Health: Allergy (Science and Technology Committee Report)

rose to move to move, That this House takes note of the report of the Science and Technology Committee on allergy (6th Report, Session 2006-07, HL Paper 166). The noble Baroness said: My Lords, it has been a great privilege to chair the committee and to introduce the debate today. The members of the committee who conducted this inquiry were notable for their enthusiasm and commitment to the subject. I know that they would wish to join me in expressing our great gratitude to our hard-working Clerk, Sarah Jones, and our wise specialist adviser, Professor Barry Kay, as well as to all who gave evidence to us, informed our seminars or hosted our visits in the UK and abroad. The report and its recommendations have been warmly received in the allergy community by professionals and patients alike and extensively covered in the media. Several authoritative reviews of clinical allergy services preceded our report, and all of them noted serious deficiencies. Against this backdrop, we set out to look at the wider social and economic implications of allergy. Yet as the inquiry developed, it became shockingly apparent just how severely allergic diseases could impair people’s quality of life and how, despite our track record of high-quality research in the field, allergy services in the UK lag far behind those of other European countries through a severe shortage of allergy specialists. During our inquiry, we heard of children with allergies who sleep poorly by night and are bullied at school by day, and whose hay fever impairs their performance in summer exams. We learnt that the workplace environment can cause or so exacerbate allergic symptoms that some adults are forced to give up work. Yet there is no clear guidance about what to do next or how to control their symptoms. We heard of fatal anaphylaxis, particularly through insect stings and food allergies. We found that we could not quantify the problem, the full health costs of allergies or the economic burden to society, because the reporting systems in the NHS do not code specifically for allergy per se. We did discover, however, that prescriptions for allergy symptoms cost nearly £1 billion a year—about 11 per cent of the total community drugs budget. We made many recommendations in the report, some of which are key to improving the situation rapidly for sufferers. The bulk of the key recommendations concerns the woeful deficit of clinical allergy services in the UK—a deficit already severely criticised in reports that preceded ours and for which the Government presented no convincing remedial plan in evidence to us. Other key recommendations were: the urgent need for the education of healthcare professionals about allergy and of those in catering about handling food allergens; the importance of research into the causes and factors that exacerbate allergy, as well as ways in which to prevent allergies, particularly peanut allergy, from developing in the first place; the adoption of immunotherapy in treatment in the UK, because it is not happening yet; and better support in schools for children with hay fever and other allergies. Without implementation of these key recommendations, our other recommendations on monitoring allergy, air pollution, occupational rehabilitation, advice to parents and the urgent need to evaluate complementary therapies and diagnostic kits would have relatively little effect. There are only 26.5 whole time-equivalent allergy specialists, many of whom are clinicians funded through research rather than the NHS, compared with several hundred specialists in some European countries. Of the 94 allergy clinics in England, only six are led by a full-time allergist. The others are uni-disciplinary clinics, which are held a couple of times a week and led by organ-specific specialists working in relative isolation. Pitifully few services of any sort are available in the north and west. The lack of allergy-service infrastructure is mirrored by a serious lack of allergy knowledge amongst clinicians at all levels, particularly in primary care. Even when a GP recognises that a patient needs to be referred, it is hard to identify who to refer to, and some patients resort to attempting self-diagnosis using inappropriate and unproven tests. Furthermore, the answer to better diagnosis in primary care is not pedalling diagnostic kits, but education, education, education, because misleading false positives abound without an accurate history and a proper clinical examination. We saw a very different picture in Denmark, where the various specialists work collaboratively to provide an efficient diagnostic and management service for patients. With the financial constraints of the NHS, we accept that it would be unrealistic to call for the immediate training of hundreds of dedicated allergists, but we do feel that more need to enter training. However, we suggest the harnessing of the pockets of allergy expertise that already exist by clustering the various specialists to work together in designated allergy centres. This would not require a vast amount of additional funding and could be implemented quickly. At least one allergy centre led by a full-time allergy specialist should be established in each strategic health authority area, bringing together those who already have a special interest in allergy: from chest medicine, dermatology, occupational medicine, ENT, paediatrics, clinical immunology and gastroenterology, with support from specialist nurses and dieticians. Each centre of excellence would form a hub where clinicians working together would learn from each other and provide expertise to investigate and diagnose complex allergies and guide management plans. They would also guide management plans as the patient goes back to their GP for their care to be monitored in an ongoing way. In a hub and spokes model, the centre could also provide outreach clinical services across their region and be a single point of contact and co-ordination, especially for those patients with complex, multi-system allergic disease, and for other clinicians with a special interest in allergy. The centre would provide outreach education to both primary and secondary care. It would also be a resource for patients, so that feedback between patients and the centre would guide development and disseminate new research evidence. The centre itself would then foster research, particularly engaging the patient’s voice in research development within its area. In their response, the Government reverted to their well-worn argument that responsibility in a devolved NHS rests with local commissioners, but acknowledged that our suggestion merited careful consideration. Since publication, I have met the Minister, Ann Keen, and the Minister in this House, the noble Lord, Lord Darzi, both of whom expressed their enthusiasm for such a pilot project. Moreover, Professor Custovic from Manchester has informed me of a prime opportunity in the north-west where a framework and business case for just such an allergy service has been developed and locally endorsed by the specialised commissioning group, but the only thing holding it up has been funding. So I look forward with great anticipation to hearing from the Minister about progress made by departmental officials who were going to explore this with stakeholders, and I hope that he will have a positive response to announce today. I am grateful to him for his work and for his recognition of the importance of developing a pilot centre. We on the committee see the clustering of expertise in allergy centres as the most important way of ensuring that the other changes are championed and followed up in order to improve the health of millions of people suffering from allergic diseases in the current allergy epidemic. I turn to therapy. Although we were not investigating appropriate ways to diagnose and treat allergic conditions, the argument to support immunotherapy in order to desensitise patients suffering from hay fever and venom anaphylaxis became evident. In Germany and Denmark we saw the efficacy of immunotherapy and realised why we had been told that the NHS is the laughing stock of Europe for its absence of immunotherapy for allergic diseases. We are puzzled that new immunotherapy products are licensed in the European Union, but the MRHA has not approved them in the UK. It is also disappointing that NICE has told us that there are no plans to carry out an appraisal of this type of treatment for allergy sufferers. Prevention is certainly better than cure. Excellent research, largely from the UK, has elucidated allergic mechanisms and genetic susceptibility, but the way the immune system develops in infancy on exposure to allergens remains poorly understood. Environmental factors which can exacerbate allergies, such as dust mites and damp housing, have been implicated in the genesis of allergy. But, as was pointed out to us, everyone lived in damp, cold housing 100 years ago and there was much less allergy. Even the hygiene hypothesis which has featured a lot in the press, we discovered, may be somewhat inconclusive. So we recommended that long-term cohort studies warrant support to explore the effect of environment on the inception, prevention or exacerbation of allergies. School poses particular hazards for children with allergies. Eczema is itchy and disfiguring and treatment creams are potentially stigmatising. Hay fever sufferers under-perform in summer examinations, dropping a grade compared with their winter mocks at times, and support varies widely between schools. For food allergic children, casual contact with food allergens can precipitate fatal anaphylaxis. Some suffer terrible bullying when other children put nuts into their pockets or lunchboxes to try to contaminate their food, yet school staff do not necessarily know how to deal with anaphylactic emergencies. That is why we called for a review of the care of hay fever sufferers, particularly schoolchildren during exams, for approved allergy training of staff and a review of the case for schools holding generic adrenaline auto-injectors. So why did the Government brush these aside quite so dismissively? Hospital admissions for anaphylactic shock rose sevenfold from 1990 to 2004 but the true number of deaths remains unknown. Potentially fatal anaphylaxis can occur anywhere and probably a fair number of drug reactions are actually allergic reactions to the medication given. For people with food allergy, eating out is particularly hazardous and food shopping presents a minefield because food labels are inconsistent, confusing and offensive, with warnings so overused that teenagers tend to ignore them. So we recommended greater accuracy on food labels to clearly specify known allergens in the product. Almost 26,000 people in England have known peanut allergy and yet, on one of our visits to the Evelina children’s hospital, we learnt that in countries such as Israel peanut in weaning foods seems associated with low rates of peanut allergy. This evidence has inspired Professor Lack’s study. His hypothesis is that the avoidance of peanuts during pregnancy and infancy may be contributing to the epidemic. That led us to recommend the Department of Health to withdraw its out-of-date advice on peanut consumption. No other Government advise peanut avoidance in pregnancy. I ask the Minister when the review commissioned from the Food Standards Agency and the Committee on Toxicity will be available. I understand that those bodies have been charged with reviewing the subject. About one-third of the population will develop symptoms due to allergy at some time, and these are not trivial problems. Today’s debate is particularly timely as the seasonal problems of hay fever, insect stings and plaque dermatitis resurge to join the perennial food and other allergies. I have been able to cover only the areas that the committee felt required the most urgent action, particularly the need to cluster expertise together to form centres of clinical excellence. Many groups are anxious to see the report’s recommendations implemented. The allergy epidemic continues and people are demanding better clinical services, reliable advice on food and better support at school for children with allergies. We hope the Minister shares our vision to improve allergy services. I am sure that he recognises the enormous public interest in the subject and I look forward—as does the committee—to his responses today. I beg to move. Moved, That this House takes note of the Report of the Science and Technology Committee on Allergy. 6th Report, Session 2006-07, HL Paper 166.—(Baroness Finlay of Llandaff.)