Should UK allergy services focus on primary care?

The marked increase in the prevalence of allergic disease over the past few decades has left the NHS ill prepared. In response to the Health Select Committee's damning report in 2004 on allergy services,¹ the Department of Health and the Scottish Executive are currently reviewing all aspects of provision of allergy care. Their separate reports will be published shortly. A key question is whether it would be more effective for the NHS to emulate the model used in other parts of Europe and North America and invest in expanding specialist services for allergy or—more controversially—to concentrate efforts on developing primary care services. This choice will have substantial and lasting implications for people with allergies in the United Kingdom and will probably affect the thinking of policy makers in other parts of the world who are grappling with similar rapid increases in the prevalence of allergic disease.

Around one in three of the UK population have allergic symptoms at some point in their lives.² Localised or organ specific allergic disorders such as atopic eczema, allergic rhinitis, and asthma are common, and small but increasing numbers of patients are now also experiencing more acute systemic allergic disorders such as anaphylaxis.³ Multiple allergies are common, affecting an estimated 10% of children and young people (< 45 years) and 5% of older people and are particularly problematic to manage, both for patients and healthcare providers.²,⁴,⁵

Most patients with allergic problems manage their own conditions and seek help from their primary care teams when necessary. Some also need support from general paediatricians and specialists such as chest physicians and, in some regions, from clinical immunologists and allergists. However, this model of care has serious drawbacks.¹

Most doctors trained in the United Kingdom have had few opportunities for undergraduate or postgraduate training in the diagnosis, assessment, and management of patients with allergic problems. Also, accurate diagnosis is hampered by the difficulty in obtaining, financing, and interpreting simple diagnostic tests, such as skin prick and specific IgE testing. Furthermore, in more complex cases needing specialist advice the lack of allergy specialists means that primary care teams typically have little choice but to refer to local specialists with limited expertise in managing multisystem disease.

Patients often have to see more than one specialist—for example an ear, nose, and throat surgeon for allergic rhinitis; a gastroenterologist for food allergy; and a respiratory physician for asthma.⁴ Currently, only eight specialist allergy centres in the United Kingdom provide a comprehensive package of care led by a consultant allergist, and all of them are in England.⁶

The national campaign to improve the provision of allergy services has focused so far on lobbying for more specialist training posts, with little success.²,⁷ Given the very large numbers of patients with multiple allergies, the demonstrable failure of allergen avoidance measures in improving clinical outcomes for patients with eczema, allergic rhinitis, and asthma,²,⁸,⁹ and the costs of establishing consultant led specialist centres, we believe it would be more pragmatic to improve service provision in primary care. The report by the House of Commons Health Select Committee and the Department of Health's response to it¹⁰ agreed that primary care organisations should focus on developing and implementing local service models for managing allergy.²

Wider training and better access to allergy testing throughout general practice would be welcome, but an intermediate level of specialism could be provided by regional practitioners with specialist interests in allergy, who could also act as catalysts for a wider primary care based allergy service. A regional practitioner (a general practitioner or nurse consultant) with a specialist interest in allergy would organise an allergy clinic to serve a whole primary care trust, taking referrals from local practitioners.

Unpublished data from Education for Health—a training organisation for primary care staff—show that approximately 800 primary care staff have had diploma level training in allergy that would prepare them for this role.¹¹,¹² Furthermore, this model is already running in at least three parts of the United Kingdom, with support from and the ability to refer patients to one or more specialist centres. No prospective evaluations from these units have been published yet, however.

Advocating primary care led allergy services in the current financial climate in the NHS carries the risk that nothing will happen. Improving standards of care will depend on having sufficient resources for better postgraduate training, better allergy testing, and better evidence on which outcome measures should be incorporated into future incarnations of the performance criteria which general practitioners have to meet—the UK general medical services quality and outcomes framework.¹³

This is not to say that there should be no investment in secondary and tertiary allergy services. On the contrary, these services do need more funding and more equal distribution throughout the United Kingdom.