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EDITORIALS: Mark L Levy, Aziz Sheikh, Samantha Walker, and Angie Woods Should UK allergy services focus on primary care? BMJ 2006; 332: 1347-1348 [Full text]

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UK allergy services need a broad approach

Anthony J Frew, Helen E Smith   (27 June 2006)

Primary Care Allergy Services

Andrew J Wardlaw   (30 June 2006)

Should UK allergy services focus on primary care?

Rita M Mirakian   (27 July 2006)

UK allergy services need a broad approach 27 June 2006
Anthony J Frew, Professor of Allergy & Respiratory Medicine Brighton General Hospital, Brighton BN2 3EW, Helen E Smith Send response to journal: Re: UK allergy services need a broad approach	Your recent editorial by Levy et al (BMJ 10th June 2006; 332:1347-8) appears to present a false choice between primary and secondary care for the development of allergy services, and advocates a primary-care-led allergy service. Outsiders could easily think there is a turf war building up here, but nothing could be further from the truth. Both the European and British specialist societies are campaigning on behalf of patients with allergic disorders, arguing that the scope and scale of the problem is so large that only a co-ordinated approach across primary, secondary and tertiary care can hope to address the needs of all patients. This has been recognised by the parliamentary health select committee at Westminster, and by the EU parliament, who voted in Strasbourg two weeks ago for the inclusion of allergic diseases at the highest possible level of the new EU framework programme for research (FP7). At present, knowledge of how to diagnose and manage allergic disease is poor, both in the community and in the hospital sector. We have clear evidence that patients with allergic rhinitis are not well served by the current primary care system, with many patients who consult in primary care having unsatisfactory control of their condition [White et al 1998]. From the same survey we also know that there are about 64,000 people in the UK who would benefit from immunotherapy to control their hay fever, and who qualify for this under existing UK guidelines, but are unable to access care. There are so many patients with allergic conditions that everyone involved in healthcare needs to understand these conditions and take them seriously. This includes pharmacists, practice nurses, GPs, acute physicians, general physicians and paediatricians. When the patient’s problems are beyond the competence of these front-line professionals, quality specialist care should be available, close to home. Whether this is provided by nurses, general practitioners working with a special interest or hospital based staff is immaterial. What matters is that these (more expert/specialist) providers are properly trained and provided with appropriate resources to diagnose and treat patients effectively. Regional centres with fully certified allergy specialists also have key roles to play, as providers of secondary and tertiary care for those patients that cannot be managed close to home, and as sources of information, education, guidelines and harmonised practice. To drive forward the agenda we need development on all fronts: we need primary care services that can recognise and manage allergies, together with a variety of intermediate services, including GPwSIs to take referrals from primary care, backed up by district-based specialists (allergy-aware organ-based specialists, immunologists and allergists); and we also need regional specialist centres to provide leadership and highly specialised expertise for the most difficult cases. The development of UK allergy services should include primary care but should not focus there to the exclusion of other components. We await the DH response to the Health Select Committee with interest. Yours sincerely Anthony Frew President European Academy of Allergology & Clinical Immunology E: ajf@eaaci.org Helen Smith Professor of Primary Care, Brighton & Sussex Medical School E: h.e.smith@bsms.ac.uk White P, Smith H, Baker N, Davis W, Frew A. Symptom control in patients with hay fever in UK general practice: how well are we doing and is there a need for allergen immunotherapy? Clin Exp Allergy 2006; 28:266- 270 Competing interests: None declared
Primary Care Allergy Services 30 June 2006
Andrew J Wardlaw, President of the British Society for Allergy and Clinical Immunology University of Leicester Glenfield Hospital, LE3 9QP Send response to journal: Re: Primary Care Allergy Services	Dear Editor Both the Royal College of Physicians(1) and the House of Commons Health Committee(2) have conclusively demonstrated that there is an epidemic of allergy which demands development of NHS allergy services. The Department of Health’s current review, which is reaching its concluding stage, will find it very difficult to ignore the overwhelming evidence of an unmet need in allergy care. Levy et al (BMJ 10th June 2006(3)), correctly diagnose the problem but in asking the question whether the solution is expansion of secondary or primary care services they are posing a false dichotomy. Both need to be radically improved. However, the much-needed improvement in the diagnosis and management of allergic disease in the primary sector cannot happen without a corresponding improvement in secondary care. The two stand and fall together. What is required is a balanced programme of investment and change – to improve the diagnosis and management of allergy in both the primary care sector as well as an expansion of specialist allergy services. A bid for expansion of one sector – presumably to the detriment of others, under present financial constraints– is not helpful. It is inaccurate to suggest that the national campaign to lobby for improved allergy services has given an exclusive focus to the need for specialist allergy training. Those bodies lobbying for change have always recognised that the majority of allergy will be treated in the community or in primary care and that it is essential that the standard of management of allergy in primary care, which is generally recognised to be sub-optimal is improved(4). A recent meeting hosted by the Royal College of General Practitioners, specifically to reach a consensus on the advice on primary care to be given to the Department of Health’s review, received analysis from the British Society for Allergy and Clinical Immunology (BSACI) on the extent to which the primary and specialist services might reasonably be expected to share the burden of allergic illness. The BSACI report (5) concluded that with more than 20 million people with illness where allergy needs to be considered about 2/ 3rds could be managed in primary care if the appropriate conditions were developed. Most of these people are being seen in primary care now; some need an allergy diagnosis but this is not being addressed (4). Primary care needs to do better by these patients, not necessarily more. Indeed, because the allergy load is so large, all GPs need to be allergy aware. This requires a massive educational effort as well as improved teaching and exposure to specialist allergy services during undergraduate and post-graduate training. Although primary care is an important component of a successful strategy for improved NHS allergy services there is still a minimum of several million people whose allergy has complex causes and/or expresses itself as serious or multi-system disease. These patients need specialist help. It is therefore necessary to begin by targeting additional Department of Health funding to the secondary care sector in order to improve specialist allergy services and create the infrastructure necessary to drive primary care allergy. If these conditions are not met we will continue to fail our patients. 1 Holgate ST, Ewan PW eds Allergy the unmet need. Royal College of Physicians of London , 2003 2 House of Commons Health Committee. The provision of allergy services. London Stationary Office 2004 (HC 696 I, 2004) 3 Levy ML, Sheikh A, Walker S, Woods A. Should UK allergy services focus on primary care? BMJ 2006; 332: 1347-8 4 Levy ML, Price D, Zheng X, Simpson C, Hannaford P, Sheikh A. Inadequacies in UK primary care allergy services: national survey of current provisions and perceptions of need. Clin Exp Allergy. 2004 Apr;34(4):518-9 5 Ewan PW for the British Society for Allergy and Clinical Immunology. The Nature and Extent of Allergy in the United Kingdom. A Report to the Department of Health Review of Allergy Services Competing interests: None declared
Should UK allergy services focus on primary care? 27 July 2006
Rita M Mirakian, Honorary Senior Lecturer in Immunology; Specialist in Allergy and Immunology Queen Mary, University of London, Mile End Road, London E1 4NS Send response to journal: Re: Should UK allergy services focus on primary care?	To solve the ‘unmet need’ related to the provision of allergy services, Levy et al (Editorial, BMJ 10th June 2006) propose the establishment of ‘regional practitioners with specialist interest in allergy’ to act as ‘catalysts’ for a larger primary care based allergy service. The British Society for Allergy and Clinical Immunology proposes that the majority (about 17 million) of allergy patients are treated in primary care but this will require a greatly improved knowledge of allergic-related issues across the whole primary care sector. There will still be several million patients with a more complex disease requiring referral to a specialist in allergy. There is a serious lack of specialist allergy centres in the UK. Without an increase in allergists, adequate patient care in either sector will not be achieved. Using unpublished data from Education of Health, Levy et al calculated that there are 800 primary care staff with diploma level training in allergy. Most of these are nurses and it remains difficult, because of the lack of allergy centres, to provide them with the clinical training and exposure to complement these courses. The aim of Levy’s proposal is to shift both allergy care provision and training to the primary sector. This solution may seem appealing particularly from a financial standpoint. However, to have diploma level training in allergy neither implies that one is in the position to train practitioners in allergy nor that one is competent in diagnosing and treating patients suffering from complex allergic conditions. These practitioners can certainly contribute to the training and they already do so in certain parts of the UK, but they cannot substitute post-graduate training because their knowledge on allergy issues is not systematic and comprehensive. Allergy specialists holding allergy training days for primary care staff consistently experience a poor level of basic knowledge on the management of allergic conditions in primary care. This is evident from patient experience and evidence from the patient charities (RCP report [1] and House of Commons Report[2]). An enormous amount of training of all practitioners is needed before a positive impact on allergy provision in primary care can be achieved. This view is actually shared by the attending practitioners who eagerly ask where and when they can be trained in allergy. In contrast to the rest of Western Europe and North America, there are currently only six specialist allergy centres in the whole of the UK which offer comprehensive allergy training. Implementing the allergy service in primary care without securing an adequate provision of specialists in allergy is a short-sighted decision which will have an irreversible impact on the management of patients. There is no doubt that if this pragmatic solution’ materialises the existing gap on allergy service provision between the UK and the rest of Europe and North America will widen. We need a combined development of allergy expertise in primary and secondary care. [1] Royal College of Physicians, Allergy: The Unmet Need, A report of the Royal College of Physicians Working Party on the provision of allergy services in the UK, 2003, Available at: http://www.rcplondon.ac.uk/pubs/books/allergy/allergy.pdf [accessed 14 July, 2006]. [2] House of Commons Health Committee, The provision of allergy services, London: Stationary Office, 2004 (HC 696_I 2004). Available at: http://www.publications.parliament.uk/pa/cm200304/cmselect/cmhealth/696/69602.htm [accessed 14 July, 2006]. Competing interests: Member of the British Society of Allergy and Clinical Immunology