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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