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The Department of Health claims to be increasing its support for research into the environmental factors that contribute to allergic disorders. It would be
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5.06 pm
Lord May of Oxford: My Lords, this Select Committee report is particularly timely. Under the excellent chairmanship of the noble Baroness, Lady Finlay, it produced a thorough, thoughtful and constructive review of the rising incidence of allergies in the United Kingdom and, helped by its excellent secretariat and its specialist adviser, Professor Kay, produced a set of constructive and sensible recommendations. However, I found the Government’s response disappointing in parts and in some cases dismissive.
I strongly endorse the remarks made by all the previous speakers, particularly by my noble friend Lady Finlay in opening the debate, and join with the noble Lord, Lord Haskel, in asking for the report to be read again, recognising that it contains important comments expressed thoughtfully by a lot of well informed people.
I wish to relate my next point to a somewhat wider area that the noble Earl, Lord Selborne, covered in detail and elaborate on the decision made nine years ago to recommend to women that they avoid eating peanuts when pregnant and avoid exposing their children to peanuts. I thought then that the advice was not well founded but I recognise that that was debatable at the time. I am given to making gestures in the Chamber as a substitute for using PowerPoint, but this time I shall not distribute my papers all over the Bench in front of me. Since then we have seen a linear rise in the incidence of peanut allergies. I understand as well as the next person that correlation is not causation. There is also the hygiene hypothesis—we have heard about this and I shall not elaborate on it further—that we live in an excessively hygienic environment and people’s immune systems are more disposed to develop pathologies. I recognise that that is not proven, and even if it were, it would not necessarily conclude that eating peanuts was advisable. None the less, careful epidemiological studies show that in Israel, where infants are exposed to peanuts, there has been no corresponding rise in the incidence of peanut allergies. The rate is low and flat, whereas our incidence of such allergies has risen even with the advice I mentioned.
In Africa, children are also commonly exposed to peanuts and have no allergies. There could be genetic differences. I realise none of those points amounts to a proof that you should tell people to rush out and expose children to peanuts, but in my mind they amount to a powerful argument for reviewing the advice not to. The Government’s response to that particular recommendation was to say that they did not think it appropriate to withdraw the advice without having alternative advice to replace it. Fair enough, but I think the advice that ought to be given now, in the light of the additional facts we have gathered over those nine years, is that we do not understand this well
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From my five years as chief scientist, I realise how uncomfortable Governments are with saying that they do not know, and yet the protocols for science advice in policy-making—issued under John Major in 1996, reviewed by myself under Blair in 2000 and further strengthened by my successor—say that you consult widely and openly, you review changing circumstance and you admit uncertainty. That, in fact, engenders confidence in the public.
That leads me to my final brief point. The noble Earl, Lord Selborne, elaborated very cogently the other piece of evidence that receives generally less attention—namely, that research into the fundamental aspects of how the immune system first creates itself somatically in the first three years of life is difficult and not fashionable. On the molecular details of some of the actual allergies that have arisen, we are among the world leaders, but the world as a whole finds it unfashionable to look at this question. The immune system is not coded in the genome. What is coded in the genome is a programme to assemble itself. The conjecture is that if it is not appropriately sufficiently challenged, it goes looking for inappropriate work to do, hence a rise in allergies. Maybe that is right; maybe it is wrong.
This requires a fusion of people who work on non-linear dynamical systems with people who do careful clinical epidemiological work. As we heard in the report, and as was emphasised by the previous speaker, one of our recommendations is that it receives more attention. If I were the Secretary of State for Health, I would bring together an informal group of people from research in the National Health Service, the Wellcome Trust and relevant research councils—because this is not just a Department of Health responsibility—to ask whether there may not be some kind of coalition that puts a little bit more effort into soliciting this kind of unfashionable, multi-disciplinary research, where the potential researchers have told us they are finding difficulty getting funding.
5.13 pm
Baroness Perry of Southwark: My Lords, I, too, would like to pay tribute to the noble Baroness, Lady Finlay, both for opening this debate so expertly today and also for her chairmanship of the sub-committee. She has a degree of energy and expertise from which we were all able to benefit and she became a very close friend to every member of the sub-committee under her guidance. I recognise the splendid support that we had from our clerk, but would like to pay a particular tribute to our specialist adviser Professor Barry Kay, whose extensive knowledge and extremely experienced wealth of time in the field so greatly enhanced our work.
I would like, in the brief time available today, to reflect on one aspect of our report—that is, the impact of allergy on children in school—and to highlight some of the problems and solutions which we proposed in our recommendations. As other speakers have commented, allergies can cause a very severe reduction
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A survey by the Department of Dermatology at the Wales College of Medicine showed the devastating impact that severe eczema might have on the lives of children. Beyond the embarrassment, which for them is often the key part of the thing, there is also evidence of sleep disturbance and therefore impaired school performance. Think of children with severe asthma. They, too, suffer great underperformance in school, for many causes. Some 38 per cent of allergy sufferers had missed a considerable part of their schooling due to their asthma problems. Their sleep disturbance also made it hard for them to concentrate at school.
Though less severe, the prevalence of hay fever among children also has a demonstrable effect on their performance, particularly in examinations. As we all know, GCSE and A-level examinations mainly fall in the peak hay fever season. A study of the impact of hay fever on exam performance by teenagers in the UK found that sufferers could drop a whole grade in their summer exams compared to the results of their mock examinations, which were taken in winter when their hay fever was not present. That drop in achievement can be caused both by the symptoms of hay fever and by the sedating antihistamines that are often given to them and which affect their long-term prospects, both of higher education and career development. This is not a small matter; children who may drop from a B to a C in their A-level results, for example, can fail to meet the offer that they have had from a university, and so miss out quite substantially on the university experience that they had planned for, and therefore be affected in their long-term future careers.
Dr Paul Harrison, the director of the Institute of Environment and Health at Cranfield University, told us that children with asthma and allergic rhinitis often also opt out of sporting activities, so compounding their fitness problems. However, we received evidence that the awareness of the problems of hay fever sufferers and other allergy sufferers varied greatly, as did the way in which they were treated by their schools and local authorities. Some local authorities and schools allow special examination arrangements for sufferers, while others simply take no account of it at all. We recommended, therefore, that the Department for Children, Schools and Families should review the care given at school to hay fever sufferers and reassess the way in which they are supported during the exam season. Consistency of provision across schools and local authorities is a responsibility of the department; it is not enough simply to leave it to individual schools. We also feel very strongly that school nurses have a role in ensuring that children are not automatically given sedative antihistamines, which can impair their performance. I will return to school nurses in a moment or two.
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There are a small number of children whose allergies are even more life-threatening; children who are at risk of anaphylaxis, for example, a reaction to food such as nuts or to insect venom. The peanut allergy alone has increased dramatically in recent years, creating a real challenge for schools, where teachers may find themselves dealing with a life-threatening emergency of which they have absolutely no knowledge. The representative from what was then the Department for Education and Skills said rather dismissively that, “It is a head teacher’s responsibility to ask themselves whether the cadre of teachers and support staff they have is able to deal with such an emergency”. I do not think that is good enough. I say to the Minister that to leave it to a lay head teacher to make such an assessment is not a response that one would expect from a responsible government department.
Children at risk from anaphylaxis usually carry an adrenalin auto-injector. We usually call them EpiPens, although I understand there are also AnaPens. Under current DCSF practice, only the EpiPen prescribed for the child is held in the school.
However, many of our witnesses felt strongly that schools should keep a stock of those generic auto-injectors available, for example, for a child who may have forgotten their EpiPen on that particular day or one who needed a second dose. We recommend that there should be clear guidance regarding the administration of auto-injectors to children with anaphylactic shock in the school environment. We also recommend to the Government that they should review the case for schools holding one or two generic auto-injectors.
Overall, however, we were concerned at evidence that allergies were poorly managed in the school environment. At the heart of this is the lack of training, most crucially for school nurses but also for teachers, support workers and heads themselves. That we felt was the heart of the problem. The evidence we would have given showed that there was a real problem in the training of school nurses. The department representative seemed to assume that school nurses were the answer to all the problems and could deal within the school with any emergency that arose and could also help with the training of the lay staff.
However, the evidence we had from the Royal College of Nursing spoke of funding cuts and shortage of staff among school nurses. There is also a problem where some school nurses are employed by the school directly and others are employed by the PCT and therefore their training needs can be dealt with in different ways: particularly those employed directly by the school have no one competent to assess their training needs and little money made available for them to update themselves in allergy treatment.
There is a lack of expert knowledge within the school system of how to deal with this huge problem. The Government document Managing Medicines in Schools and Early Years Settings suggested that every child who suffers from any form of problem that leads to them needing medication during the school day should have an individual healthcare plan. While we welcome that suggestion, we note that the heads have insufficient medical knowledge themselves to know
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We believe that the responsibility lies with Government to ensure that a health professional is available to make the assessments and to provide training where necessary. In the current shortage of school nurses and the difficulty of funding for their training, we fear that this is unlikely to happen. Our recommendation therefore is that the Department for Children, Schools and Families should audit the level of allergy training that school staff receive and should take urgent remedial action to improve this training where it is required. The impact of allergies on school performance as the life chances of many young people is immense and far-reaching. It is therefore disappointing to find that, as with most of the sub-committee recommendations, the Government response was so half-hearted. While agreeing with the Committee’s conclusions, no action was proposed, whether on the training required by staff, the storing of generic auto-injectors or the timing and arrangements of key examinations. It is not good enough. If, as we were told by our expert witnesses, allergy among children is of epidemic proportions and likely to grow, there is no excuse for us to stand back and leave it to lay people in schools and an overstretched school nursing service to deal with a national problem affecting thousands of children’s lives.
For me, the saddest comment that we heard from one of our continental experts on our visit was,
“We are simply amazed at the contrast between the world-class quality of your UK allergy research and the dreadfully low quality of your UK provision to patients”.
Lord Falconer of Thoroton: My Lords, before my noble friend Lord Bhattacharyya rises, I apologise to the noble Baroness, Lady Perry, for interrupting her excellent speech with my mobile telephone. I apologise to her and to the rest of the House.
5.24 pm
Lord Bhattacharyya: My Lords, while I am no medical expert I am glad that this debate has been scheduled for today as I recently experienced serious allergy problems and can offer a layman’s perspective on this excellent report. There is great interest in this debate and I believe that I know why. I was reading the committee’s report this morning when my daughter asked me what I was doing. When I told her that I was going to speak on allergies she laughed and said, “Well, everyone is allergic to politicians”.
My own allergic experience was in line with the report’s analysis. Last year, I noticed a rash on the left of my forehead which I assumed was an insect bite. As I often visit the tropics, one gets a lot of bites. However, within a fortnight a blister developed, so I went to my GP, who thought I had shingles. The treatment for shingles did not help and the lesion worsened. I was diagnosed with cellulitis and treated with intravenous penicillin, but the lesion did not fully heal. In addition, I developed a rash all over my body. My GP referred me to a consultant dermatologist who diagnosed me
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I will not bore the House with the details of my treatment, but as Birmingham has only two immunologists, I went to a specialist London clinic to fully identify my allergies and have immunisation treatment. I was lucky to be diagnosed with an allergy relatively early on, but my case illustrates that a full diagnosis of allergies still requires a significant delay, private care, a lot of travel or all three.
I want to be clear. I am proud of what the Government have achieved in the NHS. The West Midlands Strategic Health Authority under the leadership of Cynthia Bower has transformed the landscape of medical care in my region. We have made great strides in the past few years, with new hospitals and improved patient care. Wanting services to improve is not a criticism of the NHS. There should always be a debate about how public services should improve next. Allergy treatments currently have waiting times that are too high and a quality of diagnosis which is too low. As Dr Pumphrey of Research Councils UK stated,
The Department of Health began its report on allergies with a summary of the problems. It said:
“People can wait 3 to 9 months for an appointment to see a consultant in secondary care ... some may be passed around a number of different clinical departments for the different symptoms ... which can make diagnosis and optimal treatment difficult”.
I had no problems. I went to one clinic and very quickly all the experts were there and I was diagnosed early.
The Government tell us that 81 per cent of GPs say NHS care for allergies is poor quality and only half of GPs are trained in managing allergic problems. My experience backs that up. These issues define the problem. Doctors do not have sufficient expertise to diagnose allergies and there are not enough specialists to treat the patients that are diagnosed. This means that patients who go to a GP with asthma have to attend seven times before they get a diagnosis, while only a third of those with asthma are given an allergy test. I was born in India, so I never had all the benefits of hygiene when I was young; therefore, I never had any allergy problems until I faced this one.
Therefore, I endorse the conclusion that we need more training for GPs to diagnose allergies and an increase in clinical specialists based in a regional allergy centre. If we do not do that within the regions there are travel problems. I could afford private care, but the majority of people will have an enormous problem in accessing the sort of expertise that I experienced.
We have strengths in allergy research and courses for diagnosis in the UK—for example, at Southampton and the medical school at my own University of Warwick. I am struck by paragraph 7.27 of the report, which states:
“We are concerned that the knowledge gained from cellular and molecular research is not being translated into clinical practice. We therefore regard allergy research directly related to healthcare as an area of unmet need that requires greater priority”.
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Perhaps we should kill two birds with one stone by combining the regional allergy centre with an existing training location. This would best relate allergy research to treatments and GP training.
The Government are right to say in their response that,
We should not be recreating a “command and control” system in the NHS. I hope that Ministers also accept that local commissioners sometimes respond best to a strong lead from the centre. The Government have proved that successfully with waiting times. Launching the first regional allergy centre would be a strong lead from the centre. I welcome the Government’s conclusion that a lead strategic health authority is a worthy idea and I urge action on it.
We also need to help consumers by making it easier to detect any allergies that they might come into contact with. I now know what I am allergic to, both in chemicals and food—but it is a hell of a job to find out. When it comes to products such as aerosols, shampoos and detergents, one avoids all of them; because there is no clear labelling, one is scared.
When you suffer from an allergy, you first look for a cure from those you trust. But if none is forthcoming, you look anywhere. If the NHS makes the correct diagnosis and identifies the right treatment, patients will not require the dubious remedies that have exercised the committee. If we ensure that labelling is clear to those who suffer from allergies, consumers will not be susceptible to the pedlars of snake oil.
I hope that the Government respond constructively, so that we can make great strides in the treatment of allergies. Otherwise, we will see more patients fall into the arms of anyone who will offer them relief, no matter how far-fetched their claims.
5.30 pm
Lord Taverne: My Lords, many speeches today have stressed the seriousness of what can be described justly as an epidemic of allergy. We learned in committee that, among six and seven year-olds, one in five suffers from asthma. Some 5 million people suffer to some extent from allergy to grass pollen. There is some suggestion that the number of people affected by allergies is levelling out. However, there is no doubt that millions of people—possibly an increasing number—suffer severe impairment to their quality of life because of some form of allergy. It was therefore deeply depressing to discover how backward we are in the United Kingdom. No doubt there are centres of excellence, but the overall picture was described by the World Allergy Organisation Specialty and Training Council, which is quoted on page 89 of our report. It highlighted the paradox that in the United Kingdom, a country with an outstanding record in allergy research, there is a remarkably poor clinical service for allergy sufferers.
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