way in order to enable us to do the applied and translational research and service delivery research and cost-effectiveness research that we ought to be able to do very well in this country but we do not have the resources.

  Dr Leech: I have one slightly cynical comment. I would ask how much of that HIV research is driven by pharmaceutical funding.

  Q357  Lord May of Oxford: I would like to amplify what I said earlier, in the sense that I think your answer to me said that it is a mixture of the fashion at the academic end, in wanting to do clean questions rather than messy questions, as distinct from important. My impression would be that the community of academic/clinical people working on HIV internationally would be three orders of magnitude more than in allergy research. That seems to me out of whack. I personally think it is fashion, in a sense, but understandable fashion.

  Dr Leech: I think a lot of allergy research is around the basic science research but then the areas of uncertainty are around causes of allergies, particularly early life events and allergen exposure. I think the teams that are working on those research areas find it very difficult to find funding for those types of research projects.

  Q358  Lord May of Oxford: And not just for pharmaceutical things, it seems, but in the medical research category, it is the same people who like the neat questions rather than messy questions.

  Dr Egner: In many ways the recent Cooksey report on the future of funding of research in the NHS addressed this question. It basically said that applied research was under-funded. You are only as good as your last research grant and the outcome of that. In a competitive research environment, it is a brave person who goes into a messy area with no clear outcome because they have to justify their subsequent academic funding.

  Lord May of Oxford: There is a discussion this evening at the Royal Society which you probably know of.

  Chairman: I wonder too whether there has been a huge drive through general public pressure. Whereas diseases such as cancer and HIV are seen to be life-threatening primarily, diseases related to allergy are viewed much more in the public eye as being some kind of inconvenience rather than life-threatening and therefore they have taken a low priority in the political pressure for research funding to go into those areas.

  Q359  Lord May of Oxford: There is this concept of the disability-adjusted life years which is more and more used as a measure of medical impact rather than just looking at mortality. Has anybody looked into the impact of allergies by that kind of measure that is more conventionally used in the developing world, in terms of the disability-adjusted life year impact compared to just asking mortality?

  Dr Egner: I am not sure about disability-adjusted but various other measures of quality of life indexes and so on have been used for allergic rhinitis, showing that it may not kill you but it can make a lot of people miserable and therefore is a considerable health burden. This applies to various other allergic diseases. And of course the fear of thinking you might die if you were to accidentally ingest a bit of peanut is awful. That is a major component of giving advice; trying to give people ways of coping with this and trying to reassure them, as far as we can, that they have appropriate treatment is a very important function.

  Dr Levy: There is also good evidence that rhinitis can affect children's performance in school. That aspect of quality of life has been investigated quite thoroughly.

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