Allergy: The Primary Solution

1. Allergy: The Primary Solution Dr M Doyle General Practitioner

2. The problem… • 20 million patients in UK with allergic disease • Common presentations to primary care • Asthma • Eczema • Allergic Rhinitis (Hay Fever) • Food allergy • Perceived allergy

3. The problem… • GP training in allergic disease • Format of vocational training schemes • “On the job” training • Guidance has been historically limited • Availability of testing • 74% GPs felt they did not have the necessary skills or training to treat allergy • NASG survey 2008

4. The problem… • Lack of specialist allergy services • Consultants with specialist interest – not ring-fenced for allergy • 71% GPs rated NHS allergy provision as poor • NASG Survey 2008 • Patients often use other avenues • Alternate testing services • Complimentary medicine • Can lead to misdiagnosis and confusion for both patient and doctor

5. The cost • Direct cost to NHS pa = >£1 billion • GP consultation costs alone = £211-311 million pa • GP prescribing cost £0.7 billion • 2006 DoH figures quoted in the RCP report 2010

6. Mr H A short case history

7. Mr H 64 y o man Nasal polyps and asthma Multiple courses of steroids and medications 9 surgical polypectomies 1998-2009

8. Mr H • Diagnosed with salicylate hypersensitivity in 2004 by ENT surgeon • No dietetic support • No suggestion of onwards referral • Patient and GP unaware (only recorded in hospital notes) • Ongoing surgery until 2009

9. Mr H • Diagnosed (again) with salicylate hypersensitivity in 2010 • Now under tertiary allergy service • Awaiting next polypectomy…

10. Still not meeting the unmet need • RCP/RCPath 2010 • Following up from original report 2003 • Identified little progress in improving service provision • Overall poor education in primary care regarding allergy • Differing opinions on role of GPwSI – numbers identified as very small

11. So where are we now? • New guidance • NICE: Food allergy, Anaphylaxis and Drug Allergy • BSACI guidance • PCRS/PCDS • Other international guidance • Impact of guidance on primary and secondary care • Guidance fatigue • Monitoring

12. Priorities • GP education • Still hit and miss, depending partly on geography • Post-graduate training available but requires significant time and motivation • Allergy should form part of all vocational training schemes • Allergic disease split in current GP curriculum to multiple areas

13. Priorities • More funding for specialist services • CCG engagement • Difficult to find funding for new services when existing ones are struggling • Reallocation? • Still variability in coding

14. Solutions • Quality and Outcomes Framework • Commissioning • Hub and spoke models • Accreditation of the GPwSI • Wider availability of appropriate testing • All would help triage and improve patient journey

15. Prof Don Berwick • A promise to learn – a commitment to act • Improving the safety of patients in England • National Advisory Group on the Safety of Patients in England August 2013 • “The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.”

16. “I felt such relief. Having spent what feels like years asking for help, suddenly someone seemed to be listening.”