Introduction

9.1.The World Allergy Organization Specialty and Training Council recently reported the "remarkable paradox that in the UK, a country which has an outstanding record in allergy research, there is a remarkably poor clinical service for allergy sufferers."[128] In 2004 the House of Commons Select Committee on Health reported on the provision of allergy services in the United Kingdom. It found that "serious problems exist in the current provision of allergy services. 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 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 training primary care staff.[129]

9.2.Following this report the DH carried out A review of services for allergy to analyse the need for allergy services and to assess whether these needs were being met. The review admitted "it is evident that the NHS needs substantially more capacity in services for allergy generally, including clinical specialists." One of the recommendations of the review was that the responsibility for allergy service delivery should be placed into the hands of local commissioners. However, concern has been expressed that Primary Care Trusts (PCTs) do not have the resources to enable this local commissioning, especially as the review also conceded that there was a lack of baseline data on the profile of services for allergy.[130]

9.3.Our witnesses felt that the review did not address the underlying need to improve the training of medical practitioners in allergy (QQ 362-364). We heard that clinicians with a specialised knowledge of allergy are confined to a few specialist centres unevenly distributed around the country, and received a great deal of evidence reporting a general lack of allergy knowledge amongst healthcare professionals. We now address NHS services for patients with allergy.

Diagnosis

9.4.An accurate diagnosis is key to treating an allergic condition adequately, and much depends on taking an accurate patient history with details of a patient's symptoms, home and occupational environment, temporal and geographic features, relevant family history and any physical signs. Diagnostic tests are often based on skin tests, blood tests and challenge tests. But the results of tests are meaningless in isolation; they have to be interpreted in the context of the patient history, a difficult task which requires a solid training in allergy.[131] The Royal College of Physicians' guidance, Allergy: the unmet need, notes that "identification of potential allergic triggers" in asthma leads to "improved management and decreased morbidity" and "cost savings."[132]

9.5.When an allergy is confirmed, the risk it poses can often only be assessed using challenge tests. These tests involve administration of increasing doses of an allergen, to determine the threshold dose which induces a reaction. At the Department of Dermatology and Allergy Centre at Odense University Hospital, we learnt that these tests were invaluable in helping children with food allergies and their families to manage their allergy. For example, skin prick tests and IgE antibody tests might show that peanut caused a reaction, but the challenge tests could indicate the threshold levels at which this allergen could be tolerated, and could make the difference between rigorously having to avoid peanuts, or being able to eat foods with peanut traces or peanut oils. Such challenge tests also assess cross-reactions between foods, enabling the patient to feel more confident about what they can eat.[133]

9.6.For many patients an accurate diagnosis will exclude allergy as the cause of their symptoms, at cost saving to the patient and to the NHS. This is especially important in cases of gastrointestinal disorders, where inappropriate food avoidance can impair nutrition[134] and be socially isolating (para 6.29), or suspected drug allergies when alternative medication may prove a lot more expensive and possibly less effective (p 188).

9.7.Allergies can also frequently be outgrown. During a visit to Addenbrooke's Hospital, we heard that if regular IgE antibody tests and skin prick tests suggested that a child with food allergy had outgrown the allergy, then food challenge tests to confirm this could remove a significant burden from the child and their family.[135]

9.8.Early diagnosis and avoidance of an allergen is important in the treatment of occupational allergy. However, the BOHRF pointed out that "since many cases of occupational asthma first report to primary care, there is a need for better training in occupational medicine for GPs" (p 341). The HSE is therefore funding research to develop better training in primary care "for practice nurses on the symptoms and causes of occupational asthma, to empower them to give advice and guidance to patients as well as to reduce the time it takes to diagnose cases of occupational asthma" (p 13). The HSE also regularly convenes a Group of Occupational Respiratory Disease Specialists, which has developed "a standard of care document for the diagnosis of occupational asthma" (p 10). Professor Newman Taylor noted that this document had "the potential to improve standards of care" but doubted the "extent to which it will increase awareness" (Q 294). When asked whether a similar document for occupational skin allergies would also be useful, Dr Orton said that it would certainly be "desirable" (Q 296).

KEY RECOMMENDATION

9.9.It is vital that the Health and Safety Executive works with the Department of Health to ensure that medical practitioners are adequately educated in the diagnosis and treatment of occupational allergic disorders. We support the work of the Group of Occupational Respiratory Disease Specialists convened by the HSE, which has developed a standard of care document for the diagnosis of occupational asthma, and recommend that the Health and Safety Executive should work with stakeholders to produce a similar document for occupational allergic skin disease.

Primary care

9.10.For most people with allergy-related symptoms, their first point of contact with the National Health Service will be a consultation with their general practitioner or pharmacist. Professor Andrew Wardlaw, Director of the Institute for Lung Health at Glenfield Hospital, pointed out that a lot of allergy "can be effectively treated in primary care or in the community, but the problem is that the knowledge of allergy in primary care is very poor" (Q 174). Many general practitioners and healthcare workers in the primary care sector are not sufficiently trained in allergy to be able to provide an accurate diagnosis, and some do not know when and to whom to refer allergy cases.

9.11.Dr Levy told us that delays in referrals from GPs to specialists in allergy "ranged from three to six months" and sometimes "much longer" (Q 332). According to Asthma UK, "it still takes the average person seven trips to a doctor before they get to a diagnosis of asthma" and "only 30 per cent of people with asthma are referred for any sort of allergy test by their GP. Most people do not even know whether their asthma is allergic or non-allergic, which then means that even starting a conversation about how you self-manage, how you avoid the triggers, becomes almost impossible" (Q 781).

9.12.When a GP does recognise the need to refer a patient, identifying the correct specialist for referral poses another difficulty. Allergy UK reported that "there is a lack of recognition, due to minimal training, within primary care that allergy is a multi-organ disease and GPs will refer a suspected allergic person often to two organ based specialists rather than one referral to an allergy specialist" (p 292), and added that "often patients get referred on to the wrong person so it might be a gastroenterologist or a respiratory physician when they really need an allergist" (Q 786).

9.13.In its Review of services for allergy, the DH included an estimate, produced by the BSACI, that "approximately 50 per cent of allergy referrals to secondary care are seen by consultant allergists, 40 per cent by clinical immunologists and 10 per cent by organ-based specialists with an interest in allergy."[136] However, this must be seen in context as many patients never receive any referral at all. Dr Nasser commented that "I would say that only a very small proportion of patients get referred. There are increasing pressures in primary care not to refer patients into secondary care and these are pressures that have come on in the past six to 12 months because of cost, and because of the great debt that PCTs find themselves in" (Q 622).

9.14.The House of Commons Health Committee report recommended that in order to develop skills in primary care, "an infrastructure of specialist allergy services" was required."[137] However, the DH did not believe that increasing the number of specialist services would be "a cost-effective way of using limited resources," arguing instead that "if primary health care teams, which include General Practitioners, practice nurses and community dieticians as well, were working well then actually the need for specialist services would be far less" (Q 17). Although the DH's Review of services for allergy conceded that clinicians in primary care "may have limited knowledge or awareness of allergy," may "overlook multi-system atopy" and "lack guidelines for therapy or referral,"[138] the Department has not developed effective ways to address these issues.

9.15.The review also pledged to "consider the options for commissioning the development of NICE guidelines for allergy, and work with the Royal Colleges on guidance for referral and care pathways."[139] Despite this no guidelines have yet been developed and Mr Dillon explained that "if we can start them all in 2007 they would all be published at some point before the end of 2009" (Q 759). Mr Alan Bell, Project Lead of the DH A Review of allergy services, explained that "Ministers, including Mr Lewis, are at the moment awaiting a large submission from officials in the Department making recommendations for the next wave of clinical guidelines products to be referred to NICE" (Q 885).

9.16.To complement the NICE guidelines the Review pledged to develop "Care pathways for children with allergic symptoms," and Mr Lewis told us that the Department had "asked the Royal College of Paediatrics and Child Health to scope work" to do this, and that it had also "commissioned Skills for Health to develop National Occupational Standards for the UK for allergy" (Q 884). In addition, Dr Scadding told us that the BSACI had been collaborating with the Primary Care Allergy Network to produce "very detailed, evidence based guidelines" which would instruct general practitioners how, in an eight minute consultation, to identify "whether a problem is likely to be allergic and, if so, where the best secondary treatment should be sought" (Q 788).

9.17.However, there is a limit to the efficacy of guidelines. Mr Dillon pointed out that "local NHS organisations start from different positions for individual services" so the speed at which each will be able to meet NICE guidelines will vary (Q 761). Professor Hourihane also pointed out that "if you went into any GP's surgery the list of guidelines on their desk is taller than their computer. It is an impossible position to be put in" (Q 665).

Secondary and tertiary care

9.18.If the symptoms of allergy are severe, or several allergic disorders occur together, then the patient may have to be referred to a specialist for further investigation. Consultant allergists are able to treat the whole spectrum of allergic disorders including respiratory, dermatological and gastrointestinal allergies. However the National Allergy Strategy Group told us that "there are only 26.5 whole time equivalent consultants in allergy" in the United Kingdom (p 127), so many allergy patients are treated by organ-based specialists.

9.19.When asked about the DH's Review of services for allergy, Professor Durham noted that "they fully acknowledge that there is a problem, that there is a modern epidemic, that there is a lack of training and that there is a lack of resources, but [they] provided no solutions." Although the review had admitted that more trainees in allergy were needed "the only limp suggestion was that we contact the regional deaneries to see how this would come about with no central funding. We have gone through this consultative process, certainly within the North West Tees Deanery, and there is no money to encourage more trainees … I think it is a very inadequate response to a major problem that has already gone through four years of consultation" (Q 186).

9.20.The main thrust of the DH review was that "the responsibility for ensuring that patients' needs are met lies with local commissioners."[140] However, on a visit to the Allergy Clinic at Addenbrooke's Hospital, we 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.[141] We fail to see how PCTs and Strategic Health Authorities can commission allergy services effectively as the review stated that "the absence of baseline data on the profile of services for allergy and the cost makes it difficult to develop a strategic national view of how and where services could be developed."[142] Professor Wardlaw commented that the review "recognised, I think, that there was a major problem and that the NHS had not kept up with that problem in terms of service provision, but they came up with no real solutions to that problem and did tend to pass the buck in my view to the PCTs for whom it is not a priority and who will not pick up that buck. At the moment we feel that the Department of Health does not have adequate policies to address the allergy epidemic" (Q 186).

9.21.As part of the review, the DH took evidence from the BSACI, which stated that there were approximately 94 allergy clinics in England, although only six of these were led by full-time specialist allergists. Other clinics were led by part-time allergists, respiratory physicians, dermatologists, clinical immunologists or paediatricians with an interest in allergy.[143] The appropriateness of using these specialists to treat allergic conditions was a matter of debate amongst our witnesses. Dr Pamela Ewan, Co-Chair of the National Allergy Strategy Group, told us that due to a lack of allergy training for these specialists, "they mostly treat these diseases symptomatically without considering allergy" even though for some patients an accurate diagnosis of their allergy is vital. For example "asthma or eczema can be adequately treated with medicines without considering allergy" but "in many children, eczema will be driven by food allergy. If you can identify the food and avoid it, the eczema can disappear" (Q 326).

9.22.However, other witnesses highlighted the importance of organ-based specialists in the treatment of patients with severe conditions. For example, Professor Barnes felt it was appropriate that "people with severe asthma get managed by chest physicians because it is important to have people who understand other lung diseases that can present with symptoms like asthma" and that "the same would apply to people with severe eczema which has to be distinguished from other skin diseases." In these cases the organ-based specialist needed to take the lead in treating the patient but "the allergist has a very important role as a specialist adviser" (Q 205). Dr Ewan acknowledged that "we would not be arguing all these diseases should be seen by an allergist," but that in a significant proportion of cases, consultation with an allergist could provide an added benefit as "you sort out food allergy, drug allergy, asthma, eczema, rhinitis in a single consultation, so not only do you give the allergy diagnosis and management but you also save sequential referrals and therefore you reduce the burden on these other specialities, all of whom have their own waiting list problems" (Q 326).

THE TREATMENT OF CHILDREN

9.23.Children with allergic conditions often require a specialist paediatric allergist to manage the complexities of their conditions. Dr Leech told us that "a general paediatrician who sees a patient with allergies will usually manage the patient in a very superficial way" whereas in an allergy consultation the patient's history and often multiple problems are explored in depth. "It is a qualitative difference rather than a quantitative difference. That is not always appreciated by a lot of paediatricians who see patients with allergies" (Q 326).

9.24.For children with chronic conditions, the transition from paediatric to adult care requires particular support. Professor Hourihane told us that for allergy, "there has not been the evolution of paediatric allergy clinics on a broad enough scale to say that there is a logical and well-defined structure of transitional services." He added that there was a "real risk that the children who have been carefully supervised with food allergies will then become the adolescents who leave all their kit at home and go to restaurants at risk." Dr Hyer echoed this, reporting that "when I finish with my patients at 15 I do not have anywhere to send them. I know who my paediatric allergy colleagues are, but I do not really have access to strong adult allergy services" (Q 683).

THE TREATMENT OF DRUG AND OCCUPATIONAL ALLERGIES

9.25.For cases of rarer allergies such as drug allergies, Dr Pumphrey reported that patients "are unlikely to get ideal advice from any but the best informed of specialist clinics. I recently undertook a survey of the majority of UK clinics offering this type of testing. The variety of approaches and heterogeneity of findings suggests the need for further research into the most effective approaches and guidance for such clinics to raise the standard of all to that of the best" (p 189). During our visit to Addenbrooke's Hospital we heard that drug allergic patients who were not referred to specialist allergy clinics were often given little information about their condition, and were therefore confused about how to protect themselves in the future.[144] The Royal College of Anaesthetists noted that "because of the complexities of modern anaesthesia it is necessary for patients to be seen by an anaesthetist with a special interest in anaphylaxis at the same time as seeing an immunologist or allergist." Four bi-specialty clinics exist within the United Kingdom, along with "approximately six additional uni-specialty clinics in which patients are seen only by an immunologist or allergist" (p 351).

9.26.Rarer cases of occupational allergic disorders also warrant consultation with occupational health specialists. An audit of hospital care for occupational lung disease, jointly undertaken for the HSE and British Thoracic Society, showed that "it was usual for patients to be diagnosed in-house, as opposed to being referred to a specialist occupational respiratory centre, but that respiratory departments often lacked the necessary resources to arrive at a definitive diagnosis" (p 10). Therefore Professor Newman Taylor felt that there was "a need for a relatively small number of sub-specialists" to manage occupational asthma, as not all chest physicians had the necessary skills or experience. He added that "there are six or seven specialists within the UK who have this as a particular interest" but many are now reaching retirement age (Q 285).

9.27.Similarly, Dr Orton stressed the importance of "sub-specialists with a particular interest" in occupational dermatitis, but many of these specialists were also nearing retirement (Q 285). Professor Newman Taylor was concerned that financial constraints threatened services for occupational dermatitis and asthma, adding that "unless there is either Department of Health or, a specialist commissioning process where there are funds made available for it, which is the way it probably can best be done, I can see this as something which no individual hospitals might see as their responsibility" (Q 287).

The need for further education and training

PRIMARY CARE

9.28.We are concerned that whilst Government policy intends to devolve allergy care even further to GPs, the underlying problem of training those in primary care has not been tackled. Dr Nasser told us that for GPs at undergraduate level "there is hardly any teaching on allergy and there is certainly no structured teaching." He went on to say that when it comes to postgraduate training "there are so few allergy specialists in the country, there is no one to undertake teaching" (Q 621). Professor Marshall admitted that there were areas of weakness in allergy training, such as acquiring "an awareness of allergy as a potential diagnosis" and "understanding some of the second line issues around diagnostic procedures and treatment procedures" (Q 14). With regard to postgraduate courses, he added that "particularly one in Southampton and one in Warwick … have been around for some years and are very highly regarded" (Q 15). However, Dr Ewan commented that postgraduate courses for those in primary care were often "theoretical" and lacked "the clinical experience" (Q 330).

9.29.Concerned about the lack of training, the BSACI has organised "regional training days in allergy for general practitioners and nurses" aiming, as Professor Durham commented, to "increase awareness of allergy, to inform general practitioners" and "to encourage them to develop a specialist interest" (Q 175).

9.30.However, there appears to be a lack of incentives to encourage general practitioners to undergo further training in allergy, and Dr Levy pointed out that although asthma was included as a quality indicator in the Quality and Outcomes Framework, "allergy does not feature at all" (Q 337); he explained that "those of us who made proposals for the last Quality and Outcomes Framework did recommend that allergy was included. It was not accepted, unfortunately" (Q 339).

9.31.Although the Government has encouraged the development of General Practitioners with a Special Interest (GPwSI) in various areas of medicine,[145] Dr Levy told us that he had been the only GPwSI in allergy in the whole country, and that "despite demonstrating benefit for the patients and savings, allergy is not one of the primary care trust priorities and the clinic closed down" (Q 337). He added that this left "GPs cobbling together different courses and educational facilities" and that clinical attachments were difficult to find (Q 320). Dr Egner told us that posts for GPwSI in allergy were "entirely dependent on local initiatives" and there was no formal programme to develop GPwSI. Although many practitioners would not receive a qualification in allergy, "they will and have already gained specialist expertise which no doubt will be of use to the service in the future" (Q 338).

SECONDARY AND TERTIARY CARE

9.32.With regard to specialist allergists, Dr Ewan told us that "the first problem is that we need more trainee posts and we need more funding for them. There is no way the primary care trusts would be prepared to fund these at the moment" (Q 363).

9.33.But training specialist allergists is only part of the story. Dr Ewan also pointed out that in the training curricula for other medical specialties, allergy plays "a very minor part" so doctors can complete their specialty training "with virtually little or no exposure to allergy" (Q 320). Echoing this, Professor Durham reported that for the BSACI "it is a major priority for us to empower secondary care specialists in individual specialities—dermatologists, respiratory physicians, immunologists—in how to manage allergy effectively" (Q 203). It is therefore clear that collaboration between these different specialities is vital, and improving their training in allergy is imperative.

9.34.Mr Lewis told us that the National Institute for Health Research Integrated Academic Training Pathway had established 17 academic training programmes "relevant to allergy," during which 33 Academic Clinical Fellowships (ACFs) and 16 Clinical Lectureships (CLs) would be supported through partnerships between universities, local NHS Trusts, including PCTs and Postgraduate Deaneries. However, these programmes included immunology, dermatology, respiratory medicine and other specialties, so only six ACFs and two CLs were awarded solely in allergy. It was unclear how these academic programmes would assist in developing the clinical services, and Mr Lewis added 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 … It is up to the hosting partnership to integrate this new funding with existing posts" (p 323).

The role of the Allergy Centre

9.35.Despite the clear need for further training in allergy, the evidence we received demonstrated that organ-based specialists were a valuable resource that should be harnessed when developing an effective allergy service. Whilst visiting the Department of Dermatology and Allergy at the Universitätsmedizin Berlin, we learnt that allergy was practiced as a sub-specialty in Germany, mainly by dermatologists, but also by ENT physicians, pneumologists and immunologists. Professor Zuberbier felt that it was therefore important to encourage communication between all specialists with a particular interest in allergy.[146] During a visit to the Evelina Children's Hospital in London, we were also told that in order to diagnose and treat allergic children effectively, the hospital arranged weekly multi-disciplinary meetings to discuss cases, involving nurses, consultants and dieticians. Cross-referral was enhanced by joint clinics; for example, joint allergy and gastroenterology clinics were held every two weeks.[147]

9.36.In Denmark, we visited the Department of Dermatology and Allergy Centre at Odense University Hospital, a specialist centre for the treatment of patients with severe or complex allergy. Because complex allergy cases could involve many organs, specialists in dermatology, paediatrics, internal medicine, occupational medicine, clinical chemistry and clinical immunology all worked together at the centre to ensure that patients received the best possible treatment. The aim of the clinic, which had proved successful with patients and clinicians, was to investigate and diagnose cases of suspected allergy, produce a management plan and, where possible, refer patients back to their general practitioner or district hospital for treatment.[148]

9.37.Allergy centres also provide an educational resource. During our visit to the Allergy Clinic at Addenbrooke's Hospital, we learnt that the clinic organised short training courses in allergy for local GPs, but that many effective educational opportunities occurred in everyday work. This included telephone consultations with GPs, which avoided unnecessary referrals, and consultants' letters which established a jointly managed care plan.[149] Similarly, the Department of Dermatology and Allergy Centre in Denmark educated the local GP and specialist workforce, by making its standard operating procedures available, offering advice on allergy testing and providing guidance on appropriate referral pathways.[150] Currently, this education of healthcare workers in the United Kingdom is generally inhibited by the lack of specialists trained in allergy.

9.38.The Allergy Clinic at Addenbrooke's Hospital also played an important role in educating patients about their allergies. For example, children with nut allergies were provided with a comprehensive management plan which included guidance on avoidance, a treatment plan, and training in how to administer emergency medication. Model letters had also been constructed for schools to educate teachers and other staff about how to manage the allergic condition.[151] The Allergy Centre at Odense University Hospital similarly worked with patient organisations and other departments to organise patient education programmes in asthma, eczema and food allergy to educate patients in how to cope with allergy in everyday life.[152]

9.39.The House of Commons Health Committee recommended that "a minimum of one specialist allergy centre should be established in areas equivalent to each of the former NHS regions, serving populations of five to seven million, to offer at least some local expertise for allergy sufferers … each centre should have as a minimum two adult allergy consultants, two paediatric allergy consultants supported by paediatric nurse specialists, two full-time nurse specialists, one half-time adult paediatrician and one half-time paediatric dietician."[153] We support the development of specialist allergy centres but, in light of the evidence we received, we feel that these centres should not only comprise allergy specialists, but also chest physicians, dermatologists, ENT physicians, clinical immunologists, gastroenterologists, occupational allergists, paediatricians and others working together (see Figure 3).

The proposed Allergy Centre

The circumambient areas reflect the contribution of each speciality to allergy management. The allergy centre is an important educational resource for primary and secondary care services, as well as local charities, schools and businesses.

KEY RECOMMENDATION

9.40.We recommend that at least one allergy centre, led by a full time allergy specialist, should be established in each Strategic Health Authority. These centres would act as clusters of expertise of those with an interest in allergy, and should each contain a chest physician, dermatologist, ENT specialist, clinical immunologist, gastroenterologist, occupational health practitioner and paediatrician. Specialist nurses and dieticians trained in allergy would also be core team members.

KEY RECOMMENDATION

9.41.Each allergy centre should provide the diagnostic facilities necessary to investigate complex allergies, and should ensure that those who perform these tests have received accredited allergy training. Parallel clinics could avoid the need for multiple referrals and separate visits to hospital for those with multi-system allergic disease. Regular multi-disciplinary team meetings will ensure knowledge is shared and complex cases are discussed. This places the needs of the patient first, allowing rapid accurate diagnosis that informs comprehensive patient management plans. The inclusion of paediatric allergists within allergy centres will ensure that children with allergic conditions are treated appropriately and will enable a smooth transition from paediatric to adult allergy care.

KEY RECOMMENDATION

9.42.Once a diagnosis is obtained and a treatment plan developed at the allergy centre, the patient's disease can often be managed back in primary or general secondary care. However, patients with severe or complex allergic conditions may need long-term follow-up from specialists in the allergy centre. Allergen immunotherapy by injection (see para 8.2), should always be carried out by specialists within the allergy centre because of the risk of anaphylaxis.

KEY RECOMMENDATION

9.43.New allergy centres should enhance and build on existing pockets of excellence to bring together existing clinics and specialists, and to develop and expand upon the services already offered. Where specialist allergist posts already exist, these allergists will be key to the new allergy centres and should take the administrative lead with the appropriate time commitment. In other areas, new allergist posts should be established.

KEY RECOMMENDATION

9.44.Allergy centres should be distributed nationwide, but it is not necessary for every allergy centre to provide every service; some should become national reference centres for less common allergies, such as anaesthetic allergy. Therefore patients may need to travel a relatively long distance to a national reference centre for their condition, for accurate diagnosis and management planning. The patient should then be referred back to their local service and primary care practitioners for ongoing management.

KEY RECOMMENDATION

9.45.Collaboration between clinicians in primary, secondary and tertiary care is key to improving the diagnosis and management of people with allergic conditions. Once established, the allergy centre in each region should encourage and co-ordinate the training of local GPs and other healthcare workers in allergy. In a "hub and spokes" model, the allergy centre, or "hub," would act as a central point of expertise with outreach clinical services, education and training provided to doctors and nurses in primary and secondary care, the "spokes." In this way, knowledge regarding the diagnosis and management of allergic conditions would be disseminated throughout the region. In regions where there are GPwSI in allergy, they should also play a role in the "hub" of the allergy centre.

KEY RECOMMENDATION

9.46.The allergy centre should act as a lead in providing public information and advice. Specialists at the centre should work in collaboration with allergy charities, schools and local businesses to provide education and training courses for allergy patients, their families, school staff and employers, in how to prevent and treat allergic conditions. Feedback between patient groups and allergy centres would enable the allergy centres to assess whether they were providing the necessary services, and would ensure that the advice offered by patient groups was accurate and updated in the light of rapidly changing scientific evidence.

KEY RECOMMENDATION

9.47.The development of NICE clinical guidelines for the diagnosis and management of allergic conditions is no substitute for improving the training of those in primary care. We recommend that the Royal Colleges should work together to ensure that the training undergraduate medical students receive enables them to recognise the role of allergy in disease processes and to refer patients appropriately. It is imperative that general practitioners develop their allergy knowledge through continuing professional development and as part of their membership of the Royal College of General Practitioners.

KEY RECOMMENDATION

9.48.The Royal Colleges, the postgraduate Deans, the Postgraduate Medical Education and Training Board and the British Society for Allergy and Clinical Immunology, should also work together to develop generic quality-assured clinical postgraduate courses in allergy, for doctors in both primary and secondary care and for nurses and others, particularly those wishing to become an accredited specialist in allergy.

9.49.The DH admitted that allergy services were unequally distributed across the United Kingdom with a "relative paucity in the north and the south west."[154] Mr Lewis pointed out that the DH no longer operates a "command and control" policy from central Government. Instead it issues guidance to PCTs to draw attention to possibilities but it "cannot force or impose that at a local level." Therefore, he suggested that it would be useful to seek a lead Strategic Health Authority which could "engage with perhaps one or more than one PCT within their region," developing robust allergy services so that others could "learn from those services" (Q 877).

9.50.Dr Hyer commented that from his own audit, in "50 per cent of my new referrals to my allergy services, I can tell them they do not have an allergy and send them away. That is a significant saving bearing in mind that 10 per cent of all GP prescriptions in this country are based on some kind of atopic or allergic role … I also believe if you make the right diagnosis you can help prevent hospital admissions and complications" (Q 689). Professor Corrigan was also of the opinion that "the cost effectiveness of an effective allergy service in this country would be overwhelmingly positive" (Q 539). However, Dr Ewan told us that the DH does "not record properly what goes on with allergy in the NHS" and that it has not even begun to properly assess the cost-effectiveness of allergy services. Dr Egner added that specialists needed to be brought together and "we need to standardise care before we can look at the different models that are out there, before we can compare them and know what is cost-effective" (Q 352).

KEY RECOMMENDATION

9.51.We recommend that the Department of Health should establish a lead Strategic Health Authority, preferably not in the South of England, which would work with its Primary Care Trusts to develop the first allergy centre. A full cost analysis should be integral to this to assess the efficacy of diagnosing and managing allergy using the "hub and spokes" model. Improved education of clinicians in allergy, with an accurate diagnosis recorded on the Systemised Nomenclature of Medicine (SNOMED) system, should assist a thorough cost analysis to be carried out. The lessons learnt from the pilot allergy centre should then be used to inform the development of further allergy centres in other regions.

KEY RECOMMENDATION

9.52.Once established, allergy centres in different regions should have a contractual obligation to share the resources they develop, such as standard operating procedures, clinical guidelines and patient information. The lead Strategic Health Authority should ensure that there are national reference centres for rarer allergic conditions such as some occupational disorders or adverse drug reactions.

KEY RECOMMENDATION

9.53.The lead allergist in each allergy centre should be responsible for maintaining a patient database to support clinical research within their region. The Office for Strategic Coordination of Health Research and the Translational Medicine Funding Board should work with the lead Strategic Health Authority to support clinical research in the allergy centres and co-ordinate national research projects. The establishment of allergy centres would provide the clinical environment to undertake future clinical evaluations of immunotherapy and complementary therapies.

129  op cit. Health Committee, 6th Report (2003-04): The Provision of Allergy Services (HC 696-1), pp 3, 22-23, 32. Back

130  op cit. DH A review of services for allergy, pp 51, 63. Back

131  Note of the seminar, Appendix 4. Back

132  op cit. Royal College of Physicians, Allergy: the unmet need, 2003, p 41. Back

133  Note of the visit to Denmark, Appendix 8. Back

134  Note of the seminar, Appendix 4. Back

135  Note of the visit to Addenbrooke's Hospital, Appendix 9. Back

136  op cit. DH A Review of services for allergy, p 46. Back

137  op cit. Health Committee, 6th Report (2003-04): The Provision of Allergy Services (HC 696-I), p 54. Back

138  op cit. DH A Review of services for allergy, p 59. Back

139  op cit. DH A Review of services for allergy, p 67. Back

140  op cit. DH A review of services for allergy, p 63. Back

141  Note of the visit to Addenbrooke's Hospital, Appendix 9. Back

142  op cit. DH A review of services for allergy, p 51. Back

143  op cit. DH A review of services for allergy, pp 46-47. Back

144  Note of the visit to Addenbrooke's Hospital, Appendix 9. Back

145  Department of Health, Implementing care closer to home: Convenient quality care for patients, Part 3: The accreditation of GPs and Pharmacists with Special Interests, 2007. Back

146  Note of the visit to Germany, Appendix 6. Back

147  Note of the visit to the Evelina Children's Hospital, Appendix 5. Back

148  Note of the visit to Denmark, Appendix 8. Back

149  Note of the visit to Addenbrooke's Hospital, Appendix 9. Back

150  Note of the visit to Denmark, Appendix 8. Back

151  Note of the visit to Addenbrooke's Hospital, Appendix 9. Back

152  Note of the visit to Denmark, Appendix 8.  Back

153  op cit. Health Committee, 6th Report (2003-04): The Provision of Allergy Services (HC 696-I), p 32. Back

154  op cit. DH A review of services for allergy, p 47. Back