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2 Specialties Immunologydetection and optimal management of thecomplications of immunodeficiency. Multidisciplinarymeetings provide education and improved liaison forpatient care. A comprehensive diagnostic immunologylaboratory underpins the diagnosis of allimmunological disease and is integral to the success of aclinical immunology service.Considering the propensity of antibody-deficientpatients to develop complications involvingmultiple-organ systems, immunologists must liaiseclosely with colleagues in a range of specialtiesincluding: respiratory medicine; ear, nose and throat(ENT) surgery; haematology; ophthalmology; andgastroenterology.5 Delivering a high-quality serviceWhat is a high-quality service?A high-quality clinical immunology service willbe consultant led and adequately staffed (medical,scientific, nursing and secretarial), withappropriate resources to support service delivery.It must be supported by an accredited immunologylaboratory providing a full repertoire ofinvestigations encompassing immunochemistry,autoimmunity, allergy, and cellular and molecularimmunology.Maintaining and improving the qualityof careThe DH in England has published specialiseddefinitions for clinical immunology (definition no. 16)and allergy (definition no. 15). The previous set ofdefinitions encompassed a definition for specialisedpathology diagnostic services, including immunology(definition no. 25). Although the last has not beenrevised, collectively, these definitions provide abenchmark for the practice of immunology. 7,8 Thequality of the laboratory immunology service hasbeen underpinned by Clinical Pathology Accreditation(UK) Ltd (CPA) since 1993. This accreditation processis now encompassed within the remit of the UnitedKingdom Accreditation Service (UKAS). Enrolmentwith the CPA was made a mandatory requirement bythe DH for all laboratory disciplines in 2003. Many unitsacross the UK are now developing laboratory servicespecifications with key performance indicators aspart of the DH’s ‘modernising pathology services’initiative.Service developments to deliver improved careThe process of accreditation of clinical immunologyservices for immunodeficiency through a system of peerreview by UKPIN is actively under way. Participation inboth clinical and laboratory accreditation ensures thatimmunology services comply with current standards ofclinical governance. Evidence of active participation inaudit is an essential prerequisite for accreditation inboth clinical and laboratory immunology. Recentexamples of audits that have influenced practice includean audit of a gating policy for requesting antineutrophilcytoplasmic antibodies 9 and an on-going audit of thediagnosis and management of C1 inhibitor deficiency.UKPIN fulfils an important educational role in thedevelopment of guidelines on the diagnosis andmanagement of immunodeficiencies(www.ukpin.org.uk). The network also develops theimmunodeficiency register and works closely withgovernmental agencies involved in the provision oftherapeutic agents for patient care.In view of the patchy provision of allergy services,immunologists are actively involved in developingaccreditation standards for allergy under theauspices of the Joint Committee on Immunologyand Allergy (Royal College of Physicians (RCP) andRoyal College of Pathologists (RCPath)). The increasingrecognition of anaesthetic allergy has promptedimmunologists and allergists to work closely with theAssociation of Anaesthetists of Great Britain andIreland to develop guidelines for the investigation ofpatients who develop perioperative anaphylaxis. 10This initiative has been successful in improvingreferral pathways and ensuring that these patients areprovided with a clear management plan for futureanaesthesia.Immunologists positively embrace service developmentsand initiatives that deliver improved patient care, egtraining patients to use home immunoglobulin therapythrough intravenous or subcutaneous routes. Homeintravenous immunoglobulin (IVIg) therapy, initiallydeveloped for patients with primary antibodydeficiency, has now been extended in some centresto patients with autoimmune neuropathies in whomit is used as maintenance immunomodulatorytherapy.In the laboratory, immunologists take a lead role in theassessment of new diagnostic tests for immunologicaldiseases, followed, if appropriate, by their introductioninto routine clinical practice.C○ Royal College of Physicians 2013 139
Consultant physicians working with patientsEducation and training, clinical governance andmanagement dutiesImmunologists are actively involved in a range of dutiesthat are essential to the maintenance of high standardsof clinical practice. These include: education andtraining of StRs, laboratory scientists and nurses;continuing professional development (CPD); clinicalgovernance; General Medical Council (GMC)revalidation; local management and national work forthe RCP and RCPath and specialist immunologicalsocieties – the British Society for Immunology (BSI),the British Society for Allergy and Clinical Immunology(BSACI) and UKPIN. With the development of acompetency-based curriculum in immunology, it isenvisaged that a consultant with responsibilities as aneducational supervisor will need to devote one weeklyprogrammed activity (PA) to teaching and trainingactivities.Research – clinical studies and basic scienceThe direct relevance of immunology to much of clinicalmedicine and its strong scientific foundations provideample opportunities for clinical studies of newimmunomodulatory therapies, the recognition of newdiseases (as shown by recent descriptions of new formsof severe combined immunodeficiency and type 1cytokine deficiency) and translational research. Despitetheir heavy NHS commitments, many immunologistsare actively involved in national and internationalclinical and laboratory studies.The few full-time academic immunologists make aproportionately greater contribution to research whileshouldering a significant clinical workload for the NHS.With the disappearance of many university immunologydepartments and recent medical school expansion,consultant immunologists have major undergraduateand postgraduate teaching commitments.6 Clinical work of consultantsHow a consultant works in this specialtyThe clinical work of consultant immunologists is largelyoutpatient based, with the following broad workpatterns: Immunologists are solely responsible for patientswith primary immunodeficiencies (antibodydeficiency, combined T- and B-cell deficiency,complement deficiency and phagocytic defects). In many centres, consultant immunologists areresponsible for patients with complex, severe allergicdisease (food allergy, drug allergy, venom allergy andanaphylaxis). In most centres, consultant immunologists performjoint clinics with paediatricians to care for childrenwith immunodeficiencies and allergy. Many immunologists have an interest in connectivetissue disease and perform joint clinics withrheumatologists for patients with autoimmunerheumatic disease and systemic vasculitis. Theincreasing recognition of autoinflammatorydisorders and its inclusion in the nationalcommissioning specification for immunodeficiency,reflects the key role played by immunologists ininvestigating and managing these patients, eithersingly or jointly with rheumatologists. Day-case immunoglobulin infusion clinics forpatients with antibody deficiency form an integralpart of the clinical workload of consultantimmunologists. With increasing recognition of IVIgas a therapeutic immunomodulator, these infusionclinics have expanded in some centres to includenon-antibody-deficient patients, eg those withinflammatory neuropathies. Immunologists are increasingly involved in thesupervision of patients receiving therapeuticbiologics for systemic autoimmune disease. Theimmunology laboratory plays a key role inmonitoring the response to certain biologics asexemplified by B-cell quantification in patientsreceiving rituximab (an anti-CD20 monoclonalantibody). Many laboratories have led theintroduction of interferon-γ assays to detect latenttuberculosis as part of the pretreatment assessmentof patients receiving anti-tumour necrosis factor(TNF)-based therapies.Outpatient workOutpatient work includes the following: primary immunodeficiency clinics severe allergic disease clinics day-case desensitisation immunotherapy challenge clinics for drug and food allergy combined clinics with paediatricians for childrenwith immunodeficiency and allergy combined clinics with rheumatologists supervision of day-case immunoglobulin infusionclinics for antibody replacement and therapeuticimmunomodulation140 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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