CLINICAL MANAGEMENT

Published: 30/06/2005, Volume II5, No. 5962 Page 30 31 32

One third of the population are likely to suffer from an allergy at some point in their lives. But, as David Price and Sue Cross report, despite a highly critical report from the Commons health select committee there is still no national allergy service. Starting opposite, Ann Dix looks at primary care initiatives to improve services and reduce hospital referrals

In recent years, the incidence of allergy in the UK has increased dramatically, its prevalence rising about threefold in the past 20 years. The latest estimates suggest that one-third of the population - approximately 18 million people - will develop allergy at some time in their lives.

Yet allergy is drastically under resourced, with lack of access to appropriate services resulting in unnecessary healthcare complications. Allergic disease accounts for at least 6 per cent of general practice consultations, 0.6 per cent of hospital admissions, and 10 per cent of the GP prescribing budget. The cost to the NHS in primary care alone is£900m per annum.

The nature of allergic diseases is also changing.

Serious and previously rare disorders are now commonplace (eg nut allergy, anaphylaxis, drugrelated allergic reactions), with life-threatening peanut allergies demanding accurate diagnosis, advice and treatment. Anaphylaxis, a severe and potentially life-threatening reaction, occurs in more than one in 3,500 of the population each year. Hospital admissions for anaphylaxis have increased sevenfold over the past decade and doubled over four years.

Allergies are also increasingly affecting children, and many are now presenting with complex disorders that affect several organ systems. For example, a child with peanut allergy often co-presents with eczema, rhinitis and asthma, resulting in a very convoluted and expensive care pathway. Peanut allergy, the most common food allergy to cause fatal or near-fatal reactions, has trebled in incidence over four years and now affects one in 70 children in the UK.

Responsibility for the treatment of allergic disease in the NHS has traditionally been shared between GPs and hospital services. However, this presents three major problems.

The first is a shortage of allergy specialists.

Only six major centres staffed by consultant allergists offer a full-time specialist allergy service, with a further nine staffed by allergists offering a part-time consultancy. There is also marked geographical inequality in service provision as most allergy specialists are based in London and the South East.

Overall, the number of consultant allergists is approximately one per 2 million of the UK population. This compares poorly with mainstream specialties such as gastroenterology and cardiology, which have rates of around one per 100,000.

The second problem is that the choice of secondary care specialist has traditionally been governed by the organ system most badly affected. For example, allergic asthma is often managed by chest physicians, allergic skin disorders by dermatologists, and allergic rhinitis by ear, nose and throat specialists. However, most organ-based specialists receive no specific allergy training, and the recent increase in severe, multisystem and non-organ based disorders means that allergy now should be considered as a health issue in its own right.

Third, most primary care practitioners have no clinical allergy training and the shortage of specialists means they often have no ready source of expert advice. Consequently, the skill base needed to develop allergy services, which are led directly from primary care, is absent. As a result, patients with allergies generally have difficulty in obtaining consistently sound medical advice.

Successive reports have highlighted these problems and suggested much-needed improvements in allergy services. The most recent was a highly critical Commons health select committee report at the end of last year, which found 'a large and growing gap between need and appropriate allergy care within the NHS'.

It found a serious shortage of specialist hospital services, with no specialist allergy centres north of Manchester or west of Bournemouth. It found 'those working in primary care lack the training, expertise and incentives to deliver services'.

'Without an adequate specialist service, primary healthcare professionals do not receive the necessary clinical training, nor are they supported when managing more complex cases within primary care.

Further, they are not able to refer the most serious or complex allergy appropriately, ' it said.

The report called for the creation of a national allergy service to give patients equitable access to specialist care and support the development of primary care skills and expertise. This included the development of regional centres and an increase in the number of allergy consultants.

But it also called for frontline allergy provision to be driven by primary care and for GPs and nurses to receive specialist allergy training, creating a tier of practitioners with a special interest in allergy (Allergy PwSIs). This would need to be driven by the network of specialist centres. But because these would take time to set up, the report recommended the immediate creation of a national primary care allergy network, with a named lead in each primary care trust to improve primary care services.

The recommendations echo those of a Royal College of Physicians report in June 2003.

This stressed the need for a 'whole system' approach in which allergy is treated as a condition in its own right and not as a series of diseases depending on the organ system involved.

It called for more effective partnership between allergy specialists and primary carers through the creation of a hub-spoke network, with allergists supporting GPs and organ-based and other specialists in local hospitals.

So far the government has failed to act on these recommendations. In its response to the health select committee report at the beginning of this year, it claimed that further research was needed to determine 'the correct future direction for allergy services' and provide the 'evidence base' for improving specialist services for allergy sufferers.

While it agreed that PwSI provision would help to ensure that more serious and complex allergies could be treated within the local community, it said that primary care services should be driven by local need. It recommended that individual PCTs assess the needs of their local community and determine whether they would be best served by commissioning services from PwSIs, and/or by providing training and accreditation for practitioners who wish to specialise.

Some GP practices and PCTs are already improving local allergy services by setting up allergy clinics in primary care. For example, Harrow PCT is funding a dedicated allergy clinic as an enhanced service run jointly by a GP and a nurse (see box, previous page).

Others are linking allergy care to existing practice-based asthma services (see box, bottom left). Approximately 76 per cent of asthmatic patients also report symptoms indicative of rhinitis and its co-morbid impact is known to be profound, with recent findings demonstrating that allergic rhinitis and asthma are two clinical manifestations of a single airway disorder.

Compared to patients with asthma alone, patients with concomitant allergic rhinitis need significantly more asthma-related hospitalisations and GP visits, and incur higher asthma-related drug costs. In addition, population-based studies have shown that patients with both diseases also have substantially greater quality-of-life impairment when compared to patients with neither disease or with allergic rhinitis alone.

Allergy training for GPs and nurses is available from the National Respiratory Training Centre or the charity Allergy UK. In addition, the General Practice Airways Group website has asthma and allergy-related resources for primary care professionals, including audit material, details of research activity and a discussion forum.

Much can also be done by embracing local pharmacy-based allergy services. Some local pharmacists will offer general allergy advice and patient-focused allergy materials. A working knowledge of the extent of these local services will help to ensure continuity of care. l David Price is professor of primary care respiratory medicine, Aberdeen University, and Sue Cross is associate director of primary care nursing for Bedfordshire and Hertfordshire, the Eastern Deanery.

Send your ideas and contributions for the Clincal Management section to ann. dix@emap. com

HOLISTIC HELPER

THE NURSE SPECIALIST

Since nurse specialist Jenny Willington set up an allergy clinic in her practice in Stowmarket, Suffolk, demand has outstripped supply without any need to advertise the service.

Ms Willington completed a two-year Allergy UK diploma course, but says: 'I think I am the only one from my course who has got time dedicated to allergy... we regard it as part of our chronic-disease management.' In her twice-weekly clinic, she spends an hour with each patient.

'I look at the patient as a whole, and give them holistic advice on managing their condition.' She says the benefits are improved access and care for patients and a reduction in GPs' workload, particularly in emergency appointments. She believes it also reduces unnecessary hospital referrals.

'Because the symptoms can be very confusing, it can be hard for a GP to tell if it is allergy or something else.' Before the service, patients were more likely to be referred to 'several different consultants, with no-one coming up with an answer'.

But she stresses that the overall number of hospital referrals have stayed the same. This is because the practice has always had 'very strict referral criteria' and 'because we had a very large cohort of patients who should have been formally assessed and diagnosed, but were not'.

TWO'S COMPANY

WHERE ASTHMA AND ALLERGY MEET

The Langworthy Medical Practice in Greater Manchester has run an integrated allergy and asthma clinic since 2003.

A large student population means levels of asthma and allergy are high among the practice's 1,200 patients. The nurse-led service was set up to improve access to accurate and timely diagnosis, facilitate better patient selfmanagement and provide a point of contact for patients to help prevent deterioration of existing conditions. Up to 20 patients are referred each week by their GP or present on an ad hoc basis.

It was also hoped the service would reduce referrals to secondary care. Since its inception, fewer than one patient a month has been referred to the local hospital, usually due to unmanageable nasal or skin symptoms or a newonset food allergy.

Nurse practitioner June Roberts explains that the rationale behind setting up an integrated clinic was that: 'A lot of patients with asthma have co-morbidity with allergic disease.' The idea is to effectively manage them in a single surgery visit.' Ms Roberts trained at the National Respiratory Training Centre. Many nurses are asthma trained, so setting up an integrated clinic can be simple, she says. 'If You have got the will and manage to get the extra training you can make a measurable difference to patients.' But she adds that there are no plans to set up a PCT-wide service because of lack of funding. Previous attempts to 'invigorate allergy services in the North West met with little interest from the PCT because It is not a high priority', she said.

SIX MONTHS TO MAKE CLINIC WORK

'A year of nagging and a good proposal, ' is how Harrow GP Dr Mark Levy (pictured left with allergy nurse specialist Samantha Walker) explains his north London practice's success in securing agreement for a primary care trust-wide allergy service.

But as Dr Levy, founder of the GP in Airways Group and a clinical research fellow at Edinburgh University, concedes, the real challenge is yet to come.

Harrow PCT, which is funding the clinic as an enhanced service, is giving the service six months to demonstrate that it can reduce unnecessary hospital referrals. 'If in six months we do not perform, we will not get any more money, ' says Dr Levy.

The practice has operated an allergy clinic for the past 18 months, serving patients from five GP practices.

Ms Walker has been running the service, but PCT funding will now allow an expansion to cover 39 practices.

The clinics will be run jointly by Ms Walker and Dr Levy and will operate for half a day a week, assessing and diagnosing patients with suspected allergy.

They will also give patients advice on self management and, where necessary, refer patients back to their GP with treatment recommendations or on to specialist care.

Dr Levy says: 'The aim is to improve the quality of care for patients by improving symptoms and quality of life, and to screen out those patients who can be managed in primary care from those that need to be referred to specialists.' The PCT has awarded six months' funding to treat 162 patients at a cost of£81 per patient - a fraction of the cost of a hospital outpatient appointment, he says.

Patients will be seen within two weeks of referral and an evaluation of the service will include asking referring GPs to state whether they would have referred the patient to secondary care had the service not been available.

Ms Walker, who works mainly at the National Respiratory Training Centre, has a PhD in allergy and immunology, and has 15 years' experience of specialist allergy clinic work, says many suspected cases of allergy turn out to be something different.

She adds that as long as staff are appropriately trained, most patients with allergies can be managed in primary care.

'We can manage most things here unless they are potentially life threatening, or present anomalies.'

Further reading

Allergy: the unmet need. A blueprint for better patient care, Royal College of Physicians. June 2003.

www. rcplondon. ac. uk/pubs/books/allergy/allergy.pdf

Department of Health. Government desponse to the Commons health committee report on the provision of allergy services www. publications. parliament. uk/pa/cm200304/ cmselect/cmhealth/696/69606. htm

www. dh. gov. uk/assetRoot/04/10/08/56/0410085 6. pdf

General Practice Airways Group

www. gpiag. org

National Respiratory Training Centre -www. nrtc. org. ukm Allergy UK.

www. allergy. uk. org

Key points

Allergic disease accounts for 6 per cent of GP consultations and 0.6 per cent of hospital admissions.

A highly critical report by the Commons health select committee called for the development of a national allergy service, but the government has failed to act.

Pr imary care t rusts can help to improve local al lergy services by commissioning practice-based allergy clinics or integrated allergy/asthma services.