Consultant physicians working with patients 5th edition - FSEM

Consultant physicians working with patients
Allergies in children
Forty per cent of children have allergies. Owing to a
shortage of paediatric allergists, children are often seen
by adult allergists.
Main disease patterns
Wide-ranging nature
Allergic disease is wide ranging (as listed above).
Allergists also deal with non-IgE-mediated disorders,
including rhinitis, angioedema and anaphylaxis.
Complexity
Multiple disorders and multiple allergies are common
in an individual, eg asthma, rhinitis, eczema, food
allergy and anaphylaxis coexist. There are cross-reacting
allergens.
New allergies
New kinds of allergies are emerging, eg foods, drugs and
diagnostics.
Progression
In children, allergies develop progressively. Much of this
persists to adulthood.
Severity
A proportion of patients has severe or life-threatening
disease or disease impairing schooling or ability to work
(eg anaphylaxis, airway oedema or multi-system
allergy).
2 Organisation of the service and patterns
of referral
A typical service
There is a specialist definition for allergy (Specialised
services national definitions set, definition no 17). 6 The
purpose is to identify the activity that should be
regarded as specialised and hence within the remit of
PCT collaborative commissioning. However, there is
lack of recognition by commissioners of the need for
allergy commissioning. This occurs around the
established specialist allergy centres but is lacking in
many parts of the country. Allergy is a specialty
recognised for specialist commissioning by the DH in
England.
Specialist services
These provide high-throughput, comprehensive,
full-time services led by allergists with the expertise to
deal with a range of allergic diseases. These services
28
typically offer: one-stop diagnosis and management;
complex investigation requiring day-case service, eg for
drug or food allergy; immunotherapy; and anti-IgE
therapy. There are only a small number of these
services, but each sees large numbers and more complex
patients (eg ∼5,000 pa).
Subspecialty services
Other clinics are part time and provided by consultants
in other specialties, most of whom offer a limited
spectrum of diagnostic and treatment facilities. 5
There is a geographical inequality and national shortage
of doctors with allergy expertise. GPs dealing with the
brunt of allergic disease have limited training and access
to specialist advice.
Current services and proposals for allergy care are
outlined in the RCP report 3 and the British Society for
Allergy & Clinical Immunology (BSACI) and National
Allergy Strategy Group (NASG) submissions to the
DH. 5,7,8 The RCP proposed the following:
� Tier 1 – simpler allergic diseases managed in
primary care or by self care (allergy diagnosis often
not required)
� Tier 2a – consultant allergists in teaching hospitals
and district general hospitals to provide secondary
care
� Tier 2b – other specialists with an interest in allergy
(immunologists; dermatologists; respiratory
physicians; ear, nose and throat (ENT) specialists;
paediatricians) to contribute to secondary care
� Tier 3 – regional allergy centres to manage
specialised tertiary problems and provide local
secondary care.
This model has been developed subsequently in papers
from BSACI identifying the burden of disease and
referral pathways. 7,8
Sources of referral from primary, secondary
and tertiary levels
Referral is mainly direct to a specialist centre from a
patient’s GP (>80%) but from a wide (often regional)
catchment. Patients are also referred from other
services, eg respiratory, dermatology and anaesthetics.
Locality-based and/or regional services
Most major specialist services provide a regional and
local service because of few providers in each region.
C○ Royal College of Physicians 2011