Examination of Witnesses (Questions 760-776)
DR GILL
HART, MR
RICHARD GUTOWSKI,
MS HELEN
YOUNG AND
MR ANDREW
DILLON
15 MARCH 2007
Q760 Lord Colwyn: Are the Royal Colleges
involved?
Mr Dillon: Yes. The way we develop clinical
guidelines is to do it in conjunction with the Colleges. The guidelines
are developed through a series of national collaborating centres
and these centres are collectives of the medical Royal Colleges
and the other main, national, professional bodies.
Q761 Lord Colwyn: Do you have any
view on how these guidelines will fit into the current system
of allergy service provision in view of the financial constraints
of most PCTs?
Mr Dillon: They fit into the existing services
in that they would represent standard good practice, so the existing
services would do what the NHS does generally when NICE produces
a clinical guideline. That is to base line current service provision
against recommendations and develop in effect a project plan to
migrate towards broad accordance with those recommendations. They
also have the effect of stimulating the creation of services where
those services do not exist. There have been examples from other
NICE clinical practice recommendations where that is happening.
Clearly the NHS is expected to do an enormous amount for all of
us and we all expect it to do all of that straight away. The reality
is that local NHS organisations start from different positions
for individual services. Some are well advanced in one service
and less well advanced in another. The time it takes to get from
where somebody might be at the point at which we publish a recommendation
on a particular aspect of clinical practice to being able to say,
"We are consistent with NICE recommendations" will vary.
That variation is in part also a result of the ability of NHS
organisations to allocate resources to implement what we have
recommended.
Q762 Lord Colwyn: I suppose we might
be concerned that there is such a shortage of allergy consultants
throughout the country that services might vary from region to
region.
Mr Dillon: They do. It is not just because of
the distribution and number of allergy consultants. Most allergies
can be very competently managed in primary care by generalists
and that is where the majority of service delivery will be. NICE
guidance though would recognise both where it is appropriate for
generalist practitioners, both medical and nursing, and indeed
whether other health professionals can make a contribution to
treating and where it is necessary to refer on to more specialist
care. One of the benefits of having that guidance is that it gives
the service as a whole, as well as local NHS organisations, the
ability to work out what they actually need in order to deliver
a good quality service.
Q763 Chairman: We have heard of GPs
drowning under guidelines.
Mr Dillon: They are but the only ones they really
need are ours, so they need not drown.
Q764 Lord Soulsby of Swaffham Prior:
Can we turn to immunotherapy? We have heard from other witnesses
that immunotherapy is not very popular, if that is the proper
word, in this country compared with countries in the European
Union. One wonders why this is so. Is it because the MHRA regulation
for immunotherapy licences are particularly stringent compared
with those in other countries? There has been a visit to Germany,
for example, where the Committee found that immunotherapy was
quite frequently used.
Mr Gutowski: I can answer it very briefly in
the sense that the Committee on Safety of Medicines within the
UK restricted the use of desensitising vaccines in, I am told,
about 1986 and 1994. They advised of inadequate evidence of benefit
to support the use of these vaccines. They revisited that in 1994.
They recommended that these treatments should be restricted to
those patients who have not responded to anti-allergy drugs. I
can give the Committee a more detailed explanation of the thinking
behind the CSM's decision in this respect but I do not have any
more detail of that in front of me.
Q765 Lord Soulsby of Swaffham Prior:
One wonders, for example, whether NICE have carried out an
appraisal of allergen injection immunotherapy. Mr Dillon, have
you any information?
Mr Dillon: No.
Q766 Lord Soulsby of Swaffham Prior:
In view of the more general use of it in other countries in Europe,
is it not worth looking at in greater detail than hitherto? Obviously
its use has been rather negated by what you say.
Mr Dillon: Anything that the NHS can and does
offer, regardless of at whatever level and whatever variation,
is worthy of some consideration but with limited capacity NICE
has to prioritise what it looks at at any one point in time. That
said, the process that we operate to generate topics allows anybody
to suggest either a specific drug or another intervention or a
whole disease area as being suitable for consideration. The new
arrangements that we have put in place since the autumn of last
year provide a much more transparent, objective approach to assessing
the suitability of topics suggested and a much more objective
approach to prioritising them. We could do it but in the end we
have to make sure that we spread our available capacity across
the whole range of diseases and conditions that people would expect.
Q767 Chairman: The Cochrane review
came out with quite positive results. How much of the Cochrane
review is informing your process, particularly your guideline
development?
Mr Dillon: Looking at what Cochrane has produced
is one of the first steps that the guideline development group
take in assembling the evidence. Cochrane is a very important
source of our studies and their database would be searched as
a matter of routine by the guideline development group.
Q768 Lord Colwyn: Have any of you
a kind word about Vega testing or kinesiological testing or homeopathic
treatment?
Ms Young: I cannot offer an opinion from NHS
Direct's perspective on that. I would not feel comfortable doing
so.
Mr Dillon: I do not have any unkind words but
I do not have a view.
Q769 Chairman: Can I go to over the
counter medication, second generation antihistamines and potent
nasal corticosteroids? These are now available from pharmacies
in the high street. I wonder whether you feel—I guess it
would be particularly Ms Young—that the level of regulation
is right or whether there is an over-availability or an under-availability?
Ms Young: in relation to whether the regulation
is right, it is probably not directly my sphere but what I could
perhaps offer is that it is our experience that, from a user perspective,
the patients' perspective, both the availability of these products
and their usage is significantly both valued and used. Although
NHS Direct do not prescribe over the telephone and we do not directly
advise patients to go and take a particular drug, we do advise
on groups of drugs that might be helpful in managing their symptom
or their condition. It has been fedback to us and it is our nurses'
view that the availability of the products plus importantly the
pharmacists' advice on the usage of those products is very much
valued by patients. Whilst I would not personally have a comment
on regulation, I would say that the availability and usage of
such products has certainly increased, as you would expect. It
is a favourable option for many members of the public and unblocks
other parts of the NHS for other care.
Mr Gutowski: The move of products from prescription
only to pharmacy status was following careful consideration by
the Agency as part of the general policy of making more treatments
available to the general public, rather than by a general practitioner.
It was based on a number of considerations: a favourable safety
profiling in respect of diagnosis and misdiagnosis of these products.
The lack of abuse potential is another consideration in making
that determination and then there is the convenience of the availability
of products from a pharmacy or general sale. When the consultation
was made with regard to moving these products to pharmacy status,
there was no objection raised with the Agency with regard to the
new availability of these products.
Q770 Chairman: Does this mean pharmacists
are now managing allergy?
Mr Gutowski: I do not know. I cannot answer
that question.
Ms Young: It would be a personal view that they
are a very important part of allergy management as are general
practitioners but, because of the increase in the usage of products
over the country and the quality of advice that needs to go with
that, it is certainly worth consulting with that group because
they play a particularly important role in self-care management.
Q771 Chairman: You mentioned just
now that you would advise a caller to look at a particular group
of drugs perhaps in terms of managing their condition. Do you
advise them to seek advice from a pharmacist or do you advise
them to go to their GP before purchasing drugs from that group?
Ms Young: It depends on the nature of the call.
In urgent symptoms that we believe need to be seen by a GP, we
would automatically screen and send to the general practitioner.
Roughly speaking, about one per cent go to 999. 50 per cent of
the calls that we take in relation to allergy will end up either
directly going to a GP practice or some form of out of hours care.
The rest of it will be self-care. We will say that a particular
group of drugs might be helpful in alleviating symptoms. We will
then advise them to go to the pharmacy, speak to the pharmacist
and be advised on what is the best product. The difficulty for
NHS Direct is that we are not always face to face so our advice
to go to a pharmacy is often based on whether we have a view on
what group of drugs will work but we would obviously want another
clinician to have a face to face opportunity where that patient
is exhibiting a rash et cetera.
Q772 Chairman: Do you think the pharmacists
have clinical training appropriate to the diagnosis of these sorts
of conditions?
Ms Young: I cannot specifically comment on pharmacist
training. I only know about our collaboration with them in relation
to sending patients or callers to them.
Q773 Viscount Simon: Novel therapies
for allergic diseases are currently being developed such as anti-IgE
therapies and sublingual desensitisation vaccines. Are these being
appraised by NICE or MHRA and who can administer them?
Mr Dillon: We are looking at one of these therapies
called omalizumab and it is for treating severe, persistent, allergic
asthma. The plan at the moment, subject to appeal, would be to
publish recommendations about the use of it in August this year.
Q774 Chairman: Do you have any view
on the role of pharmacists in the diagnosis of allergy?
Mr Dillon: Not from the NICE perspective but
there will be a general view inside the Institute that pharmacists
have an important role to play in delivering services and that
role over the years has increased and is likely to increase further.
The judgment is all about risk set against convenience for patients
or individuals accessing a pharmacy as opposed to going to a GP.
Q775 Chairman: Dr Hart, from the
people who are sending in to you, do you have a feel for how many
have sought advice from health care professionals, other than
going through their GP, and have found that advice helpful or
unhelpful?
Dr Hart: I do not have exact numbers or details.
People who come to us have suffered for a long time and they tend
to come to us as for other therapies as more of a last resort
because they do not feel their needs have been met.
Q776 Chairman: I wonder whether you
anticipate that NICE might be evaluating some of the oral hay
fever vaccines such as Grazax, whether that is on your "to
do" list or whether it has not yet featured.
Mr Dillon: It is not on our "to do"
list. It has been something that we have looked at and tested
against the selection criteria for topics for the Institute. At
the time we did that, it was looked at by what was then the joint
NICE Department of Health Committee in September last year. The
view was that it was not suitable for appraisal by the Institute.
Chairman: If none of you has any particular
comment to make where you disagree with something said by somebody
else on the panel, could I thank you for having come this morning.
If there are additional pieces of information you would like to
send to us, please do. We will look at them as part of your evidence
today.
15 MARCH 2007
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