Examination of Witnesses (Questions 640-648)
28 FEBRUARY 2007
MRS MARGARET
COX, PROFESSOR
DAVID GAWKRODGER,
DR CLIVE
GRATTAN AND
DR SHUAIB
NASSER
Q640 Lord Selborne: I was going to
ask about research and we have already heard as an aside that
research and training have been squeezed by cost-cutting. Could
you tell us what research is currently being carried out into
atopic dermatitis, eczema and urticaria in the United Kingdom
and who carries it out? Is it declining?
Professor Gawkrodger: The major funder
of skin research in the UK is the British Skin Foundation. I did
check with them last week and over the last nine years or so they
have funded 139 projects of which 12 were on atopic eczema and
10 were on dermatitis. When it comes to funding I could not see
any that were funded on urticaria. When it comes to the major
funders like the MRC or the Wellcome I am not aware at the present
time, although I have not checked with them specifically, that
they are funding any research on atopic eczema or other aspects
of dermatitis. I do feel that it is an under-researched area.
One problem that we have in dermatology is that funding for research
in dermatology comes quite a long way down the pecking order in
comparison with funding for cancer and cardiovascular disease,
for example, and there has been erosion of the university bases.
University departments of dermatology have been merged into larger
departments and in some cases the departments have actually closed.
The two major departments in Liverpool and Glasgow have actually
closed over the last 10 years, so academic dermatology has been
under a big threat generally.
Q641 Lord Selborne: Do you think
that there is adequate international collaboration on the research?
Professor Gawkrodger: Certainly major
research groups do look to collaborate internationally, particularly
within Europe. I think that generally speaking there is insufficient
research on the subject of eczema and atopic dermatitis, even
at an international level.
Dr Grattan: The situation with urticaria
is even worse than you have heard for atopic dermatitis. There
is little active research in the UK and internationally less attention
is paid to urticaria than other diseases of similar prevalence.
This does have consequences for me as a clinician advising patients
who come to me often from all over the country to the tertiary
referral clinic at St Thomas'. They want to know why and they
want to know what to do and I often have to respond by my instincts
and my experience but not by written evidence, so I often have
to treat patients with unlicensed remedies that have not been
fully evaluated. There is a major need for better research and
recognition of the importance of this subject.
Q642 Chairman: Is that because there
is nobody interested in taking the lead or is it because there
are people who are interested in applying for funding but just
not getting the funding?
Dr Grattan: I think it is probably lack
of interest in people taking the lead as a whole. We have many
pressures on us to accomplish service work and I think that funding
is perhaps an issue. I can give you my personal experience very
briefly that I have now an allergist from abroad who is working
with me and will be for three years, doing what I hope will be
a very useful and enlightening series of projects, but she is
funding herself to come and work with me and I have to give my
time outside my service commitment to support her.[2]
Q643Chairman: Mrs Cox, do you want to comment?
Mrs Cox: Really I agree with everything
I have heard. From my perspective, the National Eczema Society,
along with several other of the patient support groups in dermatology
also seek to fund medical research. One of the challenges that
we are finding, in addition to the obvious one that we too find
it hard to raise funds, is that in fact it can be increasingly
difficult to find appropriate projects and centres to fund, so
I think we have a chicken and an egg.
Chairman: Thank you.
Q644 Lord Colwyn: Do you think that
the allergy specialism is an unattractive career pathway for undergraduates,
leading to postgraduate study?
Dr Nasser: I think for undergraduates
whenever I have taught allergy in Cambridge it has always been
very well received and with great interest. For postgraduates
there are so few training positions that it is difficult to answer
the question, but certainly when we advertised for a trainee specialist
registrar we had lots of applicants, but there are so few training
positions available. I do not think it is necessarily an unattractive
proposition but I think it is important there are jobs they can
go into once they are trained. So that is the way to make it more
attractive.
Q645 Chairman: I just want to finish
up with two questions which are quite unrelated. The first one
relates to cosmetics where the label "hypoallergenic"
is often attached to cosmetics, bed linen, all kinds of items.
I just wonder if you have any comments about what it actually
means, and whether it is meaningful?
Dr Nasser: I will start with that. I
do not know anything about cosmetics but I understand that hypoallergenic
simply means "less likely to cause an allergic reaction".
With that I will pass over to colleagues.
Professor Gawkrodger: I think it is meaningless
basically. There is no regulation of the term "hypoallergenic".
What may have happened if it says "dermatologist tested"
or something of that sort is that in one of a small number of
testing centres in the UK a dermatologist in conjunction with
a testing organisation has actually patch-tested a number of individuals
with different skin types, including people who say they have
got sensitive skin (which is a sort of syndrome where people say
their skin reacts easily to chemicals, it does not necessarily
imply allergy), and people with this sensitive skin have not reacted
in a very high proportion to the tested product and that is what
it really means when it says "dermatologist tested".
I look at a lot of these preparations and what is in them when
it says "hypoallergenic" and I see a whole list of things
which I know can cause allergy, so I am rather cynical about the
label of "hypoallergenic".
Q646 Chairman: Mrs Cox?
Mrs Cox: My personal view is that both
the term "hypoallergenic" and "dermatologically
tested" for somebody who has an allergic skin disease are
hugely misleading, and I can tell you from personal experience
that you can put either on atopic skin and react massively.
Q647 Chairman: My final question
to you goes back to education—and I have to redeclare an
interest which I have already declared—at Cardiff University
where the distance learning course is educating over 400 GPs every
year and those GPs are in the Royal College of General Practitioners'
Special Interest Group, forming the GPSIs (GPs with a special
interest) across the country. In five years there will be more
than a further 2,000 of these. Do you have any comment as to how
these GPs, whose education has been evaluated, are being received
by the dermatology community, given that the Royal College of
GPs has certainly embraced their development?
Professor Gawkrodger: This is a major
medical and political question at the present time and one of
the driving factors for it is the wish of the Department of Health
to see more dermatology and other specialties delivered closer
to the patient's home. The actual regulations for being a GP with
a special interest are being defined at the moment by the Royal
College of General Practitioners and other organisations and so
there will be certain criteria that these doctors will need to
fulfil to take on that role. As regards the view of the British
Association of Dermatologists, we are not against the idea per
se. I think we recognise that not all dermatology can be delivered
by dermatologists, there just are not enough, so some care has
got to be delivered by GPs with a special interest. Most skin
care at the moment, as you know, is done by general practitioners
not by dermatologists. What we are concerned to ensure is that
the GPSIs are actually integrated into the local schemes so they
actually work with secondary care doctors and are not a separate
organisation. As long as they are integrated with the secondary
care so that people in secondary care know what they are doing,
know their capabilities and they know what can be offered in a
hospital environment, then that should safeguard the patient to
receive good-quality care because it is the quality of care that
the patient gets that is the key theme to this. The patient must
not be disadvantaged by being seen by a GPSI compared to being
seen by a consultant, and if the patient requires to be referred
on to another specialist or to see a consultant dermatologist
then they have got to have that available to them. So long as
these safeguards are in place then the British Association of
Dermatologists is happy to support the scheme.
Mrs Cox: A couple of points. The first
is clearly I welcome the fact that there are GPs who are receiving
additional training in dermatology through the distance learning
courses. However, I do have from a patient's perspective some
concerns around the way patient services are already being delivered
in a lot of places across the country in that while there are
of course some excellent GPSIs, as things currently stand, there
are also people fulfilling that role with very limited education
or requirement for CPD. I have yet to hear a patient say that
they would prefer to have a lower quality of care closer to their
home. I think on balance what a patient would like to have is
an appropriate level of care. I am not at all convinced that that
is currently what they are getting. I am genuinely worried that
if we destabilise secondary care in dermatology any further that
is what they are bound to get because we will then go back to
the position where there is nobody to train people in the future.
Q648 Chairman: Do you want to add anything,
Dr Grattan?
Dr Grattan: Little; I think it has been
well said. I would just observe that distance learning courses
will produce a qualification and a certificate but that does not
necessarily translate into clinical care that has been supervised
and audited, and that is the second part of the education.[3]
Chairman: Can I thank you for coming
today. If there is additional information that you would like
to give to us as a Committee, then please feel able to send that
in. Your comments have been very helpful and you will be sent
a transcript from today's proceedings. Thank you.
2 The apparent lack of interest in research into urticaria
is due to many factors, including the diversity of presentation
of the disease, the relatively small number of doctors with a
special interest in it, the time pressures on clinical posts that
prioritise service work, training and clinical governance, the
lengthy approval process for research projects through ethics
and research committees and the current lack of new treatments
for urticaria under development by the pharmaceutical industry. Back
3
The training and supervision of GP's with a special interest in
Dermatology in Secondary Care is a requirement for achieving and
maintaining acceptable standards of practice. Whilst an expanded
base of practitioners competent to deal with dermatology problems
in the community should be in the interests of patients it is
essential that Primary Care Trusts and Practice Based Commissioners
do not fund GPSI posts in Dermatology and Independent Treatment
Centres at the expense of Dermatology specialists in Secondary
Care. These posts should be expanded rather than reduced to meet
the wide needs of patients with skin disease, including allergy. Back
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