< Previous | Contents | Next >

Immunology and Allergy Services in Scotland

I INTRODUCTION AND BACKGROUND TO THE REPORT

Introduction

1 The specialty which contributes to the diagnosis and management of patients with immunological and allergic conditions is known as immunology. This is a relatively new discipline. Improved recognition and diagnosis of primary immune deficiency syndromes and the well-documented increase in the number of patients with allergic, or perceived allergic, disorders has been a major driving force in its development.^1,2 As a consequence, the specialty is already beginning to sub-divide into immunology and allergy. The term immunology will be used throughout this report even though it is acknowledged that clinicians who work specifically with patients who suffer from allergic reactions, (i.e. allergists), have recently been recognised by the Specialist Training Authority and the Department of Health (through an Amendment to Schedule 2 of the Medical Order) as constituting a related but distinct specialty in their own right.

Background

2 Over the years the complexity of, and inter-relationship between, laboratory diagnosis and clinical treatment, particularly with regard to immunodeficiency, allergy and, in some cases, auto-immune disease, has led to the development of immunology laboratories in most acute hospitals where laboratory staff play a key role in the diagnosis and management of a broad spectrum of disorders. Throughout the UK, "regional" immunology services providing both laboratory and direct clinical functions are now the accepted norm although they are distributed and staffed inconsistently throughout the country. Ideally they should offer a full range of immunological tests with a consultant immunologist available to interpret the results and to provide expert advice to smaller immunology laboratories within the region.³

3 Staff in immunology laboratories perform blood and tissue tests for the diagnosis and monitoring of hypersensitivity (allergy) disorders, primary immunodeficiency and auto-immune disease. In some centres, laboratory immunology also encompasses histocompatibility testing. In most centres in recent years there has been a steady rise (10-20% per annum) in the total number of tests carried out and the number of samples submitted. The range and complexity of tests is increasing steadily e.g. with the identification of new auto-antigens. Most of the newer auto-antibody tests detect the antibodies which are markers of disease (for example, anti-neutrophil cytoplasmic antibodies (ANCA), and anti-cardiolipin). The growth in demand for immunological tests and their range is likely to increase as tests become available for immunological diseases which cannot yet be diagnosed in the laboratory, e.g. inflammatory bowel disease, multiple sclerosis.

4 Most immune disorders cannot be cured but early diagnosis can prevent irreversible organ damage and may eliminate the need for expensive treatment, e.g. renal or liver transplantation. Serological tests can now replace many diagnostic procedures requiring biopsy or identify those patients where biopsy is most likely to be necessary. In recent years the number of immunological requests from general practitioners has increased markedly.⁴ In large centres, around 30% of requests for tests originate from GPs. These tests can often exclude diagnoses which might warrant referral to hospital consultants in other specialties, e.g. dermatology, ENT, gastroenterology, respiratory medicine and rheumatology.

5 In Scotland, consultant-led immunology and allergy services are available in Aberdeen, Dundee, Edinburgh and Glasgow. The laboratory services in these cities also act as reference centres for other laboratories whilst individual specialist laboratories provide very specialised immunological tests such as neurological antibody testing.

6 While it is generally accepted that the provision of laboratory immunology services in the major cities in Scotland is reasonably well organised and of an appropriate standard, there are concerns that laboratory provision across the country is neither comprehensive nor consistent in terms of consultant support and configuration.

7 Of greater concern is the provision of directly delivered clinical services for immunology. These services, although available to a limited population in the major centres, are not easily accessible to the population of Scotland as a whole. Furthermore, many healthcare professionals are unaware of the service provision that is available. In Scotland services which have been shown to be clinically effective have been developed more slowly (for example, home administration of intravenous immunoglobulin and allergen desensitisation).

8 Another concern relates to the considerable attention given to allergies by the press which both testifies to, and has fuelled, public and media concern. The proliferation of private allergy clinics, allergy testing laboratories and alternative therapies demonstrates a dissatisfaction with NHS facilities.^5,6

9 It is against this background that the Working Group was constituted to review the current provision for immunology and allergy services in Scotland and to make recommendations, where appropriate.

Working Methods

10 The Group, which met on four occasions between April and October 1999, took evidence from a number of individuals and professional organisations. The composition and membership of the Group is shown in Appendix I and a list of acknowledgments is shown in Appendix II.

Outline of the Report

11 The report charts the present provision of services in Scotland for the diagnosis and management of patients with immunological and allergic disorders, identifies key deficiencies, and makes recommendations for their improvement. A brief account of service provision in England and Wales has been included for comparative purposes and reference is made to related activities in the independent sector.

12 Throughout its deliberations, the Group has made a conscious effort to view the service from the perspective of the patient, particularly with regard to issues such as quality and accessibility, and this is reflected at a number of points throughout the report. Particular emphasis has been placed on the provision of services for children and the need to secure good working practices which are in harmony with the recommendations of the Acute Services Review.

13 A glossary of terms has been added for ease of reference.

< Previous | Contents | Next >