Meeting the Challenges of the National Allergy Crisis

In 2004, the Commons Health Committee found allergy services totally inadequate and made radical suggestions for change

Change is required and is now long overdue. For the growing number of people living with allergic disease in the UK, their condition can have a significant and negative impact on their lives. It is frightening and restrictive to live with a condition which could cause a severe or life threatening reaction at any time.

This report has been produced collaboratively by the All Party Parliamentary Group for Allergy and the National Allergy Strategy Group which has been campaigning for nearly two decades to improve NHS allergy care and as a result the lives of the millions affected by allergic disease. The following would not have been possible without the joint working of the professionals, the patient organisations, and the patients themselves.

The time has come for the Government and the NHS to give allergy the priority it deserves and to recognise the true burden it can place on those who are affected and their families and wider communities. This report looks at the solutions to the problems and makes sensible, achievable recommendations for change. We look forward to seeing them implemented.

The impact of allergy

For the growing number of people living with allergic disease in the UK, their condition can have a significant and negative impact on their lives. It is frightening and restrictive to live with a condition which could cause a severe or life-threatening reaction at anytime. In particular, parents of children with allergic disease live in fear of their child having an allergic reaction when they are out of the home, where the understanding of their condition may be poor or confused. Allergies are the most common chronic disorder in children. 6-8% of children up to the age of three years have a food allergy. Drug allergy not only creates risk of severe reactions, but places restrictions on which drugs can be used, with negative impact on health. Yet many patients do not have access to a doctor trained in drug allergy and their allergy remains undiagnosed or wrongly attributed. Allergy also has other impacts including loss of school days and educational attainment, economic impact through loss of working days , health and social disadvantage, financial burdens on both individuals (and the health services) and, at the most extreme, loss of life.

Hospital admissions

It is estimated that one in 1,333 of the population in England has experienced anaphylaxis (this is a severe sudden onset and potentially life threatening reaction) at some point in their lives. Hospital admissions for a severe allergic reaction increased sevenfold in the ten years from 1990 to 2000; from 2002 to 2012 there was a doubling of admissions with anaphylaxis due to food allergy alone and from 2011-17 admissions with allergy increased by 52%, and with anaphylaxis by 29%.

The allergy epidemic and what it costs

One in four adults and about one in eight children in the UK has allergic rhinitis which equates to around 16 million people. These people are four times more likely to suffer from other related conditions which are driven by allergy, such as asthma, eczema and food allergy. However, allergic rhinitis, which includes hay fever, animal and house dust mite allergy, remains poorly managed and under recognised as an allergy. The percentage of people diagnosed with allergic rhinitis, asthma and eczema has trebled over the past 4 decades.

Prevalence rates

Prevalence rates in the UK are among the highest in the world; 40% of children in the UK have been diagnosed with allergy with each birth cohort increasing the numbers of people needing help; the epidemic continues to grow, increasing the burden on the NHS and making allergy a particular and significant problem for today’s children, and their families, and, crucially, for tomorrow’s adults. Anyone can be affected and patients from Black, Asian and minority ethnic backgrounds are at particular risk 25 demonstrating poorer outcomes from allergic disease.

Allergy care is a postcode lottery. There is major geographic variation in access to services. Most are in London and the South East. Patients near the specialist allergy centres get world class care but for the majority, care is inadequate.

Lack of consultant allergists and trainees

The fundamental problem is a gross lack of consultants and only 11 trainee posts in adult allergy in the UK, with fewer still in Paediatric Allergy. This is the major factor limiting the growth of this much needed specialty. Despite the number of people living with allergy, poor care and uncontrolled disease is consuming NHS resources and impacting on lives. Astonishingly, allergy is the smallest medical speciality. There is a huge and evident imbalance between patient need and the provision of allergy services and it is time that allergy is identified as a priority need by NHS England and Health Education England.

• Trainees in allergy (junior doctors entering specialist training to become allergists) – the facts
• There are just 11 places in England for doctors to train in allergy in comparison with the several hundred in the larger specialities
• The allergy curriculum is extensive, and the current training programme takes five (soon to be reduced to 4) years
• At most, just two doctors trained in allergy complete their training each year, and in some years there are none
• Every allergy trainee who has come through training has been appointed to a consultant post. These contrasts with some other specialties, where there can be an excess of
• trainees over the availability of consultant posts.
• For two decades, the argument for more training posts in allergy has been made to the various bodies responsible for Workforce (most recently Health Education England).
• Only once were four additional posts allocated, to be phased in, but the second two were then removed before they were realised

A small investment in increasing the number of allergy trainees and hence full specialists will have a multiplying effect across the NHS and allow integrated care

Consultants in allergy – the facts

• There are about 40 adult allergists and slightly fewer paediatric allergists.
• At present there is one adult allergist per population of 1.3 million.
• The population requiring specialist allergy care was calculated as at least 5 million (DH review of allergy services 2006, evidence paper submitted by BSACI ‘Nature and Extent of Allergy in the UK). This was assuming primary care would be ‘skilled up’ to deal with much more allergy (an additional 5 million patients). Since these figures the demand for allergy services has increased.
• The Royal College of Physicians recommended that about 200 consultant adult allergists were required (Consultant Physicians Working for Patients, 2003).

Keeping people out of hospital

Specialist care keeps patients out of hospital and in most allergy centres the aim is to achieve this objective for most patients in a single visit. By increasing the specialist workforce and including allergy in primary care training, developing integrated care, more patients could be managed in primary care with a large number quickly returned from the specialist to the GP for ongoing care or self-care.

Summary

The NHS does not work well for allergy patients; it does not make access to diagnosis and treatments either easy or timely and, crucially, it does not help people to get and stay well. COVID-19 has further compromised accessibility to services.

However, for a relatively small investment, substantial benefits for both patients and the health service itself could be achieved and the changes resulting from the pandemic, such as virtual consulting, can be built upon. With the development of the proposed robust integrated care system, more patients would be managed outside hospital. It is 15 years since our first report and in the contexts of increasing numbers and the implications of more children developing allergic disease then the case for making allergy a clinical priority is compelling.

A small investment in increasing the number of allergy trainees and hence full specialists will have a multiplying effect across the NHS and allow integrated care

Key recommendations

• Create more training posts in allergy. Train many more doctors to be allergy specialists.
• Increase the number of consultant allergists.
• Increase allergy knowledge in primary care through training and education.
• Bring allergy care into the 21st century, raise standards and the consistency of care across the UK.