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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