Containing the allergy epidemic, from the Royal College of Physicians, UK

Main Category: Allergy
Article Date: 03 Jul 2004 - 15:00 PDT

email to a friend   printer friendly   opinions  

Summary and recommendations of a new report from the Royal College of Physicians.

Allergy - the unmet need: a blueprint for better patient care published in June 2003.

There has been a dramatic increase in allergy in recent years, including severe life-threatening and multi-system allergies. There is, however, a growing gulf between the need for effective advice and treatment and the availability of professional services.

In particular, there is an urgent need (a) for specialist-led allergy centres where the more complex cases can be treated and which can provide the necessary training for other specialties dealing with allergy patients (many of whom are children), and (b) for GPs to acquire the necessary knowledge and training so that they can provide an effective primary care led allergy service in which patients can have confidence.

The recommendations of the report have been designed to form the basis for the development of a coordinated service.

WHY IS ALLERGY AN INCREASING PROBLEM?

-- Increased incidence The incidence of allergy has increased dramatically in the UK in recent years and is still rising. Recent studies put the rise as approximately three-fold in the last 20 years, giving the UK one of the highest rates of allergic disease in the world.

-- Increased severity The nature of allergic disease has also changed, so a number of severe and potentially life-threatening disorders, which were previously rare, are now common. As part of the increase in incidence, more children are now affected, particularly by previously little-known food allergies, such as peanut allergy. These are also among the most serious allergies, so accurate diagnosis, advice and treatment are vital.

-- Increased complexity Patients now usually have disorders affecting several systems. For example, a child with peanut allergy often also has eczema, rhinitis and asthma - so-called 'multi-system allergic disease'. Poorly controlled asthma in a patient with nut allergy is a risk factor for life-threatening or fatal reactions.

WHAT IS THE SCALE OF THE ALLERGY PROBLEM?

-- The latest estimates suggest that one-third of the total UK population - approximately 18 million people - will develop allergy at some time in their lives.

-- Asthma, rhinitis and eczema have increased in incidence two- to three-fold in the last 20 years.

-- Anaphylaxis, a severe and potentially life-threatening reaction, occurs in over one in 3,500 of the population each year as a result of exposure to substances to which the sufferer is allergic. Hospital admissions due to anaphylaxis have increased seven-fold over the last decade and doubled over four years.

-- Food allergy is increasingly widespread and is the most common cause of anaphylaxis in children. Peanut allergy, the most common food allergy to cause fatal or near-fatal reactions, has trebled in incidence over four years and now affects one in 70 children in the UK. Yet only 10 years ago this was a rare disorder.

-- Drug allergy is also increasingly common. Adverse drug reactions account for 5% of all hospital admissions in the UK. Up to 15% of inpatients have a hospital stay prolonged as a result of drug allergy. These figures do not include the majority of drug allergies, which occur in primary care and remain undiagnosed and unrecorded.

-- Some 8% of healthcare workers now have an allergy to latex rubber, which in some cases can lead to anaphylaxis. Yet until 1979 only two cases of latex allergy had been reported.

-- Allergic disease currently accounts for 6% of general practice consultations, 0.6% of hospital admissions, and 10% of the GP prescribing budget. The cost (in primary care, excluding hospital services) to the NHS is £900 million per annum.

WHY ARE CURRENT SERVICES NOW INADEQUATE TO MEET THE NEED?

-- Across the whole country, 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 allergy clinics in the UK - the majority - are run part-time by consultants in other disciplines. However, they do not have the facilities to cope with the rising tide of allergies or with the problems posed by severe or multi-system allergic disorders.

-- There is a marked geographical inequality in service provision, as most allergy specialists are based in London and the south-east. Services are extremely poor in the rest of the country.

-- Overall, the provision of consultant allergists is approximately one per 2 million of the UK population, compared with rates of around one per 100,000 for mainstream specialties such as gastroenterology, cardiology etc.

-- Most organ-based specialists, who have traditionally dealt with allergic conditions such as asthma, allergic skin disorders and allergic rhinitis, have no training in allergy.

-- The skill base needed to develop allergy services which are led directly from primary care is currently absent. The majority of GPs have no clinical training in allergy and no access to expert advice.

RECOMMENDATIONS

The recommendations set out in this report are intended to form the basis for the development of a coordinated service over the coming decade. It is envisaged that such a service will progressively become primary care led, with expertise available from the hospital setting for more severe and complex problems. First, however, there must be an increase in the number of allergy consultants, who could then support these developments. Within the hospital sector, the increase in multi-system and severe allergic disease indicates the need for consultant allergists who can provide a 'one-stop-shop' approach for patients.

GENERAL RECOMMENDATIONS FOR AN IMPROVED ALLERGY SERVICE

1 The provision of allergy care in the NHS must be led by specialists trained in allergy so that appropriate standards of care can be achieved and maintained. Given the scale of what amounts to a national epidemic, the front line for allergy management must be within primary care. However, with virtually no primary care skill base to work from, clinical leadership must come initially from specialist centres. They will need to take on the dual role of diagnosis and management of the most complex cases, and of supporting the development of capacity within primary care.

2 The NHS therefore needs to move forward on two fronts. As an essential first step, more consultant posts and funded training posts in allergy are required. Specialist allergists must become the core leadership for a national training and clinical development initiative for the whole service. They must also provide the essence of a genuinely national allergy service for the NHS.

The creation of these posts, and their appropriate service development context, requires a recognition of need by the Department of Health, the Workforce Numbers Advisory Board, primary care trusts, regional commissioners and trust managers.

3 The report proposes the setting up of appropriately staffed regional allergy centres evenly distributed across the whole country. Based on the service models that exist in those parts of the UK fortunate enough to have established specialist centres, they will give equality of access to appropriate allergy services for adults and children in all parts of the country. They will also provide expertise and lead the development of other local services, networking with organbased specialists and GPs.

4 Regional commissioning for specialist allergy must also be implemented. This will require central direction. The specific recommendations of the report are grouped under five headings:

SPECIFIC RECOMMENDATIONS REGIONAL ALLERGY CENTRES

5 The working party endorses the recommendations of the British Society for Allergy and Clinical Immunology (BSACI) that each of the eight NHS Regions in England (as configured in 2001, each with a population of approximately 5-7 million), as well as Scotland, Wales and Northern Ireland, should have an absolute minimum of one regional specialist allergy centre.

6 Staffing levels required to set up a new regional centre or develop an existing one are as follows:

- a minimum of two new/additional (whole time equivalent) consultant allergists (for adult services) offering a multidisciplinary approach. This is the minimum requirement to provide necessary cover for diagnostic procedures and specialist treatment.

- a minimum of two full-time allergy nurse specialists

- one half-time adult dietitian and one half-time paediatric dietitian with specialist training in food allergy

- two consultants in paediatric allergy, supported by paediatric nurse specialists and dietitians with expertise in paediatric allergy

- facilities for training for two specialist registrars in allergy (in some centres).

7 The regional centres should:

- provide specialist expertise for adult and paediatric allergic disease throughout their Region (tertiary care), including allergic disorders recognised for regional commissioning

- manage allergic disease in the local population which cannot be dealt with in general practice (secondary care)

- act as an educational resource for the Region

- network with and facilitate local training in allergy for organ-based specialists and paediatricians

- support training at local level for GPs and nurses in the management of common allergies in primary care.

TRAINEES IN ALLERGY

8 In order to create new consultant posts, it is essential to increase the number of trainees in the specialty. There are now only five trainees nationally.

9 The lack of trainees is creating a planning blight, because NHS trusts wishing to create new consultant posts cannot readily find suitable applicants. The Department of Health and the Workforce Numbers Advisory Board must recognise the need and provide for more funded training posts in allergy. Despite the pressing case for an increase in specialist registrar numbers, and a provisional agreement for seven additional funded posts, allergy has been allocated no new funded posts for 2003-2005.

FURTHER CONSULTANT POSTS IN ALLERGY

10 In addition to regional allergy centres, further consultant allergist posts need to be created in teaching hospitals and district general hospitals in each Region to deal with local needs. All teaching hospitals should have an allergy service provided by a consultant allergist; one model might be for a shared appointment between trusts. This should follow the establishment of regional centres.

TRAINING IN ALLERGY FOR PRIMARY CARE

11 Primary care must ultimately provide the front line care for allergy, but considerable development is needed.

12 The training of GPs and practice nurses in allergy needs to be improved. A key part of this will follow from interaction with consultant allergists, and the inclusion of clinical allergy training in the undergraduate medical curriculum. There are currently a number of allergy courses for GPs and practice nurses, eg through the National Respiratory Training Centre, Southampton University, or one-day training courses run by the BSACI. However, a much more comprehensive nationwide approach is needed, covering primary care training across the NHS. The development of general practitioners with a special interest (GPSIs) in allergy, trained in and linked to regional centres, should support this.

ORGAN-BASED SPECIALISTS WITH AN INTEREST IN allergy

13 Organ-based specialists will continue to contribute to allergy care and have primary responsibility for patients with asthma and eczema, in patients with single-organ involvement.

They should network with the specialist allergist who can act as a resource in identifying/ managing allergy. The increase in allergic diseases, and in their severity and complexity, means that greater awareness of the significance of allergy in these organ-based specialties is important.

Copyright © Royal College of Physicians 2003

Royal College of Physicians
11 St Andrews Place,
London NW1 4LE
Registered Charity No. 210508
Tel 020 7935 1174
Fax 020 7486 5425
http://www.rcplondon.ac.uk

• Additional
• References
• Citations