Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (Questions 360-379)

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

17 JANUARY 2007

  Q360  Chairman: How much have things like the dermatology life-quality index been picked up in general practice research in relation to eczema?

  Dr Levy: It is not on the Quality and Outcomes Framework so it is unlikely to be picked up as routine data.

  Q361  Countess of Mar: I recall about 15 or 20 years ago there was a rush of papers which put a stigma on allergy, saying that it was "all in the mind". Are you suffering from the tailback of that in relation to these multi-symptomatic, multi-system diseases?

  Dr Leech: Yes. I think that has been a big problem in Britain. If you compare the development of allergy services in Britain with those in Europe and the United States, Britain has been in the backwater for the last 20 years, possibly as a result of papers you have described. In Europe and in the United States, allergy has continued to grow and we feel we are just starting to catch up with what has been happening elsewhere in the world.

  Q362  Lord Rea: In 2004 the House of Commons Health Select Committee produced a report and recommendations on allergy training posts and the specialist allergy workforce to which there was a Government/Department of Health response. Are the Royal Colleges satisfied with that response?

  Dr Ewan: No, they are not, they are extremely dissatisfied. The Department of Health's initial response to the Commons Committee was that on most of the key questions they evaded a direct response and said they would hold their own review. Those key recommendations from the Commons Select Committee were to increase allergy trainees and to increase allergy consultants and to improve training in primary care. When the Department of Health eventually did hold their review, which was a year-long review, at the end of it they produced a report which still did not address the Commons' recommendations so they really remain unanswered. I think they completely evaded the main points. One of the difficulties is that at least the Department of Health in their review recognised and agreed with the problem, so they have accepted that there is a problem and the size of the problem and that there is a need to do something but they have not really addressed how one would go about solving it. They suggested in their report that this should be up to primary care trusts and to strategic health authorities so they have failed to take on any central responsibility for putting any pressure to actually bring about change. I think the difficulty now is primary care trusts have huge financial problems and so they have two roles really, firstly, to serve the health needs of their populations and, secondly, to balance their books and these two roles are incompatible and at the moment balancing their books is the priority, so to expect primary care trusts to be able to do anything for a new speciality or a growing speciality just will not happen; it is unrealistic.

  Q363  Lord Rea: Are there any possible plans for maybe when this crisis is over—if it ever is—to encourage or endorse the creation of additional consultant posts for trainees to move into?

  Dr Ewan: I think the first problem is that we need more trainee posts and we need more funding for them. There is no way the primary care trusts would be prepared to fund these at the moment. Although we are getting a few more consultant posts that is not primarily coming from PCT initiative; it is coming from the driver of local champions who have been pushing the service. I think the whole thing is extremely disappointing and speaking on behalf of the Royal College of Physicians, they are extremely disappointed with the outcome.

  Dr Egner: The College of Pathologists are also disappointed with the outcome. If there were any positives that came out of the review, I suppose at least the intention to consider options for commissioning NICE guidelines is some form of progress and to work with the Royal Colleges on development of guidelines and referral and care pathways is a potentially positive development. It is good to see that the review recognised the multi-disciplinary contribution to allergy services and a lot of good work and leadership that is already going on out there. What it did not do was give us any tools or any drivers which would help local champions, or individuals who were interested in setting up and running networks, or putting in place a governance structure and standardisation of care to work with and that was very disappointing. They left it to local commissioning, so deaneries were to decide whether or not they needed trainees in allergy—"to consider the options" I think was the wording—and commissioners were to consider whether allergy services were needed, but yet the whole thrust of the report was that allergy services are needed and are dreadfully under-resourced and they are inequitably distributed around the country and the training network could be better, so I am afraid overall a very disappointing outcome.

  Dr Leech: The Royal College of Paediatrics and Child Health has similar problems. One of the additional problems is that there are so few paediatric allergy specialists and there are huge areas of the country where there is nobody to champion paediatric allergy services and those issues are therefore just not dealt with.

  Q364  Chairman: We heard from the Department of Health that their plans are that a lot will be devolved out to general practitioners. Who is going to do the education of those GPs?

  Dr Leech: That is the problem, there are not the people to do that.

  Dr Levy: Without coding systems which identify the actual burden of allergy, GPs will not be aware of the need for training.

  Dr Egner: I think we need to understand the context here. If all future developments are going to rely on persuading local commissioners and PCTs that they require local services, you have to be able to justify your existence by producing some data to show that you are a fit-for-purpose service that can meet national standards, but we do not have those national standards yet. You have to demonstrate that you provide value for money. You have to compete with 57 other medical specialities who are all producing cases that their services are under-resourced and you are doing this on the basis that you have a specialist workforce which is tiny and already over-stretched and the reality is that is going to make life very difficult. It is incumbent on us to try and do it, but it took a very long time for immunology to establish itself as a specialty and this is going to set allergy back quite some time.

  Q365  Lord Colwyn: I think your evidence today and in fact all the evidence we have heard since this inquiry started, has made it quite clear that the paediatric and adult specialist workforce is totally inadequate. You mentioned earlier that there had been an increase of five consultant posts and six in paediatrics. Can you make any recommendation about how many consultant posts there should be in the ideal world to deal with this increasing problem?

  Dr Leech: The figure that was quoted in Allergy: The Unmet Need was 20 paediatric allergy consultants and 20 adult allergy consultants, and that was to provide one in each region of the country. I think that will probably just be a start. I think you would also need allergy consultants in each hospital.

  Q366  Lord Colwyn: Our briefing from the Royal College of Physicians talks about one in 3,500 members of the public having some anaphylactic reaction and drug allergy responses are responsible for five per cent of hospital admissions. What are the estimates of the number of patients who have multi-system allergic disease or allergic problems?

  Dr Ewan: This has been worked out very carefully and was produced in a paper by the British Society for Allergy and Clinical Immunology and submitted to the Department of Health review and a lot of work went into trying to calculate this. They tried to come up with some fairly conservative numbers because there is missing data over quite a number of these areas, but at a conservative estimate it was felt that about seven million patients had severe or complex or multi-system disease which warranted referral to a specialist. This still leaves an enormous number, many millions, a much larger number for primary care. There is no way that the sort of diseases in this seven million could be dealt with in primary care. There is not the time, the competence, it would be risky, there are more complex procedures required, so there is a huge burden. As Dr Leech has said, the Royal College of Physicians recommended this start-up of 20 extra adult and 20 extra paediatric consultants which was simply to try and get a centre in every area of the country so one had at least a focus to develop the services locally. At the same time the Royal College of Physicians Workforce Department calculated the true need and this was done in 2003 on the data at that time, which has probably increased a little since, and they calculated the ideal need, which of course no-one was expecting or asking for, would be 520 consultants. This is combining adult and paediatric allergy, so that puts it into context. It seems a ridiculously large number so asking for 20 and 20 was a start-up but it was thought important because that would begin to turn around the service. Even if it just doubled in size and one had this geographical spread it would be a very important focus to network with immunologists, to network with primary care and to grow the service.

  Q367  Lord Colwyn: Is there a nationally agreed definition of "complex allergic disorder"?

  Dr Ewan: It is all set out in this paper in detail.

  Dr Levy: I wanted to just add that while I agree we do need more specialists, it would be impossible for all of the patients with allergies to be treated by specialists, and while we are increasing the specialist contingency we need to focus quite a lot on primary care expertise. For example, access to tests and investigation. Very few primary care practices provide allergy testing. It is less than four per cent in fact who do skin-prick testing and access to specialised blood tests is variable throughout the country. In some areas we can get access to IgE tests but in most areas we cannot get access to specific IgE tests because of the cost.

  Dr Egner: I think the consultant workforce and the GP workforce and the training issues and manpower issues related to those are all critical and key in terms of underpinning the structure but if there is such a big need we need to think creatively about how we can deliver these services effectively and nearer to the patient, which is the direction in which the Health Service is going. We should not forget nurse specialists, we should not forget GP clinics or GP with specialist interests and other mechanisms for delivering care closer to the patient, all of which we do not have models for at the moment nor any evidence for cost-effectiveness. I think all of these things need to be considered in the round.

  Q368  Viscount Simon: Having heard how close immunology is to allergy, would there be any advantages in combining the Certificate of Completion of Training in Immunology with that for Allergy?

  Dr Egner: I think that has been tried in the past and was not successful. It is a model that applies in other countries but I think we need a UK solution that best fits UK needs. I personally am in favour of it, others are completely opposed to it, and there are arguments and pros and cons on both sides. My worry about the future direction of consultant staffing in the NHS is that we need to retain flexibility. It is a core concept in the new medical world that people's competences need to be configured for local needs and in many ways, prior to Modernising Medical Careers and the new CCT, people were relatively flexible in the competences that they acquired before qualifying as a consultant and going on to the specialist register or whatever preceded that. Now we are much less flexible I think that is to our disadvantage and may be to our disadvantage with regard to recruitment. The other issue of course is that it is not all about the CCT any more. The CCT is where you start and the Academy of Royal Medical Colleges has considered whether perhaps CCT credentialing—adding on whistles and bells and other competencies—is a way in which that flexibility can be delivered, and all of that remains in the round. It may be that a respiratory physician can add on another competency specifically related to management of allergic disease and so on and so forth. We do not really know where we are going yet.

  Dr Ewan: Coming back to Viscount Simon's question, one of the disadvantages of combining those two CCTs is that immunologists have many roles other than allergy. Allergy is one thing they do but they have an important role in providing a diagnostic laboratory service and looking after patients with immunodeficiency—some of them look after rheumatological problems or vasculitis—so they have a wide remit and allergy is part of that, in some cases a small part and for other immunologists a larger part depending on personal interest, whereas allergy is focused 100 per cent on allergy. In terms of need, the need is the allergy patient, so if you come at it from the patient perspective, it is less efficient to train people up to do a lot of other things where there is not an increased need whereas the allergy need is the important aspect. So that would be a disadvantage of combining the training because you would have to spend all these years doing training that immunologists do which allergists do not require to do.

  Q369  Lord Colwyn: Do allergists get on well with immunologists?

  Dr Egner: On a personal level, yes. It is quite normal, in fact it would probably be abnormal, if we did not have different views on how services should be constructed and in fact even on the allergy content of the curricula. What is important is whether patients are going to get the service they deserve? Specialist allergists are going to be extremely important and a key provider of allergy services, so how can we support them because they are in the situation that immunologists were in the 1970s. They have a very small (almost no) critical mass of specialists and minor changes to training, to recruitment and to the availability of jobs (which we need to look at as well because there is no point training people if no-one will employ them) can have disastrous effects on small specialities, which is why in many ways the situation with immunology and allergy and other specialists with a small workforce actually requires more nurturing and support from government policy and more drivers. Losing a few haematologists would cause major problems as they are already understaffed but it would not cause the whole service's future to be in doubt, which could very easily happen with either of these specialties, and I think they both need to be valued and to be nurtured.

  Q370  Chairman: Given the shortages that you have described and the uneven distribution of services, how do you see the resource of the immunologists, which seem to be a resource better spread geographically, certainly across the UK, being harnessed to meet clinical needs? How do you think that the shortage that you have outlined could be addressed in the short term by more collaborative working between the two groups in adult and also, possibly, with paediatric allergy as well?

  Dr Egner: I think the paediatricians are an exemplar in this in that they work together completely; paediatric training is organised in a different way from adult training. We do already. The idea that we do not, I think, is incorrect. We have a joint committee of immunology and allergy; we have the BSACI, we have the new immunology society under the aegis of the BSI, all of which have an interest in promoting and developing the standardisation of services, networking and promotion of clinical guidelines. The Department of Health has made a statement saying that it is keen to facilitate that, and the Royal Colleges will have an interest in that. All of this can do nothing but strengthen our hand by allowing us to provide the evidence which the Department of Health review indicated was not there, in terms of what are the best models for service delivery, what is the most cost-effective way of service delivery and how can we improve training and education. In many ways, of course, it is back to us, is it not, to try and lead this? Immunologists and others work together very well in doing this. Some centres have both; some centres only have one—who knows what the right model is. It may be different in different places.

  Dr Leech: The story for paediatrics is completely different. When you train as a paediatric allergist your fundamental training is within paediatrics—it is the same for immunology and it is the same for a paediatric infectious diseases consultant. The CCST that you get following completion of training is paediatrics, and then in brackets there is a recognition of your sub-speciality training. There are not separate sub-specialities for allergy, immunology and infectious diseases, so the sub-speciality you are awarded at the end of your, for example, mainly allergy training, is a CCST in paediatrics, (allergy, immunology and infectious diseases). Paediatric immunologists focus on treating children with very complex genetic defects in the development of the immune system; they treat patients with bone marrow transplants; they are very focused on that kind of work, and that is focused within two centres in Britain. They are really not interested in developing big allergy services. Most of the development of paediatric allergy service is left to the paediatric allergy people that are based within the south of England.

  Dr Ewan: What I think is important to emphasise is we need increased capacity, and that can come about in multiple ways. All service contributors are needed, and are useful. However, unless you increase the capacity from the point of view of the allergy patient there is a big problem. So whether it comes from immunology or paediatrics or allergists or other specialists, that is the important point. The way you will most efficiently increase capacity is to train more people who will spend 100 per cent of their time doing allergy, but all these other ways of working will interlink. Importantly, from the patient point of view, if the driver in the NHS is to keep as much in primary care, what is going to be coming up to hospitals will be the more complicated and difficult patient. So not only do you need capacity but you need comprehensive expertise to provide that. Another important aspect of emphasising the value of centres is the huge education role that needs to take place across the board of all health care professionals.

  Dr Leech: One thing we have not talked about yet is that, in the way we talked about increasing the knowledge of general practitioners around allergy, there is also a need for developing the knowledge of general paediatricians elsewhere in the country to help manage this load of paediatric allergy patients.

  Q371  Baroness Perry of Southwark: Is allergy research a necessary part of allergy clinical training, and is it currently included in the curriculum?

  Dr Ewan: It is a part, yes. Of the five-year training, one year is devoted to research, and it is an important part because it provides an important understanding of research and enables people to be able to independently conduct research in the future. It is also a very important part of learning, but there is a one-year component, which might be clinical or more basic research in the training curriculum.

  Dr Leech: The way it works in paediatrics is that, again, we have got one year which is accredited for research but the trainee can do a research programme that lasts three years, but one year of that would be accredited towards their five-year training programme.

  Dr Egner: Immunology shares most of those features. Trainees are encouraged to do research because the skills and the critical thinking skills which are generated by participating in peer-reviewed research, either within programme or out of programme, doing an MSc or a PhD or a DPhil, is regarded as being useful in what are, basically, cutting-edge specialities with complex science that require you to keep abreast of the literature and to somehow translate that, eventually, into something which can be used in the clinic. That is equally true for paediatric and adult allergy and adult immunology, but it is not mandatory; you do not have to. As Dr Ewan alluded to before, the good news, but also the bad news, is that most new posts are being based on service commitment. They are NHS posts, and what PCTs are interested in is how many patients can be seen and given appropriate care and advice most effectively. Finding time for research and development within those heavy and increasing commitments is an increasing difficulty for both trainees and existing consultants, as historically that has always been an important role of immunologists and now it is to generate new applied research. Most of them are based in academic centres, but there is a separate pathway now for people who wish to specialise in academic careers, who are expected to slot into this at a very early stage in their career before they have taken any other training. There are worries about how that will affect our ability to deliver research and development, and the future role of the specialities in that, but we do not know how that is going to pan out. I should point out that the research someone chooses to do depends on local opportunities and interest. For example, at least two of the immunology trainees in post at the moment are doing PhDs and DPhils in allergic conditions or immunotherapy. I do not know about the allergy trainees.

  Dr Levy: We have had a number of questions related to evaluating quality of care, and in primary care while research training is not essential as part of clinical training it would certainly help if it was incorporated within primary care training, both to understand the literature that is coming out and, also, politically, to defend oneself against the claims of `evidence-based' decisions by managers. A lot of our services are determined by primary care organisations, and very much on the basis of evidence, which the managers have interpreted, and I think it would be helpful to be able to have a clearer understanding in general practice.

  Q372  Baroness Perry of Southwark: I was going to ask a supplementary, but it might chime with what you were going to say. I just wondered if the Walport process, with the additional fellowships and the 11 new training posts, is going to make a substantial difference.

  Dr Egner: It might if we bid, but I have not been involved.

  Dr Ewan: It would depend on whether any of them were allocated to allergy.

  Q373  Chairman: We had heard from Professor Sally Davies when she gave evidence to us that there were 11 being allocated specifically to allergy. That was in our first evidence session.

  Dr Egner: It is good news we are not aware of![5]

    (a)        At what level are these posts—Are they Academic Clinical Fellowships, Clinical Lectureships of "new blood" Senior lectureships, Academic GP fellowships of GP one year post-doctoral fellowships?

    (b)        Where are they based—Much allergy research into asthma is performed by respiratory physicians and into allergic skin disease by dermatologists—are they in existing allergy centres with links to a specialist allergy or immunology service?

    (c)        Are any of the appointees undertaking training as Allergists or Immunologists or are they pursuing other speciality training programmes? In other words what will their CCT speciality be?

    (d)        What is the scope and type of the research programmes that will be supported by these posts?—Are they supporting research into allergic diseases which are currently less favoured in the UK such as rhinoconjunctivitis and food allergy? Are they supporting basic science, applied science or service delivery?

  Dr Leech: [6]

We feel it is imperative that the needs of children are considered in addition and an equivalent number of academic training posts should be allocated for training in paediatric allergy.

  Q374Lord May of Oxford: How do the curriculum for allergy training and the number of allergy training posts in the UK compare with other OECD countries, like the US or Australia and, most particularly, with other countries in Europe?

  Dr Ewan: I am a representative for Allergy in Europe, and the Union of European Medical Specialities has an allergy section, and they have recently developed an allergy curriculum for Europe, trying to bring together the various countries in the EU. The curriculum is quite similar to the UK curriculum and they partly used the UK curriculum when developing the European curriculum. There have had to be some variations in terms of duration of training, because there are a lot of differences between individual countries as to how they practice. In some countries of Europe allergy is a full speciality and in others it is a sub-speciality. For example, in Germany it is heavily linked to dermatology, so there are differences, but there are a number of countries in Europe where allergy is a full speciality, and the curriculum is somewhat like ours. The numbers of posts are hugely different. It is quite difficult to get exact numbers from many of these countries, and it is easier to get numbers of consultants, or to have an idea of consultants, than trainees but one is talking about hundreds or, in some cases, thousands in some European countries, whereas we have eight trainees and 34 consultants here in immunology. So there is a huge difference in numbers, and we are very much a poor relation.

  Dr Leech: I can give you the figures for consultant paediatric allergists. At the time it was estimated, in about 2003-04, there were five British UK allergists, and in France, Sweden and Switzerland there were 20.

  Q375  Lord Colwyn: In each?

  Dr Leech: Each.

  Dr Egner: Just to emphasise their heterogeneity; in a EUMS survey of 23 European countries, which I think was presented at the European Congress of Immunology in 2006, there were 16 European countries with training programmes in immunology, five of whom were conjoint with allergy and include allergy within that training programme; seven had stand-alone allergy programmes and six had stand-alone laboratory immunology programmes (which would not be a runner in this country). In Australasia they have two programmes, a three-year training programme, which effectively produces a physician immunologist and allergist who can see patients with any spectrum of immunological or allergic disease, and a four-year programme which includes laboratory training which also qualifies that individual to supervise the laboratory, which is core to, certainly, the UK immunology training programme, because that is a core competency.

  Q376  Lord May of Oxford: Is that actually co-ordinated in Australia and New Zealand?

  Dr Egner: Yes, it is. It covers both and it is a model I particularly like.

  Q377  Lord May of Oxford: How about the US? Is that too varied to be able to give an answer? I do realise the written thing you were given just said "Europe" and I am not quite sure why.

  Dr Egner: There are laboratory immunologists who do have little in the way of clinical practice in the USA, and most of their physician practice is dedicated to serving allergy.

  Dr Ewan: I do not know the numbers in the States but they are very large. However, allergy in the States will be either in hospitals and often linked to academic centres, and then there is a huge amount of private practice. I do not know the numbers, but it is enormous.

  Dr Levy: There are probably a lot of hidden allergists in Europe. For example, in Germany a lot of primary care doctors are trained in allergy and they would not be counted amongst the consultants. Certainly in Scandinavia a lot of general practitioners provide allergy services. It is an area where we do need more information. Can I just ask, if it is not too big an imposition, if maybe some follow-up note could be sent about that. It would be really helpful.

  Chairman: Yes, it would be helpful and it would help us understand the details which would fit with Lord Taverne's request as well.

  Q378  Earl of Selborne: I wanted to ask about the Global Asthma and Allergy European Network which offers training and educational activities. Do we take full advantage of these activities and do we adopt the standards and resource utilisation signalled by the Network?

  Dr Leech: I spoke to John Warner yesterday who has a large part in GA2LEN within paediatrics. Their educational activities are that there is a sort of spring school in Davos for postdocs and doctoral scientists and then there is a summer school which is a clinical allergy school which they hold once a year. His response was really that they are preaching to the converted. These are people who are already interested in allergy and already committed to a significant part of their allergy service which, when you go on these courses, you can get knowledge from. It does not really filter down to the grassroots which is what I think we have identified as being needed here.

  Q379  Earl of Selborne: Do you know whether any allergy treatment centre in the United Kingdom has ever been certified by this Network either at certificate level one or two?

  Dr Ewan: No, they have not yet. This is a very recently introduced scheme. There are three centres in the UK which might be possible to be accredited at level two which is Guy's and King's, and the Brompton and Cambridge might be possible centres, but no one has yet made an application. It seems a very complex and quite bureaucratic process just submitting the application, but these centres are considering this at the moment. Another thing perhaps to mention in relation to GA2LEN is that they do produce guidelines on management of allergy, so they have a number of educational initiatives in addition to their training courses. Of course we do in the UK have guidelines on allergy, but we are perhaps behind Europe in the number we produce, but the British Society of Allergy and Clinical Immunology produce guidelines on the management of certain disorders and this is a relatively new initiative that has only been going for the last three years, so that is in progress, but there are GA2LEN guidelines which are quite helpful within education.

  Dr Egner: A very important initiative, although whether it will have practical implications for the practice and management of allergy patients in the UK remains to be seen because in the UK-based guidelines, practice differs—and not only within the UK, but within Europe and America—so there are many guidelines which are freely available from the American Academy of Clinical Allergy, Asthma and Clinical Immunology, but they cannot be directly translated into service-based guidelines here. There are lots of local initiatives that we need to network and share. For example, locally we organise our allergy practice using standardised guidelines, protocols and care pathways which are modelled on those immunologists use in immunodeficiency. There is a national network of all UK PIN clinics and you are required, in order to be accredited, to have a quality manual, a quality statement, document-controlled guidelines which cover your nursing, your doctor-led activities, your dietician activities and care pathways for individual patients, and I think that is a very useful model and some centres are already sharing this. For example, we are doing that within Trent to see if we can standardise care within the immunology and hopefully the allergy centres there. I think sharing good practice is something we could do a lot better and we could do much to facilitate networking. I think the GA2LEN guidelines and international guidelines may inform this, but they will not replace them.

5   <ep8 With regard to the additional allergy posts under the Walport scheme announced by Professor Davies-this is potentially good news but requires clarification before it can be assumed that it will affect service provision and consequent applied research in allergy for the benefit of patients. Back

6   We are delighted to hear about the 11 clinical academic training programmes in allergy. We would, however, like to point out that there will be a minimum of eight years from commencing a clinical fellowship to gaining a CST and being eligible for a consultant of senior lecturer post. Back

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