Examination of Witnesses (Questions 680-691)
PROFESSOR JOHN
HARPER, PROFESSOR
JONATHAN HOURIHANE,
DR WARREN
HYER AND
DR MARK
ROSENTHAL
7 MARCH 2007
Q680 Chairman: Is there an onus then
on midwives and health visitors to understand allergy better?
Professor Hourihane: They are very powerful
intermediaries of medical advice. The advice the Government gave
about peanut avoidance was much more commonly adhered to if it
was received from a midwife than from a family care doctor or
an allergist, if you happen to have seen one. So they are very
important people. They also have got to stop the habit of giving
individual bottles of milk to children just to keep them quiet
while the mother rests on her first night, lying in. There are
a key target population for training.
Q681 Lord Colwyn: We have covered
some aspects of training already this morning, and it has become
clear there is not a lot of postgraduate training available, although
I think in previous evidence we did hear that it has been suggested
that in group practices specific doctors might be allocated the
job of being particularly interested in allergy. Literally, all
my own training in medicine and later in dentistry consisted of
was training in how to deal with allergic reactions to substances
that we had introduced into the patients at the time. Can you
tell us what training programme there is for paediatric allergists
and is it an attractive career path for a doctor?
Dr Hyer: In answer to the last bit, if you look
at the recent applicants by paediatricians for clinical training
programmes and specialists in areas of speciality for the year
three registrars, (in other words they have got about three more
years to go) allergy is one of the most popular specialties to
go into. It is now a credible paediatric resource and so it is
popular. For the training I would have to refer to Professor Hourihane.
Professor Hourihane: We need to have centres
that can do the training where they can give the whole experienced
complement of dermatology, gastroenterology, asthma and immunotherapy.
It has always got to be in centres where this can be done and
then these people need to be diffused out into other regions following
training where they would then be able to interact with primary
care. It needs to be in a place where everything can be done.
Dr Hyer: Whilst you are being trained in your
allergy I think it is true to say that if you take on other specialties,
particularly paediatric gastroenterology, you cannot really do
it unless you have had some allergy training, such is the burden
of clinical work that will come to you from food allergy. The
training programme for juniors needs to be modified to take into
account that there is a specialty of allergy and that it will
impact on their clinical practice and they need to be trained
in it. That is going to require training centres—proper
tertiary units with specialist supervisors in paediatric allergy
and specialists who can train you in respiratory complications
such as asthma—and those need to be in place.
Q682 Lord Colwyn: Does the Certificate
of Completion of Specialist Training in Allergy involve paediatric
training as well as adult allergy training?
Professor Hourihane: No, I think I was the first
paediatric allergist to go through the CCST scheme and I have
got a CCST in general paediatrics and immunology because allergy
was not a recognised specialty at the time in paediatrics, and
it remains so.
Q683 Lord Colwyn: How do paediatric
allergists work with adult allergists and organ specialists to
ensure long-term care for patients as they grow older?
Professor Hourihane: Paediatricians are very
good at organising transitional care. It is well-established for
cystic fibrosis and asthma and other chronic respiratory conditions.
There has not been the evolution of paediatric allergy clinics
on a broad enough scale to say that there is a logical and well-defined
structure of transitional services. In Southampton, we transferred
patients to the adult services with an overlap of appointments.
We did not share clinics but we co-ordinated appointments. It
is a real risk that the children who have been carefully supervised
with food allergies will then become the adolescents who leave
all their kit at home and go to restaurants at risk, so care of
adolescents with significant allergies as well as significant
asthma or cystic fibrosis could be better co-ordinated.
Dr Hyer: When I finish with my patients at 15
I do not have anywhere to send them. I know who my paediatric
allergy colleagues are, but I do not really have access to strong
adult allergy services. The numbers are small because, as we have
said, food allergy is principally a phenomenon of the pre-school
child, so it mainly fits within the remit of paediatrics, but
I do get 16-year-olds turning up to my clinic who have oral allergy
problems with pollen et cetera who want to know where to go because
I cannot see them any more, and I do not think I have anywhere
to send them yet.
Q684 Lord Colwyn: So are there particular
difficulties for specialised paediatric allergy services in district
general hospitals?
Professor Hourihane: They do not exist in district
general hospitals.
Dr Hyer: What happens in district general hospitals
is what is happening here. I am an organ-specific specialist,
I deal with the gut, and invariably I have to deal with food allergy.
I got myself trained. I trained myself in Australia in order to
get the training that I really needed, and I do not mean that
in a derogatory fashion and I am sure my colleagues would understand
that. I had to do that because of the demand for services and
the referral patterns. I think that probably answers the question.
In a district general hospital we are not allergists, we are organ-specific
consultants who have to do allergy with different passions, so
I would be passionate about my food allergies and less passionate
about my asthma, but hopefully as a paediatrician I can deliver
the whole package. That may not be true in adult practice where
if you have got food allergy you go to an adult doctor and he
may not be an adult gastroenterologist and he may not be able
to help you with your eczema.
Professor Hourihane: I would say that allergic
conditions are diseases that live in the community but are looked
after by professors in university hospitals, and that is not a
reasonable model of care.
Q685 Lord Rea: How long does it take
for a consultant in any of the specialties in which allergy plays
a part to get a sufficient body of knowledge in allergy to consider
themselves well-trained as an allergist in their particular field?
Professor Hourihane: There are European standards
of training which say that they should have four years of specialist
training or so. If you take the British model of higher specialist
training, that is two years as a registrar and then three years
of higher specialist training and many people who would go into
what are niche areas would do primary research at that stage,
so it is at least five years as a registrar with maybe a couple
of years for higher degrees.
Q686 Lord Rea: What I am talking
about is somebody who has already got a consultant post in their
particular area but wanted to establish an expertise also in allergic
manifestations of their particular specialty.
Professor Hourihane: There is a specific allergy
MSc course in Southampton which can be taken in a modular fashion
and that can be done at certificate, diploma or full MSc level
over the course of four years. So there is postgraduate training
available but it is very unavailable!
Dr Hyer: If you ask how long does it take: I
have had to train myself and I do not know how good I am because
I am only trying to do the job, no-one has validated it, I just
have not made mistakes. You will need to ask Dr Rosenthal his
opinion on how long he has had to do it as a respiratory doctor,
but I think it has taken me several years of clinical practice
and close liaison with my colleagues who are allergists within
London to get a feel for what I am doing. Just as GPs get back
a reply from a consultant, I get responses back from my colleagues
and so I know how to step forward. I have many shared patients
with for example Professor Harper so I have learnt how to address
some of his practices as well. It has taken me a long time. If
you put it in a training programme the minimum you would need,
for example as a gastroenterologist, if you want to practise it
at a hospital level, is six months doing allergy, to meet the
burden of work that comes to you in a district general hospital.
Q687 Lord Rea: Would a general practitioner
be able to enrol on the MSc course?
Professor Hourihane: Yes, it is multi-disciplinary.
Q688 Lord Taverne: Just following
that up, with the general practitioners being so ignorant about
allergies and being in such a crucial position to refer people,
there are many pressures on their time to get up-to-date on all
sorts of different developments. What would be the minimum education
and training they would need in the diagnosis or recognition of
allergy? What sort of base model would they have to get and how
long would it take them to get it? It does seem to be a rather
desperate situation when they know nothing and the training courses
appear to be so long.
Professor Harper: It should be incorporated
in part of the core training. Not just for general practice, but
in thinking about my own specialty—dermatology—there
is very little provision, even nowadays, for incorporating adequate
allergy training in becoming a consultant dermatologist. I think
it should be done at core level. If there are already general
practitioners who are out there practising, then they would need
to attend courses, or undertake an MSC if they had a particular
interest, but perhaps one particular person within a general practice
who had a particular interest in allergy could take it on.
Dr Rosenthal: To be completely pragmatic, given
the number of hours that GPs are compulsorily required to be educated,
I would have said four hours in a year would get you a fair way
up the learning curve.
Dr Hyer: What you are asking them to do in those
four hours is learn to recognise allergy because you are going
to have colleagues who will take it on. I am being a bit controversial
here, but I do not expect a GP to diagnose and manage a young
child who may be at risk from multiple food allergies. I think
this child has a degree of complexity that validates him seeing
a specialist in hospital so those four hours are principally about
recognition and sharing treatment, but I still think there is
a role for the hospital doctor in actually seeing them. If you
had two hospital admissions with asthma and they have multiple
food allergies, surely they merit seeing Mark or another specialty
or a general paediatrician to address that? I do not know if the
others agree.
Professor Hourihane: I agree.
Dr Rosenthal: I agree, the principle of the
training is to recognise the problem. Management is a separate
issue but you cannot do management without recognition.
Q689 Chairman: I would like to just
finish by asking one short question to each of you and that is
whether we know what the burden is of misdiagnosis or wrong diagnosis
amongst allergy in children in this country?
Dr Hyer: I can tell you from my own audit that
50 per cent of my new referrals to my allergy services, I can
tell them they do not have an allergy and send them away. That
is a significant saving bearing in mind that 10 per cent of all
GP prescriptions in this country are based on some kind of atopic
or allergic role. I can stop that in 50 per cent of the patients
where they are alleged to have food driving their atopy, overcoming
some of the myths. I also believe if you make the right diagnosis
you can help prevent hospital admissions and complications, etcetera.
You are quite right; you can reduce the misdiagnosis if you offer
the right service.
Q690 Chairman: Did you want to add
anything?
Dr Rosenthal: My biggest worry is the consumption
of what might be called fringe diagnostic things or "high
street quackery" that may make an erroneous diagnosis of
allergy and lead to dangerous management practice.
Q691 Chairman: Are systemic steroids
appropriately used in children?
Dr Rosenthal: It depends who is doing the using.
That is not the question I expected. All medicines have to be
treated with respect, but the failure to use systemic steroids
where appropriate is as big a problem as using them when they
are not appropriate.
Professor Hourihane: I would say that an integrated
allergy service spends more time normalising a diet rather than
restricting a diet, and we take the worries of allergic disease
off families by showing them or proving to them that they have
not got the allergy. Effective management to address the allergic
components of asthma can decrease hospital attendance by 55 per
cent and medication use by 60 per cent, so there is an enormous
added bonus to the NHS to invest in allergy services.
Professor Harper: We have heard that eczema
is often the presenting feature so many of these children are
referred to dermatologists and the severe ones often to me. It
is both ends of the spectrum. I think very often allergy is under-rated
and perhaps missed but there is also a drive from the parents
themselves who have initiated a diet or been given advice from
friends, family or someone in the high street, so it really is
a subject that needs to be more expertly managed.
Chairman: Could I thank you all for coming
today and for all the information that you have given us. If there
is any additional information that you would like to submit to
the Committee, we would receive it as part of your evidence today
so please feel able to send anything in. You are very welcome
to stay and listen to the next session. Thank you.
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