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Raising the standards of allergy treatment

In the recent Nursing in Practice-UCB Pharma allergy survey,(1) three-quarters of primary care nurses admitted to lacking basic training in treating allergies, and more than half said they were uncomfortable seeing patients with allergic conditions. Samantha Walker takes a look at what difference allergy training can make

Samantha Walker
RGN PhD
Director of Education and Research
Education for Health

There is now good evidence to show that approximately one in three of the UK population will develop allergic symptoms at some point in their lives, accounting for approximately 6% of GP consultations. The most commonly encountered problems are allergic rhinitis, asthma and atopic eczema, all of which have increased significantly in prevalence over the last three to four decades, but now appear to be levelling off. In contrast, small but increasing numbers of patients experience more acute systemic allergic disorders such as food allergy, urticaria, angioedema and anaphylaxis; hospital admissions for severe allergic disease have increased 10-fold in the last 10 years.(2) Even in patients with nonlife-threatening problems such as hayfever, symptoms can be irritating, disrupting and sometimes disabling and have been shown to impair exam performance in schoolchildren.(3) Comorbidity is common and is particularly problematic to manage, both for patients and healthcare providers.

The current model of care
The majority of patients with allergic problems in the UK either self-manage and/or are cared for in primary care. GPs receive support in this role primarily from general paediatricians and organ-based hospital specialists, with some additional support, in some regions, from clinical immunologists and allergists.
While this model could be satisfactory for the majority of patients with relatively mild single organ disease, there are at present several important shortcomings:

  • The majority of health professionals will have received very little training in the diagnosis, assessment and management of patients with allergic problems, which may occur in a number of different organ systems.
  • GPs and practice nurses wishing to try and identify an allergic trigger are currently hampered by the difficulty in obtaining/financing diagnostic tests. Skin prick testing requires training, involves a cost, and is time-consuming, without any reimbursement from the NHS; specific IgE testing is in many regions difficult, if not impossible, to obtain. Both tests require specialist interpretative skills, which the majority of primary care teams do not have. And other diagnostic tests such as patch testing or double-blind placebo-controlled food challenges are generally not available (and are furthermore inadvisable) in a community setting.
  • In more complex cases where specialist advice is needed, most GPs have little choice but to refer to local organ-based specialists, which is often problematic as they themselves typically have little allergy expertise and often also lack interest in this area; thus patients often see more than one organ-based specialist, eg, an ENT surgeon for allergic rhinitis, a gastroenterologist for food allergy and a respiratory physician for asthma.
  • While it would certainly be preferable for people with allergies to be assessed and managed by a fully trained allergist, this is often impossible as there are currently very few UK specialist allergy centres providing a comprehensive package of care; and these centres are all located in England (see Resources).

Based on these shortcomings the Health Select Committee expressed grave concerns in 2004, reporting that "serious problems exist in the current provision of allergy services [in the UK]", and adding that, "those working in primary care lack the training, expertise and incentives to deliver services."(4)
In response to this damning report on allergy services, the Department of Health and Scottish Executive recently reviewed all aspects of allergy care provision. The findings were published in 2006 and were closely followed by a further report from the House of Lords Science and Technology Select Committee in 2007.(5) The reports recommended that more allergy centres be established with an initial centre to be created outside of the London and South East area, although it is clear that the need for careful monitoring and evaluation will mean that it may be several years before allergy patients can look forward to being able to easily obtain a referral to a local allergy specialist.

The campaign to improve care for patients with allergic problems
Specialist-led initiatives to increase the number of hospital training posts in allergy have so far failed to generate further training numbers for allergy as a single specialty. Although the campaign to improve access to tertiary allergy services continues, this model is unlikely to meet the needs of the very large number of patients involved (5-10% of the population), the majority of whom have mild or moderate allergy symptoms. Moreover, in view of the demonstrable failure of allergen avoidance measures in improving clinical outcomes for patients with eczema, allergic rhinitis and asthma, and the cost of establishing consultant-led specialist centres, a more pragmatic and cost-effective approach would arguably be for greater investment in improving service provision within primary care. This view concurs with the House of Commons Health Select Committee report and also the Department of Health's response to this report, in which it was argued that primary care organisations should focus on developing and implementing local service models, rather than formulating a national strategy.

The way forward: development of local allergy services
Primary care must remain as the frontline provider of allergy care. However, standards of care need to improve and to achieve this a multifaceted approach is needed, including improving access to accredited postgraduate training courses, improved access to diagnostic testing, identifying quality outcome parameters that may be incorporated into future incarnations of the General Medical Services (GMS) contract, and the introduction of practitioners with specialist interests in allergy to oversee and facilitate implementation of such an approach.

The importance of training
The NHS faces continuous financial pressures as it attempts to transfer the majority of chronic disease management into the community. This has been particularly obvious over the last year and as strategic health authorities, primary care trusts and hospital trusts have grappled with financial deficits and structural reorganisations. It is of little surprise that training interventions for health professionals have not been given a priority.
However, at a time when the NHS health policy is purporting to support a drive to an even greater primary care-led NHS than before, it is important to maintain a clinically sound and well-educated workforce.
Nevertheless we live in a world that "looks for return in investment", and anecdotal claims that education makes a difference to care may no longer carry sufficient weight. And while there has been little good evidence that training actually improves patient outcomes, the whole premise of continuing nursing and medical education is based on that assumption.
Nurses with an interest and training in allergy have an important role to play in the management of allergic patients who often have coexisting symptoms in different organ systems. However, it is important that the training provides a holistic approach to diagnosing and managing allergic conditions so that mild or moderate symptoms can be managed effectively and life-threatening symptoms identified and referred where necessary. It is also important to recognise the potential impact of accredited allergy training for health professionals on patients' symptoms and quality of life.

What difference does allergy training make?
Allergy training is clearly an important component of high-quality allergy care, although as mentioned previously there has been little evidence to date that it leads to any improvements in health outcomes. A recent landmark study, however, compared the effectiveness of standardised allergy training (accredited by the Open University and delivered by Education for Health) of primary healthcare professionals with usual care in promoting improvements in disease-specific quality of life in adults with perennial rhinitis.(6) (See www.
educationforhealth.org.uk for a link to the published research paper)

What is perennial rhinitis?
Rhinitis, defined as a collection of symptoms including a runny and/or blocked nose, sneezing, itching and sometimes postnasal drip (mucus running down the back of the throat) or conjunctivitis occurring for an hour or more on most days, affects about a quarter of the UK adult population.(7) Symptoms can be seasonal (hayfever), perennial all year round or perennial with seasonal exacerbations.

Why is rhinitis important?
Rhinitis symptoms frequently result in significant morbidity, with research showing that they may adversely affect concentration, reduce productivity and impair learning ability in children and adolescents.(8,9)
Given the high prevalence and debilitating nature of rhinitis symptoms in some individuals, ensuring that patients have access to the best treatment should clearly be high on any practice nurse's agenda, and most patients with rhinitis can be managed successfully in primary care with appropriate interest and training. Management consists of pharmacotherapy including antihistamines and nasal corticosteroids, which are extremely effective if taken regularly and prophylactically. An algorithm to guide the management of hayfever and perennial rhinitis is available at www.educationforhealth.org.uk

The allergy study
The study was a primary care-based trial comparing a six month, distance-learning allergy module given to 20 GPs and practice nurses from 12 general practices in the UK with usual allergy care.6 The training consisted of Education for Health's Allergy Course, which contains 11 modules covering all aspects of allergic disease. The doctors and nurses invited all adult patients with perennial rhinitis on their practice lists to participate; the 202 consenting patients were randomised to the training group (where they received care from a trained allergy health professional) or the control group (where they received routine care and a leaflet on rhinitis
management).

Findings from the study
Disease-specific quality-of-life scores improved significantly in the trained group but not in the control group. Patients who consulted the trained doctor/nurse experienced significant improvements in overall assessment of nasal symptoms compared with those in the control group. Healthcare professionals' self-rated improvement at the completion of the module compared with baseline showed that the educational intervention was perceived to be of educational value in increasing self-assessed confidence and behaviour. The greatest improvements in confidence were reported in history-taking (100% of participants), skin prick testing (80%), allergy diagnosis (80%), treatment strategies (90%) and practical use of nasal spray devices (80%). The majority (75%) also reported an increase in prescriptions for nasal steroids. The allergy training module was well evaluated, the learning objectives being met by 100% of participants. Participants also reported that the module was relevant to their current practice and that the content was appropriate. Seventy-eight percent were of the opinion that they had acquired new knowledge/skills.
 
Summary and implications of this work
In this study, standardised allergy training was well evaluated by healthcare professionals and resulted in improvements in health-related quality of life in patients with perennial rhinitis. These findings make an important contribution to the evidence and highlight the importance of continued investment in professional education. As a result of this work, Education for Health has put together a toolkit entitled "How to make your case for education and training". It contains evidence-based, disease-specific business proposals for nurses to use to establish their current levels of knowledge, understanding and experience, and plan development of their competencies within the framework of the health needs of their practice population in a way that is meaningful to the Quality and Outcomes Framework (QOF), the Knowledge and Skills Framework (KSF) and National Workforce Competencies. It can be accessed free of charge at www.educationforhealth.org.uk/pages/businesscase.asp

Conclusion
In today's climate of financial instability and with a culture of evidence-based practice, it is important that we are able to show a clear benefit of allergy investment to patients as well as health professionals. Allergy-trained practice nurses have the potential to make a substantial difference to the lives of rhinitis sufferers, and should expect great job satisfaction from doing so.

Allergy training
Allergy training at diploma and degree level is available from Education for Health. Please contact Ellen McCutcheon, allergy education coordinator, on 01926 838973 for more details.
The British Society for Allergy & Clinical Immunology (BSACI) is a health professional organisation that aims to improve the management of allergic diseases in the UK. They have recently established a primary care group that represents the interests of GPs and community-based nurses, and have an online discussion forum that can be accessed by non-BSACI members by contacting Kerry Walsh at kerry@bsaci.org
or on 020 7430 9919.
The BSACI annual conference takes place on 14-16 July 2008 and has a clinical allergy day specifically aimed at primary care health professionals. See www.bsaci.org for more information.

References

  1. Linnane E. Allergy in the UK: results from the latest NiP survey. NiP 2008;42:16-20.
  2. Sheikh A, Alves B. Hospital admissions for acute anaphylaxis: time trend study. BMJ 2000;320:1441.
  3. Vuurman EPF, van Veggel LMA, Uiterwijk MMC, et al. Seasonal allergic rhinitis and antihistamine effects on children's learning. Ann Allergy 1993;71:121-6.
  4. House of Commons Health Committee. The provision of allergy services. Sixth report of session 2003-04. Volume 1. Available from: http://www.bsaci.org/open/pdf/provision_of_allergy_services.pdf
  5. Department of Health. A review of services for allergy: the epidemiology, demand for and provision of treatment and effectiveness of clinical interventions. London: DH; 2006.
  6. 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;37:90-9.
  7. Sibbald B, Rink E. Epidemiology of seasonal and perennial rhinitis: clinical presentation and clinical history. Thorax 1991;46:895-901.
  8. Walker S, Khan-Wasti S, Fletcher M, et al. Seasonal allergic rhinitis is associated with a detrimental impact on exam performance in UK teenagers: case-control study. J Allergy Clin Immunol 2007;120:381-7.
  9. Juniper EF, Guyatt GH. Development and testing of a new measure of health status for clinical trials in rhinoconjunctivitis. Clin Exp Allergy 1990;21:77-83.

Resources
British Society for Allergy & Clinical Immunology
W: www.bsaci.org

Education for Health
W: www.educationforhealth.org.uk