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I was disappointed that when the Committee pointed out how backward we were, the Government reaction seemed to lack the appropriate urgency—they seemed relaxed about our deficiencies. Yet, as our chairman stated, we are considered the laughing stock of Europe in this field. By the way, I add my tribute to the noble
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There are at least three respects in which we are backward compared with many of our European partners. The first is in training and education. The diagnosis and treatment of allergies is not part of the basic training of medical students—an astonishing situation. Nor are there adequate general clinical postgraduate courses in allergies for nurses and doctors, which is most important in the case of GPs. Most GPs are not properly equipped to diagnose allergies or recommend appropriate treatment.
A second result of this inadequate training and education is that we have an appalling shortage of specialists. As the noble Baroness, Lady Finlay, pointed out, we have 26.5 specialists—I am not sure who is the half. Spain, with a much smaller population, has 1,300 specialists—50 times as many. Equally unfavourable comparisons can be made with Denmark, Germany, Sweden and many other European countries.
One of the most damning comparisons concerns the very limited facilities we offer for immunotherapy. I quote figures given to committee members who visited Germany. They appear in the appendix to the committee’s report, on page 128. Germany prescribes about 700,000 courses in specific immunotherapy, France about 500,000 and the UK about 5,000, yet the evidence that we received was quite clear. Immunotherapy is a standard and effective way of managing allergies in other European countries. It allows patients to lead much more normal lives, especially in the case of hay fever, asthma and allergies to wasp and bee stings, and it has a more lasting effect than treatment with drugs such as antihistamines or steroids. Immunotherapy can be administered either subcutaneously by injection, involving a lengthy and expensive form of treatment, or more cheaply and conveniently sublingually, by oral tablets. Sublingual treatment is very common in France but is almost unavailable in the United Kingdom. However, even the more expensive form of subcutaneous treatment saves costs in the end because it is much longer lasting and much more effective than drugs.
Why do we neglect desensitisation or immunotherapy? We do so because the MHRA has created the strictest regulation in Europe. Its attitude seems to be determined by safety concerns based on 27 deaths from anaphylactic shock between 1956 and 1982—over a quarter of a century ago. A Danish company gave evidence that it had product licences for subcutaneous immunotherapy in many European countries but had given up seeking licences in Britain because of the attitude of the MHRA. We were also told that NICE has no plans to appraise immunotherapy products. However, the evidence that we received was clear. If administered by specialists in a proper environment, the treatment is safe. If there is a severe reaction, it can be promptly recognised and dealt with. The MHRA has simply not kept up with
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There is no justification for that defensive attitude. We seem to be unique in our view of the safety of the treatment. Not only other European countries but also the WHO regard immunotherapy as the most effective treatment—the only one that can influence the natural course of allergic disease. Its views are found at page 131.
Therefore, I return to the question of why we are so backward and why we refuse to learn from the experience of other European countries. I fear that it is part of a wider disease—a certain insularity and a refusal to accept, because of insular attitudes, that in many ways other European countries are more civilised than we are. That is certainly the case in their approach to crime and penal policy but it is also the case in many aspects of health policy. Our National Health Service has many virtues and is often unfairly criticised, but our public attitude towards the scourge of allergy is, frankly, a national disgrace.
5.38 pm
Lord Crickhowell: My Lords, the noble Baroness who initiated this debate and chaired the committee which produced this important report has, not for the first time, rendered a very considerable service to the House, to medicine and, above all, to those afflicted by illness.
This allergy report was produced by the Science and Technology Committee before I joined it but, invited by the noble Baroness to participate in the debate, I said that I would speak of the experience of my own family and of the difficulty of finding general practitioners with the knowledge and time needed to provide the right diagnosis for a wide range of complaints. On reading the report, I found that the experience of my wife exactly bore out some of the most crucial evidence received by the committee and underlined the importance of some of its key recommendations.
Going back to the early 1960s, after the birth of our first child, my wife felt the kind of pain all over her body that one suffers from a poisoned finger. Our unsympathetic GP said that it was probably postnatal depression and that she should see a psychiatrist. She was finally diagnosed by a patient and understanding doctor as suffering from an allergy to cow’s milk. She consulted Professor Jonathan Brostoff, who gave evidence to the committee, one of the leading experts on food allergy and food intolerance. Some years later, after I had become an MP, she suffered from sores in her mouth, constant sore throats and swollen glands, was fed with antibiotics and told to lead a less stressful life. A wise doctor in Abergavenny, feeling sure that it was a food allergy, questioned her closely and suggested that it might be tomatoes. He was right. A long time later, suffering muscle weakness and aching joints, she finally found that she was suffering from an allergy to wheat. Today, when vineyards and wine companies are speeding up the maturing process of wines by adding sulphites, my wife has joined many others unable to drink wine.
Talking to friends about these experiences I have often referred to the doctors who did come up with
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“Those working in primary care lack the training, expertise and incentives to deliver services ... Many of the deficiencies in primary care are matched by weaknesses in secondary and tertiary care”.
The Commons committee recommended that the GP curriculum should include allergy training and that specialist allergy clinics should be developed across the country as centres of good practice for the training of primary care staff.
The report we are debating today reveals a shocking state of affairs. It is astonishing that it should be necessary for parliamentary committees to suggest that allergy training for GPs should be necessary. It is disturbing that witnesses report that the knowledge of allergy in primary care is poor and refer to minimal training. As if that was not bad enough we are told that there is a shortage of allergy consultants—and of expertise among consultants to whom GPs are likely to turn.
On a visit to the allergy clinic at Addenbrooke’s Hospital, committee members were told that it was a struggle to convince local commissioners to invest in allergy training and services because allergy was not yet recognised as an important subject.
Allergy UK, a leading allergy charity, reported that for patients,
- “the major problem is the lack of knowledge at primary care level. GPs do not recognise allergic symptoms when presented with them due to a lack of training in allergy”.
A consultant allergist at the Royal National Throat, Nose and Ear Hospital told the Committee that:
Another doctor, making the same point, went on to say that when it comes to postgraduate training,
Paragraphs 9.28 to 9.31 of the report provide a damning indictment of the current situation. Its second volume, which contains all the evidence received, adds powerfully to that indictment. The key recommendations on allergy centres—those described by the noble Baroness when opening the debate—in Paragraphs 9.40 to 9.46 of the report, on NICE clinical guidelines in Paragraph 9.47 and on education in Paragraph 9.48, demand a full and adequate response.
However, the Government response to all these recommendations is deeply depressing. They refer to a review carried out by the Department of Health and then make use of that review to justify one of the most inadequate responses ever given to a report by a Select Committee of this House, made much worse because, effectively, it is also a response to a committee of the other place that came to similar conclusions. They argue that,
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- “lack of baseline data ... published examples of whole systems modelling of services ... analysis of the effects of active demand management of patient flows in allergy care ... absence of agreed service models and protocols”,
make it impossible to make meaningful comments on the existing and desirable capacity of services for allergy. Surely that is not an adequate response to the recommendations but an admission that the Department of Health has failed to do its job.
If all those business jargon phrases that I have quoted identify work that should have been done, the question is why it has not been done and why the information is not available when provision of services is identifiably inadequate and huge sums of taxpayers’ money is being put into the health service. One thing is absolutely certain: with that kind of guidance, few with regional responsibilities will make a positive move to improve the service and provide the allergy centres that the report recommends.
We are told that none of the allergy-related,
- “topics has been judged to be of sufficient priority against other proposals to warrant inclusion in NICE’s ... programme”.
That represents a combined failure by both NICE and the department to address priorities that have been identified by two parliamentary committees on the back of a mass of evidence. As to education, I suppose that we are expected to find comfort from the statement that the Department of Health,
- “does share a commitment with statutory and professional bodies that all health professionals are trained, so that they have the skills and knowledge to deliver a high quality health service to all groups of the population with whom they deal”,
even though the department first washes its hands of responsibility for setting curricula for health professional training. However, it really is not good enough to be fobbed off with the feeble comment that the department,
- “would encourage the Royal Colleges to work together with the bodies responsible for medical training at all levels, in order to ensure that the knowledge and expertise of those working with people with allergies are enhanced”,
and with the recommendation that,
If I appear angry and impatient, it is because I am. That anger and impatience are shared by a large number of professors and consultants in the field, many of whom signed a devastating letter to the Times, which appeared on 31 January. Today we are considering a report that identifies grave shortcomings in the knowledge and training of a large number of health professionals, who as a result are unable to provide the quality of service that is, I am sure, their ambition and the understandable and justified expectation of their patients. It is the job of Ministers to ensure that shortcomings, when identified, are remedied. It is they and not others who should be held responsible if remedies are not found. With a Minister rightly described in the debate as highly qualified, perhaps at long last there is hope.
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5.48 pm
Lord Rea: My Lords, as always it was a great privilege to serve on your Lordships’ Science and Technology Committee. We were extremely lucky to have such a cheerful and energetic chair. She has already paid tribute to our specialist adviser, but I should like to pay special tribute to our clerk, Sarah Jones, who came through her initiation as a committee clerk with flying colours. I also thank our hosts on external visits, who went out of their way to make us feel welcome and arranged fascinating and informative programmes.
I am not an allergist or an immunologist but, as a general practitioner without special training in allergies, I saw many patients with allergy problems. The great majority of these could be helped by simple measures to mitigate the symptons. Inhaled, topical and, occasionally, systemic steroids were extremely useful, as were antihistamines and cromoglycate. I usually referred more severe or intractable problems, mostly asthma or severe skin allergy, to the appropriate chest or skin specialist. It was difficult to get an early NHS appointment to see our one allergist in the catchment area, who always had a long waiting list. I was fortunate never to have to deal personally with a severe anaphylactic reaction, though one of my patients died as a result of a wasp sting while on holiday in Greece.
I have suffered a moderately severe reaction myself as a result of a wasp sting, dealt with competently and effectively by the A&E department at the Royal Sussex Hospital in Brighton. Subsequently, I received a long drawn-out but effective course of desensitisation at Professor Stephen Durham's unit at the Royal Brompton. I know that it was effective because, a year or so later, I was stung eight times at once after treading on a wasp nest in the dark—an experience not to be recommended. Thanks to my desensitisation, it was not a fatal experience—as it might have been, because I had left my EpiPen at home.
In my practice, it would have been extremely useful if one of our practice nurses had received training in the use of patch testing and other allergy diagnostic procedures. As it was, we had only empirical knowledge of the allergens that triggered allergic responses in patients. In many cases, no single factor seemed to be responsible and control of the symptoms—whether a skin rash, wheezing attack or rhinitis—was the doctor’s sole aim, rather than finding out exactly what was causing it.
The main recommendation of the report—to establish a network of specialist allergy centres similar to the one that the committee visited in Cambridge—would make that much more possible. Not only could patients with troublesome allergies be referred there, but GPs and practice nurses could be trained in allergy procedures, as the noble Lord, Lord Crickhowell, suggested. Already, at the Cambridge centre, GPs have improved their allergy skills through their correspondence through referrals. My noble friend will know of the new allergy centre proposed for Manchester, which the noble Baroness, Lady Finlay, mentioned, which consultants want to set up and requires only modest funding. I understand that my noble friend’s colleague, Ann Keen, has agreed
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The rise in allergic disease in the past few decades—which all our witnesses mentioned and which is well understood to be real and not simply due to changes in clinical awareness or diagnostic criteria—has occurred in all modern industrialised countries, not merely in Britain, although we have perhaps had the highest rise. It has not occurred among the populations of developing countries living a traditional lifestyle but, interestingly, it has increased to some extent among the better-off members of those societies, whose standard of living is similar to ours. As we have heard, that phenomenon has been labelled the hygiene hypothesis: those at greater likelihood of exposure to more infections, infestation, environmental pollution or certain foods very early in life—possibly even in utero—are less likely to develop allergies as older children or adults. The clean, the hygienic, thus has a downside. That is perhaps another way of saying, “A bit of dirt never harmed anyone”—and may even do some good.
An example of research carried out in Berlin and Munich on whether the hygiene hypothesis applied was described to us; it has already been alluded to. Before the unification of Germany, the incidence of allergic disease was lower in poor children in the east, where there were higher levels of atmospheric pollution than in the west. After unification, which led to less pollution and higher living standards in the east, levels of allergy gradually rose, so that there is now no difference between east and west. In rural Germany, children brought up on farms, exposed to animals and drinking unpasteurised milk, had lower levels of asthma and other respiratory problems than children in the same area not living on farms. Research that has been described to us, as noble Lords will have heard, by Professor Gideon Lack at the Evelina Children’s Hospital demonstrated that the prevalence of peanut allergy in Jewish children living in Israel was much lower than in genetically similar children living in the UK. As my noble friend has described, the Israeli children had been weaned on to a food based on peanuts. I will not describe the study known as LEAP—Learning Early About Peanut Allergy—which Professor Lack is conducting because it has already been well described.
As its name suggests, the hygiene hypothesis is a hypothesis rather than a full explanation, as there are many exceptions to the rule. It is not much help being allergy free if, as a result of living in an unhygienic environment, a young child were to get seriously ill and fail to survive to enjoy its allergy-free status. However, the hygiene hypothesis may be helpful in understanding the origins of allergy. The mechanism of the immune response to certain bacilli—possibly in the gut flora—in early life appears to enable an individual to deal more efficiently with potentially allergenic challenges later.
Research to identify and understand the processes involved in the acquisition of tolerance early in life has far-reaching potential, and hopefully it will be possible to identify and isolate at a molecular level the factors in the “unhygienic” environment initiating this process. Thus “clean dirt” could be given to vulnerable individuals,
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Food allergy is an increasing problem. Although many who think they may be allergic to certain products—according to some estimates about a quarter of the population at some time in their life—may in fact be suffering from food intolerance or ascribe a variety of symptoms to certain foods, encouraged by some complementary practitioners and the media, rather than having a true allergy mediated by IgE or T helper cells. Five to seven per cent of infants are thought to have some manifestation of true food allergy, but the figure is not precise due to diagnostic difficulties. This prevalence reduces to about 1 to 2 per cent of adults, according to the Institute of Food Science and Technology. As has been said, peanut allergy has increased in prevalence so that about 25,000 people may now be affected. New food allergies are being described, such as to kiwi fruit and certain other fruits, tree nuts as well as ground-nuts, chickpeas, sesame, mustard and soya. Dr Clare Mills of the Institute of Food Science and Technology ranges potentially allergenic food products in a hierarchy of severity, with peanuts and hazelnuts at the top of the list and carrots, tomatoes and melon at the bottom.
To conclude, the European Union is reviewing its food-labelling legislation. This should provide an opportunity to rationalise what is at present a confusing set of regulations that cover only 12 known allergens added to food. The list is constantly changing. The review should provide the Food Standards Agency with an opportunity to influence the rationalisation of EU food labelling legislation. Our report recommends that food labels should specify the amount of each allergen listed if it is contained in the product, and we support the FSA in discouraging vague, defensive warnings which can severely restrict the choice of those with possible allergic tendencies, especially if they are of a cautious disposition.
6 pm
Lord Soulsby of Swaffham Prior: My Lords, much of the fundamental research on allergy and its management has been done in the United Kingdom, and yet with allergy reaching epidemic proportions, this report of the sub-committee so ably chaired by the noble Baroness, Lady Finlay of Llandaff, and guided by our expert adviser, Professor Barry Kay, identifies major deficiencies in allergy services in the country, including a shortage of specialists, lack of training and deficiencies in management when compared, for example, with the continent of Europe.
I wish to focus on immunotherapy in allergy. Immunotherapy, or desensitisation, can lead to a potential cure for an allergy rather than merely alleviating the symptoms with drugs. Immunotherapy has been found to be highly effective in numerous rigorously controlled clinical trials. Importantly, desensitisation treatment
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