Examination of Witnesses (Questions 880-898)
MR IVAN
LEWIS, MR
ALAN BELL
AND MR
JOHN BROMLEY
18 APRIL 2007
Q880 Baroness Platt of Writtle: We
have heard in evidence that GPs receive very little undergraduate
training in managing allergy and cannot appropriately diagnose
or treat allergic diseases. What is the Department doing to improve
allergy training for GPs, either in initial training or during
continued professional development?
Mr Lewis: The straight answer is that we do
not define the curriculum content for training; what we can do
is bring this issue to the attention of the bodies that do have
that responsibility—the Postgraduate Medical Education and
Training Board, and the General Medical Council, to name but two.
So we do not decide the content of the curriculum for training
GPs. But we share your view that early intervention is really
important and for early intervention to happen it is going to
be the GP in most circumstances who is going to be absolutely
crucial. I think there is significant evidence to suggest that
many, many GPs have inadequate knowledge in this area. Of course
the other issue would be about continuing professional development
beyond initial entry-level training, and again I think we need
to have a dialogue with the relevant professional bodies that
are responsible for that to make sure that allergies are taken
more seriously than they have been hitherto.
Q881 Baroness Platt of Writtle: This
does seem to us to be very important indeed. How many postgraduate
training places are there per annum and are there any incentives
to encourage GPs to undergo further allergy training? Would you
consider including all allergic diseases in the Quality and Outcomes
Framework for GPs?
Mr Lewis: I can give some statistics. There
was a survey done in 2002, and of 500 UK GPs only 50 per cent
had undergone training in managing allergic problems and most
of them—78 per cent of that 50 per cent—as undergraduates.
There was a study done in 2006 of people who used these services
and very interestingly 76 per cent of them felt that their GP
did not understand their health needs at all well. I think we
have in a sense two issues: one is that we need every GP to have
a basic minimum level of knowledge; we then need to find a way
of encouraging some to develop far more specialist knowledge.
Q882 Baroness Platt of Writtle: Yes,
because there is a shortage of specialists too.
Mr Lewis: And on a network basis you need people
who are seen as leaders, specialists, who can then support and
influence professional colleagues, peers.
Q883 Baroness Platt of Writtle: Perhaps
on a regional basis.
Mr Lewis: Absolutely. Again, it is for us, I
think, to engage seriously with the bodies that are responsible
for training, to make sure that this issue is taken more seriously.
Baroness Platt of Writtle: We think this
is vital.
Q884 Earl of Selborne: Minister,
you said just now that many GPs have an inadequate knowledge on
how to diagnose, treat and refer patients for allergies and I
think the Committee would agree with that. GPs, of course, get
guidelines thrown at them from all directions but this does seem
to be an area where accessible guidelines for GPs are very much
in need. What is the Department doing to provide guidelines for
GPs on this matter?
Mr Lewis: There is quite a lot of guidance available—good
practice guidance, for example, drawn up by a number of Royal
Colleges and other professional bodies for specific conditions.
The National Prescribing Centre has published a number of documents
to inform GPs and other health professionals on specific allergic
conditions. NICE is currently developing guidelines for atopic
eczema in children. We are, as you know, as part of the review
that we have undertaken, committed to look at the options for
referring to NICE a request to specifically develop clinical guidance
for the diagnosis and management of allergic conditions, so that
is something that is active and under consideration at the moment.
We have asked the Royal College of Paediatrics and Child Health
to scope work to develop care pathways for children with allergic
symptoms, and we have also commissioned Skills for Health to develop
National Occupational Standards for the UK for allergy, and those
competences stemming from those standards would be relevant to
all clinical staff including GPs. So there is quite a lot of guidance
and guidelines out there in the system.
Q885 Earl of Selborne: You referred
to the NICE guidelines and you say they are under consideration.
We heard in March from the Chief Executive of NICE that these
proposals were now back with the Department of Health Ministers,
so what happens now?
Mr Bell: If I may, the position on that is that
Ministers, including Mr Lewis, are at the moment awaiting a large
submission from officials in the Department making recommendations
for the next wave of clinical guidelines products to be referred
to NICE. I cannot anticipate what those recommendations will be
or what Ministers will decide on the basis of them, but that is
due, I am told by colleagues in the Department, in the next few
weeks.
Mr Lewis: There are obviously competing priorities
and the question for me is, if this does not make it into this
series of referrals, whether we can commit to saying that it may
not happen this time but we can give a specific timeframe, otherwise
I think people will be quite sceptical.
Q886 Chairman: Mr Bell, could you
just clarify because I think you said Ministers—is this
going to several Ministers or is it going to be specifically—
Mr Lewis: The NICE issue obviously cuts across—what
we refer to NICE will cut across several Ministers.
Mr Bell: The process as I understand it, Lord
Chairman, is that the team within the Department that coordinates
the various recommendations that have come from different directions,
including us, put together this magnum opus, which goes to Lord
Hunt as the lead Minister for NICE but is copied to all the other
Ministers including our Minister, and it gives them the opportunity
to comment. The Secretary of State will then make the final decisions.
Q887 Earl of Selborne: And the Department
of Health officials told us that the Department was working with
the Royal College of Paediatrics and Child Health to fulfil its
pledge to develop care pathways for children with allergic symptoms.
Can you tell us what progress has been made towards this and how
you will disseminate these guidelines through the medical community?
Mr Bell: I can tell you where we are at on that.
We have had constructive discussions with the Royal College of
Paediatrics and Child Health and, at our request, they have gone
away and are working up a scoping document at the moment for taking
forward this work, which they are very keen to do. I am hoping
that we will be able to commission them to take this forward very
quickly, with the expectation that the work would be completed
by the College, bringing together all the other professional groups
and other stakeholders with an interest to do this development
work, in the current financial year.
Q888 Baroness Perry of Southwark: One
of our witnesses, Professor Davies, told us that 11 new training
posts had been agreed to train clinical academics in allergy.
However, other expert witnesses were quite unaware of this. Could
you clarify for us whether these posts have been allocated, whether
they are specific to allergy and how they will impact upon clinical
practice?
Mr Lewis: I can tell you what has happened in
terms of training. Basically, the National Institute for Health
Research Integrated Academic Training Pathway has established
academic training programmes in strong host environments to provide
training support for either Academic Clinical Fellowships or Clinical
Lectureships. Once identified, successful programmes may appoint
trainees into the posts through local competition and via the
Postgraduate Deanery. A total of 17 programmes relevant to allergy
have been funded, each for five years. During the course of these
programmes, a total of 33 Academic Clinical Fellowships and 16
Clinical Lectureships will be supported. A range of universities
are carrying out these programmes—Birmingham, Brighton and
Sussex, Imperial College, King's College, Manchester, Newcastle-upon-Tyne,
Oxford, Sheffield and Southampton. What I am unclear about is
the specific reference to these 11 posts and perhaps officials
will be able to help me with this.
Mr Bromley: Yes. We refer to the 16 Clinical
Lectureships—that is what Sally was referring to, so in
fact we actually have more than the 11.
Q889 Chairman: Those are the Walport
posts for the Walport money?
Mr Bromley: Yes.
Q890 Chairman: Can you just clarify
what "relevant to allergy" means because are you including
in those numbers dermatology, respiratory medicine and so on?
Mr Bromley: Yes.
Mr Lewis: Immunology, dermatology, respiratory
medicine and paediatric allergy and infection.
Q891 Chairman: And you are including
the specific allergy training posts as well, of which there are
eight currently SpRs in the country, or not?
Mr Bromley: Can we get back to you on that because
if it is possible we would like to check? I would like to check
because it is not in the written evidence. I think what we would
like to say is that we have researched what Sally has said and
we are quite pleased to say that, yes, the 11 are there, plus.
Q892 Chairman: Can I just finish
with asking you about a completely different area, which is complementary
medicine? We heard that a lot of patients are going to complementary
therapists of different sorts, often because they feel that they
cannot get the services from their GP or within their area. We
know that there is legislation being developed to regulate acupuncture
and practitioners of herbal medicine. We wondered whether there
are any plans to extend such regulation to other people who provide
services for patients, either diagnostic or reportedly therapeutic?
Mr Lewis: You are right, we have asked Professor
Pitillo to look at acupuncture, herbal medicine and traditional
Chinese medicine, and we are waiting for recommendations in those
areas. We have also funded the Prince of Wales' Foundation for
Integrated Health to set up a voluntary register of unregulated
professions, and we are also setting up a UK working party to
consider the criteria to be used to decide whether a profession
should or should not be statutorily regulated. The very direct
answer to the question, do we have any immediate plans, is no.
Q893 Chairman: We have heard of the
lack of evidence to support the efficacy of some of these treatments
and yet a very high uptake and high level of belief on the part
of the public, and we wondered who you felt should be pushing
for and funding evaluative research of some of these different
diagnostic and treatment modalities?
Mr Lewis: You mean who should be assessing the
health benefits of these alternative interventions?
Q894 Chairman: Yes, in terms of cost-efficacy,
rather than people just having pressure groups suggesting that
some of these things should be available or making claims on their
behalf.
Mr Lewis: I suppose evidence-based policy would
be an exciting development! The answer to that is I do not know.
As far as I know, at the moment the Department of Health is not
formally undertaking evaluation of the impact of those interventions
which will then be made public. Are there other bodies? Do officials
know other bodies that are actively doing that in terms of trying
to gather hard evidence in these areas?
Mr Bell: Lord Chairman, I am aware that there
is research that is being done by academic bodies into different
complementary and alternative medicines, so it is not a completely
un-researched area, but clearly there is a lot we do not know.
Mr Lewis: I think we can perhaps write to you.
Mr Bromley: I think the answer is we do not
know. The problem is, as you know, some of these products are
food; some of them are not medicines, that is the problem at the
moment. We need to look at this situation and say, "Where
does the responsibility lie, and how do we separate the responsibility
in terms of whether it is a food product or maybe a cosmetic product?"
I think that is the problem at the moment.
Q895 Chairman: Our other concern
was on the diagnostic side, that there are patients who are absolutely
desperate who will be spending several hundreds of pounds on processes
believing that that is diagnosing an allergy, and yet the evidence
is not there that that is actually diagnosing an allergy, and
that there is not any particular group that have a vested interest
into researching into this because, unlike the pharmaceutical
industry, where they will be producing a product which is prescribable,
it does not fall into that group and these people are often not
trained in scientific approaches to research; and so, even if
they do want to do some evaluation and apply for a grant, with
the competition for research grants they are going to fall out
before they even start. So there are difficulties in kick-starting
good evaluative projects and that is the background to this question
you are going to be looking into.
Mr Bromley: I think when the DCMO, Martin Marshall
gave evidence, this is one of the things he took away, as well
as with the GPs' issue—it was one of the issues he took
away, and wanted us to work on more of this issue.
Chairman: Lord May.
Lord May of Oxford: Very quickly, and
not all my colleagues will agree with what I am about to say,
but my own view is that one of the most under researched areas
is the interplay between health and mental state, because if you
look at the studies of most of these complementary medicines what
turns out is real benefits accrue, but if you do double-blind
it does not matter whether you give them the medicine or not—it
is the actual act of treatment. That is a comment—many of
the practitioners believe that they are doing something, when
in fact they are not, but the interplay between mental states
and health is real and it is something that we seem to distance
ourselves from, that it belongs in the more difficult areas of
the social sciences and yet it is a really important thing. I
do not see the answer to it because no one wants to pick it up.
Q896 Chairman: A concern that I would
echo is that sometimes the wrong question is being asked in the
research.
Mr Lewis: I think there is a debate beginning
in this area about well being, which is a healthy debate, which
then over time may lead to a very, very different approach to
some of these issues. There is also the Layard work around CVT.
We can agree or disagree that CVT is an incredibly effective psychological
intervention, but the point is that for a lot of people at the
root of their health problems and conditions is unhappiness, depression,
anxiety and sadness about their lives genuinely, and I think we
would all as civilians—if we take away our respective titles—understand
that that is real. The difficult bit is how you set about proving
that and how you create a situation from a very, very low base
where you have sufficient evidence to suggest—which I think
Layard tries to present—the economic case and the societal
benefits of investing far more significantly in those kind of
psychological interventions, which in the end not only end up
leading to a much better society and happier individuals and more
well individuals but actually mean we of course spend less resources
at the acute end of the National Health Service. I think this
debate is rolling and I think it is a very important debate we
need to have in society.
Q897 Lord May of Oxford: If I may
just say, it is a splendid book but it is on economics and how
you measure how well off we are. I encouraged people at the Royal
Society to have one of our dozen a year discussion meetings on
this subject. I thought it was a good idea to do it—there
is a lot of criticism for doing it and some of the papers really
were a bit off putting, but nonetheless important. The difficulty
is that the practitioners of alternative medicines would not welcome
what I have just said—or many would not—so they are
not keen on it. On the other hand, many of the people in the heart
of science would disagree with my statements about the need for
better understanding of the interplay. I just do not really see
how we get there from here.
Mr Lewis: I do not think we should limit this
to alternative medicine. Every day in this country there are many
health practitioners and professionals who are issuing prescription
drugs when actually there would be far better solutions. That
is the way that primary care frequently deals with mental health,
and we have revolving or rotating patients who sit and fill up
GPs practices in many parts of the country, where the answer is
the prescription in terms of the antidepressants or whatever.
That is not getting to the root of the problem, it is not being
innovative and imaginative and it is not trying to support the
person to change their life, if you like. I think this debate,
in a sense, needs to be removed from the confines of the practice
of alternative medicine and look far more broadly at "is
the health service a sickness service or is it a health service"
and what do we mean by well being, which is the new, trendy, fashionable
word? But we need to do a lot more work in defining what we mean
by well being and how we go about securing it for as many people
as possible.
Q898 Lord Colwyn: I think I prefer
you to call it complementary medicine. I had a letter yesterday
from George Lewith and I have left the figures behind, but despite
the millions of people who have treatment I think the total research
budget is 0.008 per cent of the entire budget, which is minute.
Mr Lewis: I was not really seeking to make any
statement by using the term alternative—I am equally happy
using the term complementary, so I do not want to provoke a debate
that is not necessary.
Chairman: Minister, can I thank you very
much? I feel as if we should continue this debate, even in another
forum and informally because it is absolutely fascinating, and
some of it relates to the role of the practitioners themselves
on the individual patient and whether they augment or decrease
anxiety and how the whole situation is managed in helping the
patients change their behaviour as well. Thank you very much for
coming today, for having spent so long giving this detailed evidence
and also for offering to take away so many issues and look at
them. We look forward to working with the Department. We will
be producing our report, obviously, but we hope it will be a very
constructive dialogue. Can I thank you also, Mr Bromley and Mr
Bell, for having come with the Minister today.
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