Consultant physicians working with patients - Royal College of ...

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2 Specialties AllergyAllergyDr Pamela Ewan Consultant allergistDr Shuaib Nasser Consultant allergist1 Description of the specialtyAllergy is a non-organ-based specialty, with its owntraining programme and Certificate of Completion ofTraining (CCT). The allergist provides expertise indiagnosis and management of allergy that is different,and complementary to, services of other specialties.Allergic disorders are common and increasing inprevalence. They cause significant impairment ofquality of life and considerable direct cost to theNHS. 1,2 The need is to identify or exclude allergy as acause of disease, eg an acute allergic reaction, or in achronic disorder such as asthma, rhinitis, eczema orurticaria; and to provide management. Allergydiagnosis and avoidance can prevent further episodesor reduce disease. This results in substantial healthcareimpact, reducing healthcare costs and improvingquality of life for the patient.There has been a documented rise in allergic diseaseover the lasts three decades in numbers, severity andcomplexity, eg admissions for anaphylaxis have risensevenfold in 10 years, 1,2 and nut allergy, previously rare,now occurs in 2% of children and persists to adulthood.Food and drug allergy and angioedema are common.New allergies are also appearing. The allergy epidemichas created a new and substantial demand for consultantallergists, not previously addressed by the NHS.There are a small number of specialist allergy servicesrun by academic or NHS consultant allergists. Inresponse to demand, some organ-based specialists,immunologists and paediatricians provide part-time orlimited allergy services in addition to their main service,which is only a partial response to patient need. Formany patients, however, there is an unmet need. Thereis inadequate access to care, suboptimal healthcaredelivery and, consequently, unnecessary cost to the NHSin avoidable disease. 3,4A Royal College of Physicians (RCP) report proposed arational approach to improve patient care in response tocurrent inequalities and the developing allergyepidemic. 3 Key to services is development of at least onemajor allergy centre in each region, staffed by adult andpaediatric allergists. This requires increased numbers ofallergy consultants and allergy trainees. Such aninvestment would provide the infrastructure andexpertise for the development of services throughoutthe region and support education in primary andsecondary care. A House of Commons HealthCommittee inquiry into allergy services endorsed theRCP report, recommending the development ofnational allergy services and commissioning of allergycentres. 4 In England, a Department of Health (DH)review recognised the need for allergy services. 5 Pivotalto service development and patient care is the need totrain more allergists.Who are the patients?NumbersAllergic disease is one of the most common diseases anda major public health problem. About 20 million peopleintheUKhaveadiseasewhereallergymaybeinvolved.Around 3.5–7 million require the care of a specialistallergist. 5DisordersDisorders commonly coexist. Some may beimmunoglobulin E (IgE)- or non-IgE-mediated: asthma rhinitis, conjunctivitis, rhino–sinusitis, nasal polyps eczema anaphylaxis urticaria angioedema glottal oedema food allergy, eosinophilic enteropathies food intolerance drug allergy latex allergy venom allergy mast-cell disorders occupational allergy.C○ Royal College of Physicians 2013 27
Consultant physicians working with patientsAllergies in childrenForty per cent of children have allergies. Owing to ashortage of paediatric allergists, children are often seenby adult allergists.Main disease patternsWide-ranging natureAllergic disease is wide ranging (as listed above).Allergists also deal with non-IgE-mediated disorders,including rhinitis, angioedema and anaphylaxis.ComplexityMultiple disorders and multiple allergies are commonin an individual, eg asthma, rhinitis, eczema, foodallergy and anaphylaxis coexist. There are cross-reactingallergens.New allergiesNew kinds of allergies are emerging, eg foods, drugs anddiagnostics.ProgressionIn children, allergies develop progressively. Much of thispersists to adulthood.SeverityA proportion of patients has severe or life-threateningdisease or disease impairing schooling or ability to work(eg anaphylaxis, airway oedema or multi-systemallergy).2 Organisation of the service and patternsof referralA typical serviceThere is a specialist definition for allergy (Specialisedservices national definitions set, definition no 17). 6 Thepurpose is to identify the activity that should beregarded as specialised and hence within the remit ofPCT collaborative commissioning. However, there islack of recognition by commissioners of the need forallergy commissioning. This occurs around theestablished specialist allergy centres but is lacking inmany parts of the country. Allergy is a specialtyrecognised for specialist commissioning by the DH inEngland.Specialist servicesThese provide high-throughput, comprehensive,full-time services led by allergists with the expertise todeal with a range of allergic diseases. These servicestypically offer: one-stop diagnosis and management;complex investigation requiring day-case service, eg fordrug or food allergy; immunotherapy; and anti-IgEtherapy. There are only a small number of theseservices, but each sees large numbers and more complexpatients (eg ∼5,000 pa).Subspecialty servicesOther clinics are part time and provided by consultantsin other specialties, most of whom offer a limitedspectrum of diagnostic and treatment facilities. 5There is a geographical inequality and national shortageof doctors with allergy expertise. GPs dealing with thebrunt of allergic disease have limited training and accessto specialist advice.Current services and proposals for allergy care areoutlined in the RCP report 3 and the British Society forAllergy & Clinical Immunology (BSACI) and NationalAllergy Strategy Group (NASG) submissions to theDH. 5,7,8 The RCP proposed the following: Tier 1 – simpler allergic diseases managed inprimary care or by self care (allergy diagnosis oftennot required) Tier 2a – consultant allergists in teaching hospitalsand district general hospitals to provide secondarycare Tier 2b – other specialists with an interest in allergy(immunologists; dermatologists; respiratoryphysicians; ear, nose and throat (ENT) specialists;paediatricians) to contribute to secondary care Tier 3 – regional allergy centres to managespecialised tertiary problems and provide localsecondary care.This model has been developed subsequently in papersfrom BSACI identifying the burden of disease andreferral pathways. 7,8Sources of referral from primary, secondaryand tertiary levelsReferral is mainly direct to a specialist centre from apatient’s GP (>80%) but from a wide (often regional)catchment. Patients are also referred from otherservices, eg respiratory, dermatology and anaesthetics.Locality-based and/or regional servicesMost major specialist services provide a regional andlocal service because of few providers in each region.28 C○ Royal College of Physicians 2013
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