Comments of the Royal College of Physicians on the Health Committee Inquiry - The Provision of Allergy Services
In 2004 Parliament published the SELECT COMMITTEE ON HEALTH 6TH REPORT which explored the provision of allergy services in the UK. You can read a summary of that report on this site or visit the UK Parliament site to read the report in full.
The following is a summary of comments in response from The Royal College of Physicians Working Party.
1. Availability of Allergy Services
1.1 The College believes that allergy services in the NHS are totally inadequate and cannot cope with the rising amount and increasing severity of allergy in the UK. An acute shortage of allergy consultants and specialist centres has meant patients face major difficulties in obtaining accurate diagnoses, advice and treatment.
1.2 The provision of allergy services has not kept pace with the growth of allergy itself - only six major centres staffed by consultant allergists offer a full-time service with expertise in all types of allergic problems. A further nine centres staffed by allergists offer a part-time service. The remaining 86 allergy clinics in Britain are run part-time by consultants in other medical specialties. However, they do not have the facilities to cope with the sheer number of referrals, nor patients with multi-system disease.
1.3 Due to the shortage of specialists, many patients with allergy are treated by their GP, who in most cases will have no specialist training in allergy. The shortage of specialists means it is also difficult for GPs to access specialist advice.
1.4 The College has published guidance on the conditions necessary for effective practice of internal medicine and its specialties including allergy under the title 'Consultant Physicians Working with Patients'. This guidance is currently undergoing revision and we are enclosing a copy of the section on allergy from the 3rd edition of this publication (forthcoming 2004). This document sets out a model allergy service. The summary on page 18 gives workforce calculations which demonstrate a need for 520 allergy consultants for adult and paediatric services. There are currently only 26.5 whole time equivalent consultant allergists in England, and none in Wales, Scotland or Northern Ireland. The geographic spread across the UK is very uneven and allergy provision is an extreme example of postal code medicine.
2. Priorities for improving services
2.1 Allergy is a problem which the Royal College of Physicians has brought to the attention of the Department of Health and other stakeholders previously with publications on Allergy - conventional and alternative concepts (1992); Good Allergy Practice (1994) and, most recently, Allergy: the unmet need (2003).
2.2 As set out in Allergy: the unmet need, major governance issues are raised by the lack of adequate numbers of specialists that are trained to treat allergy. Consultants in other disciplines already deliver the majority of care to patients with single-organ allergies, for instance respiratory physicians looking after those with asthma. However it is important to recognise that allergic disease appears to be getting more severe with fatal anaphylaxis and multi-system allergic disease increasing in prevalence. It is mandatory for such patients to see a specialist allergist but for much of the country this is impossible.
2.3 Priorities for improving services include investing in an infrastructure of specialist staff both in adult and paediatric allergy to create regional centres in allergy. This would provide expertise and leadership to develop services and improve standards in primary and secondary care.
2.4 Urgent action needs to be taken to set up specialist allergy centres in each NHS region. The centres would provide specialist expertise for allergic diseases throughout the region, act as an educational resource, and enable training at local level for GPs and nurses to manage common allergies. However, these will not be easy to achieve as allergy has no representation in large parts of the country that can influence regional decisions. There are also grave concerns whether the current arrangements for commissioning are sufficiently robust to cope with the financial pressures and service aspirations of specialist allergy centres. There will be an inevitable debate on the funding of specialist services versus the funding of local initiatives. It is important for the commissioning process to understand the need to provide care for larger populations by specialist teams. This is essential not only to guarantee the quality of patient care but also allow time and space for the training of specialists, promoting innovation and research.
2.5 More consultant allergists must be appointed - an extra 32 to work in regional centres, and more to cover the workload in teaching hospitals, and district general hospitals.
2.6 It is impossible to dissociate the expansion of an NHS allergy service from the requirement to have more trainees in allergy. More training posts must be created and fully funded to meet the future need for more consultants. The Department of Health has recommended 20 new National Training Numbers between 2005 and 2007. However, there is no certainty that this will become reality as the quota was reduced from 7 to 0 last year. Allergy eventually received one new NTN after rigorous appeal. Allergy is in predicted negative growth by 2012 by Department of Health's own estimates; it is one of only two such specialties. The specialty cannot grow unless more trainees are provided.
2.7 In the long-term allergy services should be led by GP practices, with expertise available from hospitals for more severe and complex problems. To achieve this, there needs to be an improvement in GP education in allergy, and the development of general practitioners with a special interest (GPSIs) in allergy. Much could also be done by training nurse specialists in this area of health care.
2.8 An increase in consultant allergists would enable consultant physicians in other specialties with an interest in allergy to use the allergists and specialist centres as a resource.
3. Governance and regulation of independent sector providers, and links between the NHS and the independent sector
3.1 In the independent sector there are some excellent services provided but they are few and far between. This scarcity is compounded by the lack of NHS services and as a result practitioners in alternative medicine are being sought out by patients with allergies. The alternative practitioners often use approaches without any evidence base for diagnosis and/or treatment. For example, advertisements appear in women's magazines offering hair analysis, vega testing, various types of 'magnetic and force field' tests, neutralisation therapies and tests for food allergy, and many more. In many cases these fail to make a proper diagnosis and offer rational management and can lead to significant morbidity from, for example, use of inappropriate dietary elimination and other changes in lifestyle. This is not only expensive for patients but costs the country money because of time lost from work due to continuing illness. This eventually returns to burden the NHS because of complications caused by delays in treatment.
June 2004
The full report can be downloaded as a PDF.
Click here to download the PDF version of, Allergy: the unmet need - A blueprint for better patient care. A report of the Royal College of Physicians Working Party on the provision of allergy services in the UK.
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