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Remarks on UK Allergy care at
present, and a hope for the future |
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During the 20th century the development of clinical allergy was a
piecemeal process during which the allergists of the time made great
efforts to identify the causes of their patient’s problems, as there
were no really effective drugs until around 1950. Crude allergen
extracts provided a means of diagnosis by skin testing, and also
treatment by desensitisation.
Allergy was a mysterious and often frustrating problem, and close
attention to the case histories of the patients was often the only
way to reach a diagnosis. A tremendous amount of clinical research
took place between the wars, mainly in the USA. The top allergists,
many of whom I have had the privilege to meet, became very skilled
in identifying the causes of their patients sufferings, often
including eczema. The published research in the American journals in
the thirties and forties makes fascinating reading, but now gathers
dust in the basement of the Library of the Royal Society of
Medicine.
The introduction of corticosteroids and antihistamine drugs from
1950 onwards revolutionised the treatment of allergies and many
other diseases, but the side-effects soon became evident. For the
first time symptoms of allergic disease could be suppressed no
matter what the cause might be, making it less important to discover
and if possible eliminate the cause of the allergy.
It has been said, with some truth, that steroid creams were so
effective that there was no longer much incentive for dermatologists
to think about what was causing the eczema. On the other hand it is
also obvious that had it not been for the development of effective
and powerful drugs for asthma in the last fifty years the current
allergy epidemic would have been a national emergency with many
deaths.
In the last fifty years the scientific study of allergic reactions
in laboratory animals and in man, and the identification of mediator
chemicals, has made tremendous strides in explaining what happens
when an allergic reaction takes place. These scientific developments
have involved very advanced techniques in immunology, biochemistry,
genetics, and many other scientific disciplines. Although most
scientists involved in allergy research do not have medical
qualifications, their discoveries may have considerable impact on
clinical practice. A great deal of this fundamental research is
supported by the pharmaceutical industry because the discovery of
new and effective drugs can be very profitable.
The development of many scientific tests in the last fifty years has
been phenomenal, but can be abused by ordering a battery of tests
hoping the answer will turn up. Also it is tempting to ask for
another test to exclude some remote possibility, thus enabling a
decision to be deferred until the result has been received. I think
that the introduction of more and more laboratory tests into medical
practice can result in undue reliance on tests at the expense of the
interactive cooperation with the patient which is so essential in
solving allergic problems. In the final analysis the establishment
of a good old-fashioned doctor/patient relationship is essential,
and it is the doctor who has to assess the significance of the test
results.
Although much more science is involved in medical practice today,
the art of medicine is still of paramount importance when treating
and investigating allergic patients. I feel strongly that we may not
always take full advantage of the fact that, unlike laboratory
animals, patients can tell us how they feel, keep records, give a
detailed history, ask questions, record their symptoms and be
willing partners in clinical research.
 The Development of Effective Medicines
 When
I achieved my first medical qualification there were so few really
effective drugs that I have difficulty in remembering more than ten.
Today we are spoiled for choice, as dramatically illustrated by this
picture of a lady made up entirely from tablets, coloured with dyes
which sometimes cause allergic reactions. Nowadays patients usually
go to the doctor seeking a pill to relieve symptoms. Perhaps the
doctor’s hidden employer has become the pharmaceutical industry, as
our dependence on medication, especially for allergies, is nearly
total.
Is 'joined-up'
medicine no more?
Patients often complain that they seldom see the same
doctor twice nowadays, but the NHS administration will be satisfied
as long as they are seen by a properly qualified person, who may
have neither the time nor the inclination to read the thick notes of
a chronic case if they are unlikely to see them again.
At hospital out-patients too the chronic patient may be seen by a
junior doctor in a short-term job who will read only the last
report, make no change in treatment unless necessary, and make
another appointment which will probably be after he or she has gone
elsewhere. Thus the notes get thicker and thicker, the patients get
a poor service, and they will seldom be discharged from the clinic.
In my opinion continuity of care is very important for the doctor as
well as for the patient in the management of any chronic problem,.
Consulting the same doctor every time facilitates the establishment
of a personal relationship and respect, and also makes medical
practice more satisfying and interesting for the doctor as well as
the patient. This ideal situation may be difficult to establish in a
modern medical centre which has succeeded the old family doctor who
often knew his patients personally from cradle to grave. The
impersonal type of practice of today must tend to be as boring for
the doctor as it is unsatisfactory for the patient.
Allergy Specialisation in
the NHS
Over the last fifty
years phenomenal developments in medicine and in surgery have saved
many patients who would otherwise have died. Their continued
survival is dependent on new drugs and innovative new techniques,
thus creating a requirement for more and more specialised doctors
and other health professionals to care for them, and an increased
burden on the health services.
The growth of special interests in one part of the body could be
said to resemble a group of children who have each taken over a
piece of the family business, and expanded and developed it to a
variable extent. They soon develop their own jargon, so they have
difficulty in understanding one another, and they scrabble for their
share of resources for more development. Today the ‘jack of all
trades’ general physician or surgeon has all but disappeared, and
the barriers between the specialities become ever higher. The family
doctor may be the only surviving general physician dealing with all
sorts of problems, but the allergist also has general interests
which ignore these barriers.
For specialities where other organ systems are seldom involved
specialisation is excellent, but allergy can affect any part of the
body, encroaching on dermatology, ear nose and throat, respiratory
medicine, gastroenterology, paediatrics, etc. etc. The development
of the specialities and the decline of the generalist has led to
more frequent cross referrals from one specialist department to
another. Many consultants are unaware of the wide scope of allergic
diseases and their potential to involve any one or even several
organ systems, and in the UK it is most unusual for there to be an
allergy department to which patients can be referred for advice.
Since the inception of the NHS in 1948 every other medical
speciality has flourished and expanded, while clinical allergy has
failed to become established as a major speciality, and almost
disappeared a few years ago The primary reason is the lack of even
elementary instruction regarding allergy in most medical schools,
plus the fact that since 1948 not one of the physicians who had a
special interest in allergy were replaced on retirement by anyone
with the same interests, including myself.
I consider myself most fortunate to have
served the British National Health Service when it was possible to
take an initiative without bureaucratic interference, and to have a
happy research collaboration with many allergic patients. They
helped me and taught me a great deal, and all I have done is tried
to make sense of what they told me, sometimes discovered the reason
for their problems, and sometimes actually effected a cure.
Recent
developments in the Speciality of Clinical Allergy
The increasing
allergy problem was belatedly recognised by the Royal College of
Physicians, who laid down the training requirements for allergists,
established a code of best allergy practice, and finally published a
report entitled the “Unmet Need” for an allergy service in 2003.
The initial response to this report by the Ministry of Health was to
state that the NHS is coping “reasonably well” and that there was no
evidence of this “unmet need”. This response really meant that
because there was no allergy service to which patients could be
referred, there was no demand for an allergy service!!! Increasing
pressure from the Royal College, allergy charities, and the public
intensified, eventually resulting in an enquiry by the House of
Commons Select Committee on Health in 2004.
This committee listened patiently to all the evidence and issued a
two volume report
healthcom@parliament.allergy which condemned NHS provision for
allergic disease as totally inadequate, and made very encouraging
suggestions, such as:-
“It is imperative that specialist clinics should be developed across
the country-----a minimum of one specialist allergy centre should be
established in each NHS region” ….. “The first crucial step towards
developing an NHS allergy service is for the Department of Health to
endorse and underwrite the creation of additional consultant
allergist posts----------20 new allergy doctors beginning in 2005,
and a further 20 in 2006-9” and “ we believe that a start on this
work must be made NOW”
Practically all the recommendations of the Health Committee were
accepted by the Government, giving the impression that things were
really going to happen at last, although there are so few specialist
registrars on a five year training course that there was clearly no
way that twenty new consultants could be found unless they were to
be imported from overseas.
On closer reading, however, the Governmental response consists of
fourteen pages of masterly obfuscation worthy of Sir Humphry in “Yes
Minister” which ended by asking for reviews of “ all the available
data and research on the epidemiology of allergic conditions.” This
will ensure a delay of many years before any action has to be taken,
and completely ignored the fact that adequate published evidence is
already available from research carried out in the UK and in Europe
which formed the basis of the Royal College of Physicians Report.
Since then there has been another House of Commons Committee and one
from the House of Lords, but apart from the appointment of a few
consultant allergists nothing has transpired.
To quote further
from the Governmental response to the Health Committee:-
“It is vital that the
action to improve allergy services should have the support of all
the many practitioners and organisations involved------------, as
well as the allergy sufferers themselves. The Department of Health
and the NHS will therefore need to work not only with practitioners
who currently specialise in allergies, but also with specialists in
other key areas such as immunology, respiratory disease,
dermatology, and nutrition as well as with GPs, with community
nurses and health visitor, with schools and with patients
themselves”
It is not difficult to imagine how many discussion papers and
time-wasting meetings will be generated by this suggestion,
especially as knowledge about allergies in all these groups is very
limited. A further extract reads:-
“The responsibilities for local health services are now firmly in
the hands of the Primary Care Trusts,
including the needs
for the allergy services”. It
would be very surprising if more than a few medical advisers to the
PCTs know anything about allergy, or appreciate the the impact of
chronic allergy on the health and quality of life of millions of
sufferers.
Effects of the
new Coalition Government
The change of government means that a new set of politicians have to
be indoctrinated regarding of the severity of the allergy problem,
and stimulated to do something about it.
In recent years the British Society for Allergy and Clinical
Immunology (BSACI) has been exerting increasing pressure on the
Ministry of Health, where the officials do not change, and appear
not to realise the seriousness of the problem. It is very unlikely
that medically qualified administrators in the Ministry of Health
have knowledge of allergies or any appreciation of the effects of
chronic allergic diseases on quality of life, employment, and
education.
To stimulate awareness in the House of Commons the ‘National Allergy
Strategy Group’ has been organised to link patients, doctors, and
politicians , and held a reception at the House of Commons last
December. There is also a Primary Care Committee and a Nurses in
Allergy Group, and pressure on NICE recently resulted in publication
of a Food Allergy Guideline for all doctors . Six new consultant
allergists were appointed in the last year, as a result of previous
representations, and the new Evalina Hospital for paediatric allergy
is flourishing .
. The proposed health bill has led to chaos in the NHS. The
suggestion that general practitioners are placed at the top of the
NHS tree instead of the bottom could be very encouraging but for the
fact that knowledge of the allergy problem is uncommon.
A practical solution which I have been proposing for years without
success, is that allergy could be a satisfying sub-speciality for
one member of today’s large medical practices to choose. In the past
I have personally proved that with some basic training for
practitioners it is quite possible to deal effectively with most
allergic problems in primary care,. This would be the most rapid and
effective way to cope with the “unmet need”, leaving the difficult
problems for the true specialist allergists..
But it is going to take much time to build a comprehensive allergy
service within the NHS. Perhaps there will be a good service in
about twenty-five years time?
In conclusion I would like to acknowledge the kindness of my good
friend Dr Bill Frankland, the doyen of British clinical allergy, who
survived a Japanese POW camp and is now in his 99th year. He has
read my manuscript critically, corrected errors, and in many ways
encouraged the birth of my website.
Dr. Frankland succeeded John Freeman, who first used desensitisation
in 1911, as consultant in charge of the Allergy Department at St.
Mary’s Hospital, Paddington, subsequently at Guy’s Hospital, and now
the London Allergy Clinic.
(This website revision
- June 2011 - by
Graeme G Storey)
In my opinion the current
official attitude towards the provision of an effective Clinical
Allergy service is aptly illustrated by this cartoon:
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