§ Jon Cruddas (Dagenham)I wish to raise a number of issues concerning allergy in the UK. I will talk specifically about paediatric allergy and the lack of allergy services within the national health service.
Allergy is a major public health problem in developed countries. In the UK over the past 20 years, the incidence of common allergic diseases has trebled, giving this country one of the highest rates of allergy in the world. In any one year, 12 million people in the UK—one fifth of the population—are likely to be seeking treatment for an allergy. Allergies range from debilitating conditions such as asthma and hay fever to life threatening conditions such as anaphylaxis.
There are solutions to the problems that face us. However, they require an understanding of the issues from within the NHS and a new strategic approach to the issues of allergy within the Department. A recent report from the Royal College of Physicians stated that
despite the epidemic proportions of the disease, the health service is failing to meet the most minimal standards of care—far less clinical governance".Today's short debate gives me the opportunity to raise some points regarding allergy—these are very real concerns to my constituents in Dagenham—as well as to probe the Department about why there are so few specialist allergists to meet the needs of the population in the UK. On a more positive note, however, the debate gives me the opportunity to propose a series of initiatives that might allow the Department to demonstrate an acknowledgement of the problem and a readiness to develop a training programme and infrastructure to improve the care available within the NHS.At the outset I must declare an interest. My family has had first-hand experience of severe allergy and anaphylaxis. I am a member of the Anaphylaxis Campaign, which is the research and campaigning group raising awareness of issues centred around allergy and anaphylaxis. The campaign's food safety adviser Hazel Gowland is listening to the debate this afternoon.
I want to place on record my own personal debt of thanks first to the Anaphylaxis Campaign and its director David Reading for the support that they offer to thousands of families who have to confront issues of child anaphylaxis every year. From personal experience, I know that their work is critical for many families in terms of offering support and understanding to enable people to deal with the condition. Secondly, I thank the excellent paediatric allergy centre at St. Mary's hospital under Dr. Gideon Lack. As a family, we were fortunate to live close to that hospital. The problems that I will describe are centred around the postcode lottery of being referred, or not, to a specialist paediatric allergy centre.
Thirdly, I am thankful for all the hard work being carried out within the medical community on allergy, especially by all those involved in the Royal College of Physicians working party on the provision of allergy services in the UK. The working party has meant that this summer has seen greater awareness of allergy issues in the public press. The headlines were generated by the 62WH report by the Royal College of Physicians, "Allergy: the unmet need. A blueprint for better patient care", which was launched in the House of Commons in June.
The Royal College of Physicians has sought to put allergy higher up the health care agenda of the Department of Health and of planners and managers. It has made proposals for an improved allergy service for the British people, which, if taken up, would result in more consultants, a network of accessible centres around the country and better training.
In terms of the nature of allergy in the UK, it is worth considering some of the statistics. One in three members of the UK population?about 19 million people—will develop an allergy at some point in their lives. Asthma, rhinitis and eczema have increased in incidence two to threefold over the past 20 years. Among 13 to 14-year-old children, 32 per cent. report symptoms of asthma, 9 per cent. have eczema and 40 per cent. have allergic rhinitis. The UK ranks highest in the world for asthma symptoms and is also near the top for allergic rhinitis and eczema.
High and increasing trends are also apparent in nut allergy, anaphylaxis and occupational allergy to latex, for example, and allergic reactions to drugs. Anaphylaxis occurs in one in 3,500 of the population each year. Hospital admissions have increased sevenfold over the last decade and doubled over the last four years. 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. Only 10 years ago this was deemed a rare disorder.
Allergic reaction currently accounts for 6 per cent. of general practice consultations, according to the Royal College of Physicians report, 0.6 per cent. of hospital admissions and 10 per cent. of the GP prescribing budget. It is estimated that the cost in primary care, excluding hospital services to the NHS, is around £900 million per annum. Even before the recent increases in allergy were registered, it was estimated that paediatric allergic disease in the USA constituted 28 per cent. of all chronic disorders requiring medical attention and resulting in school absence.
In a nationwide study of children's allergies in the UK, of the 27,507 children surveyed in 1999, 20.4 per cent. were reported to have had asthma in the previous year, and 16.4 per cent. eczema. One or more atopic symptoms were reported in 47 per cent. of all children. Those rates are reflected in acute paediatric care. In a recent survey of accident and emergency admissions at St. Mary's hospital in London, 7 per cent. of children seen as emergencies were diagnosed as having an allergy disorder. Those children required twice the rate of admission and twice the rate of specialist tertiary referral compared with other children attending as emergencies.
Is it any wonder that many experts in the field now talk of an allergy epidemic in this country specifically with reference to allergies in children? The allergy charities are inundated with telephone inquiries from a desperate public. The vast majority of GPs have no training in allergies and few are aware of any of the formal guidelines for allergy management. In many instances, the severity of the symptoms, with attendant high morbidity, has forced the public to look outside the NHS.
63WH Urgent action is required. However, consider the deficits in current paediatric care. Across the whole country, there are only six centres staffed by consultant allergists who offer a full-time service with expertise in all types of allergy problems. Three are based in London; at Guy's, Royal Brompton and St. Mary's. The others are in Cambridge, Southampton and Leicester. Services are extremely poor in the rest of the country. There is no specialist provision north of Manchester or west of Bournemouth. All six specialist centres provide a high quality multi-disciplinary approach. Moreover, they have an international reputation for research. Five of the six—the exception is Leicester—were developed as academic units with university funding. That is an indication of the lack of tradition within the NHS of allergy support.
Demand is enormous and waiting lists are very high. In Cambridge, for example, the number of patients seen increased by 440 per cent. between 1993 and 2000. Referral rates rise continuously while waiting lists remain unacceptably high for serious disease. This pattern is the same in all six specialist centres. Overall there is only one consultant allergist for every 2 million people in the UK, compared with rates of around one per 100,000 for mainstream specialties such as heart disease.
Allergic diseases comprise a significant percentage of the workload of primary care and the majority of children with allergy problems will have their care provided exclusively by a GP. Yet according to a survey of GPs carried out by the British Society for Allergy and Clinical Immunology, the majority of GPs had received no training in the management of allergic disorders. Only 23 per cent. of respondents reported that they were familiar with any guidelines for the management of an allergic condition. More than 80 per cent. of respondents considered current allergy service provision throughout the NHS poor, with deficiencies being most marked in secondary care and in accessing appropriate specialists.
There are four NHS paediatric allergists in the UK. In Sweden, there are 96 trained paediatric allergy specialists; in Germany, there are 500. Compared with the UK, there are five times the number of paediatric allergists in Greece, and four and a half times the number in Switzerland. In Japan, the paediatric allergy society has 2,000 members. As a consequence, parents who are desperate for treatment for their children seek help from complementary and alternative medicine, which can sometimes lead to potentially dangerous recommendations.
Given the lack of specialist care, many children with different types of allergy such as eczema, rhinitis, asthma and food allergy may be seen consecutively in different settings—general paediatrics, ear, nose and throat, dermatology, chest medicine and the like. That remains a highly inefficient method of delivering health care. As such, the underlying causes of allergic disease are often left undiagnosed. Delivery of care by a paediatric allergist would provide a more rational, integrated and cost-effective service—in effect, a one-stop shop. All the above can lead to so-called steroid loading, owing to no single specialist taking charge of overall management.
64WH The report by the Royal College of Physicians contains a series of excellent proposals for the way forward. It proposes that each new NHS region should have at least one specialist allergy centre staffed by a multi-disciplinary team covering a population of 5 million to 7 million people. Staffing levels in those centres should include two new additional consultants to cover diagnostic procedures and specialist treatment, a minimum of two full-time allergy nurse specialists, one half-time dietician and one half-time paediatric dietician with specialist training in food allergy and two consultants in paediatric allergy supported by paediatric nurse specialists and dieticians.
The development of services should be gradual, and long-term savings through better-educated GPs and more effective referrals would largely offset the increase in costs. That, in turn, would lead to a more efficient use of allergy services. There would be fewer hospital admissions, less accident and emergency attendance, reduced drug costs and lower levels of illness. Moreover, to create more new consultant posts, it is essential to increase the number of trainees in the specialty. There are only five trainees nationally. Despite the explosion in allergies, the Department of Health has allocated no new funded posts for 2004–05.
In conclusion, it is not melodramatic to talk about an allergy epidemic in this country, especially over the past 10 years. The issues will not go away. All evidence suggests that the number of people affected will continue to rise, especially given the profiles among children. In one sense, it is not surprising that the extraordinary growth over the past 10 years appears to have caught the NHS by surprise. What is lacking, however, is an adequate response from the Department of Health.
Evidence locally suggests that some primary care trusts are considering cuts in the minimal specialist provision that currently exists. The people who work in that area are extraordinarily committed and they know that the situation cannot be resolved overnight. They are, however, looking for a lead from the Department of Health that demonstrates a commitment to the work. They are looking for a commitment to fund new training posts in paediatric allergy over the next 10 years with a corresponding number of consultant posts, support to start investing in regional specialist centres and a commitment to further research, particularly into the early prevention of allergies in children. A willingness by the Minister to meet a representative group of campaigners and medical experts would also be very welcome. Paradoxically, given what I have said, there is a great opportunity for the Government to recognise those problems and to demonstrate that they are moving toward some solutions.
I hope that we will receive such a response from the Minister. It would be a welcome development as, too often in the past, the Department of Health and health managers have been in denial about what is really happening across the country.
§ The Parliamentary Under-Secretary of State for Health (Miss Melanie Johnson)I congratulate my hon. Friend the Member for Dagenham (Jon Cruddas) on securing the debate. I am aware both from his remarks and earlier that he has a personal interest in the subject. I welcome the opportunity to outline the Government's policy on allergy services.
65WH I should say that a friend of my son has a severe peanut allergy. As my son has grown up—he is now 17—I have seen his friend at close quarters, having taken them on holiday, and I am well aware of the issues surrounding allergies for parents and families.
Perhaps it would be helpful for hon. Members if I defined anaphylaxis, an acute, immune reaction requiring urgent medical attention that may occur in children or adults who suffer from severe allergies. The most common cause of anaphylactic attack is a severe allergy to food, although certain drugs such as penicillin, and the venom of stinging insects, such as bees and wasps, can result in an attack. In its most severe form the condition is life-threatening but it can be treated with medication, such as antihistamine, adrenaline inhaler or adrenaline injection, depending on the severity of the reaction. Most parents are normally prescribed a device for personally injecting adrenaline. It looks like a fountain pen and is pre-loaded with the correct dose. It is not possible to give too large a dose when using the device.
The Royal College of Physicians recently published a report called "Allergy: the unmet need. A blueprint for better patient care". The report notes that allergies, including asthma, rhinitis, eczema, food allergy and drug allergy, are becoming increasingly common, as my hon. Friend remarked. It called for improved NHS allergy services across the board and offered useful models of how that could be achieved.
We agree that NHS allergy services need improvement and our substantial extra investment in the NHS will help to deliver service improvements. My hon. Friend will be aware that up to 2002–03, expenditure on the NHS has increased by an average of 5.7 per cent. in real terms each year since the Government came to power. NHS expenditure is set to increase further by an average of 7.4 per cent. in real terms over each of the next five years. Such substantial investment in the NHS is not being wasted. It is producing real results, including significant increases in the number of health professionals, increases in capacity, prescribing of new and better drugs, shorter waiting times and greater choice for patients. There will be further improvements, including expanding capacity, increasing staff and training numbers, and reducing waiting times.
Although the waiting times figures do not relate specifically to allergy, it is worth mentioning that the vast majority of patients receive their first out-patient appointment within 21 weeks. In the quarter ending June 2003—the last for which we have data—82 per cent. were seen within 13 weeks and 99 per cent. within 26 weeks of referral by their GP. At the end of June, the number of patients waiting over 21 weeks for their first out-patient appointment with a consultant had fallen by more than 29,500 over the past year. That is real progress and it is making a difference to all patients, including those with allergies.
I should like to comment on the role of the Food Standards Agency. My hon. Friend mentioned the growing incidence of allergy and there is a question relating particularly to food. The FSA's approach to food allergy and intolerance has three main components. The first is to help those with food allergy by improving understanding of the issue among consumers, all sectors of the food industry, including 66WH caterers, and local authority enforcement officers. The second is the funding of research to investigate the causes and mechanisms of food allergy, and the third is to encourage fully informative labelling of foods.
The board of the FSA recently agreed a detailed action plan to help food-allergic consumers. The work is concentrating particularly on teenagers and young adults and on the catering sector, as most food allergy deaths occur in that age group when eating away from the home environment. That could create a particular difficulty when selecting food and knowing what is in it.
The agency has put a detailed fact sheet about food allergy and food intolerance on its website to provide food-allergic consumers with information. It is also conducting research into other sources of information about food allergy for consumers, the food industry and enforcement officers, and into the knowledge and understanding of the issue in those sectors.
The agency will work with others to provide further information and training and education to address the gaps identified. It will also work with health professionals and dieticians to help to provide patients with food allergy such information as they need to make safe choices about the foods that they eat.
The FSA also funds research on food allergy and intolerance, with particular emphasis on severe allergies, how often they occur and what causes them. A large programme of research on food intolerance and allergy, costing about £1 million a year, is ongoing.
Part of that research programme is examining the impact of advice issued by the Government in 1998 that, where there is a family history of allergic disease, pregnant women and breast-feeding mothers should avoid consumption of peanuts during pregnancy and lactation. That advice arose from a report issued by the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment in 1998, which addressed some of the issues behind the possible causation of peanut allergy. In July 2000, the committee issued a further report on adverse reactions to food and food ingredients.
The agency has been working with a wide range of interested parties in the UK and Europe to ensure that food labelling is informative to allow those with food allergy get the information that they need. A new EU directive on allergen labelling has just been agreed in Brussels. It will tighten up existing legislation and will help to ensure that consumers are provided with comprehensive ingredient information to allow those with food allergies to identify products that they must avoid.
The agency has also been addressing consumer concerns about the inappropriate use of "may contain nut" labelling—we have all seen it—which can severely restrict consumer choice. We will shortly seek comments on an alternative phrase for use in labelling.
My hon. Friend said that hon. Members often call for research into various conditions. It is worth saying that the research effort is not confined to the UK Government because there is also an international dimension. The main agency through which the Government support medical and clinical research is the Medical Research Council. The MRC is an independent body that receives its grant in aid from the Office of Science and Technology. The Department of Health 67WH also funds research to support policy and the delivery of effective practice in the NHS. The MRC spent an estimated £11.9 million in 2001–02 on its respiratory disorders portfolio, which includes allergies.
A number of research studies into aspects of allergy are under way. The national research register, for instance, shows that there is a study under way on peanut allergy in children at Southampton general hospital; my hon. Friend mentioned Southampton. The study is called "The Prevalence of Peanut Allergy in British Children at School Entry Age" and it is funded by the Food Standards Agency. It is due to report in 2005.
"The International Study of Asthma and Allergies in Childhood" was established in 1991. Phase one measured the prevalence of childhood asthma, hay fever and atopic eczema for international comparisons. Phase two began in 1998 and involves more intensive studies in a smaller number of countries. The Department of Health funded the UK contribution to phase two.
We are currently working up a children's national service framework to set standards to improve health services for children. It would clearly be impractical for the NSF to cover every specific condition or problem in detail. However, in illustrating what the NSF standards will mean for children with asthma, the asthma exemplar, which will be published in tandem with the main NSF, is likely to make a general reference to allergy. Consideration will be given to the general issues relating to the problems encountered by allergic children in schools.
My hon. Friend raised the issue of the number of consultants. Consultant numbers in immunology, which includes allergy, have increased by 11 per cent. from 63 consultants in September 1997 to 70 in June 2003. There are, however, ongoing discussions between the British Society for Allergy and Clinical Immunology and the Department of Health, which are aimed at improving the provision of consultant allergists, and I recognise that that is a specific issue.
A small number of specific full-time or full-time equivalent posts are devoted to allergy. The British Society for Allergy and Clinical Immunology handbook 68WH lists 86 NHS consultant-led clinics in the UK, and the British Allergy Foundation handbook lists an additional 15 clinics. However, only six of those 101 clinics offer services provided by a whole-time specialist allergist. I recognise the problem that my hon. Friend outlined and we are doing what we can to improve the situation. In June 2003, there were 10 consultants in allergy, an increase of four, or 66 per cent., on the September 2000 level. September 2000 was the earliest date at which specific numbers on allergy consultants were collected in the work force census, so I cannot give my hon. Friend a better figure than that.
From 2003–04, the trusts will have an opportunity to create up to five locally funded specialist registrar posts for training opportunities in allergy. Central funding will also be distributed to support the implementation of an additional registrar post in immunology. Trusts will have the opportunity to create up to five locally funded training opportunities. Work is going on to improve the spread and degree of specialism available, but I recognise that we have some way to go given the starting point and the level of need, which my hon. Friend rightly sketched out.
I am not the Minister in the Department who principally deals with allergy, although the Food Standards Agency obviously falls within my remit. I am sure that the Under-Secretary of State for Health, my hon. Friend the Member for South Thanet (Dr. Ladyman) would be happy to meet members of the organisations which my hon. Friend the Member for Dagenham mentioned to discuss the provision of services.
In conclusion, I hope that my hon. Friend agrees that we must take the provision of allergy services and paediatric allergy services very seriously indeed. Our substantial extra investment in the NHS and the action on waiting times will lead to better allergy services for all NHS patients. The work of the Food Standards Agency will give us a greater understanding of the problems caused by food intolerance, and research is under way into the causes of allergy. We are starting from a low base and have some way to go, but the debate has been useful.
§ Question put and agreed to.
§ Adjourned accordingly at four minutes to Two o'clock.