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2 Specialties Immunologyexpansion of 75%. In addition to replacing retiringconsultants, numbers will need to expand by 7.5% perannum over the next 10 years to achieve this figure.9 Consultant work programme/specimenjob planTable 1 shows a consultant work programme/specimenjob plan.10 Key points for commissioners1 Immunology and allergy services for patients withprimary immunodeficiency, complex allergy andC1 inhibitor deficiency have been designated asnationally commissioned services.2 The specialty deals with many rareimmunodeficiency disorders that have designated‘orphan status’ within the European Union.3 Specialist management for patients with primaryantibody deficiency is highlighted by theimprovements in actuarial survival and reductionsin morbidity that have accrued as a direct result ofpatients receiving dedicated care fromimmunologists. 16,174 Evidence-based guidelines for the management ofpatients with primary antibody deficiency havebeen developed by UKPIN (including guidance forcommissioners) and, as major users,immunologists have played a key role in thedevelopment and implementation of the DH’simmunoglobulin demand management plan.5 The use of therapeutic immunoglobulin forantibody deficiency and immunomodulation isunderpinned by a number of key performanceindicators (KPIs), which will be monitored as partof a national dashboard.6 Patients with C1 inhibitor deficiency (hereditaryand acquired) are dependent on emergencytreatment with C1 inhibitor and/or bradykininreceptor antagonists (Icatibant) for crises, with aminority requiring prophylactic treatment. As withantibody deficiency, these patients should bemanaged in centres with appropriate specialistimmunological expertise.7 Immunologists have led the development of hometherapy for patients with antibody deficiency(immunoglobulin), autoimmune neuropathies andhereditary angioedema (C1 inhibitor).8 Immunologists are major providers ofcomprehensive allergy services and are closelyinvolved in the development of accreditationstandards for allergy centres.9 The need for, and evidence supporting, growth inthe capacity of specialised allergy services has beenmade repeatedly in recommendations (2003–2010)from the medical royal colleges, the House ofCommons Health Select Committee and the Houseof Lords Science and Technology Committee.10 Specialised immunology diagnostic laboratoryservices should only be commissioned fromaccredited laboratories.References1 Lambert PH, Metzger H, Miyamoto T, et al. Clinicalimmunology: guidelines for its organization, trainingand certification. Relationships with allergology andother medical disciplines. A WHO/IUIS/IAACI report.Clin Exp Immunol 1993;93:484–91.2 Wood P, Stanworth S, Burton J, et al. UK PrimaryImmunodeficiency Network. Recognition, clinicaldiagnosis and management of patients with primaryantibody deficiencies: a systematic review. Clin ExpImmunol 2007;149:410–23.3 El-Shanawany TM, Arnold H, Carne E, et al. Survey ofclinical allergy services provided by clinicalimmunologists in the UK. J Clin Pathol 2005;58:1283–90.4 Longhurst HJ, Carr S, Khair K. C1-inhibitor concentratehome therapy for hereditary angioedema: a viable,effective treatment option. Clin Exp Immunol2007;147:11–17.5 Gompels MM, Lock RJ, Abinun M, et al. C1 inhibitordeficiency: consensus document. Clin Exp Immunol2005;139:379–94.6 Provan D, Chapel HM, Sewell WAC, O’Shaughnessy D.Prescribing intravenous immunoglobulin: summary ofDepartment of Health guidelines (on behalf of the UKImmunoglobulin Expert Working Group). BMJ2008;337:990–2.7 Department of Health. Specialised services nationaldefinitions set: 3rd edn. Specialised immunology services(all ages). Definition no 16. London: DH, 2008.8 Department of Health. Specialised services nationaldefinition set, 2nd edn. Specialised pathology services (allages). Definition no. 25. London: DH, 2002.9 Arnold DF, Timms A, Luqmani R, Misbah SA. Does agating policy for ANCA overlook patients with ANCAassociated vasculitis? An audit of 263 patients. JClinPathol 2010;63:678–80.10 Harper NJ, Dixon T, DuguéP,et al. Suspectedanaphylactic reactions associated with anaesthesia.Anaesthesia 2009;64:199–211.11 Spickett GP, Askew T, Chapel HM. Management ofprimary antibody deficiency by consultantC○ Royal College of Physicians 2013 143
Consultant physicians working with patientsimmunologists in the UK: a paradigm for other rarediseases. Qual Health Care 1995;4:263–8.12 Misbah SA, Kokkinou V, Jeffery K, et al. The role of thephysician in laboratory medicine: a Europeanperspective. JClinPathol2013 (In press).13 Department of Health. Independent review of NHSpathology services in England (Carter review). London:DH, 2010.14 Royal College of Pathologists. Medical and scientificstaffing of National Health Service pathology departments.London: RCPath, 1999.15 The Federation of the Royal Colleges of Physicians of theUnited Kingdom. Census of consultant physicians andmedical registrars in the UK, 2011: data and commentary.London: RCP, 2013.16 Orange JS, Grossman WJ, Navickis RJ, Wilkes MM.Impact of trough IgG on pneumonia incidence inprimary immunodeficiency: a meta-analysis of clinicalstudies. Clin Immunol 2010;137:21–30.17 Chapel H, Lucas M, Lee M, et al. Common variableimmunodeficiency disorders: division into distinctclinical phenotypes. Blood 2008;112:277–86.144 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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