Allergy – will we ever meet the unmet need?
Authors: Ilora Finlay, William Egner
Journal: Journal of the Royal Society of Medicine (2010)

With all the changes afoot in the NHS, where will allergy services be in five years? They are already rudimentary in most of the UK, with little action taken to meet the needs of patients. Through the years of plenty, allergy services remained in famine; reiteration through report after report had little effect.

In 2003 the Royal College of Physicians (RCP) reported a great unmet need,1 confirmed in the House of Commons Select Committee report highlighting the inadequacy of allergy services.2 That report was so scathing that the Department of Health (DH) conducted a review in 2004. All reports concluded that improvements were urgent – but still no action. In 2006 the House of Lords Science and Technology Committee (HoL) launched an inquiry into allergy, focusing initially on its causes and management.3 In the light of the wealth of evidence, its key recommendations focused on improving service provision.

In May 2009 a joint working party of the RCP and Royal College of Pathologists (RCPath) was established, supported by the British Society for Allergy and Clinical Immunology (BSACI), with a remit to collate evidence of progress in implementing the HoL recommendations.4 The patient voice was at the heart of this process, through a subcommittee linking together the different patients' interest groups.

The future direction of the NHS is currently uncertain and the financial climate was very different when all these reports were written. GPs have not provided the allergy services that the DH had hoped for in 2004 for many reasons. How were GPs to gain the expert skills needed without a specialist service nearby? How could they do so without PCT support or undergraduate/postgraduate teaching? Would GPs prioritize the improvement of allergy care in the face of the other competing demands on their time?

Following the House of Lords report, the North West Strategic Health Authority (SHA) was tasked with piloting and evaluating the clustering of services in the North West of England. With the demise of SHAs, new lead commissioners will have to be engaged. Sadly, at PCT level engagement has been disappointing, leaving allergy off the ‘must-do’ list.

Yet there is some hope. With the advent of GP commissioning, the fact that allergy impacts so strongly on GP workload and budget may be the driver that finally generates some cost-effective action. If the headquarters of the NHS are now in the consulting room, GPs are well placed, as the first port of call for allergy, to ensure the patient journey is appropriate and ensure holistic care. The best care will represent good synergy between GPs at the coalface (well-trained in managing common simple allergies) who know when the specialist services can add value. Good communication and an appreciation of the generalist and specialist roles are particularly important for allergy. The Royal College of General Practitioners (RCGP) has recognized allergy as a priority for the next three years and the BSACI Primary Care Group aims to improve allergy care and raise awareness of allergy in the community.

Yet commissioning GP consortia need to act. Allergic disease is rising, particularly food anaphylaxis. Bad allergy advice is worse than no allergy advice; it leads to inappropriate anxiety, inappropriate diets, inappropriate drug avoidance and consequent medication costs, and repeated GP consultations with unresolved problems. There is a touching but misplaced faith in diagnostic tests; all tests are essentially worthless without expert interpretation; many provide an alarming number of false-positive and false-negative results. Less than half of those with a positive test may have clinical allergy, even to common allergens. The self-diagnosis market place is being flooded with kits of unproven and often dubious value; some do not even test for allergen specific IgE.

Compared to the rest of Europe, there is a severe shortage of allergy consultants in the UK. Historically, consultants have come into the field through a variety of specialty training routes. Now registrars can train specifically in allergy. Work – unfunded – by allergy pioneers is developing accreditation processes and networking, to encourage all those in allergy to work cost-effectively and drive up standards.

GPs are central to care and will have to shoulder the greatest burden if allergy care is to improve. GPs should know what their patients want and need. How will they be supported and guided to deliver what's best in a complex specialty?

The evidence from the patient groups is loud and clear. Patients need accurate diagnosis, state of the art management and expert clinicians who can distinguish what is and what is not allergy. They need integrated care, empowering them to take effective control of their disease.

Without that, there will be a rising catalogue of those whose lives are at risk from anaphylaxis, from malnutrition through inappropriate diets, and dominated by inappropriate anxiety. Without access to new sublingual immunotherapies, school children with severe hayfever will continue to underperform.

Services like allergy, which have been chronically under-resourced and under-supplied compared to the rest of Europe, are especially vulnerable now. We hope that GP consortia will listen to patients, recognize that more effective management of this substantial proportion of their consultations will save both time and money, and will commission the clustering of expertise that the HoL and RCP/RCPath follow-up recommended, to support local integrated care and better management of patients.

Networking/clustering of services is slowly occurring, but trainee numbers in allergy are pitifully low and there are gaps in clinical leadership in allergy across the UK. Yet the UK's scientific research into allergy is world-class. Improving use of the multidisciplinary resource that currently provides fragmented allergy care across the UK is essential; it needs strong leadership from the clinicians whose work revolves around allergic disease to improve patient care, to develop education and training and foster translational research. Specialist service hubs and networks, shared guidelines and patient care pathways are the key to dissemination so that local GPs can access expert support to design locally viable approaches to managing their patients.

For GPs to know that they are commissioning the best care, the accreditation processes need further development and will provide a mechanism to improve care against agreed standards. Patient outcome measures, already in gestation, need to be rapidly agreed and incorporated into routine clinical practice across the UK. It is only by demonstrating the benefits of these new approaches that the service will survive, let alone grow.

Progress can be optimized by having a cohesive group in each region which represents all aspects of allergy, immunology and allergy-related disorders, empowered to take services forward, working across historic specialty/professional boundaries to provide a new model of allergy care, with clear pathways into the GP consultation and supporting the patient managing allergy at home. Clustering or networking of services should progress where centres are currently impractical. Each NHS Trust should appoint a lead consultant allergy specialist to improve cost-effective service provision and enhance quality. The best models of care must be disseminated, shared and emulated nationally.

The allergy community knew it remained in crisis when the RCP/ RCPath report came out recently; the current climate creates a serious risk to allergy patients. Services would do well to rapidly look at the House of Lords and the RCP/RCPath follow-up reports and take inspiration from them where possible. With some innovative approaches, a lot could happen, even without more money.