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I want to focus on the issues that noble Lords have raised but put them into a context. The context is that there will in future be nothing like the level of funding in the NHS that there has been in recent times. Therefore, for any service, particularly a specialist one like this, it is a question of how we redesign services in order to make what we have more effective. From data gathering and management at the beginning of this report right through to the end, the noble Baroness and her committee have offered the House and the noble Lord, Lord Darzi, an excellent blueprint for how services can be redesigned.
I am not a scientist or a historian, but other noble Lords have referred in their speeches to population conditions 100 years ago. Forgive me if I am wrong, but I think we need to be a bit careful. The survival rates from anaphylaxis 100 years ago would have been pretty near to zero. Although great advances have been made, the noble Baroness is right that the overall picture on prevalence is, when set against advances in public health, truly disappointing. I would go further and say that, if anything, some of the figures in this report and in previous reports by the Royal College of Physicians and the Health Select Committee are probably underestimates. Why? Because most people, like me, do not have severe and acute reactions and manage the condition themselves. Therefore, I suspect that the NHS really gets to see only those who are towards the more acute end of the spectrum. Moreover, those who have allergies are increasingly using the internet to find ways round and manage things for themselves.
The report is a disappointment in that very little appears to have changed in the 40 years since I sat in my GP’s surgery with pinpricks up my arms, watching all the reactions take place, and was sent off home with a list of things to avoid and a tin of Betnovate for when the eczema got really bad. The only thing that has changed is incidence. I thought one of the most interesting findings in the report was the observation by Professor Custovic of Manchester University that the genetic background of the population has not changed dramatically and yet the incidence of allergic disease has. That is worth noting.
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I know something else anecdotally; I have tried desperately to find data on it but have been unable to. I understand that in the Italian population there is a high and growing incidence of coeliac disease. As a very good friend of a member of my family has coeliac disease, I know that you can go to Italian restaurants even in this country and find gluten-free pasta. That is increasingly the norm in Italy. It is interesting because in the past 20 years people in this country have adopted a diet with a lot of Italian food in it. I just wonder whether it is another form of allergic disease for which we should be taking preventive action.
I agree with the noble Lord, Lord Rea, that the issue of food labelling is tremendously important. The only thing that one can do with a food allergy—and they tend to be very violent—is avoid the substances that you know you are allergic to. It is useful that EU directives are increasingly updated, but they are unclear. The food industry needs to know that it is not in its interest to have unclear labelling. I hope that, with the FSA, work can be done to improve that.
As somebody who frequently has reactions to skin products and soap, it was a delight to have my own anecdotal feelings set down as being right—namely, that the terms “hypoallergenic” and “dermatologically tested” are meaningless. There is absolutely no way of knowing whether a particular product will set off an allergic reaction. I shall make one point which for obvious reasons is not in the report. As someone who experiences such reactions, I have always wondered why it is impossible, when one has a mild allergic reaction to a product, to draw that to the attention of the manufacturer. I suspect that I am like thousands of other people; I do not want any kind of redress, I do not want money and I do not want to pursue them through the courts. I simply want to tell them that something has happened to me in the hope that they will record that systematically and begin to build up a picture that, somewhere down the line, will either make their product better or help other people. I wish that somehow the Government could encourage especially the cosmetic industry to do that.
I speak at some risk about alternative therapies, because I know that my noble friend Lord Taverne has very strong views on them. A large number of people are turning to alternative therapies, principally because they fear prolonged use of steroids. I cannot blame anyone for seeking relief from some of the symptoms of allergy. If they choose to do that, they should do it in a way that is integrated with conventional medicine. I hope that the department responds to that.
In the National Health Service, we have an unprecedented facility to study allergic disease and not only to conduct trials, but to do population-controlled trials. This morning, someone in my house asked me what I was going to do today, and when I told them about this debate, they said that they developed an allergy when they went to a particular university. Apparently it happens to loads of people who go to that university, because it is surrounded by fields of rapeseed which is a very potent allergen. If we can do nothing else with the regional allergy system, we could look at the incidence of that kind of condition.
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Regional allergy centres are important, and they will have to be formed not by the creation of specific new posts but by drawing together and clustering experts who already exist across the field. The key importance of regional allergy centres is twofold. First, they deal with those who have acute and life-threatening conditions, as the noble Lord, Lord Lipsey, said. Secondly and importantly, they can increase the skills in primary care, because that is where the bulk of people who have such conditions go for diagnosis, reassurance and treatment. I wish the report well, and I hope that the Minister accepts its recommendations.
6.38 pm
Lord McColl of Dulwich: My Lords, this is a first-class report, as has been mentioned several times; it is highly professional, lucid and well illustrated, and the House is rightly grateful to all those who have taken part, especially to the chairman, the noble Baroness, Lady Finlay of Llandaff.
The report draws attention to the centre for the study and treatment of allergy, which emanated from Guy’s Hospital, which is where I continue to work. The centre is directed by Professor Tak Lee, and it is known as the MRC-Asthma UK Centre. It is the only centre of its kind in the country. It is a collaboration between the MRC, Asthma UK, King’s College, Imperial College, the hospitals of Guy’s and St Thomas’s, King’s, Royal Brompton and St Mary’s. As the report says,
- “all the organisations had been able to combine their research strengths into one cohesive strategy for the first time”.
The centre also works with general practices in east London. It focuses on teaching, research and patient care. Many more similar centres are required urgently throughout the country, as has been said, and that has been the verdict of several recent reports. All have emphasised that there are fewer allergy centres in the UK than in Europe and the USA yet nothing seems to have been done to increase capacity. Ministers have made the excuse that it is the fault of the PCTs whose job it is to make these decisions.
But Ministers know that PCT's have never been accused of understanding complex subjects like allergy. As has been mentioned, the Times newspaper headline of 26 September stated,
Ministers need to give a lead. We desperately need a big drive from the top.
Irrespective of any single centre that may be created in the future, right now there are some departments around the country that have critical mass and already fulfil many of the criteria that the report recommends for a centre; for instance, Cambridge, Southampton, the Royal Brompton with St Mary’s, and Leicester. For a relatively small amount of extra investment one could create a number of allergy centres as envisaged by the report: for example, the extras that would be required would be a half-time dietician, one full-time specialist nurse and one paediatric and one adult allergist.
We also need to put money into trainee slots; there are only 12 of these, known as SPRs, in the whole country—one for every 5 million of us. That is totally
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Of course, any increase in trainee numbers needs to be matched by an increase in the number of consultant posts to build capacity. The charity Asthma UK has drawn attention to the large number of hospital admissions in England for patients with an asthmatic attack. My noble friend Lord Colwyn mentioned that from April 2006 to March 2007 there were over 67,000 emergency admissions, 40 per cent of which were for children under 16. It estimates that 75 per cent of those admissions could be avoided with good asthma care.
Professor Tak Lee emphasises that there are many professionals treating patients with asthma but they concentrate on treating the symptoms but fail to look for the cause of the asthma, failing to hunt for an allergic basis for the problem. That is why it is so important to have allergy experts involved in the care of these patients. Accurate diagnosis is so important, as the noble Lord, Lord Bhattacharyya, stressed. I was especially interested in the section on allergy in the school environment, where the problem of hay fever during examinations is discussed and mentioned by the noble Baroness, Lady Finlay, and the noble Baroness, Lady Perry. For many years I have advocated that one solution would be to hold the examinations in March or April. However, the congenital snag hunters have always dismissed this out of hand, as is done in paragraph 5.25 of the report, where a senior civil servant stated that,
- “the structure of the school year is based upon centuries of history ... It would not be practical to suggest an alteration of the examination timetable purely to benefit hay fever sufferers”.
Have we not heard that before? That civil servant seems to have forgotten that the examination system has been radically altered dozens of times in the past 60 years. Perhaps he is unaware that the baccalaureate exam is held in May, and the GCSE drama examination was held in April this year by some of the examination boards.
It is not only hay fever sufferers who would benefit from that change, but the thousands of candidates who suffer intolerable heat in the height of summer in poorly designed examination halls, even in quite expensive public schools. A sauna can be an enjoyable experience but not in the middle of a crucial examination which will determine one’s career for life. There would be other advantages—for instance, the summer term could be spent by pupils engaged in more practical work to prepare themselves for citizenship, charitable enterprises and so on. And the examiners could complete their tasks before the summer holidays. This would have a further advantage in that it would allow the universities
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Another aspect of the report deals with the most dangerous of all allergies; namely, anaphylactic shock. This may be caused by many different antigens, including peanuts, drugs, insects and so on. In order to deal with this hazard and forestall disaster, those who are known to be susceptible are provided with the devices that have already been mentioned—EpiPen and Anapen. There is confusion about who can help the child in school and whether anyone should do. The report rightly recommends that staff should be taught about how to deal with these emergencies and have clear guidance. Potential sufferers have to carry the adrenalin themselves, as well as it being available in school. As this is so important, can the Minister assure the House that what must be a relatively straightforward matter is sorted out quickly without resorting to umpteen meaningful, ongoing working parties and committees, which the Minister and I used to call group psychotherapy meetings when we worked together in surgery?
This subject brought to the surface some strange comments in the report. One witness, at paragraph 5.35 suggested that these adrenalin auto-injectors were overprescribed. He said,
- “of countless prescriptions I have written over the last 12 years for such devices only one has ever been used”.
Perhaps that witness should have been asked how many of the fire extinguishers in his area had been used in the past 10 years. I always have in my pocket ampoules of adrenalin and hydrocortisone with a syringe and needle. These are probably the only drugs that are required immediately—and there is never time to get them. Recently, I was presented with two patients in anaphylactic shock due to the stings of French hornets. Had I not been carrying these essential drugs, one of the patients might well have died; although of course one can never be certain. Medicine and prophecy are two quite separate subjects.
To many people it is a puzzle how anaphylactic shock actually kills the patient. The cardiovascular system is greatly impaired, blood pressure drops to the boots, and the excess fluid which rapidly collects in the tissues obstructs the larynx because the fluid cannot escape downwards, as the lining is firmly attached to the vocal cords.
Finally, several noble Lords have described the key recommendations of the report in detail. My question is: when will the Government implement these recommendations, so that Britain will no longer be the laughing stock of Europe?
6.49 pm
The Parliamentary Under-Secretary of State, Department of Health (Lord Darzi of Denham): My Lords, I greatly enjoyed the debate. As my noble friend and others have declared their allergic reactions, I probably should declare my own. I am a hay fever sufferer and, for years, living from April to July has always been hell, although my asthma is certainly not as severe as that of my noble friend.
First, I congratulate the noble Baroness on securing today’s debate. I also congratulate her on the excellent work on allergy produced by the House of Lords
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As the noble Baroness is aware, allergies are common and on the increase. In addition to the obvious health effects, allergic reactions can make unavoidable daily activities very difficult. They can compromise a sufferer’s performance at work and, as we have heard, hinder children’s educational progress. Clearly, allergic conditions represent a huge challenge, not just for our healthcare system, but for society as a whole. It is for these reasons that the Government welcomed the committee’s report, which highlighted very clearly that allergy is an issue that needs to be addressed by a wide range of stakeholders.
Noble Lords will be aware that in 2006, the Department of Health published a report of its review on allergy services. The review looked at the epidemiology of allergic conditions; the demand for, and provision of, treatments; and the effectiveness of interventions. This review was a crucial first step in building a programme of improvements that would be based on sound evidence, and would reflect the views of patients and healthcare providers. We are pleased that it was published in time to inform the inquiry led by the noble Baroness.
Our review concluded that one key lever for changing allergy services in future will be local rather than national action. However, I sympathise with what I have heard today and the reasons so eloquently articulated throughout the House. I will take forward some of the suggestions made, but I still believe that we need to engrave in the NHS at a local level a self-improving system to deal with today’s problem of allergies, as well as with other challenging long-term conditions such as dementia that we have debated in this House and that our NHS will face over the next decade.
The report of the inquiry led by the noble Baroness made a number of recommendations to improve allergy services further. In their response, the Government committed themselves to taking action. Ann Keen, the Minister with lead responsibility for improving allergy services, recently met the noble Baroness to explore how we can work together to take forward the recommendations in the report. As we heard, she made a personal commitment to this report.
Due to the pressure of time today, it will not be possible to run through every recommendation and all the actions that have been taken. I shall therefore focus on the committee’s key recommendations and on some of the specific issues raised today, setting out what we are doing to address them.
A lead strategic health authority should be established to take forward the development of a pilot allergy centre on a hub-and-spokes model. We agree that services need to be better organised if they are to meet
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We are also in the process of exploring the feasibility of that approach with interested parties. As part of the consultation process, Professor Sir Bruce Keogh, our recently appointed NHS medical director, has written to all SHA chief executives asking them to declare whether they are interested in taking on this very important role. I have no doubt that Manchester will be a very strong contender. However, there are 10 strategic health authorities and I think it is only fair that they are all asked who should take on the leadership role. The process has started and will be completed soon.
I turn to the issue of workforce planning and education and training, in which my noble friend Lord Bhattacharyya has personal experience. The noble Lords, Lord Taverne and Lord Crickhowell, raised the issue of our educational needs and competences in the service. The noble Lord, Lord McColl, highlighted the fact that last year we were able to create an additional five centrally funded training posts for allergy and a further five for immunology. In total, that is 10 posts. If the current figure is 12, that is near enough a 90 per cent increase in our training numbers. I have no doubt that we need to do significantly more, and we will continue to remind the workforce review team of the need to consider increasing training numbers in relation to allergy as part of its annual review programme.
We have also encouraged the royal colleges to work with other bodies responsible for medical training to enhance the knowledge and expertise of those working with people with allergies. No doubt we all agree that the first contact that a patient makes is in the primary and community services, and if the competences for managing some of the demand from our patients out in the community are lacking, we have to do something about that. That issue is very close to my heart. I feel strongly that it should be part of our reform of primary and community services so as to meet some of the future demands on the service.
As part of the annual review process, we have also endorsed the need for more training numbers for allergy. I have asked deaneries and trusts to examine whether they need to commission more local training posts for allergy.
We also commissioned Skills for Health to work with stakeholders to develop national occupational standards for allergy for the UK in order to improve the quality and consistency of patient care. We anticipate that the standards will be published and implemented this summer.
As well as training, health professionals need the tools to enable them accurately to diagnose and treat patients. We commissioned the Royal College of
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I now turn to another area close to my heart, that of research. I have no doubt that I should declare my interest, still working in a university and carrying out research. The noble Earl, Lord Selbourne, eloquently highlighted the importance of research and reminded us of the committee’s recommendation that further research should be undertaken to increase understanding of allergic causes. Work is being taken forward across government to increase our knowledge of these conditions. For example, the Medical Research Council and the Food Standards Agency are collaborating to fund a major new clinical intervention study on the effects of early weaning on food allergy. In addition, the National Institute for Health Research has provided some £4.7 million over five years for research on asthma and allergy.
The noble Earl also raised the issue that more research needs to be carried out on early exposure and long-term cohort studies. Again, the NIHR has funded a project on primary prevention of asthma by allergen avoidance in infancy. The subjects were recruited antenatally and are now 17 and 18 years old. The occurrence of asthma and allergic diseases will be assessed and reported in due course.
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