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Immunology and Allergy Services in Scotland

Terms of Reference

"To review the current service provision for immunology and allergy services in the NHS in Scotland and to make recommendations for change, where appropriate".

Readers should note that this report does not cover the management of patients with HIV/AIDS although the Working Group recognise that in some places immunology departments undertake lymphocyte subset counting as part of their overall responsibilities.

EXECUTIVE SUMMARY

Immunology, which is a relatively new discipline, is concerned with the diagnosis and management of patients with both immunological and allergic conditions. It has been primarily a laboratory-based discipline providing support and advice for a large number of other specialties (e.g. rheumatology, respiratory medicine, dermatology, gastroenterology, nephrology, paediatrics and infectious diseases). However, in recent years, whilst retaining this role, it is also evolving into a clinic and laboratory-based discipline in its own right, in much the same way that haematology has done. The main groups of diseases which warrant specialist immunology clinics are immunodeficiencies and allergic disorders. To fulfil this role, most clinical immunologists in training will now qualify with both MRCP and MRCPath.

In recent years there has been a dramatic increase in the incidence of allergic disorders. Some estimates suggest that as many as 1 in 4 individuals might have a clinical allergy. This has resulted in the realisation that the necessary clinical expertise might not be met from a single source and, in addition to immunologists / allergists, "allergy" has also now been recognised by the Specialist Training Authority and the Department of Health as constituting a distinct specialty in its own right.

The report sets out the present provision of services in Scotland for the diagnosis and management of patients with immunological and allergic disorders, identifies key deficiencies in service provision and makes recommendations for their improvement.

In Scotland, consultant-led immunology and allergy services are available in Aberdeen, Dundee, Edinburgh and Glasgow. The services in these cities also act as reference centres for other laboratories. Whilst it is generally accepted that these services are reasonably well organised and of an appropriate standard, there are concerns that laboratory provision even in these centres and in other laboratories across the country is neither comprehensive nor consistent in terms of consultant support, resource infrastructure and configuration.

Of greater concern is the provision of directly delivered clinical services for primary immunodeficiency and allergy diagnosis and treatment. The absence of adequate NHS services is providing an opportunity for unqualified and unregulated laboratories and clinics to flourish.

The report recognises that the complex inter-relationship between these disciplines and other specialties means that their presence in major teaching hospitals is essential. It is equally essential that such services should be accessible to staff in non-teaching hospitals and to primary care practitioners. The complexity of the immune system has made it all the more important that comprehensive clinical services are backed up by appropriate laboratory support which is needed to define and interpret the relevant hypersensitivity, autoimmune and immunodeficiency investigations accurately and appropriately.

Key recommendations for improving services include

• a plan to increase the establishment of consultant immunologists and (in the long-term) the establishment of consultant allergist posts in Scotland and the associated training for these posts

• the development of a series of Managed Clinical Networks for adult and paediatric immunology services

• the provision of resources, education and training to facilitate the introduction of home-based self-infusion of immunoglobulin (home therapy)

• increased availability of allergy out-patient services including desensitisation

• the provision of an immunology and allergy component in the educational programme for general practitioners in the diagnosis and management of patients with immune deficiency syndromes, allergies, anaphylaxis and other immunological disorders

• publication of a comprehensive guide to allergy services for professionals in the NHS

• the development of a system for the regular collection of accurate laboratory workload statistics

• the establishment of a Scottish Registry for the more severe forms of allergy, including anaphylaxis

• a call for a nationwide epidemiological study into the incidence of the more severe forms of allergy, including anaphylaxis.

It is recognised that there are resource implications attached to all of these recommendations. However, it is the Working Group's belief that much can be improved at very little extra cost to the Service. The introduction of a series of Managed Clinical Networks has the potential to do much to enhance communication and understanding between primary, secondary and tertiary care and also between related disciplines. Managed Clinical Networks also have the potential to inform and enhance public understanding. Throughout the course of the Group's deliberations, there was a growing awareness of the need for improved communication. A constant comment was that many healthcare professionals were unaware of the service provision already available in Scotland. Improved communication, particularly through the use of modern electronic technology, has the potential to lead to effective management and to reduce the number of inappropriate referrals.

Appropriate use of non-medical staff through greater recognition and appreciation of the skills of, for example, nurses, dietitians and pharmacists, can also free up consultant time.

The single most expensive investment to emerge from these recommendations is the plan to increase the consultant establishment. The Group recognise that this is not something which can be achieved overnight but urges Health Boards and Trusts to bring the service up to an acceptable minimum standard. It realises that these posts will have to vie with other competing claims but urges Health Boards and Trusts to reflect provision for immunology and allergy services in their Health Improvement Plans and Trust Implementation Programmes. It is urged that advanced planning is put in place now in terms of training in order to allow for this expansion of consultant staff.

Earlier drafts of this report were circulated to a wide audience of interested parties both north and south of the border. The Group is grateful for the many helpful and constructive comments which emerged as a result of this period of consultation. It is also encouraged by the fact that many respondents see this report as a lead which they would do well to follow themselves.

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