Towards excellence in paediatric allergy care for all

Abstract

In this month s issue of the journal, Diwakar and colleagues publish the findings of the first in‐depth study into patient experiences in accessing paediatric allergy services in the UK. Sadly, the findings make not only uncomfortable reading but also have a ring of familiarity about them. The themes identified all resonate with the stories that many of us hear when we talk to our patients about their experiences of trying to get help with their or their children s allergy problems. Whilst the study was based around two clinics in the West Midlands, the authors rightly point out that with the well‐ documented problems of access to allergy services in the UK, it seems very reasonable to assume that many of the themes identified are generalizable across the country. The narrative around the epidemic of allergic disease in the UK, accounting for approximately 8% of GP consultations and affecting almost 20 million people, alongside the ongoing failure of the NHS to provide adequate provision, is well rehearsed. These facts have been the thread through a series of reports from Royal Colleges, the House of Commons Health Committee and the House of Lords Science & Technology Committee as well as the Department of Health. This year marks the 16‐year anniversary of the first such report—Allergy: The Unmet Need—where allergists, through the Royal College of Physicians, spelt out the scale of the problem and detailed their proposals for a solution involving a significant step change in the number of specialists—both adult and paediatric—to manage the demand. Whilst many may feel that little has been delivered, the world of allergy feels like a very different place in 2019, when compared to 2003. The UK undoubtedly boasts some of the largest, most comprehensive and forward‐thinking allergy services in Europe—not just in terms of high quality service provision, but also in terms of research output. UK‐based allergy centres continue to contribute impressively to the many advances that are changing our speciality in terms of both allergy prevention and treatment. There is much to be proud about, including guidelines produced by the British Society for Allergy & Clinical Immunology (BSACI) and accredited by NICE and some local investment in consultant allergist posts. With our improved understanding of food allergy, we can now envisage a British child, born to a mother with allergic disease, receiving advice from their health visitor about the potential value of regular emollients as a means to reduce the risks associated with early onset eczema. If troublesome eczema does develop, then the health visitor will ensure they are quickly triaged to see a GP. The GP, well‐educated by local specialist outreach clinics and following carefully developed protocols, may initiate a chain of management allowing the earlier introduction of potential food allergens as a means to prevent food allergy, with the input of local specialist healthcare professionals working as part of a multidisciplinary team. Such models are already partly established, but only for the fortunate minority, and are based on the most up‐to‐date evidence, much of this generated by research conducted in the UK. Specialist involvement provides the initial leadership needed to establish this type of service, whilst its delivery would be much less reliant and thus more scalable. However, a similar child born in one of the many areas of the country where there is no specialist allergy service, and whose GP has had little or no access to education around allergy, will have a very different experience and almost certainly, a higher chance of more severe eczema and life‐long food allergy. This is the common experience. We are witnessing the emergence of two distinct classes of allergy “citizen”: one who receives fast access to high quality care, and another who for no reason other than an accident of geography is less likely to receive appropriate advice in terms of prevention and management. Unfortunately, the latter is the norm. As we stand on the cusp of a paradigm shift in our speciality, with food desensitisation emerging as a therapeutic option, it is critical that we begin to consider how we address not only the paucity but also the consistency of allergy services for all children. We need to have proven exemplars of high quality care, to convince commissioners of the value in making the investments needed to ensure that all children, wherever they live in the UK, get access to the best possible care. After all, the NHS has a legal duty to ensure equality of access to healthcare—and this has never been so important as now, some 70 years after the establishment of the NHS. The themes that emerge from Diwakar s paper mirror those already identified in previous work, and are common to other specialties. They are familiar: frustration with poor access to services, long waits for clinic appointments, a lack of reliable information and a lack of support with ongoing management. But in allergy, this is worse because of the dearth of allergy knowledge in most of the NHS. Specialists are required to provide leadership and education in regions, to care for the more complex cases and deliver highly specialist treatments, and more are very much needed for this. But many cases of allergy are not severe and could potentially be managed by competent and confident primary care practitioners or general paediatricians in secondary care. A recent study estimated that over 40% of referrals to a specialist paediatric allergy service could be managed in the community by a suitably trained GP. Diwakar s findings seem to point to an openness by patients to see a specialist This editorial discusses the findings of the paper in this issue by L. Diwakar et al. [1], pp. 357–365. This logo highlights the Editorial article on the cover and the first page of the article. DOI: 10.1111/cea.13350