Examination of Witnesses (Questions 860-879)
MR IVAN
LEWIS, MR
ALAN BELL
AND MR
JOHN BROMLEY
18 APRIL 2007
Q860 Chairman: Yes, it is serious.
Mr Lewis: It seems to me that if people are
misunderstanding the advice that is one issue but if the advice
is entirely wrong and counterproductive and actually damaging
people then we really need to move rather quickly, rather than
having ongoing incessant reviews. So what I will commit to do
is to get the research that has been published, have a very intensive
look at that in the next few weeks and then come back to the Committee,
having drawn some conclusions about what we need to do next. But
if we continually set up reviews it seems to me that we have information
and we now need to act and make a judgment, and this will always
be a judgment based on available evidence; but we have a responsibility,
if the advice is wrong or damaging or counterproductive, we ought
to change it as quickly as possible.
Lord Colwyn: And I think this advice
should come from the Department rather than from the Food Standards
Agency.
Q861 Chairman: Yes, I think the questions
are quite different—the question the Food Standards Agency
is asking. Could I also ask you on that to look at the advice
in relation to breastfeeding because we also heard about the very
high allergenic potential of using top-up formula when women are
breastfeeding, and there is a concern over the lack of support
to mothers, particularly with their first baby, during establishing
breastfeeding and that there is a tendency still in this country,
more than in others, to default to formula simply when the women
have not had enough support to establish breastfeeding, and it
becomes particularly important for those who have atopy.
Mr Lewis: I think what we have to do is look
at all of the content of the current advice with the independent
body that initiated it the first place, which still exists. I
think we have to take account of the FSA's research on the impact.
But we should also utilise international evidence; and if it is
evidence rather than simply judgment or perspective then we ought
to take account of that, and if it is persuasive we have to ensure
that that influences our advice.
Q862 Lord Broers: This brings us
back again to labelling, having been around the houses, as it
were. Evidence has shown that the ubiquitous use of defensive
allergy warnings on food labels unnecessarily limits the range
of products allergy sufferers can buy. How will you work with
the Food Standards Agency to ensure that information regarding
allergens is made more accurate, or should I say sufficiently
numeric, when the EU reviews its food labelling legislation this
year?
Mr Lewis: The FSA acts on behalf of the government
in this area and we will expect them to ensure that our views
on this are taken very, very seriously as part of the European
Union review. Having spent a lot of time in the EU when I was
a Treasury Minister I certainly cannot guarantee the outcome,
but I can assure the Committee that we will be seeking to influence
this review so we end up with the outcome that we desire. Would
it be helpful to give you some update on what they have recently
done on this issue because the European Commission has actually
made some changes in this area recently?
Q863 Lord Broers: Yes, please.
Mr Lewis: They have recently decided to extend
the list of allergenic foods to include molluscs and lupin, and
that is based on advice from the EFSA that these also present
a public health concern. The consequence of the Commission's decision
is that national legislation to add those two additional foods
to the list of allergenic foods will be implemented by 23 December
2007. I am not sure that the Committee is aware of that particular
change? I certainly was not aware of it before I looked at the
information for this Committee.
Q864 Lord Broers: I would like to
extend that a little. It is the actual quantity of allergen that
may be the problem. If you take sulphites in wine, all wines contain
sulphite and people will only be allergic, perhaps, if the quantity
exceeds a given amount. So that is what I see this question getting
at to a certain extent, because if you put on every single bottle
of wine that it contains sulphites then you are either stopping
people drinking—which may be a very good thing indeed, but
that is not the purpose of the label, which is meant to tell people
who are going to be allergic to something. So my suggestion is
that it should actually be quantitative and say so many milligrams
or such and such a percentage.
Mr Lewis: I think I can confirm that stopping
people drinking wine will not form part of our manifesto at the
next general election! Yes, I think that is a very specific point
that we ought to feed into the FSA. What I can say to my Lord
is that I can write to the Committee with a bit more information
about how the FSA are approaching their attempts, on our behalf,
to influence the EU decisions on these matters, and we can ask
very specifically, as part of the way that we are seeking to influence
the EU, taking account of the point that you have just made.
Mr Bell: Might I just stress that our understanding
is that this current review that the EU is undertaking of all
food labelling, which, as we have been saying, we will feed into
through the Food Standards Agency in this country, is really going
back to basics and looking at all aspects of food labelling and
the requirements for and the scope of allergen labelling as part
of it.
Chairman: I think that becomes very important
because lupin cross reactivity with house dust mite is not something
that people would initially think of in relation to food, and
yet we know that asthma is triggered by house dust mite in those
who are allergic to house dust mites. Lord Broers.
Q865 Lord Broers: We have also heard
that teenagers and young adults who suffer from food allergies
tend to be less vigilant when buying food and take risks when
eating out. Who is responsible for educating these patients about
how to manage their condition responsibly?
Mr Lewis: I think most of the work in this area
is training caterers and enforcement officers. I am not sure,
to be clear, that there is a great amount of work going on, focused
or targeted, if I am frank with you, about young people in terms
of the choices they make when they are eating out. There is genuinely
quite a bit of investment in training caterers and enforcement
officers in terms of allergen-related issues but I am not aware
of any great awareness-raising programme in terms of the choices
that young people make.
Mr Bromley: What I would say is that the Committee
is probably aware that catering establishments do not have to
list allergens on menus, but what the FSA is doing at the moment
is they have quite a large engagement programme. They are operating
training courses where they have environmental health and trading
standards officers in local areas to educate caterers on how to
provide information on allergens and also be more educational
in terms of their menus. So I would say that, although there is
not a huge amount going on, there is work that the FSA is doing.
Also, in terms of educating young people, there is a lot of work
now going on in schools as well and that is part of the NSF, but
also in part of the programme that we have, the public health
programme that is now getting school nurses into every school.
So I would say in defence of the Department of Health that we
are working with the FSA on that.
Q866 Chairman: When we were in Denmark
we heard about programmes for young people in particular to have
their threshold of allergy to different substances properly diagnosed
so that they knew themselves the level that would trigger a response,
or would be likely to, and they also set up allergy schools which
were as schools for one day, two days, or sometimes later, to
teach the young people with the allergy about the dos and don'ts
and the things that they could do to free them up, rather than
telling them all the things that they could not do, and to help
them understand the things that they could do safely and how to
live a very active life safely. It did seem there that they were
empowering the patients much more through these programmes that
were organised through the allergy centres.
Mr Lewis: I think there is an opportunity here.
The Healthy Schools programme has been a tremendous success, essentially
a voluntary programme and, as far as I know, probably the majority
of schools have signed up to this, which means that they spend
a lot of time as part of the school's educational programme on
health-related issues with their students. It seems to me that
on this specific issue there has to be a question mark, under
the banner of Healthy Schools, whether schools will, unless they
are encouraged, be focusing on some of these issues specifically,
to be very frank.
Q867 Chairman: These were not done
through the schools; these were done through the allergy clinics.
They called them schools because they went along to learn about
them rather than being treated.
Mr Lewis: I am sure, but what I am saying is
that this programme would give us an opportunity to maybe do some
testing, some piloting and it may well be that we want to have
at an official level on this one a dialogue with our DfES colleagues
to see whether we could integrate into that programme some level
of discussion about allergies and the consequences for young people;
so, rather than create a separate programme, whether something
could come out of the Healthy Schools initiative which would help
in this area.
Q868 Chairman: Yes, but patient programmes.
Mr Lewis: Yes.
Mr Bromley: We know of the scheme in Denmark,
it is just that there are issues around young people that you
cannot predict people's sensitivity day to day because it does
change. So there is a risk about telling somebody, "You have
this level of allergy" and then that changing, and I think
we need to take account of that as well.
Chairman: I think they were aiming to
help them assess risks for themselves, though. Lady Platt, I think
your question has probably been answered in that last answer.
Baroness Platt of Writtle: I think so
too.
Q869 Baroness Perry of Southwark: Minister,
turning yet again to another topic, do you know how many adrenaline
auto-injectors, often called EpiPens, are prescribed through the
NHS each year and what the cost is of issuing those?
Mr Lewis: I do. I can give you very precise
information. In the year to 30 September 2006, almost 165,000
prescriptions were dispensed in the community in England for Epipens,
at a cost of about £8.2 million.
Q870 Baroness Perry of Southwark: Thank
you for that. We understand that there is disagreement amongst
experts as to when these EpiPens should be issued and yet the
decision about issuing them is left to GPs, most of whom have
virtually no allergy training at all. We wondered if there are
any plans to develop national guidance over who needs to carry
an EpiPen at all times and who does not?
Mr Lewis: No, there are not any plans to do
that, as I understand it, at this stage.
Q871 Baroness Perry of Southwark: There
is a sub issue about this, which we regard as extremely important,
Minister. The Anaphylaxis Campaign has suggested that a stock
of generic auto-injectors should be kept in schools for allergic
children, because many of them need a second dose in addition
to the emergency adrenaline they carry. Do you think this would
be useful and cost effective because, as we understand at the
moment, there is a very restrictive policy over school nurses,
that they are unable to issue an EpiPen to a child unless it is
their own prescription—they cannot pass on a prescription,
so to speak, which is extremely restrictive? And it does often
happen; I have been an EpiPen carrier myself and I know you do
sometimes need a second dose.
Mr Lewis: I agree. I think it is a major issue.
I think what we need to do, because I do not think we have made
a decision on this in terms of schools, is to review it, and within
a relatively short period of time make some decisions about what
is appropriate. I think you are right to raise the issue, but
we have not at this stage made a decision.
Baroness Perry of Southwark: Thank you,
I think we would welcome that.
Chairman: Thank you, that is extremely
helpful, Minister. Lord Haskel.
Q872 Lord Haskel: If we move on to
schools, the DfES told us that any school nurse who administers
an immunisation in a school setting would receive anaphylaxis
update training on an annual basis. However, we have also heard
that the standard and amount of training received varies widely
between nurses in different areas. Can you tell us who is responsible
for ensuring that all school nurses receive comparable training?
Are any standards set? Who pays? Is this the same for both private
and state schools?
Mr Lewis: First of all, I would say that any
nurse responsible for immunisations should be properly trained
as a matter of course. Most school nurses are employed by Primary
Care Trusts and therefore they have responsibility for their training.
Clearly there will be some who are employed directly by schools—increasingly
budgets are devolved to individual schools, certainly in the individual
sector—and the school will then be the employer. It seems
to me in those circumstances that there are two issues: one, that
the school, in the state system or the private sector, has a responsibility
to secure adequate training for anybody providing those kinds
of services within their school environment; equally, nurses are
bound by certain professional expectations and best practice and
therefore, if they do not feel adequately trained in that area,
they also partially have some responsibility to access the training.
It seems to me that the employer has a duty to make sure that
anybody carrying out this role on their behalf is appropriately
trained and there is funding to enable that to happen; but also
the professional has to make sure in terms of standards of best
practice that they are up to date and are accessing training that
is appropriate.
Q873 Lord Haskel: The problem that
was put to us is that the Royal College of Nursing said that virtually
across the nation at the moment school nurses are not being allowed
to go on training, even the training for their specific degree
course or for their professional training places; that they have
been cut. And in further evidence from the Royal College of Nursing
they said that a recent RCN survey showed that almost a quarter
of school nurses were unable to take time off to undergo further
training, and we wondered how you reacted to that?
Mr Lewis: The RCN is issuing very helpful press
releases at the moment. I think we have to be very, very clear
about this. By next year the amount of money going into the health
service in this country will have tripled. Has there been a difficult
year during the course of the past 12 months and has that had
an impact in certain health economies? Absolutely, because the
Government, for the first time in the history of the health service,
has looked people in the eye and said overspending and out of
control budgets are no longer culturally acceptable in the health
service, just in the same way that it is not acceptable in any
other part of the public sector or any other sector. So it has
been a difficult year for the NHS and that difficult year has
impacted in different areas in different ways, and there is no
doubt that just like every other part of the system school nurses
will have been affected by that. But we should not make sweeping
generalised statements based on one challenging and difficult
year. To be absolutely clear about where the Government's position
is in terms of funding and commitment to school nurses, the relevant
White Paper, the Choosing Health White Paper, made a commitment
to provide new funding for school nurses so that by 2010 we will
have at least one full time qualified school nurse working with
each cluster of primary schools and its related secondary school.
That remains the position of the Government. What we also have
to be clear about, in the same way as I talked about maximum devolution
now of power responsibility and budgets to schools, is that we
have a similar scenario in the National Health Service, in that
we do not run a command and control health service from offices
at Richmond House. It would be nice sometimes to be able to do
so but we no longer do, we devolve significant amounts of power
and resource and budget to individual PCTs and the key decisions
that are being made in those organisations these days are to do
with commissioning. But in terms of commissioning, it is absolutely
clear the expectation is that commissioners in every PCT will
secure the outcome that I have just referred to, and the outcome
is making sure that those clusters of schools in their communities
have access to the nurse. Now, the training related issue is of
course that if you are going to employ a school nurse who is going
to be fulfilling certain tasks in schools then it is the employer's
responsibility to make sure those people are appropriately trained.
Q874 Lord May of Oxford: Changing
direction a little and coming back in a sense to Denmark and Germany,
the MHRA recommends that immunotherapy be restricted to patients
who fail to respond to other allergy treatments, but that is a
decision that has not been reviewed since 1994 and NICE has never
even carried out an appraisal of allergen injection immunotherapy.
The Committee heard evidence both in Germany and Denmark on the
efficacy of immunotherapy, so is it not time that more thought
should be given to this and the policy be re-reviewed or, perhaps,
one might less generously say, reviewed?
Mr Lewis: An option that is available to us
would be to ask NICE to appraise immunotherapy, but obviously
what happens really on an annual basis is that there are all sorts
of competing suggestions about what we ought to ask NICE to appraise.
But we can certainly consider putting this as part of that process.
Essentially the question, I assume, was rhetorical in the sense
that my Lord believes that it is time for a fresh appraisal.
Lord May of Oxford: That is certainly
what we heard; in fact we heard it in some rather strong terms.
One of the people who spoke to us—not even in Germany or
Denmark—is a paediatrician from Cork University Hospital
and he said that the NHS is the laughing stock of Europe for its
absence of immunotherapy for allergic diseases. I am inclined
maybe to discount that as rhetorical overstatement—my own
background being partly Irish—and Irish blarney, but nonetheless
it gives a sense of the sort of things we heard. We also heard
that immunotherapy treatments that do not have a UK product licence
can be used to treat patients on a named patient basis within
the NHS and that struck us as a peculiar anomaly within the more
general question. So I wonder if you are, in a sense, not as up
on this—which would be fair enough—but if you could
give us some sort of lengthy reply.
Q875 Lord Colwyn: And of course if
the patient can afford to pay for it it does work.
Mr Lewis: I think we ought to go away and reflect
on whether this ought to be a matter we send to NICE for appraisal;
but equally we will have to come back to the Committee with the
process because we cannot guarantee that this will end up as one
of the priorities this year. I think it would be about saying
that, over a specified period, we will seek to get NICE to look
at this as one of its priorities. I would be happy to write to
the Committee to that effect.
Q876 Chairman: I think one of our
concerns that arose, Minister, and it may be helpful for you to
know, from the NICE evidence that we had, was that we had the
sense that immunotherapy was not really on their list at all and
they did not seem to be aware of the sublingual immunotherapy
route, which is extremely acceptable to patients and has a very
good safety profile, and they did not seem to know about product
licensing of sublingual immunotherapy. So that was our concern.
And it also linked to the shortage of specialist centres who obviously
will be key in driving forward any such therapy, but particularly
for young people: if it frees them up from being shackled by severe
allergic response it can be very dramatic, and we are concerned
about young people with hay fever under performing in exams and
so on, and that it can blight their careers. So that is some of
the background to our concern. I hope that is helpful to you.
Mr Lewis: It is; it reinforces the point.
Q877 Lord May of Oxford: That was
Lord Soulsby's question and my question was carrying us back to
the review of services for allergy that we discussed at the beginning,
which, amongst other things, recommended that Primary Care Trusts
and local health authorities should develop local allergy services
based on need. When might we look to see that being commissioned?
Mr Lewis: As Lord May will appreciate, as we
no longer do command and control we basically issue guidance to
PCTs, to commissioners; we have drawn their attention to this
and the possibilities of, in their localities, creating specialist
services, but we cannot force or impose that at a local level.
I could go through a long description of the way we are seeking
for the NHS to work now, but the more useful and constructive
response to the question would be that, again, this evidence session
highlights the potential benefits of having a lead Strategic Health
Authority for this issue and then seeking to get that lead Strategic
Health Authority to engage with perhaps one or more than one PCT
within their region, to say that it would be really good if you
could take responsibility as a national lead, if you like, for
creating some specialist allergy services and then consider what
we can learn from those services. I would certainly be willing
to explore, as a result of this session, and of course to give
the Committee due credit for this, to have a dialogue with the
NHS about a Strategic Health Authority taking lead responsibility
with allergy as part of that, to see whether they can engage with
PCTs in their region to stimulate some new specialist services.
Q878 Lord May of Oxford: I take your
point about command and control but how does the Department know
what local commissioning of allergy services are taking place?
That is being informed.
Mr Lewis: Again, it is the balance, is it not,
between being accused of seeking more and more data and information,
which is called bureaucracy, and wanting evidence to inform policy—it
is a constant tension. I think part of a lead Strategic Health
Authority's responsibility, Lord May, would be to consider how
we do on a national basis, to ensure that we are collecting appropriate
information and evidence to inform policy. So I would see that
as part of a lead Strategic Health Authority's role in this area.
Q879 Lord May of Oxford: Just continuing
this one more moment, we heard from officials from the Department
of Health—and I am quoting now—that "gaps in
current knowledge around issues like service configuration, the
best skill mix, the best balance of generalist against specialist
services and, also, in data on cost-effectiveness", that
there are gaps in all of those things. More specifically, what
analysis is being undertaken to assess whether allergy is best
treated by primary care workers or specialist services? We heard
quite a lot on that theme from people in general practice who
felt that they did not know what to do within their local remit.
Mr Lewis: I am not sure that we have a very
robust system which is actually providing us with reliable data
to inform policy development. I think that is probably the frank
answer that we ought to give. The question then is, what mechanisms
are available to us to develop that kind of infrastructure and
I think, to be honest, it is not just the responsibility of the
Department of Health or government it is also the responsibility
of the Royal Colleges and also some of these specialist professionals
who work in these areas.
Mr Bromley: I think we recognise this. When
Martin Marshall, the DCMO, came and gave evidence you questioned
him on how we are going to engage with the service on this particular
area, and the first step is that the DCMO is organising a high
level meeting with a number of the Royal Colleges to look at and
address the issues that you have put forward. We also have in
the Department a small team that works on this particular topic,
and that team will look at the future of how we develop a service
around allergy, and that will form part of the work in the Government
Response to this inquiry that will take place over the summer.
I think the Minister is right, no, we do not have a framework
set up at the moment but we hope to have a framework set up when
this Committee has reported and when we take a view of how we
develop the services, as the Minister has said, through a Strategic
Health Authority format or through another format.
Chairman: One issue that Lady Platt wanted
to ask specifically about is GP education and I think it would
be appropriate to switch to that now in the light of your comments,
Mr Bromley.
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