This site is intended for health professionals only

Allergy in the UK: results from the latest NiP survey

In our latest online survey, sponsored by UCB Pharma, we looked at the subject of allergy, and more specifically, your experiences of treating patients with allergy. Over 1,100 of you responded, and here is a summary of the results

Elaine Linnane
Editor-in-Chief
Nursing in Practice

In 2004 the House of Commons Select Committee on Health reported that "serious problems exist in the current provision of allergy services [in the UK]."(1) It added that: "Those working in primary care lack the training, expertise and incentives to deliver services."
In September last year, a report by the House of Lords Science and Technology committee warned that allergy services in the UK were inadequate.(2) In the report, Professor Andrew Wardlaw, Director of the Institute for Lung Health at Glenfield Hospital, pointed out that a lot of allergy "can be effectively treated in primary care or in the community, but the problem is that the knowledge of allergy in primary care is very poor." It concluded that many GPs and healthcare workers in the primary care sector are not sufficiently trained in allergy to be able to provide an accurate diagnosis, and some do not know when and to whom to refer allergy cases.
The term "allergy" covers a large variety of conditions, from hayfever (seasonal rhinitis) and asthma* to eczema and anaphylaxis. In the UK the incidence of common allergic diseases has trebled in the last 20 years, to become one of the highest in the world.(3)
This is increasing the burden on primary care - in fact 70% of respondents to the Nursing in Practice survey reported noticing an increase in the number of cases of allergic conditions presenting in primary care over the past five years.(4)
With this in mind Nursing in Practice, in association with UCB Pharma, ran a survey to gauge the breadth of experience and knowledge of allergic conditions among primary care nurses.

*It is worth noting that not all asthma is allergy driven and not all patients with allergy have asthma

Education and training
The DH, in response to the House of Lords Science and Technology committee report, recognised the importance of those working in primary care having sufficient clinical knowledge and support systems to recognise allergy in the early stages, and being able to differentiate between serious allergies requiring specialist interventions (coexisting food allergy, asthma, particularly in children and anaphylaxis) and those that can be managed in primary care (asthma, rhinitis and eczema).
We asked respondents to describe any training they had received in allergy and allergic conditions. Twenty-five percent of respondents had received some sort of formal training in allergy, although this was mainly the compulsory training in treating anaphylaxis for all nurses who carry out immunisations. Just 13% had carried out academic accredited training in allergy and allergic-related conditions - and almost all of these had done an asthma diploma.
"Training in 'general' allergy is difficult for nurses to access locally," says John Collard, Clinical Director of Allergy UK. "The few nurses who have had training have normally done this in relation to a particular condition relating to allergy, such as asthma or eczema.
Dr Samantha Walker, Director of Education and Research at Education for Health, disagrees. "We don't find this, and indeed offer industry-funded bursaries to support allergy training at degree and diploma level. There are also pockets of the country where we have allocated PCT funds to support training. We have trained around 700 nurses over the last five years."
With about one in three of the UK population at some time in their life being affected by allergic disease,(3) anyone working in primary care will be dealing with allergic patients on an almost daily basis. People with severe or complex allergic disease will hopefully be referred on to a specialist (although this is far from being universal), but the vast majority with more minor or moderate symptoms relating to allergy will remain in the primary care setting.
Therefore primary care nurses may well find themselves dealing more and more with patients with allergic conditions. "Without formal training I'm lacking in confidence," said one PN from Scotland. "If I was faced with an allergy-related problem I would seek GP advice." Seeking advice from another, more experienced health professional, either GP or nurse, was echoed by many other respondents. But specific training was high on most people's wish list, because, as one health visitor, also from Scotland, commented: "Access to relevant courses would make me feel more confident and improve my care of these patients."
It was probably not surprising that of those who had no training, 53% said they felt uncomfortable working with patients with allergy-related conditions.(4) "I don't feel I know enough about allergy to be able to advise on anything more than on a superficial level," commented a practice nurse from Sheffield.
Figure 1 provides information on how nurses were keeping their allergy knowledge up-to-date. Table 1 lists the top answers in each category.

[[nip42_fig1_18]]

[[nip42_table1_18]]

Prevalence
Seventy percent of respondents reported noticing an increase in the number of allergic conditions presenting in primary care over the last five years. Several of you commented that you had seen an increase in the number of cases of hayfever (seasonal rhinitis) and perennial rhinitis (year round); that more babies, children and young people appeared to have allergies; that more people were showing allergic reactions to wound dressings and tapes (however, this is contact dermatitis, and is not related to allergic disease); and that food allergies were on the up.
However, a number of respondents felt that it wasn't the prevalence of allergy that was on the increase, but that there was more awareness, and therefore more people presenting who might not have sought medical help previously. "I think patients are coming forward more - I don't think there is an actual increase," said a practice nurse from Staffordshire. "The older patients tended to put up with allergies. Pharmacists appear reluctant to OTC treat and will send patients back to their GP/practice nurse."
However, Samantha Walker warns that this perception doesn't correlate with research. "There clearly has been a rise in allergic disease, as evidenced by the many epidemiology papers that have been published," she explains.

Experience
Twenty-three percent of nurses who responded to this survey described themselves as the main nurse in their practice dealing with allergy.(4) Surprisingly only 29% of these had any form of accredited training in allergy. Only 3% of nurses said there was a nurse-led allergy clinic in their practice/PCT.
Figure 2 shows the different types of allergy that our respondents routinely treated.

[[nip42_fig2_18]]
 
Almost a third (30.3%) of respondents regularly prescribe/supply medication for allergy.(4) Of these, almost half (47%) said that price could affect their choice of medication. Most followed PCT guidance in this respect, but acknowledged that the PCT formulary was issued with cost-effectiveness in mind. Comments on this topic included:

  • "Price not first factor but one consideration among safety, efficacy, patient choice, national and local guidelines, and so on" (nurse practitioner, Essex).
  • "One of the GPs is the PCT lead on prescribing so I must use the cheapest product first!" (practice nurse, Dorset).
  • "As an example, cetirizine is cheaper than fexofenadine, so this would be firstline" (practice nurse, Nottingham).
  • "I am aware that some antihistamines can be expensive and research has shown cheaper alternatives are just as effective, but patients are prescribed whatever is needed to control their symptoms" (specialist practice nurse, Glasgow).

Treatments
Respondents were asked to indicate what allergy treatments they routinely recommend/prescribe (see Table 2).

[[nip42_table2_19]]

Sixty percent of respondents said that they routinely provide patients with a practical demonstration on how to correctly use a certain allergy devices/products.(4) Figure 3 shows some of devices that this included.

[[nip42_fig3_19]]

Reasons given by those who do not routinely give patients a practical demonstration included:

  • Lack of knowledge and competence.
  • No placebo products available.
  • Lack of time and resources.
  • The GP/senior practice nurse deals with this.

Marilyn Eveleigh, Consultant Editor of NiP, believes that most patients take the lead here: "Many patients purchase and self-medicate with over-the-counter medication from pharmacists. However, there is certainly a need for support in teaching the best administrative technique for allergic rhinitis and antihistamine use. Community nurses can opportunistically support patients but need the training themselves."
Forty-three percent of respondents routinely offer lifestyle/dietary advice to patients. This was primarily advice on allergen avoidance, as well as advice on damp dusting, vacuuming, special bedding and checking food labels. A total of 102 respondents (8.6%) would recommend alternative/complementary therapies. These ranged from homeopathy, acupuncture, herbal remedies to reflexology and Indian head massage. In fact one nurse practitioner from a multipartnered practice in the Wirral described how her practice had a holistic aromatherapy service available.
Debbie Campbell, a clinical nurse specialist from Royal Brompton and Harefield NHS Trust in London and member of the Assocation of Respiratory Nurse Specialists, is concerned at some of the advice offered to allergy patients. She told us: "My concern is that advice may be given without confirmation of diagnosis, and some of these avoidance measures are very expensive and are not well supported by the literature."
Debbie continues: "For example, skin prick testing is a simple and relatively safe procedure for identifying common aeroallergens, and this would ensure that treatment and advice is targeted specifically. Those patients with more complex problems, such as food and antibiotic allergy, should be given referrals. Who to refer to is another question!"
She is also dubious of the benefits of complementary therapy: "Again the evidence supporting these therapies is poor," she said. Mary Brydon, Allergy Nurse Consultant Primary Care for Norfolk Allergy Diagnostic And Advisory Service, agreed with Debbie about complementary therapies: "The NHS Reviews and Dissemination publication in October 2007 states that: 'Herbal medicine has very sparse evidence base and there is no convincing evidence that it is effective in any indication.' The potential for adverse and negative interactions mean that its use cannot be recommended." Mary points readers to the BSACI (British Society for Allergy and Clinical Immunology) paper from 1992, entitled Allergy: Conventional and Alternative Concepts.
Self-management is one of the cornerstones of allergy treatment. Patients are increasingly being challenged to take responsibility for their own condition, but it is down to healthcare professionals to empower patients to do so. However, only 36.7% of respondents said that they routinely provide patients with relevant information about their condition.(4)

Conclusion
One of the main messages from this survey is that more training is required in primary care specific to allergy. According to Marilyn Eveleigh: "It is frustrating that nurses won't/can't undertake training. A one-day intense session would make such a difference to nursing confidence and patient support. Training is available but prioritising, funding and capacity are often lacking in primary care." Mary Brydon agrees, but adds, "All the training in the world won't help the allergy sufferer if dedicated time cannot be allocated to their assessment and care."
In July 2006 the Department of Health undertook a Review of Services for Allergy. One of the recommendations of this report was to ensure that National Occupational Standards (NOS) are available to the workforce. Skills For Health have been commissioned to develop a National Competence Framework for Allergy.
The development of these NOS will help employers assess the skills needs of staff working in this area and to develop staff appropriately. Employers and education and training providers may choose to integrate the NOS into training programmes. They will help individuals and employers to meet the demands of the NHS Knowledge and Skills Framework (KSF) where all staff will have a KSF post outline against which they are developed and appraised. Skills for Health are currently testing the draft allergy competences.
Samantha Walker is keen to point out the benefits of improving allergy services. "There is evidence that training given to health professionals improves quality of life in patients with rhinitis."(5) She also points to the importance of treating problems like hayfever given its impact on exam performance in teenagers.(6)
"Allergy is a condition ideally suited to management in primary care by GPs, nurses and pharmacists," says Marilyn Eveleigh. "Practice-based commissioning groups would be well advised to consider this as a cost-effective service for patients."

The Nursing in Practice Allergy survey was conducted online at www.nursinginpractice.com from 4 March to 24 March 2008. A total of 1,183 nurses filled out the survey. The survey was sponsored by UCB Pharma

Date of preparation April 2008 08XY0109

References

  1. Health Committee. The provision of allergy services. 6th report (2003-04). HC 696-1. London: TSO; 2004.
  2. House of Lords Science and Technology Committee. Allergy. 6th report of session 2006-07. London: TSO 2007.
  3. Royal College of Physicians. Allergy: the unmet need. London: RCP; 2003.
  4. Results from Nursing in Practice online survey - conducted online at www.nursinginpractice.com from 4 March to 24 March 2008.
  5. Sheikh A, Khan-Wasti S, Price D, et al. Standardized training for healthcare professionals and its impact on patients with perennial rhinitis: a multi-centre randomized controlled trial. Clin Exp Allergy 2007; 37(1):90-9.
  6. Walker S, Khan-Wasti S, Fletcher M, et al. Seasonal allergic rhinitis is associated with a detrimental effect on examination performance in United Kingdom teenagers: case-control study. J Allergy Clin Immunol 2007;120:381-7.