Examination of Witnesses (Questions 620-639)
28 FEBRUARY 2007
MRS MARGARET
COX, PROFESSOR
DAVID GAWKRODGER,
DR CLIVE
GRATTAN AND
DR SHUAIB
NASSER
Q620 Lord Colwyn: Do the treatments
vary with children and how does the school environment deal with
this?
Mrs Cox: In the school environment, as
so often happens, truthfully it is hugely variable. Issues that
are commonly experienced by children with eczema in school tend
I think to stem from a failure to take eczema terribly seriously
combined with the fact that it requires frequent topical treatment
which of course can be very difficult to achieve particularly
at the younger age.
Q621 Lord Rea: I wonder if you could
deal a little more with the training of general practitioners.
How do you think this training could be improved either as undergraduates
or perhaps as postgraduates? In primary care, what proportion
of patients is referred to specialists in allergy or dermatologists
and which?
Dr Nasser: The first thing I would say
is that, if you look at the curriculum for most undergraduates,
there is hardly any teaching on allergy and there is certainly
no structured teaching. It may be given as part of an asthma lecture,
for example on one slide, but there is certainly no structured
teaching in allergy and there are so many other demands on the
curriculum at the moment in terms of communication skills etc
that some important aspects of the curriculum do not actually
make it into training. Unless that is remedied, we are not going
to get general practitioners who understand anything about allergy
at all. The second aspect of the question I think is the postgraduate
training and, because there are so few allergy specialists in
the country, there is no one to undertake teaching. Certainly
in our area in the eastern region, we undertake quite a lot of
teaching and I suspect that our general practitioners are better
educated than in any other parts of the country, but that is something
that cannot be rectified unless there are centres with allergy
specialists. What was the last part of your question?
Q622 Lord Rea: The question of whether
to refer to dermatologists or allergists if somebody has atopic
dermatitis and urticaria.
Dr Nasser: I would say that only a very
small proportion of patients get referred. There are increasing
pressures in primary care not to refer patients into secondary
care and these are pressures that have come on in the past six
to 12 months because of cost, and because of the great debt that
PCTs find themselves in. My wife is a general practitioner, so
I can talk about this subject—and certainly there are internal
pressures to refer as few patients as possible to hospital.
Q623 Lord Rea: As a former GP, my
problem was that there were difficulties in referring people to
allergists because there was a very long waiting list, six months
or more, and it was easier to refer to a dermatologist something
which perhaps appropriately should have gone to an allergist.
Dr Nasser: I am sure that is right. The
waiting lists are coming down but, unless you have an allergist
in your locality, you cannot refer patients.
Q624 Earl of Selborne: I want to
come in on this rather familiar story but a very depressing story
that Dr Nasser was spelling out that patients see GPs and indeed
nurses, dieticians and the people at the frontline, the people
to whom most patients are referred, and do not go much further
and yet, as you point out, the knowledge of GPs and indeed others
is really very poor. Addressing the curriculum at undergraduate
level is not going to solve the problem, is it, or not for a generation
or two? Would you have any radical thoughts as to how this great
omission could be addressed? What structure would you like to
see put in place to allow GPs, nurses, dieticians and other people
like that to get a grasp of these issues?
Dr Nasser: I would say two things. The
first is that we have to look long term and sort out the problem
from the beginning, so that has to be thought of as an important
aspect of introducing allergy training into the undergraduate
curriculum. So, we must think long term. In the shorter term,
I think what can be done is that we must educate our primary care
physicians and the way in which you do that is by conventional
means but, unless you have a local allergist, you cannot do it.
So, the best short-term solution to that would be to increase
the number of trainee physicians in allergy in order to create
more centres that are able to deliver teaching. There are large
parts of the country that will have very little exposure to an
allergy clinic. So, in the short term—and by that I mean
four or five years—you can achieve that simply by increasing
the number of trainees but, in the longer term, I think it is
essential that allergy, which is one of the most frequently encountered
illnesses in general practice, is entered into the undergraduate
curriculum.
Q625 Earl of Selborne: If you are
going to increase the provision of training to GPs and others,
does that imply that you have specialist clinics or does it imply
a peripatetic training which goes round to the GP practices?
Dr Nasser: I think a bit of both. I would
be supportive of both things. There is so little knowledge in
primary care that we should do both.
Q626 Lord Taverne: Since we have
a shortage of teachers who can train, is this a case where we
should import the expertise from abroad, if we can get it?
Dr Nasser: I would not be a fan of that.
I think that we should develop the expertise within our own trainees.
Certainly it could be a short-term measure but again we have to
think long term about this.
Q627 Chairman: Is there an adequate
use of modern education methods such as e-learning and distance
learning in the subject?
Dr Nasser: Yes and I am sure that that
is something that could be employed. The question is, how effective
would that be simply because I think that the most effective training
is from seeing patients and, unless it is ingrained from the very
beginning that allergy is an important aspect of many disorders,
for example asthma and atopic dermatitis, then it is unlikely
to succeed. E-learning is certainly taking off. I do not know
how effective it is.
Q628 Chairman: Do any of the dermatologists
want to comment on the effectiveness of e-learning?
Dr Grattan: I would be happy to comment
but may I steer the discussion back a little to the education
of GPs in dermatology. Although dermatology is on the undergraduate
curriculum, it is often allocated a relatively short period of
time and there is no compulsory postgraduate training of general
practitioners in dermatology that I am aware of. However, they
do get education on rotational training schemes when dermatology
is included as a specialty. My own experience is that they find
this extremely valuable. This might be a way forward with allergy
if allergy were to be included on GP vocational training schemes
where that expertise is available.[1]
Chairman: Would you like to comment on that,
Mrs Cox?
Mrs Cox: I believe that there is some
limited availability of postgraduate training in dermatology but
I would agree with the overall point, namely that, on the whole,
when you go to see your GP with atopic eczema, you will be extraordinarily
lucky if your GP has had any significant training in dermatology
and even luckier still if that training is anything remotely recent.
Q629 Baroness Platt of Writtle: I
am just thinking at what level the people who do the training
would need to have a qualification. I understand that GPs are
having CPD, it is part of their on-going qualification; could
the allergy skills be included there? How do we train the trainers?
Professor Gawkrodger: I think when it
comes to training GPs and specialist registrars, all consultants
are trainers so there is no problem; any consultant has to train
a registrar and can train GPs.
Q630 Baroness Platt of Writtle: But
there is a shortage of them?
Professor Gawkrodger: I think perhaps
one of the points that could be made there is that there is not
enough attention given to time set aside for training in consultants'
job plans because consultants' job plans have now been squeezed
and squeezed to reduce the amount of time there for training people—and
for research, I might add—and to increase the proportion
of the time spent in clinics and seeing patients, which is where
the target-driven ethos that now pervades the NHS comes into play.
I would like to just support the views of my colleagues here in
saying that GPs need far more training in dermatology and allergy
than they currently get, and there is no doubt the best way of
getting that experience is for specific training posts for general
practitioners to include an element of dermatology and allergy
within the training.
Q631 Lord Colwyn: Do you think the
GMC might ever make it compulsory as part of CPD to do certain
aspects of medicine?
Professor Gawkrodger: Training is regulated
by something called PMETB—the Postgraduate Medical Education
and Training Board—and the exact components of training
are determined by that with influence from the Royal College of
General Practitioners.
Chairman: I want to move on with some
of our questions now. Lady Platt?
Q632 Baroness Platt of Writtle: Patients
suffering from latex allergy often experience difficulty in obtaining
medical care due to the contact with latex-containing articles
such as gloves or vial stoppers. What information is available
to these patients when they enter hospitals, health clinics—and
I had better add or GPs'—and how could awareness of the
potential risks be improved?
Dr Nasser: Well, latex allergy is actually
one of the success stories and it is an example of where Government
and Department of Health intervention has actually improved matters.
In Cambridge we have had a written hospital latex policy with
patient leaflets for at least six or seven years and we have seen
a decline in the number of referrals of patients who are essentially
health care workers, but also people in other industries, and
the number of referrals has come down considerably. The main reason
for this is the written policy and also the fact that we got rid
of powdered gloves many years ago. Up until recently the National
Patient Safety Agency identified that up to 40 per cent of health
care institutions did not have a written latex policy and they
have now made it compulsory for every health care organisation
to have a written policy, which I think had to be done within
the last few months. I am sure that this will further reduce the
number of people with latex sensitisation.
Q633 Lord Selborne: I wanted to ask
about occupational diseases. Could you tell us what proportion
of patients suffering from skin allergies have developed their
disorder due to conditions at work? Perhaps you could tell us
what occupations are most commonly affected by allergic dermatological
conditions and what could be done in the workplace to prevent
the development of these disorders?
Professor Gawkrodger: Firstly, with regard
to the proportion of patients that have developed their skin allergy
from occupation, it is not known. The number of patients who have
occupational skin disease, which is almost all dermatitis, is
just over 100,000 per year by an estimate from the EPIDERM Unit
at Manchester University. Of those, up to 50 per cent will have
a contact allergy as part of their problem. That is about the
best figure I can put on it. The commonest occupations to figure
there—and I think it is best to look at the proportion per
occupation—one of the highest ones is hairdressers. Hairdressers
are a particular problem because they have very poor access to
occupational health services and they work in very small firms
and the message about good hand care, avoidance of allergens (of
which there are several in the hairdressing industry) and also
sensible glove use does not get through as well as it should.
Of the other industries, the ones that appear in the top five
include the chemical and petroleum industry, the construction
industry, health care workers and people working in agriculture.
As regards what can be done to prevent it, I think there are a
number of things and some are legislative, as I mentioned before,
for example the limiting of chromate in cement is an important
thing, and getting the message through about being careful when
handling toxic chemicals because very commonly people handle chemicals
in an inappropriate way and they do not wear the appropriate personal
care equipment, and better education of the workforce can go a
long way to improving matters there. Also I would agree that there
should be the proper use of the correct type of gloves. Perhaps
also people who may be inclined to develop eczema, perhaps people
with an atopic eczema past history should not go into certain
occupations where they are likely to develop problems, for example
hairdressing, which has got a lot of wet work involved in it,
tends to make people with a past history of atopic eczema develop
severe hand dermatitis which then means they have to leave the
job.
Q634 Lord Selborne: It is interesting,
is it not, to reflect that where you have got a large, structured
organisation such as the hospitals you get the success stories
which we have just heard about with the latex, and then you refer
to the small businesses of hairdressers or farmers, where presumably
it is much harder to impart this information. Do you think that
there are any other success stories? Is for example the National
Hairdresser Day which we have heard about likely to impact on
this problem, do you think?
Professor Gawkrodger: I get the impression
that the hairdressing industry is taking the message on board
about better hand care and more sensible use. They are a very
difficult group to reach, but I think the Health and Safety Executive
have got a project on this in mind and I hope that it will make
a difference.
Q635 Lord Rea: We have heard about
the Centre for Occupational and Environmental Health at the University
of Manchester which records the incidence of occupational dermatological
diseases as part of the OPRA and EPIDERM projects. Would you perhaps
spell out what those acronyms stand for? I gather these projects
have been criticised because they suffer from under-reporting,
and I think you referred to that. How could the recording of occupational
allergic diseases be improved?
Professor Gawkrodger: The OPRA scheme
is the reporting scheme for occupational physicians and the EPIDERM
scheme is the reporting scheme for dermatologists. Yes, the problem
about these schemes, as you mention, is that they are selected
reporting. In both schemes there is a core group of reporters
who report every single case of occupational skin disease that
they see, but then also there is a sampling group who only report
for one month every year, so the figure of the number of people
who have an occupational problem is a figure that has been produced
by multiplying a number of other figures, and so it is an estimate
not a firm figure. Another problem with the scheme is that it
both under-estimates and over-estimates. It under-estimates because
there is general under-reporting and under-recognition of occupational
skin problems, but it can also over-estimate the importance of
an allergen because you only have to have suspicion that it might
be involved to report it, and it does not need to be verified
by somebody who knows the answer. I think the biggest problem
about the gross under-reporting of occupational dermatitis is
the problem that general practitioners cannot recognise properly,
because they are not educated sufficiently, when occupation is
playing a role in somebody's skin problem. It is not recognised
enough. What you can do about it is a very difficult thing to
answer. I think the best way of getting a really pure answer to
it—and it is really a research question—is to take
a defined population out there in the community and look at it
in great detail by people who can truly recognise and investigate
for an occupational skin problem and then somehow translate the
results you get on a national basis, but that has got problems
as well.
Q636 Lord Rea: There is a problem
in distinguishing objectively whether allergic disease has an
occupational origin or not. I believe that the Health and Safety
Executive has suggested that there should be standardised criteria
introduced which might help measure the trends in these diseases.
Professor Gawkrodger: Yes, at the moment
the way we say whether we think somebody who is exposed to a certain
chemical whether that chemical is an occupational chemical or
not, is once you have shown on patch-testing that they are allergic
to it, once you have demonstrated the allergy, then we say are
they exposed to it, and if they are exposed to it we more or less
say, well, in that case we think it is playing a part. I agree
that a better definition of the situation would be helpful.
Q637 Lord Taverne: Can all dermatologists
adequately treat patients suffering from a disorder with an occupational
cause or is there a need for a small number of subspecialists?
Professor Gawkrodger: All dermatologists
are trained in contact dermatitis and that will include some training
in occupational skin problems, so if it is a relatively straight
forward occupational skin problem, such as somebody is allergic
to rubber chemicals in rubber gloves or latex or to chromate,
then it should be within the capability of the average dermatologist.
If it is a rather more complex case, then it may not be and it
may require somebody who is specifically trained and has specific
expertise in occupational skin disease, of which there are a number
of people in the major centres, so I think if you take the major
centres in the UK, the big cities with the large departments,
you will find one person there or sometimes more than one person
who does take a specific interest but you are then only talking
about 20 or so individuals. I personally do favour that because
the subject of occupational skin disease is becoming more and
more complicated and I think it would be the best way forward.
Dr Grattan: I would support everything
that I have heard and I think that specialist groups who have
particular experience in occupational dermatology and patch-testing
should be promoted and encouraged. The subject of dermatology
is becoming more diverse. Skin cancers are becoming more common.
Practitioners are being asked to do more things than ever before
and there is a future risk of training skills in, say, patch-testing
and occupational dermatology becoming diluted by the requirement
to do other aspects of dermatology, so even having centrally funded
posts that recognised the importance of this would be helpful.
Q638 Lord Taverne: In the case of
occupational asthma, a Group of Occupational Respiratory Disease
Specialists (GORDS) convened regularly by the Health and Safety
Executive aims to develop a standard of care document for diagnosis.
Would it be useful to have a similar document circulated for dermatitis?
Professor Gawkrodger: I am not aware
of the document on asthma, but I certainly would agree that better
definition of the problem and greater awareness would be helpful.
Q639 Lord Taverne: Dr Nassar is perhaps
aware of the GORDS approach?
Dr Nasser: I am and like with any written
guidelines it is always helpful to have a set of standards because
you can then compare the incidence of a particular disease from
one year to the next knowing that you have used the same set of
standards, otherwise you have many practitioners up and down the
country using perhaps different standards so I guess that would
be helpful.
1 Most departments of dermatology in the UK offer programmes
of postgraduate education for General Practitioners for the purpose
of CME (continuing medical education) credits but only some GP's
will have the opportunity of a formal training in Dermatology
as an element of their Vocational Training and this should be
encouraged. Back
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