Allergy: the unmet need

Transcription

1 Allergy: te unmet need A blueprint for better patient care A report of te Royal College of Pysicians Working Party on te provision of allergy services in te UK Royal College of Pysicians June 2003

2 Royal College of Pysicians of London 11 St Andrews Place, London NW1 4LE Registered carity No Copyrigt 2003 Royal College of Pysicians of London ISBN Cover design: Merriton Sarp Typeset by Dan-Set Grapics, Telford, Sropsire Printed in Great Britain by Te Lavenam Press Ltd, Sudbury, Suffolk

3 Contents Members of te Working Party Foreword Preface Executive summary and recommendations vii ix xi xiii PART ONE Allergy services: current deficits and recommendations for improvement 1. Wat is allergy? 3 2. Te burden of allergic disease in te UK 7 A study on prevalence, ealtcare utilisation and trends 7 3. Allergy in cildren: special issues 9 Prevalence of paediatric allergic diseases in te UK 9 Special requirements of cildren wit allergy 9 Delivery of care 9 Nutrition, growt and development 10 Psycological, social and educational issues 10 Patient education 10 Deficits in current paediatric care 11 Primary care 11 Lack of trained paediatric allergists 11 Fragmented specialty care 11 Medication and side effects 11 Researc and preventive measures: te importance of early life events Allergy in primary care 13 A UK survey of allergy care in general practice 13 Metods 13 Results 13 Discussion 14 Furter researc on primary care 15 Management of allergy in primary care 15 Te need for more training 16 GP wit a special interest (GPSI) in allergy: a new concept 16 Recommendations 17 iii

4 Allergy: te unmet need 5. Te role of allergy carities 19 Evidence of need 19 Te demand for information 19 Meeting demand Proposals to improve NHS allergy services 21 Disorders managed by an allergist 21 Lack of expertise and lack of training in allergy 21 Hospital care: mostly provided by non-allergists 21 Multi-system allergy 23 Paediatric allergy 23 Primary care 23 Helplines 23 Benefits of a specialist allergy service 23 Te costs of mismanagement 24 Current NHS allergy clinics 24 Demand for services 26 Regional commissioning for allergy 26 Recommendations 28 General recommendations for an improved allergy service 28 Specific recommendations 28 Regional allergy centres 28 Trainees in allergy 30 Oter consultant posts in allergy 30 Training in allergy for primary care 30 Organ-based specialists wit an interest in allergy 31 Mecanisms for expansion 31 PART TWO Allergy: a brief guide to causes, diagnosis and management 7. Environmental exposure to airborne allergens 35 Sources of outdoor inaled allergens 35 Allergenic pollen and spores in te UK and seasonal variation 35 Sources of indoor inaled allergens 37 House dust mites 37 Domestic pets 39 Indoor fungi 39 iv

5 Contents 8. Common diseases associated wit allergy 41 Astma 41 Allergic rinitis 44 Drug allergy 47 Food allergy and intolerance 52 Allergy and te skin 59 Venom allergy (allergy to stings) 62 Anapylaxis 65 Occupational allergy Diagnostic tests Specialist services: treatment and callenge tests 79 Anapylaxis 79 Glottal oedema 79 Immunoterapy (desensitisation) 80 Efficacy 80 Indications 80 Practical aspects 80 Mecanism 80 Oter vaccines 81 Future terapies 81 Callenge tests Prevention 83 Genetic factors 83 Environmental factors 84 Immunoterapy 85 Appendix 1. Te burden of allergic disease in te UK 87 Introduction 87 Aims and objectives 87 Metods 87 Main findings 88 Epidemiology 88 Costs to te NHS 89 Trends in disease frequency 90 Appendix 2. Useful addresses 93 v

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7 Members of te Working Party Stepen T Holgate MD DSc FRCP FRCPE FIBiol FRCPat FMedSci (Cair), MRC Clinical Professor of Immunoparmacology, Scool of Medicine, University of Soutampton Pamela W Ewan MA MB FRCP FRCPat (Deputy Cair), Consultant in Allergy and Honorary Lecturer, Addenbrooke s Hospital, University of Cambridge Clinical Scool Antony P Bewley MB CB FRCP, Consultant in Dermatology, Wipps Cross Hospital, London Carol M Black CBE ND PRCP, President, Royal College of Pysicians Jonatan Brostoff DM DSc(Med) FRCP FRCPat FIBiol, Senior Researc Fellow, Professor Emeritus of Allergy and Enviromental Healt, King s College London Cristine Carter BSc SRD, Specialist Paediatric Dietitian, Great Ormond Street Hospital for Cildren, London Jon W Coleman BSc PD, Reader, Department of Parmacology and Terapeutics, University of Liverpool Paul Cullinan MB FRCP, Senior Lecturer, Department of Occupational and Environmental Medicine, Imperial College National Heart and Lung Institute, London Adnan Custovic PD DM MD, Professorial Clinical Researc Fellow, Nort West Lung Centre, Wytensawe Hospital, Mancester Stepen R Duram MA MD FRCP, Professor of Allergy and Respiratory Medicine, Faculty of Medicine, Imperial College National Heart and Lung Institute, London Jean Emberlin PD, Director, National Pollen Researc Unit, University College Worcester Antony J Frew MD FRCP, Professor of Allergy and Respiratory Medicine, Scool of Medicine, University of Soutampton G Jon Gibson MD FRCP FRCPE, Professor of Respiratory Medicine, University of Newcastle upon Tyne Ian T Gilmore MB FRCP, Registrar, Royal College of Pysicians Julian M Hopkin MD MSc FRCP FRCPE, Professor of Medicine and Director of te Clinical Scool, University of Wales Swansea Peter H Howart DM FRCP, Consultant Allergist, Soutampton General Hospital A Barry Kay PD DSc FRCP FRCPE FRCPat FRSE FMedSci, Professor of Allergy and Clinical Immunology, Imperial College National Heart and Lung Institute, London M Tirumula Krisna MB PD MRCP MRCPat, Specialist Registrar in Allergy, Soutampton General Hospital Gideon Lack BM BCH FRCPCH, Consultant in Paediatric Allergy and Immunology, St Mary s Hospital, London Tak H Lee MA MD ScD FRCP FRCPat FMedSci, Head of Division, Department of Astma, Allergy and Respiratory Science, Guy s, King s and St Tomas Scool of Medicine, London vii

8 Allergy: te unmet need Roy E Pounder MD DSc(Med) FCRP, Clinical Vice President, Royal College of Pysicians Ricard J Powell DM FRCP FRCPat, Reader and Consultant Pysician in Allergy and Clinical Immunology, University Hospital, Queen s Medical Centre, Nottingam David Reading Director, Anapylaxis Campaign, Farnboroug, Hants Dermot Ryan MB MRCGP RCPI DCH, General Practitioner, Woodbrook Medical Centre, Lougboroug; Clinical Researc Fellow, University of Aberdeen Samanta Walker RGN PD, Director of Researc, National Respiratory Training Centre, Warwick Jon O Warner MD FRCP FRCPCH, Professor of Cild Healt, Soutampton General Hospital Tose wo were consulted H Ross Anderson MD FRCP, Professor of Public Healt Medicine, St George s Hospital Medical Scool, London Peter S Friedmanm MD FRCP FMedSci, Professor of Dermatology, Scool of Medicine, University of Soutampton Jeffrey M Graam MA PD FFPHM, Department of Healt Ramyani Gupta MSc, Epidemiologist, Lung and Astma Information Agency, St George s Hospital Medical Scool, London Pil Hannaford MD FRCGP MFFP MFPHM DRCOG DCH, Grampian Healt Board Cair of Primary Care; Director of Institute of Applied Healt Sciences, University of Aberdeen; Department of General Practice and Primary Care, University of Aberdeen Mark L Levy MBCB FRCGP, General Practitioner, Harrow; Senior Lecturer, Department of Primary Care and General Practice, Aberdeen University MS Suaib Nasser MD MCRP, Consultant in Allergy and Astma, Addenbrooke s Hospital, Cambridge David Price MA MB DRCOG MRCGP, General Practice Airways Group Professor of Primary Care Respiratory Medicine, Department of General Practice and Primary Care, University of Aberdeen Aziz Seik MD MSc MRCP MRCGP, NHS R&D National Primary Care Post Doctoral Fellow, St George s Hospital Medical Scool, London Colin Simpson MSc PD, Researc Fellow, Department of General Practice and Primary Care, University of Aberdeen David Stracan MD FRCP FFPHM MRCGP, Professor of Epidemiology, St George s Hospital Medical Scool, London Stepen Wasserman MD, Professor of Medicine, University of San Diego, California Xiaoong Zeng MSc PD, Researc Assistant, Department of General Practice and Primary Care, University of Aberdeen viii

9 Foreword Allergy is a major public ealt problem in developed countries. In te UK over te last twenty years, te incidence of common allergic diseases as trebled, giving tis country one of te igest rates of allergy in te world. In any one year, 12 million people in te UK (one-fift of te population) are now likely to be seeking treatment for allergy. Potentially life-treatening but previously rare allergies, suc as peanut allergy wic now affects one in 70 cildren, are increasing. But despite te epidemic proportions of te disease, te ealt service is failing to meet te most minimal standards of care far less clinical governance. Tis report sows clearly tat tere are far too few specialist allergists to meet te needs of te population, eiter in terms of delivering direct care in dedicated allergy centres, or in providing training for oter specialists, general practitioners and practice nurses. It sould be possible for milder cases of allergy to be recognised and treated in primary care so tat only te more severe and complex cases need referral to a consultant. However, witout te appropriate infrastructure and training tis is not possible and te ealt service will continue to fail to keep pace wit te needs of allergy patients. In publising tis report, te Royal College of Pysicians aims to put allergy iger on te ealtcare agendas of te Department of Healt and planners and managers. We ave made proposals for a muc improved allergy service wic, given te will to cange and understanding of te problems faced by allergy patients, will result in more consultants, a network of accessible centres around te country, and muc improved and wider training of tose wo care for patients. Tese proposals require urgent action. June 2003 Professor Carol Black President, Royal College of Pysicians ix

10 Preface Allergic disease is one of te major causes of illness in developed countries and its prevalence is increasing steadily. In te UK, allergic disease affects about one in tree of te population. In 13- to14-year-old cildren, 32% report symptoms of astma, 9% ave eczema, and 40% ave allergic rinitis. 1 Te UK ranks igest in te world for astma symptoms, wit a prevalence 20-fold iger tan tat of Indonesia, and is also near te top of te world ranking for allergic rinitis and eczema. 1,2 Hig and increasing trends are also apparent in nut allergy, 3,4 anapylaxis, 5,6 occupational allergy (eg latex), 7 and allergic reactions to drugs. 8 Altoug genetic susceptibility is an important risk factor for allergic sensitisation and its expression as disease in different organs, te current allergy epidemic is a consequence of our canging environment. Increased exposure to allergens and air pollutants, over-use of antibiotics and oter drugs, reduced fruit and vegetable intake, reduced early life exposure to bacterial products, and an alteration in bacterial colonisation of te gut ave all been blamed. Allergy is an important branc of medicine and specialisation is required to provide a igquality service for te diagnosis and treatment of allergic disease. 9 Unfortunately, in te UK suc a service as not developed. Allergic disease now causes problems of increased complexity and commonly involves several organ systems, 10 so patients are often referred to a succession of different specialists, resulting only in confusion. Instead, a single referral to an allergy specialist would be bot effective and cost saving. General practices and ospitals usually ave little, if any, resources for establising te presence (or absence) of sensitisation to specific allergens. In consequence, most allergic disease is treated wit drugs, wit little attention being paid to establising causative agents and allergen avoidance strategies. Tere is a major sortage of allergy specialists, wit only six fully staffed allergy clinics in te UK, tat ave developed mainly around researc interests. Allergy barely features in te undergraduate medical curriculum, and te lack of specialists means virtually no clinical training is available. Opportunities for postgraduate clinical training are limited. Knowledge of good allergy management in practice is terefore minimal or non-existent. Te allergy carities, along wit NHS Direct, are inundated wit telepone enquiries from a public desperate for elp wit teir allergy problems. Te severity of teir symptoms, wit attendant ig morbidity, as forced te public to look outside te NHS. Tis as led to te proliferation of dubious allergy practice in te field of complementary and alternative medicine, were unproven tecniques for diagnosis and treatment are used. 11,12 In 1992, te Royal College of Pysicians (RCP) produced a report, Allergy: conventional and alternative concepts, 13 wic drew attention to te importance of good clinical practice in allergy and te dangers of relying on practitioners of complementary and alternative medicine to deliver a competent allergy service to te public. In 1994, tis was reinforced by a second report, Good allergy practice: standards of care for providers and purcasers of allergy services witin te NHS. 14 Altoug bot reports were well received, teir impact on improving te provision of allergy services in te NHS as been limited. xi

11 Allergy: te unmet need Te impact of allergic disease, te deart of NHS services, and wide differences in disease management across te UK created te impetus for tis tird RCP report. In drawing attention to te ig and ever-increasing prevalence and complexity of allergy, te disease burden tis creates, and te lack of any coesive approac to delivering an adequate clinical service witin te NHS, tis report igligts te unmet needs of te many patients wo suffer from allergy, and te impaired quality of life tat tey endure. 4,15 Wit te influence tat te public now exerts over teir ealtcare, te increase in multi-professional working, and te political will to provide furter resources for te NHS, te time as come to make a determined effort to improve clinical services for patients wit allergic disease in te UK. June 2003 Stepen T Holgate Pamela W Ewan References 1 Te International Study of Astma and Allergies in Cildood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of astma, allergic rinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998;351: European Community Respiratory Healt Survey. Variations in te prevalence of respiratory symptoms, self-reported astma attacks, and use of astma medication in te European Community Respiratory Healt Survey (ECRHS). Eur Respir J 1996;9: Tariq SM, Stevens M, Mattews S, Ridout S et al. Coort study of peanut and tree nut sensitisation by age of 4 years. BMJ 1996;313: Grundy J, Mattews S, Bateman B, Dean T, Arsad SH. Rising prevalence of allergy to peanut in cildren: data from 2 sequential coorts. J Allergy Clin Immunol 2002;110: Ewan PW. Anapylaxis. BMJ 1998;316: Seik A, Alves B. Hospital admissions for anapylaxis: time trend study. BMJ 2000;320: Garabrant DH, Scweitzer S. Epidemiology of latex sensitization and allergies in ealt care workers. JAllergy Clin Immunol 2002:110: (Review). 8 Demoly P, Bousquet J. Epidemiology of drug allergy. Curr Opin Allergy Clin Immunol 2001:1; Pepys J. Clinical immunology and te practise of allergy. Clin Allergy 1971;1: Bousquet J. Allergy as a global problem: Tink globally, act globally. Allergy 2000;57: Bielory L. Complementary and alternative medicine population based studies: a growing focus on allergy and astma. Allergy 2002;57: Scäfer T, Riele A, Wicmann H-E, Ring J. Alternative medicine in allergies: prevalence, patterns of use and costs. Allergy 2002;57: Royal College of Pysicians. Allergy: conventional and alternative concepts. Report of te Royal College of Pysicians Committee on Clinical Immunology and Allergy. London: RCP, Royal College of Pysicians and Royal College of Patologists. Good allergy practice: standards of care for providers and purcasers of allergy services witin te NHS. London: RCP, Van Vijk RG. Allergy: a global problem. Quality of life. Allergy 2002;47: xii

12 Executive summary and recommendations Background Tis report discusses te implications for te NHS of te dramatic increase in allergy in recent years, including severe life-treatening and multi-system allergies. Drawing on recent researc on te prevalence of allergic disease in te UK, it reveals te gulf between te need for effective advice and treatment and te lack of appropriate professional services, and proposes a strategy to address tis. Tere is an urgent need for tese proposals to be implemented, given tat te incidence of allergy and related diseases is almost certain to continue to rise. Te report is terefore addressed to te Department of Healt, primary care trusts, ospital trusts, as well as all ealtcare professionals involved in allergy care, including tose in primary care. Allergy and allergy specialists Allergy specialists deal wit a wide range of disorders, suc as rinitis, astma, urticaria, angioedema (including ereditary angioedema), eczema, anapylaxis, and allergy to food, drugs, latex rubber and venom. Tey also ave te expertise to exclude allergy as a diagnosis, allowing te patient to proceed wit oter appropriate investigations. Te above disorders may result from generation of IgE antibody (allergic antibody), but te same disorders and symptoms, eg anapylaxis, drug or food allergy, can occur troug mecanisms tat are independent of IgE. Wilst symptoms may be restricted to one organ for example te nose in ay fever in many allergic disorders tere are systemic effects tat involve several different sites in te body. Allergy specialists undergo a long period of training to acquire te knowledge and experience needed to correctly diagnose and treat bot IgE- and non-ige-mediated allergies. An increasing problem Allergy is an increasing problem in te UK for tree main reasons: Increased incidence Te incidence of allergy as increased dramatically in te UK in recent years and is still rising. Recent studies put te rise as approximately tree-fold in te last 20 years, giving te UK one of te igest rates of allergic disease in te world. Te latest estimates suggest tat one-tird of te total UK population approximately 18 million people will develop allergy at some time in teir lives. Increased severity Te nature of allergic disease as also canged, so a number of severe and potentially life-treatening disorders, wic were previously rare, are now common. As part of te increase in incidence, more cildren are now affected, particularly by previously littleknown food allergies, suc as peanut allergy. Tese are also among te most serious allergies, and accurate diagnosis, advice and treatment are vital. Increased complexity Anoter development is tat patients now usually ave disorders affecting several systems. For example, a cild wit peanut allergy often also as eczema, xiii

13 Allergy: te unmet need rinitis and astma so-called multi-system allergic disease. Poorly controlled astma in a patient wit nut allergy is a risk factor for life-treatening or fatal reactions. Te following statistics, taken from te body of te report, illustrate tese canges (some of tese statistics are underestimates, since allergy can remain undiagnosed): Astma, rinitis and eczema ave increased in incidence two- to tree-fold in te last 20 years. Anapylaxis, a severe and potentially life-treatening reaction, occurs in over one in 3,500 of te population eac year as a result of exposure to substances to wic te sufferer is allergic. Hospital admissions because of anapylaxis ave increased sevenfold over te last decade and doubled over four years. Food allergy is increasingly common and is te most common cause of anapylaxis in cildren. Peanut allergy, te most common food allergy to cause fatal or near-fatal reactions, as trebled in incidence over four years and now affects one in 70 cildren in te UK. Yet only 10 years ago tis was a rare disorder. Drug allergy is also increasingly common. Adverse drug reactions account for 5% of all ospital admissions in te UK. Up to 15% of inpatients ave a ospital stay prolonged as a result of drug allergy. Tese figures do not include te majority of drug allergies, wic occur in primary care and remain undiagnosed and unrecorded. Some 8% of ealtcare workers now ave an allergy to latex rubber, wic in some cases can lead to anapylaxis. Yet until 1979 only two cases of latex allergy ad been reported. Allergic disease currently accounts for 6% of general practice consultations, 0.6% of ospital admissions, and 10% of te GP prescribing budget. Te cost (in primary care, excluding ospital services) to te NHS is 900 million per annum. Current deficits in NHS allergy services Responsibility for te treatment of allergic disease in te NHS is sared between GPs and ospital services. However, tere are tree major problems: 1 Even before te recent increases in te incidence of allergic disease, tere was a sortage of specialists wit te expertise required to give te necessary advice and treatment, and to lead te searc for ways to contain te epidemic : Across te wole country, only six major centres staffed by consultant allergists offer a full-time service wit expertise in all types of allergic problems. A furter nine centres staffed by allergists offer a part-time service. Te remaining allergy clinics in te UK te majority are run part-time by consultants in oter disciplines. However, tey do not ave te facilities to cope wit te rising tide of allergies or wit te problems posed by severe or multi-system allergic disorders. Tere is a marked geograpical inequality in service provision, as most allergy specialists are based in London and te sout-east. Services are extremely poor in te rest of te country. Overall, te provision of consultant allergists is approximately one per 2 million of te UK population, compared wit rates of around one per 100,000 for mainstream specialties suc as gastroenterology, cardiology, etc. xiv

14 Executive summary and recommendations 2 Allergy services in ospitals ave traditionally been provided by different specialists according to te organ system affected; for example, allergic astma is often managed by cest pysicians, allergic skin disorders by dermatologists, and allergic rinitis by ENT specialists. However, most organ-based specialists ave no training in allergy. In addition, te development of severe, multi-system and non-organ-based disorders means tat allergy now as to be considered as a ealt issue in its own rigt. 3 Currently, many allergy cases are dealt wit by GPs, but because allergy as only recently become suc a major problem, te majority of GPs ave no clinical training in allergy. Furtermore, te sortage of specialists means tat GPs often ave no ready source of expert advice. Te skill base needed to develop allergy services wic are led directly from primary care is currently absent. As a result of te problems outlined above, patients generally find great difficulty in obtaining good advice on allergy. Te ealt service lacks te infrastructure to close te gap between needs and services. Tus, te most common reasons for calls to elplines run by allergy carities, eg te Anapylaxis Campaign or Allergy UK, are: My GP does not know about allergy. Tere is no allergy service near me. Te allergy clinic I was referred to did not know ow to elp me. A strategy for addressing te problems 1 Allergy needs a wole system approac in wic allergy is treated as a condition in its own rigt, and not as a series of diseases depending on te organ system involved. 2 Te number of allergy specialists is totally insufficient to meet te need. Proper provision of allergy specialists would mean better access, diagnosis and advice for patients, and would provide a knowledge base from wic primary carers could develop teir services. 3 A more effective partnersip is required between allergy specialists and te primary carers, wo will need to provide te bulk of te day-to-day support for people wit allergy. A ub-spoke network wit allergists supporting GPs and organ-based and oter specialists in local ospitals sould be developed. Recommendations Te recommendations set out in tis report are intended to form te basis for te development of a coordinated service over te coming decade. It is envisaged tat suc a service will progressively become primary care led, wit expertise available from te ospital setting for more severe and complex problems. However, given te current lack of training and knowledge in primary care, initially an allergy service would need to be led by allergy specialists. It follows tat tere must first be an increase in numbers of allergy consultants, as detailed below. Witin te ospital sector, te increase in multi-system and severe allergic disease indicates te need for consultant allergists wo can provide a one-stop-sop approac for patients. xv

15 Allergy: te unmet need General recommendations for an improved allergy service 1 Te provision of allergy care in te NHS must be led by specialists trained in allergy so tat appropriate standards of care can be acieved and maintained. Given te scale of wat amounts to a national epidemic, te front line for allergy management must be witin primary care. However, wit virtually no primary care skill base to work from, clinical leadersip must come initially from specialist centres. Tey will need to take on te dual role of diagnosis and management of te most complex cases, and of supporting te development of capacity witin primary care. 2 Te NHS terefore needs to move forward on two fronts. As an essential first step, more consultant posts and funded training posts in allergy are required. Specialist allergists must become te core leadersip for a national training and clinical development initiative for te wole service. Tey must also provide te essence of a genuinely national allergy service for te NHS. Te creation of tese posts, and teir appropriate service development context, requires a recognition of need by te Department of Healt, te Workforce Numbers Advisory Board, primary care trusts, regional commissioners and trust managers. 3 Te report proposes te setting up of appropriately staffed regional allergy centres evenly distributed across te wole country. Based on te service models wic exist in tose parts of te UK fortunate enoug to ave establised specialist centres, tey will give equality of access to appropriate allergy services for adults and cildren in all parts of te country. Tey will also provide expertise and lead te development of oter local services, networking wit organbased specialists and GPs. 4 Regional commissioning for specialist allergy must also be implemented. Tis will require central direction. Te specific recommendations of te report are grouped below under five eadings. Specific recommendations Regional allergy centres 5 Te working party endorses te recommendations of te Britis Society for Allergy and Clinical Immunology (BSACI) tat eac of te eigt NHS Regions in England (as configured in 2001, eac wit a population of approximately 5 7 million), as well as Scotland, Wales and Nortern Ireland, sould ave an absolute minimum of one regional specialist allergy centre. 6 Staffing levels required to set up a new regional centre or develop an existing one are as follows: a minimum of two new/additional (wole time equivalent) consultant allergists (for adult services) offering a multidisciplinary approac. Tis is te minimum requirement to provide necessary cover for diagnostic procedures and specialist treatment. a minimum of two full-time allergy nurse specialists one alf-time adult dietitian and one alf-time paediatric dietitian wit specialist training in food allergy two consultants in paediatric allergy, supported by paediatric nurse specialists and dietitians wit expertise in paediatric allergy facilities for training for two specialist registrars in allergy (in some centres). xvi

16 Executive summary and recommendations 7 Te regional centres sould: provide specialist expertise for adult and paediatric allergic disease trougout teir Region (tertiary care), including allergic disorders recognised for regional commissioning manage allergic disease in te local population wic cannot be dealt wit in general practice (secondary care) act as an educational resource for te Region network wit and facilitate local training in allergy for organ-based specialists and paediatricians support training at local level for GPs and nurses in te management of common allergies in primary care. Trainees in allergy 8 In order to create new consultant posts, it is essential to increase te number of trainees in te specialty. Tere are now only five trainees nationally. 9 Te lack of trainees is creating a planning bligt, because NHS trusts wising to create new consultant posts cannot readily find suitable applicants. Te Department of Healt and te Workforce Numbers Advisory Board must recognise te need and provide for more funded training posts in allergy. Despite te pressing case for an increase in specialist registrar numbers, and a provisional agreement for seven additional funded posts, allergy as been allocated no new funded posts for Oter consultant posts in allergy 10 In addition to regional allergy centres, furter consultant allergist posts need to be created in oter teacing ospitals and district general ospitals in eac Region to deal wit local needs. All teacing ospitals sould ave an allergy service provided by a consultant allergist. One model migt be for a sared appointment between trusts. Tis sould follow te establisment of regional centres. Training in allergy for primary care 11 Primary care must ultimately provide te front line care for allergy but considerable development is needed. 12 Te training of GPs and practice nurses in allergy needs to be improved. A key part of tis will follow from interaction wit consultant allergists, and te inclusion of clinical allergy training in te undergraduate medical curriculum. Tere are currently a number of allergy courses for GPs and practice nurses, eg troug te National Respiratory Training Centre, Soutampton University, or one-day training courses run by te BSACI. However, a muc more compreensive nationwide approac is needed, covering primary care training across te NHS. Te development of general practitioners wit a special interest (GPSIs) in allergy, trained in and linked to regional centres, sould support tis. xvii

17 Allergy: te unmet need Organ-based specialists wit an interest in allergy 13 Organ-based specialists will continue to contribute to allergy care and ave primary responsibility for patients wit astma and eczema, in patients wit single-organ involvement. Tey sould network wit te specialist allergist wo can act as a resource in identifying/ managing allergy. Te increase in allergy means tat greater awareness of te contribution of allergy in tese organ-based specialties is important. Summary Te NHS is currently not coping wit te size and nature of te problems presented by allergy and related conditions. In order to develop a coerent model of service delivery, wic would eventually be primary care based but networked to specialist allergists, major allergy centres must first be developed in all parts of te country. Tis requires te urgent creation of more consultant posts and training posts in allergy. Tese are key to: te improvement of patient care te prevention of severe and fatal allergic reactions te development of a coordinated allergy service understanding and containing te allergy epidemic. xviii