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Select Committee on Science and Technology Sixth Report

CHAPTER 10: Summary of Recommendations

KEY RECOMMENDATIONS

ALLERGY CENTRES

10.1.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. (9.40)

10.2.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. (9.41)

10.3.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 should always be carried out by specialists within the allergy centre because of the risk of anaphylaxis. (9.42)

10.4.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. (9.43)

10.5.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. (9.44)

10.6.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. (9.45)

10.7.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. (9.46)

10.8.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. (9.51)

10.9.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. (9.52)

10.10.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. (9.53)

PROFESSIONAL EDUCATION

10.11.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. (9.9)

10.12.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. (9.47)

10.13.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. (9.48)

RESEARCH AND PRODUCT DEVELOPMENT

10.14.Although high quality research into cellular and molecular mechanisms of allergy is advancing, the factors contributing to allergy development and the "allergy epidemic," are poorly understood. It is imperative that further research should focus on the environmental factors, such as early allergen exposure, which may contribute to the inception, prevention or exacerbation, of allergic disorders. Long-term cohort studies are a vital part of this research, and interventional studies are key to verifying the role which these factors may play. We look to the development of the Office for Strategic Coordination of Health Research to improve the co-ordination and funding for these types of projects. (7.26)

10.15.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 health care to be an area of unmet need that requires greater priority. The Translational Medicine Funding Board must ensure that allergy research is applied to develop novel individualised treatments. The cost of a central disease registry may be too high to warrant investment. Therefore, a comprehensive patient database within each allergy centre will be key to epidemiological and other studies, and is best maintained by ownership at a local level. (7.27)

10.16.Immunotherapy is a valuable resource in the prophylactic treatment of patients with life-threatening allergies, or whose allergic disease does not respond to other medication. Although initially expensive, immunotherapy can prevent a symptomatic allergic response for many years, and may prevent the development of additional allergic conditions, so its wider use could potentially result in significant long-term savings for the NHS. We recommend that NICE should conduct a full cost-benefit analysis of the potential health, social and economic value of immunotherapy treatment. (8.9)

FOOD

10.17.It is imperative that environmental health officers, trading standards officers and catering workers are adequately and comprehensively trained in practical allergen management. We welcome the development of a training programme by the Food Standards Agency and recommend that the FSA should work with other training providers to produce consistent practical training courses of a high standard. (6.28)

10.18.It is imperative that work is carried out to investigate whether peanut consumption or avoidance in early life significantly affects a child's risk of developing peanut allergy. We therefore support the work of the Learning Early About Peanut allergy (LEAP) study. We are very concerned that Department of Health dietary advice regarding peanut consumption for pregnant women and infants is based upon evidence that was reported nine years ago. Recent evidence suggests that this advice has not succeeded in reducing the prevalence of peanut allergy and may indeed be counterproductive. We recommend that this advice should be withdrawn immediately, pending a comprehensive review by the Food Standards Agency and the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment. (6.57)

SCHOOLCHILDREN

10.19.We recommend that the Department for Children, Schools and Families should review the clinical care that hayfever sufferers receive at school, and should reassess the way in which they are supported throughout the examination season. The Department for Children, Schools and Families should also ensure that the provisions made by different schools are fair and consistent. (5.26)

FURTHER RECOMMENDATIONS

MONITORING ALLERGY

10.20.We recommend that the Department of Health should ensure the Systemized Nomenclature of Medicine (SNOMED) system is supported by appropriate training, to ensure its efficacy as a simple consistent classification system to record allergic disease, monitor its prevalence and inform the commissioning of allergy services. (3.8)

10.21.We welcome the involvement of the Health and Safety Executive in EU working groups to standardise the collection of data on occupational illness. The use of common standards in the diagnosis of occupational allergic conditions would allow international comparisons of disease incidence, and enable the evaluation of disease reduction strategies. We recommend that the Health and Safety Executive should fund The Health and Occupation Reporting network with the full economic cost of its surveillance programmes, and we urge the Government to ensure support for this work in the future. (3.16)

10.22.Information from children on sensitisation and symptoms is especially important and must be followed up to assess the progression of allergic diseases in order to predict workload. We recommend that future epidemiological studies measure not only the incidence of allergic symptoms, but also record the prevalence of confirmed allergic sensitisation. (4.22)

THE AIR WE BREATHE

10.23.We recommend that the Department of Health should work with the Department for Communities and Local Government to support and encourage controlled trials involving multiple interventions, to examine the effect of ventilation, humidity and mite-reduction strategies on allergy development and control. As chemicals used in the construction industry may play a role in triggering symptoms in some allergic patients, further evaluation of their role is also required in order to inform procurement policies. (5.14)

10.24.As climate change and air pollution may significantly impact upon the development of allergic disease, we support the thrust of the recommendations in the report, Air Quality and Climate Change: A UK perspective. We recommend that when developing policies for industry, transport or housing, the Government should take account of the interlinkages between air quality, climate change and human health. (5.22)

SCHOOLCHILDREN

10.25.We support the use of individual care plans for children with medical needs, as described in the Government guidance Managing Medicines in Schools and Early Years Settings. However, we are concerned that many teachers and support staff within schools are not appropriately educated in how to deal with allergic emergencies. We recommend that the Department for Children, Schools and Families should audit the level of allergy training these staff receive, and should take urgent remedial action to improve this training where required. (5.33)

10.26.We are concerned about the lack of clear guidance regarding the administration of autoinjectors to children with anaphylactic shock in the school environment, and recommend that the Government should review the case for schools holding one or two generic autoinjectors. (5.37)

WORKFORCE

10.27.We welcome the educational work of the Health and Safety Executive to raise awareness and decrease the risk of occupational allergic disorders amongst employers and staff, and would like to see this work developed. Once allergy centres have been developed we recommend that the HSE should liaise with the occupational allergy specialist in each centre to inform its policies and develop strategies to prevent occupational allergic disorders. (5.53)

10.28.We are concerned that employees who are forced to leave work due to an occupational allergic disease can remain unemployed for long periods of time. We recommend that job centres should review the way they work with employers, to improve the way in which they can assist these workers to enter retraining schemes and find alternative employment. (5.58)

INFORMATION FOR CONSUMERS

10.29.Vague defensive warnings on labels for consumers with food allergy can lead to dangerous confusion and an unnecessary restriction of choice. We recommend that the Food Standards Agency should ensure the needs of food allergic consumers are clearly recognised during the review of food labelling legislation being undertaken by the European Union. (6.10)

10.30.As sensitivities to various allergens vary widely, we believe that setting standardised threshold levels for package labelling is potentially dangerous for consumers with allergies. Instead, we recommend that food labels should clearly specify the amount of each allergen listed within the European Union directive, if it is contained within the products, and we endorse the Food Standards Agency's initiative to discourage vague defensive warnings. (6.11)

10.31.The phrases "hypoallergenic" and "dermatologically tested" are almost meaningless, as they only demonstrate a low potential for the products to be a topical irritant. We recommend that such products should warn those with a tendency to allergy that they may still get a marked reaction to such products. (6.21)

ADVICE FOR ALLERGY SUFFERERS

10.32.Many teenagers and young adults with food allergies sometimes take dangerously high risks when buying food. We therefore recommend that the Department of Health, working with the Food Standards Agency, charities and others, should explore novel ways to educate young people about allergy and the prevention of anaphylaxis. (6.34)

10.33.We recommend that the education of children about indoor air quality and its role in allergy development, should be a priority for the Interdepartmental Steering Group producing the "Children's Environment and Health Strategy." (6.41)

10.34.Allergy charities play an important role in providing public advice, but must continue to work together and with clinical services to avoid duplication of work, and ensure that consistent, evidence-based policies and public advice are provided. (6.64)

10.35.Pharmacists are often consulted by the general public about allergic conditions, and thus lift a significant burden from general practitioners. It is therefore essential that the advice offered regarding allergy is accurate, and should be given by trained pharmacists rather than unqualified assistants. We recommend that as part of the implementation of the Pharmacists and Pharmacy Technicians Order 2007, adequate allergy education should be provided for all pharmacists, to ensure that they provide high quality advice to allergy sufferers. (8.20)

EVALUATION OF COMPLEMENTARY TECHNIQUES

10.36.We recommend that robust research into the use of complementary diagnostic tests and treatments for allergy should examine the holistic needs of the patient, assessing not only the clinical improvement of allergy symptoms, but also analysing the impact of these methods upon patient wellbeing. Such trials should have clear hypotheses, validated outcome measures, risk-benefit and cost-effectiveness comparisons made with conventional treatments. Allergy centres will allow the collection of information about any indirect consequences of misdiagnoses or delayed treatment. (8.33)

10.37.We are concerned both that the results of allergy self testing kits available to the public are being interpreted without the advice of appropriately trained healthcare personnel, and that the IgG food antibody test is being used to diagnose food intolerance in the absence of stringent scientific evidence. We recommend further research into the relevance of IgG antibodies in food intolerance, and with the establishment of more allergy centres, the necessary controlled clinical trials should be conducted. We urge general practitioners, pharmacists and charities not to endorse the use of these products until conclusive proof of their efficacy has been established. (8.40)