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2 Specialties AllergyDrug allergy and anaphylaxis during anaesthesia requireexpertise and high throughput and should be part of aregional service.Community models of careClose links between specialists and GPs are needed withearly discharge and supported care in the community.Because of the lack of specialists, it has not been costeffective to develop outreach services. Specialist allergynurses from major centres could be commissioned toprovide diagnostic skin test services to local GPs. Pleasenote that consortia are not in place in Wales andNorthern Ireland.Complementary servicesA wide range of alternative allergy diagnostic tests andtreatments are available to the public but these are notscientifically based and cannot be recommended.3 Working with patients: patient-centredcareWhat you do with patients and how you do itGood allergy care requires accurate allergy diagnosisthrough identification or exclusion of allergic triggers.Essential are a detailed allergy history and skin-pricktests. Intradermal and challenge testing may be requiredas well. Management includes avoidance advice,training in self-use of rescue medication in case ofinadvertent acute reactions and medication to controlchronic conditions. Monitoring is required in somedisorders.Involving patients in their treatmentInforming and involving patients is a crucial aspect ofeffective allergy care. Patients are trained in: avoidanceof triggers (eg foods, drugs) to prevent or reducedisease (eg anaphylaxis, asthma, eczema);self-administration of drugs in self-management plansfor acute attacks; and prophylactic treatment forpredictable allergen exposure. Early whole-systemeffective intervention prevents the development ofchronic illness.Education and self careThis is a major part of allergy care (see above).Chronic conditionsMany allergic conditions are chronic but controllable(asthma, rhinitis, eczema) or avoidable (food ordrug allergy, anaphylaxis). These require long-termcare, which can be shared with or transferred toprimary care.The role of the carerInvolvement of the carer is vital in terms of food andother allergies. When injected adrenaline is required,partners/parents must be trained to administer this.Patient support groupsPatientgroups–AllergyUKandtheAnaphylaxisCampaign – are members of NASG 8 and play a vital rolein providing support and information in the absence ofan adequate NHS service. The most common reason forcalls to their helplines is difficulty in being referred to anallergy clinic or finding one able to deal with thepatient’s problem.Access to informationSpecialist centres have a wide range of patient literature,as do BSACI 7 and patient charities.Availability of clinical records/resultsThese can be supplied according to patient preference.Role of expert patientAllergy management involves training patients toself-manage.Communication with patientsGood communication is essential to elicit the allergyhistory and explain the diagnosis and management.4 Interspecialty and interdisciplinaryliaisonMultidisciplinary teamworkingThe following groups fulfil important roles in the team: allergy specialist nurses dietitians (adult and paediatric) trained in allergy pharmacy and drug information services.Working with other specialists For a minority of patients, allergists liaise withrespiratory physicians, dermatologists,immunologists, ENT consultants or paediatricians.These consultants may refer patients; somecontribute to allergy care.C○ Royal College of Physicians 2013 29
Consultant physicians working with patients Most allergy diagnosis is done by skin testing. Animmunology laboratory service is required. A paediatrician is identified as a contact wherephysicians dealing with adults provide paediatricallergy services. Other specialists include community paediatriciansand nurses (for children at risk of anaphylaxis) andoccupational health physicians (for occupationalallergies and vaccination reactions).Working with GPs and GPs with a special interest(GPwSIs)There is no formal GPwSI curriculum in allergy, but asmall number of GPs work in allergy departments.Extensive GP liaison occurs as a result of referrals andshared care.Other specialty activity beyond local servicesThere are regional and national services for drug allergyand anaphylaxis during anaesthesia. Joint ENT/allergyclinics exist for selected patients.5 Delivering a high-quality serviceWhat is a high-quality service?Consultant allergists should have completed the allergytraining programme (allergy CCT). A minimum of twofull-time consultant allergists are required withappropriate support staff.The following resources are recommended foroutpatient, day-case and inpatient settings.Outpatient services a comprehensive, high-volume service ableto diagnose and manage all types of allergicdisease skin-prick test primary investigation defined and integrated clinic facilities foroutpatients and day cases immediate access to drugs and equipment fortreatment of anaphylaxis.Day-case investigation and immunotherapy agreed protocols and approach to diagnosis sufficient caseload to ensure expertise andcontinuing standards of care; dedicated sessions fordrug challenge and immunotherapy at least weekly facilities to store and prepare drugs and conductchallenge tests team approach.Inpatients rapid consultation service.Work to maintain and improve the quality of careService developments to deliver improved patientcare Nut allergy managed in specialist allergy clinicsreduces morbidity. ENT surgery can be avoided by treatment of rhinitisby allergists. Immunotherapy reduces chronic disease, drug useand improves quality of life. Challenge testing enables diagnosis of drug and foodallergy. Liaison with community paediatricians improvescare for children at risk of anaphylaxis. A single consultation with an allergist is moreeffective than multiple referrals to organ-basedspecialists. Development of new therapies, eg anti-IgE, anddesensitisation for peanut allergy.Education and trainingThe allergist may act as educational supervisor forallergy trainees and has a role in the education andsupport of colleagues in primary care and otherspecialist services in their region. The centre willnetwork with these other providers to enhance allergyprovision in the region. This encompasses clinicalgovernance, professional self-regulation, andcontinuing professional development (CPD).Research – clinical studies and basic scienceThere is a strong tradition of academic allergy in theUK. Most allergy centres have developed throughacademic funding. Academic allergists make animportant contribution to allergy within NHS truststhrough service delivery, service development, guidelinedevelopment, clinical research and training. Basic andclinical allergy research in the UK is internationallyrecognised for excellence and has led to improvementsin patient care.Specialty and national guidelines and auditTable 1 lists some useful guidelines and audits for thisspecialty.A national audit of venom immunotherapy revealedvariable practice; BSACI guidelines were subsequentlyproduced. 7 An audit of asthma deaths suggested allergywas a cause but that this had not been addressed in life.30 C○ Royal College of Physicians 2013
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