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During our inquiry, we heard of children with allergies who sleep poorly by night and are bullied at school by day, and whose hay fever impairs their performance in summer exams. We learnt that the workplace environment can cause or so exacerbate allergic symptoms that some adults are forced to give up work. Yet there is no clear guidance about what to do next or how to control their symptoms. We heard of fatal anaphylaxis, particularly through insect stings and food allergies. We found that we could not quantify the problem, the full health costs of allergies or the economic burden to society, because the reporting systems in the NHS do not code specifically for allergy per se. We did discover, however, that prescriptions for allergy symptoms cost nearly £1 billion a year—about 11 per cent of the total community drugs budget.
We made many recommendations in the report, some of which are key to improving the situation rapidly for sufferers. The bulk of the key recommendations concerns the woeful deficit of clinical allergy services in the UK—a deficit already severely criticised in
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Other key recommendations were: the urgent need for the education of healthcare professionals about allergy and of those in catering about handling food allergens; the importance of research into the causes and factors that exacerbate allergy, as well as ways in which to prevent allergies, particularly peanut allergy, from developing in the first place; the adoption of immunotherapy in treatment in the UK, because it is not happening yet; and better support in schools for children with hay fever and other allergies. Without implementation of these key recommendations, our other recommendations on monitoring allergy, air pollution, occupational rehabilitation, advice to parents and the urgent need to evaluate complementary therapies and diagnostic kits would have relatively little effect.
There are only 26.5 whole-time-equivalent allergy specialists, many of whom are clinicians funded through research rather than the NHS, compared with several hundred specialists in some European countries. Of the 94 allergy clinics in England, only six are led by a full-time allergist. The others are uni-disciplinary clinics, which are held a couple of times a week and led by organ-specific specialists working in relative isolation. Pitifully few services of any sort are available in the north and west.
The lack of allergy-service infrastructure is mirrored by a serious lack of allergy knowledge amongst clinicians at all levels, particularly in primary care. Even when a GP recognises that a patient needs to be referred, it is hard to identify whom to refer to, and some patients resort to attempting self-diagnosis using inappropriate and unproven tests. Furthermore, the answer to better diagnosis in primary care is not pedalling diagnostic kits, but education, education, education, because misleading false positives abound without an accurate history and a proper clinical examination.
We saw a very different picture in Denmark, where the various specialists work collaboratively to provide an efficient diagnostic and management service for patients. With the financial constraints of the NHS, we accept that it would be unrealistic to call for the immediate training of hundreds of dedicated allergists, but we do feel that more need to enter training. However, we suggest the harnessing of the pockets of allergy expertise that already exist by clustering the various specialists to work together in designated allergy centres. This would not require a vast amount of additional funding and could be implemented quickly. At least one allergy centre led by a full-time allergy specialist should be established in each strategic health authority area, bringing together those who already have a special interest in allergy: from chest medicine, dermatology, occupational medicine, ENT, paediatrics, clinical immunology and gastroenterology, with support from specialist nurses and dieticians.
Each centre of excellence would form a hub where clinicians working together would learn from each other and provide expertise to investigate and diagnose complex allergies and guide management plans. They would also guide management plans as the patient goes back to their GP for their care to be monitored in
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In their response, the Government reverted to their well-worn argument that responsibility in a devolved NHS rests with local commissioners, but acknowledged that our suggestion merited careful consideration. Since publication, I have met the Minister, Ann Keen, and the Minister in this House, the noble Lord, Lord Darzi, both of whom expressed their enthusiasm for such a pilot project. Moreover, Professor Custovic from Manchester has informed me of a prime opportunity in the north-west where a framework and business case for just such an allergy service has been developed and locally endorsed by the specialised commissioning group, but the only thing holding it up has been funding. So I look forward with great anticipation to hearing from the Minister about progress made by departmental officials who were going to explore this with stakeholders, and I hope that he will have a positive response to announce today. I am grateful to him for his work and for his recognition of the importance of developing a pilot centre. We on the committee see the clustering of expertise in allergy centres as the most important way of ensuring that the other changes are championed and followed up in order to improve the health of millions of people suffering from allergic diseases in the current allergy epidemic.
I turn to therapy. Although we were not investigating appropriate ways to diagnose and treat allergic conditions, the argument to support immunotherapy in order to desensitise patients suffering from hay fever and venom anaphylaxis became evident. In Germany and Denmark we saw the efficacy of immunotherapy and realised why we had been told that the NHS is the laughing stock of Europe for its absence of immunotherapy for allergic diseases. We are puzzled that new immunotherapy products are licensed in the European Union, but the MRHA has not approved them in the UK. It is also disappointing that NICE has told us that there are no plans to carry out an appraisal of this type of treatment for allergy sufferers.
Prevention is certainly better than cure. Excellent research, largely from the UK, has elucidated allergic mechanisms and genetic susceptibility, but the way the immune system develops in infancy on exposure to allergens remains poorly understood. Environmental factors which can exacerbate allergies, such as dust mites and damp housing, have been implicated in the genesis of allergy. But, as was pointed out to us, everyone lived in damp, cold housing 100 years ago and there was much less allergy. Even the hygiene hypothesis which has featured a lot in the press, we discovered, may be somewhat inconclusive. So we recommended that long-term cohort studies warrant
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School poses particular hazards for children with allergies. Eczema is itchy and disfiguring and treatment creams are potentially stigmatising. Hay fever sufferers under-perform in summer examinations, dropping a grade compared with their winter mocks at times, and support varies widely between schools. For food allergic children, casual contact with food allergens can precipitate fatal anaphylaxis. Some suffer terrible bullying when other children put nuts into their pockets or lunchboxes to try to contaminate their food, yet school staff do not necessarily know how to deal with anaphylactic emergencies. That is why we called for a review of the care of hay fever sufferers, particularly schoolchildren during exams, for approved allergy training of staff and a review of the case for schools holding generic adrenaline auto-injectors.
So why did the Government brush these aside quite so dismissively? Hospital admissions for anaphylactic shock rose sevenfold from 1990 to 2004 but the true number of deaths remains unknown. Potentially fatal anaphylaxis can occur anywhere and probably a fair number of drug reactions are actually allergic reactions to the medication given. For people with food allergy, eating out is particularly hazardous and food shopping presents a minefield because food labels are inconsistent, confusing and offensive, with warnings so overused that teenagers tend to ignore them. So we recommended greater accuracy on food labels to clearly specify known allergens in the product.
Almost 26,000 people in England have known peanut allergy and yet, on one of our visits to the Evelina children’s hospital, we learnt that in countries such as Israel peanut in weaning foods seems associated with low rates of peanut allergy. This evidence has inspired Professor Lack’s study. His hypothesis is that the avoidance of peanuts during pregnancy and infancy may be contributing to the epidemic. That led us to recommend the Department of Health to withdraw its out-of-date advice on peanut consumption. No other Government advise peanut avoidance in pregnancy. I ask the Minister when the review commissioned from the Food Standards Agency and the Committee on Toxicity will be available. I understand that those bodies have been charged with reviewing the subject.
About one-third of the population will develop symptoms due to allergy at some time, and these are not trivial problems. Today’s debate is particularly timely as the seasonal problems of hay fever, insect stings and plaque dermatitis resurge to join the perennial food and other allergies. I have been able to cover only the areas that the committee felt required the most urgent action, particularly the need to cluster expertise together to form centres of clinical excellence. Many groups are anxious to see the report’s recommendations implemented. The allergy epidemic continues and people are demanding better clinical services, reliable advice on food and better support at school for children with allergies. We hope the Minister shares our vision to improve allergy services. I am sure that he recognises the enormous public interest in the subject and I look forward—as does the committee—to his responses today. I beg to move.
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Moved, That this House takes note of the Report of the Science and Technology Committee on Allergy. 6th Report, Session 2006-07, HL Paper 166.—(Baroness Finlay of Llandaff.)
4.50 pm
Lord Haskel: My Lords, I put on record my appreciation for the work of our clerk, our special adviser, my colleagues and our chair. It has been a wonderful experience to work with them. It is sometimes quite daunting to be a member of your Lordships’ Committee on Science and Technology. There are many eminent and highly qualified people serving on the committee. Participating in this debate are eminent physicians who are experienced in diagnosing allergies; eminent scientists who know all about the little that is known about allergies; and people who, unfortunately, suffer from allergies. They are all well qualified to speak. Of course, there is the Minister, himself highly qualified.
What are my qualifications? My qualification is that I am a strong supporter of this Government and wish them well. More than ever, I am anxious that they should keep in touch with the public, address people’s concern and, as they say, be a listening Government. Working on this inquiry, one thing came across loud and clear: people are concerned about allergy. Every time I told friends about our inquiry, inevitably they would respond with an account of their experience of allergy or that of a family member. My children are young parents, and they responded with concerns about their children. Every few days somebody would bring to my attention media items about allergy. There was a supplement last Sunday, mentioning our report and, indeed, the noble Baroness, Lady Finlay. As the Minister knows, the media make it their business to reflect people’s concerns. Teenagers tell me that allergies are now a topic appearing in the social networking sites. The concern seems to be that allergies are a feature of modern life. The noble Baroness, Lady Finlay, spoke about there being fewer allergies 100 years ago. As we raise our standards of living, so, apparently, allergies increase. It would appear that they are not going to go away.
The noble Baroness spoke about regular warnings. Yes, the Royal College of Physicians reported in 2003; the House of Commons reported in 2004; the Department of Health itself reviewed the services for allergies in 2006; and your Lordships reported in 2007. All showed concern. I do not know about the other reports but I can confidently tell the Minister that the British public listen to House of Lords reports. How do I know? I have the privilege of being a member of the Lord Speaker’s outreach team. I have also moderated young people’s debates. Invariably, people tell me how much they value your Lordships’ reports for their authority and impartiality. This is why I ask the Minister to listen more carefully to our report. The public are certainly listening to it. One day the Minister may have to explain why it was ignored.
It is not going to go away. This year there have been letters in the Times, one from medical experts and one from the public, represented by the Surrey Women’s
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There is another reason why the Government should listen: money. As the noble Baroness, Lady Finlay, explained, nobody really knows what allergy costs the economy. As we explained in our report, this is all to do with record-keeping. There are a number of straws in the wind which indicate that the amount could be substantial. For instance, the Royal College of Physicians states in its report that contact dermatitis accounts for half of all days lost from work through sickness. That in itself would amount to an awful lot of money. There are indications that one in five of the UK population suffers from hay fever. That must be a considerable cost to the economy, as well as affecting children’s performance at school or during exams. The House of Commons has tried to put a number on this: it states that allergy accounts for primary care expenditure of £900 million a year.
Although these costs may not be exact, they could be considerable—and when they relate to a matter of public concern, costs have a horrible habit of achieving major significance. So it will come as no surprise to the Minister that when I read the Government’s response I was disappointed that they did not seem to share the concern of the public and the experts. Certainly, the response dealt with our recommendations; they were sent down the line for action and consideration in a most efficient manner. Any sign of shared concern with the public, however, was absent. Dealing with public concern is rarely a matter of administration. It involves political will.
Perhaps we were at fault in addressing our concerns to the Department of Health. Allergy issues are much broader than that. The Government’s response includes contributions from other departments: business, regulation, children and families, communities, local government, environment, food, work and pensions, health and safety. It is a very broad topic. That is why so many people are aware of it and why so many of them are concerned. Will the Minister look at this report again, not from the point of view of administration, but from the point of view of a Government who are in touch with the public, listen to their concerns and want to know what is being done by all those different parts of government to deal with those concerns? If the Government do not do that, it will come back to bite them.
4.57 pm
The Earl of Selborne: My Lords, the whole House will be grateful to the noble Baroness, Lady Finlay, for introducing the debate with such authority and for having chaired the inquiry so skilfully. We all learnt a lot. Like the noble Lord, Lord Haskel, I do not feel myself as qualified as some of the great experts we have on the committee. I cannot say, however, that I feel I have the same qualifications to speak that he feels he has speaking from those Benches to urge the Government from behind, but I agree with him that
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I shall deal with the research issues arising from this allergy epidemic. We have already heard that we have one of the highest prevalences of allergic diseases in the world. The costs for the National Health Service are rising. We have already heard what the figures might be, but let us just say that the direct cost to the NHS is around £1 billion while primary care prescribing costs are around 11 per cent of the total drugs budget. Something like 17 million working days have been lost due to asthma alone, at a cost of another £1 billion—you can just talk about round billions with these figures.
The most startling thing of all for me—I say again that I start from a position of total ignorance on this subject—is that we do not seem to know why the incidence of allergy and allergic disease is rising. As the noble Lord, Lord Haskel, reminded us just now, it is clearly linked to some aspect of the more prosperous living conditions we have enjoyed since the 1960s. Dramatic increases were seen between 1964 and 1980, and there have been continuing increases since then. In Germany following reunification, and in other parts of Eastern Europe, there has been an increase in the incidence of allergic diseases right across the former Iron Curtain countries. It seems that there is a critical window of exposure in the first year of life during which the child’s immune system can be influenced, and their risk of allergic disease substantially reduced. Yet once children pass their first birthday, the same factors that would have prevented them from becoming allergic no longer operate, implying that any intervention to change the prevalence of allergy would have to target that very early phase of life and not be brought in some five years later.
There is still uncertainty on whether avoidance of specific allergens during pregnancy is desirable, or whether exposure to some allergies in appropriate contexts actually helps to protect children. A lack of research into the development of the immune system and the establishment of allergy means that the scientific community is still not able to answer fundamental questions, such as whether peanut avoidance protects the child from peanut allergy.
To answer such questions, we need broader studies; as the noble Baroness, Lady Finlay, said, long-term cohort studies are required. Those are not easily funded and do not produce specific conclusions. As Dr Egner of the Royal College of Pathologists advised us,
“In a competitive research environment, it is a brave person who goes into a messy area with no clear outcome”.
Professor Burney, who is a Professor of Respiratory Epidemiology and Public Health, said that it was a dilemma for those funding research to choose between good, basic science that will,
- “a more speculative bit of work that is going to advance general knowledge but is not going to give you the same kind of precise answers”.
The majority of research funding, from the research councils and other public funding streams, focuses on the basic allergy mechanisms; indeed, this research is
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Research in academia is hindered because of that separation between clinical work and the research centres. If the recommendations of our report help those specialist allergy centres, it would certainly help enormously to bridge the gap, as it is difficult at present for the academic researcher to access patients’ data from general practitioners. Indeed, those are sometimes impossible to obtain. Without access to a good, representative sample of the population at reasonable cost, epidemiological research is hamstrung.
In supplementary evidence, recorded on page 60 of the second volume, Professor Burney explains how the patients’ data are now regarded as confidential and access is denied—in marked contrast to such countries as Germany where data are more accessible. The professor said:
“Under the current rules, because we cannot have access to the names and addresses until the patients have replied to say that they are willing to participate, we are unable to help with any of this process. For a busy general practice this is an all but impossible task and it is amazing that we have any volunteers”.
He went on to ask, not unreasonably, for permission to use names and addresses of patients registered with GPs, together with their dates of birth and gender, providing; first, that the programme of work—including the letter of invitation to participate and the questionnaire—had ethical committee approval and, secondly, that the staff were adequately trained and had honorary contracts with the health authority or trust. Professor Burney ended his letter to the committee,
“The irony is that a properly designed and well vetted study to improve our knowledge of public health is forbidden, but any company can ring me up at home and conduct surveys or try and sell me whatever they please. If your committee were able to find a solution, this would be greatly and widely welcomed”.
We address this issue in paragraph 7.26, which states:
“It is imperative that further research should focus on the environmental factors, such as early allergen exposure, which may contribute to the inception, prevention or exacerbation, of allergic disorders. Long-term cohort studies are a vital part of this research ... We look to the ... Office for Strategic Coordination of Health Research to improve the co-ordination and funding for these types of projects”.
The Office for Strategic Co-ordination of Health Research arose from the Cooksey review which addressed this issue, which has been a problem for so long that the Medical Research Council undertakes research into it, as does the National Health Service. But before the Cooksey review the two lacked co-ordination. This is a challenge, if ever there was one, for the new Office for Strategic Co-ordination to try to ensure that there can be an exchange of data and a seamless join between the two funding research streams.
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