Supplementary memorandum by the Department
of Health
You asked me to comment on a number of questions
which were not explored fully during the meeting. I shall deal
with each of these in turn, and add comments on a few other matters
on which officials and I undertook to submit additional material
to the Sub-Committee.
What is the Department's view of establishing
a central disease registry? (Q.832)
Our view is that, in general, investment in
disease research registries is not a good use of central research
and development provision. Such registries are expensive to develop,
and funding their long-term maintenance can create difficulties
in a system that has to be responsive to changing demands and
priorities. The setting up of disease registries for the purpose
of clinical audit is a matter for local decision and funding.
Has the Government agreed to fund the specialist
THOR schemes in the future and for how long will this funding
be agreed? (Q.838)
The Health and Safety Executive (HSE) is seeking
to secure the long term funding of both the THOR GP and THOR Specialist
schemes of work. Representatives met with Professor Agius on 4
April and made an offer which, if accepted, will guarantee funding
of data collection within the THOR GP scheme until 31 December
2010 and the THOR Specialist scheme until 31 December 2011. Professor
Agius is yet to respond formally to the offer but is due to do
so by mid-May. (Please see p 111, Supplementary Memorandum by
Professor Raymond Agius).
A significant reason for the delay in responding
is that Professor Agius has been preparing a request seeking EU
funding for his THOR related work. This process was due to be
completed by 26 April. It is not clear whether any EU funding
would be used to subsidise the work that Professor Agius is undertaking
on behalf of HSE, or whether he intends to use it to broaden the
scope or scale of his work.
The Sub-Committee also asked (Q.843) about sponsorship
of the "Bad Hand Day?" campaign. HSE developed this
campaign by working in partnership with Local Authorities and
industry Habia (Hair and Beauty Industry Association) and NHF
(National Hairdressers' Federation). It aims to raise awareness
of dermatitis among hairdressers, and to offer help and advice
on the simple steps that can be taken to prevent it. As part of
the campaign, Local Authority inspectors visited salons around
the country, and ran awareness raising events for local businesses
and colleges.
Information on the "Bad Hand Day?"
campaign, and the resources developed to support it, are available
from the HSE website at http://www.hse.gov.uk/hairdressing/index.htm.
HSE has formally evaluated the impact of the
campaign and this has shown that it was very well received by
hairdressers. HSE is now working with Local Authorities and industry
to develop a second phase for the campaign, to build on this initial
success and further to promote the uptake of preventative measures
within salons and during hairdressing training.
Could you clarify the details of the DTI strategy
for sustainable construction, the work that has been carried out
so far, and how your Department might be able to work with the
DTI to take the needs of allergy sufferers into account when building
new homes? (Q.855)
Following a review in 2006, the Department Of
Trade and Industry (DTI) is co-ordinating the current development
of a combined industry/cross-Departmental strategy for sustainable
construction. The proposed new strategy will provide a framework
to guide future progress within the construction industry. It
will go to public consultation in the near future. During that
consultation, contributions on this and other matters relevant
to sustainable construction would be welcomed.
Responsibility for the Building Regulation,
however, rests with the Department for Communities and Local Government
(DCLG). Through the Building Regulations for ventilation (Part
F), Government can have some control over indoor air quality in
new homes, including the provision of sufficient ventilation to
dilute reasonable levels of the main pollutants—which include
volatile organic compounds (VOCs) and moisture—thereby stemming
the development of mould growth.
There is, however, still a lack of evidence
on the direct impact of some types of building materials on health
or the balance between the effects of building materials, furnishings
and cleaning solvents. It is not clear if the Building Regulations
have powers to control use of VOC-emitting materials, even if
a health case could be made. They cannot control emissions from
furnishings and products that people bring into their homes. Currently,
building material manufacturers are not required to declare emission
levels.
The Sub-Committee also asked (Q.850) about Departmental
responsibilities for indoor air quality. I have looked into this
complex area and an overview follows.
First, I should clarify that although I made
reference to the Department for Environment, Food and Rural Affairs
(Defra) Air Quality Forum, that body's remit does not include
indoor air pollution. The Forum was established in 1998 as part
of the requirements under the Environment Act 1995 for the Secretary
of State to consult stakeholders when developing and reviewing
the Government's Air Quality Strategy. The Strategy is concerned
with ambient air quality and does not cover indoor pollution.
Despite this, at its quarterly meeting held
on 22 March, the Air Quality Forum did specifically look at the
matter of the responsibilities across a series of Government Departments.
I should emphasise, however, that this was done as a single exercise
simply to inform the Forum of the current position.
I also undertook to write to the Sub-Committee
about the Interdepartmental Liaison Group on Indoor Air Quality.
The Group was originally set up by the then Department of the
Environment (DOE) and was responsible for considering a programme
of commissioned work around the quality of indoor air. This programme
continued as the DOE later merged with the Department for Transport
(DfT) to become part of the new Department for the Environment,
Transport and the Regions (DETR). Towards the end of the 1990s,
the programme ended and, consequently, the work of the Interdepartmental
Liaison Group on Indoor Air Quality ceased.
Responsibility for indoor air quality has fallen
to different Departments, largely as Departments have merged or
new Departments have been formed. It originally sat with DOE but
in 1997, when DOE and DfT merged to form the DETR, the health
aspects of indoor air were assigned to the Department of Health
(DH) whilst DETR retained responsibility for indoor air quality
with respect to the Building Regulations.
In 2001, the picture changed again when DETR
was ended and its work was split into a number of separate Departments.
As a result, responsibility for the Building Regulations went
to the newly formed Office of the Deputy Prime Minister (ODPM),
now DCLG, and the health aspects of indoor air remained with DH.
This is how it currently stands.
May I add that, in recent years, DH has funded
the World Health Organization (WHO) to help it develop guidelines
on indoor air quality. Health Protection Agency (HPA) colleagues
attend its meetings.
In addition, at the fourth WHO Europe Ministerial
Conference on Environment and Health in Budapest in June 2004,
DH and Defra Ministers, on behalf of the UK Government, made a
commitment to develop and implement a Children's Environment and
Health Strategy for the UK. This would address national priorities
as well as set goals to address the four key objectives, one of
which is to ensure clean outdoor and indoor air.
To date, much work has been done towards the
UK Strategy and this is being co-ordinated by an Interdepartmental
Steering Group chaired by DH, with a membership comprising representatives
of relevant other Government Departments, Devolved Administrations,
the Environment Agency, the Scottish Environment Protection Agency,
the HPA, the Food Standards Agency and others.
My officials will continue to work with their
DCLG colleagues, and those other Government Departments as necessary,
on indoor air issues.
In Q.861 you committed to review the evidence
regarding peanut avoidance during pregnancy and weaning. What
plans does the Department have to review its dietary guidance
as soon as possible?
In my oral evidence, I referred to two (recently
published studies that investigated the impact of the current
Government advice on avoidance of peanuts during pregnancy and
lactation. I am enclosing copies of these papers with this letter
[not printed]. I also undertook to ensure that the basis for this
advice would be re-evaluated as quickly as possible. This review
will proceed as follows.
As you are aware, the current advice, which
was issued in 1998, was based on a review of all the scientific
literature available at that time by one of the Government's scientific
advisory committees, the Committee on Toxicity (COT). In order
to review its advice, the COT will need not only to review the
two papers that I am now providing for you, but also to evaluate
carefully any other relevant evidence that has become available
since 1998. This is in accordance with the Office of Science and
Technology Guidelines on Scientific Analysis in Policy Making,
which set out the basic principles which Government Departments
should follow in assembling and using scientific advice, and the
Code of Practice for Scientific Advisory Committees, which was
issued in 2001.
I can report that the Food Standards Agency
has already begun the process of identifying and systematically
reviewing the evidence, and a paper will be taken to the COT as
soon as this review is complete. The COT will then consider this
evidence at an open committee meeting and will issue a statement.
After that, the Government will reconsider its advice in the light
of the views of the COT. Given the need to evaluate fully and
carefully all the relevant scientific evidence, this process is
likely to take six to 12 months.
How is the Food Standards Agency attempting, on
your behalf, to influence the EU review on food labelling to specify
the levels of allergens in food products? (Q.865)
The current EU review is a fundamental review
of all food labelling. Following initial discussions, the European
Commission is expected to produce a proposal by the end of 2007.
The Food Standards Agency will negotiate this proposal on behalf
of the UK and will liaise with other Government Departments to
agree a UK line. The experience gained in developing the guidance
that the Agency published last year, on allergen management and
advisory labelling, will help the UK in ensuring that future EU
labelling is as helpful and informative as possible for food allergic
and food intolerant consumers.
I should like to add some further detail to
my reply to Q.865, regarding limits for sulphites. The current
legislation requiring the declaration of allergenic ingredients
does contain a threshold limit for sulphites and requires only
added sulphites above 10mg/I or 10mg/kg to be declared.
Over what sort of timescale does the Department
of Health envisage asking NICE to appraise immunotherapy? (Q.876)
The arrangements for selecting topics for the
National Institute for Health and Clinical Excellence (NICE) work
programme were changed in September 2006. Under the new system,
there is a more transparent approach to assessing the suitability
of topics suggested and an objective approach to prioritising
them, which is supported by a larger role for NICE in the selection
process. I hope the Sub-Committee will find it helpful if I outline
the process of selecting topics for referral to NICE.
NICE administers the initial stages of the topic
selection process and is the principal point of contact for individuals
and organisations wishing to submit proposals. NICE has established
consideration panels dedicated to specific conditions and diseases,
whose specialist composition allows topics to be assessed on their
relative priority within a given specialty. Topic proposals are
assessed against published DH selection criteria.
Ministers make the final decisions on the referral
of the NICE work programme on the basis of the advice they receive
from a variety of sources including NICE, the NHS and strategic
policy advice from within DH.
The process for determining the next NICE work
programme, its fifteenth, has not yet completed. Whilst I can
confirm that there are a number of topics in relation to allergy
under consideration as part of this work programme, it is not
possible for me to provide any further information until the Secretary
of State has taken a decision on the referral of the programme.
With regard to allergen injection immunotherapy,
we have passed the Sub-Committee's views to the NICE topic selection
team, who will feed the suggestion in to the topic selection process.
This will allow the topic to be considered alongside all other
topics in order to establish its relative importance and priority
for referral. At this stage, I could not offer a guarantee of
its inclusion in the NICE work programme.
You stated that 33 advanced clinical fellowships
and 16 clinical lectureships will be supported by new training
programmes (Q.889). Does this figure include the eight Allergy
Specialist Registrar training posts available in the UK? Could
you outline which discipline each of these posts cover—for
example are they specifically for allergology, immunology, dermatology
or respiratory medicine?
I referred to the academic training programmes
that the National Institute for Health Research (NIHR) Integrated
Academic Training Pathway has established, through two rounds
of national competition, in strong host environments (through
partnerships between universities, local NHS Trusts, including
PCTs, and Postgraduate Deaneries), to provide training support
for either Academic Clinical Fellowships (ACFs) Or Clinical Lectureships
(CLs).
In all, 17 programmes relevant to allergy (including
immunology, dermatology, respiratory medicine and paediatric allergy
and infection) have been funded, each for five years. During the
course of these programmes, a total of 33 ACFs and 16 CLs will
be supported. Details are given in the appended table. [not printed]
There are six ACFs and two CLs awarded solely
in allergy. However, it is not possible to say whether these are
the same as the eight allergy Specialist Registrars. The reason
is that, although the scheme provides funding for posts, it is
up to the local institution how it uses the funding to create
posts and who is appointed to them.
For ACFs, 25 per cent salary (for up to three
years) and for CLs, 50 per cent salary (for up to four years)
is new funding to protect time for academic activity. It is up
to the hosting partnership to integrate this new funding with
existing posts. In some cases, whole new posts are being created
locally where additional funding can be found. Not all of these
posts have yet been filled, as far as we understand.
In Q.893 you commented on funding for the Prince
of Wales Foundation for integrated health and the UK working party
to consider statutory regulation. Could you provide some further
information about these groups, the work they are carrying out,
and the level of funding and support they receive from the Department
of Health?
In previous evidence we have referred to the
joint working group (JWG), chaired by Professor Michael Pittilo,
which we have set up actively to prepare for statutory regulation
of acupuncture, herbal medicine and traditional Chinese medicine.
JWG members receive funding from DH for travel expenses, including
loss of earnings where, appropriate. Our budget for the JWG is
£25,000 for 2007-08.
The Government currently has no plans to extend
statutory regulation to any other professions. However, DH has
commissioned the Prince of Wales' Foundation for Integrated Health
(FIH) to develop voluntary self-regulation amongst a range of
currently unregulated professions. The professions working towards
self-regulation are Alexander Technique, Aromatherapy, Bowen Technique,
Cranial Sacral Therapy, Homeopathy, Massage Therapy, Naturopathy,
Nutritional Therapy, Reflexology and Yoga Therapy.
The FIH has undertaken a public consultation
exercise, which closed at the end of July 2006. The results show
a clear mandate to move forward with a federal approach to regulation.
The FIH has set up a joint working group to move towards the agreed
federal model for self-regulation. We have awarded a Section 64
grant to the FIH for the above work, totalling £900,000 over
the three years 2005-06 to 2007-08.
In oral evidence (Q.893), I also mentioned the
proposed UK working party to consider statutory regulation. Paragraph
7.9 of the White Paper Trust, Assurance and Safety—the
regulation of health professionals in the 21st century (published
on 21 February 2007) says, "For emerging professions, the
Department will establish a United Kingdom working party to develop
criteria to determine which roles should be statutory regulated."
DH will be announcing its proposals for taking forward the policies
set out in the White Paper at a direction-setting event at the
beginning of June. We shall announce the working groups and their
terms of reference at this event.
The Sub-Committee asked as well (Q.894) about
funding for evaluative research on CAM diagnosis and treatments.
In recent years, the Government has made a substantial investment
in CAM-related research. Following the recommendations of the
House of Lords Sixth Report on Science and Technology (2000),
over £3.5 million of new funding is being invested in research
and development under the National Complementary and Alternative
Medicine Personal Award Scheme. The Scheme is designed to develop
research capacity in the area of CAM, and to promote the development
of a robust research evidence base in the future.
DH has funded a programme of research at the
University of Sheffield on complementary medicine in primary care,
and research studies on the use of CAM in the care of cancer patients.
The National Coordinating Centre for Research Capacity, as well
as being responsible for the personal award scheme, has contributed
funding to CAMEOL (Complementary and Alternative Medicine Evidence
Online). This programme, funded at the level of around £300,000,
involves a detailed review and critical appraisal of the published
research on specific complementary therapies, focusing on key
areas of NHS priority—including chronic conditions.
The Government's health research strategy; Best
Research for Best Health, will allow researchers to bid for
research in the area of CAM. The strategy includes a responsive
funding scheme—the Research for Patient Benefit programme—that
is open to research proposals on CAM therapies, among other topics.
Finally, the Committee has also been made aware
of the Skills for Health team which are establishing a Project
Reference Group to develop National Occupational Standards for
Allergy Services. l would be very grateful if you could clarify
how the Skills for Health team relates to the Allergy Services
Review team in your Department and what work you plan to carry
out together on this project?
I mentioned on 18 April (Q.885) that DH had
commissioned Skills for Health to develop National Occupational
Standards (NOS) for the UK for allergy. This was one of the next
steps identified in our review of services for allergy. NOS will
help employers determine the skills needs of staff involved in
allergy. Employers and education and training providers will be
able to integrate the NOS into training programmes. The DH allergy
services review team is represented on both the project executive
group and the strategy group for this project, and also attends
meetings of the national reference group, which brings together
a wide range of stakeholders. We expect the NOS for allergy to
be produced by December 2007.
Following your letter of 24 April, you also
asked a further question on behalf of the Sub-Committee—
In the evidence, you have said that the cost to
the NHS of allergies is over £1 billion. To put this in perspective,
what is the overall cost of the NHS? And can you provide a source
for this figure?
The source for the estimated direct cost to
the NHS of managing allergic diseases is the following journal
article: Gupta R, Sheikh A, Strachan DP, Anderson HR. Burden of
allergic disease in the UK: secondary analyses of national databases.
Clin Exp Allergy 2004; 34:520-6.
Total NHS expenditure in England has increased
from £33.0 billion in 1996-97 to £75.8 billion in 2005-06. Investment
is expected to rise further, to £90.7 billion in the current
financial year. This extra money, most of which is held locally,
has improved access to healthcare for millions of people.
Finally, I should like to clear up some apparent
confusion that arose from my response to Q.845, in which one of
the points I made was that "hypoallergenic" is a medicinal
claim and, if made for a medicine, would have to be supported
by clinical data before it was given a marketing authorisation
by the MHRA. I was not suggesting that the term "hypoallergenic
would be thus defined in the Regulations to implement the Unfair
Commercial Practices Directive, to which I had just referred and
to which I subsequently returned.
14 May 2006
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