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Health: Allergy (Science and Technology Committee Report)

Volume 701: debated on Thursday 8 May 2008

rose to move to move, That this House takes note of the report of the Science and Technology Committee on allergy (6th Report, Session 2006-07, HL Paper 166).

The noble Baroness said: My Lords, it has been a great privilege to chair the committee and to introduce the debate today. The members of the committee who conducted this inquiry were notable for their enthusiasm and commitment to the subject. I know that they would wish to join me in expressing our great gratitude to our hard-working Clerk, Sarah Jones, and our wise specialist adviser, Professor Barry Kay, as well as to all who gave evidence to us, informed our seminars or hosted our visits in the UK and abroad.

The report and its recommendations have been warmly received in the allergy community by professionals and patients alike and extensively covered in the media. Several authoritative reviews of clinical allergy services preceded our report, and all of them noted serious deficiencies. Against this backdrop, we set out to look at the wider social and economic implications of allergy. Yet as the inquiry developed, it became shockingly apparent just how severely allergic diseases could impair people’s quality of life and how, despite our track record of high-quality research in the field, allergy services in the UK lag far behind those of other European countries through a severe shortage of allergy specialists.

During our inquiry, we heard of children with allergies who sleep poorly by night and are bullied at school by day, and whose hay fever impairs their performance in summer exams. We learnt that the workplace environment can cause or so exacerbate allergic symptoms that some adults are forced to give up work. Yet there is no clear guidance about what to do next or how to control their symptoms. We heard of fatal anaphylaxis, particularly through insect stings and food allergies. We found that we could not quantify the problem, the full health costs of allergies or the economic burden to society, because the reporting systems in the NHS do not code specifically for allergy per se. We did discover, however, that prescriptions for allergy symptoms cost nearly £1 billion a year—about 11 per cent of the total community drugs budget.

We made many recommendations in the report, some of which are key to improving the situation rapidly for sufferers. The bulk of the key recommendations concerns the woeful deficit of clinical allergy services in the UK—a deficit already severely criticised in reports that preceded ours and for which the Government presented no convincing remedial plan in evidence to us.

Other key recommendations were: the urgent need for the education of healthcare professionals about allergy and of those in catering about handling food allergens; the importance of research into the causes and factors that exacerbate allergy, as well as ways in which to prevent allergies, particularly peanut allergy, from developing in the first place; the adoption of immunotherapy in treatment in the UK, because it is not happening yet; and better support in schools for children with hay fever and other allergies. Without implementation of these key recommendations, our other recommendations on monitoring allergy, air pollution, occupational rehabilitation, advice to parents and the urgent need to evaluate complementary therapies and diagnostic kits would have relatively little effect.

There are only 26.5 whole-time-equivalent allergy specialists, many of whom are clinicians funded through research rather than the NHS, compared with several hundred specialists in some European countries. Of the 94 allergy clinics in England, only six are led by a full-time allergist. The others are uni-disciplinary clinics, which are held a couple of times a week and led by organ-specific specialists working in relative isolation. Pitifully few services of any sort are available in the north and west.

The lack of allergy-service infrastructure is mirrored by a serious lack of allergy knowledge amongst clinicians at all levels, particularly in primary care. Even when a GP recognises that a patient needs to be referred, it is hard to identify whom to refer to, and some patients resort to attempting self-diagnosis using inappropriate and unproven tests. Furthermore, the answer to better diagnosis in primary care is not pedalling diagnostic kits, but education, education, education, because misleading false positives abound without an accurate history and a proper clinical examination.

We saw a very different picture in Denmark, where the various specialists work collaboratively to provide an efficient diagnostic and management service for patients. With the financial constraints of the NHS, we accept that it would be unrealistic to call for the immediate training of hundreds of dedicated allergists, but we do feel that more need to enter training. However, we suggest the harnessing of the pockets of allergy expertise that already exist by clustering the various specialists to work together in designated allergy centres. This would not require a vast amount of additional funding and could be implemented quickly. At least one allergy centre led by a full-time allergy specialist should be established in each strategic health authority area, bringing together those who already have a special interest in allergy: from chest medicine, dermatology, occupational medicine, ENT, paediatrics, clinical immunology and gastroenterology, with support from specialist nurses and dieticians.

Each centre of excellence would form a hub where clinicians working together would learn from each other and provide expertise to investigate and diagnose complex allergies and guide management plans. They would also guide management plans as the patient goes back to their GP for their care to be monitored in an ongoing way. In a hub and spokes model, the centre could also provide outreach clinical services across their region and be a single point of contact and co-ordination, especially for those patients with complex, multi-system allergic disease, and for other clinicians with a special interest in allergy. The centre would provide outreach education to both primary and secondary care. It would also be a resource for patients, so that feedback between patients and the centre would guide development and disseminate new research evidence. The centre itself would then foster research, particularly engaging the patient’s voice in research development within its area.

In their response, the Government reverted to their well-worn argument that responsibility in a devolved NHS rests with local commissioners, but acknowledged that our suggestion merited careful consideration. Since publication, I have met the Minister, Ann Keen, and the Minister in this House, the noble Lord, Lord Darzi, both of whom expressed their enthusiasm for such a pilot project. Moreover, Professor Custovic from Manchester has informed me of a prime opportunity in the north-west where a framework and business case for just such an allergy service has been developed and locally endorsed by the specialised commissioning group, but the only thing holding it up has been funding. So I look forward with great anticipation to hearing from the Minister about progress made by departmental officials who were going to explore this with stakeholders, and I hope that he will have a positive response to announce today. I am grateful to him for his work and for his recognition of the importance of developing a pilot centre. We on the committee see the clustering of expertise in allergy centres as the most important way of ensuring that the other changes are championed and followed up in order to improve the health of millions of people suffering from allergic diseases in the current allergy epidemic.

I turn to therapy. Although we were not investigating appropriate ways to diagnose and treat allergic conditions, the argument to support immunotherapy in order to desensitise patients suffering from hay fever and venom anaphylaxis became evident. In Germany and Denmark we saw the efficacy of immunotherapy and realised why we had been told that the NHS is the laughing stock of Europe for its absence of immunotherapy for allergic diseases. We are puzzled that new immunotherapy products are licensed in the European Union, but the MRHA has not approved them in the UK. It is also disappointing that NICE has told us that there are no plans to carry out an appraisal of this type of treatment for allergy sufferers.

Prevention is certainly better than cure. Excellent research, largely from the UK, has elucidated allergic mechanisms and genetic susceptibility, but the way the immune system develops in infancy on exposure to allergens remains poorly understood. Environmental factors which can exacerbate allergies, such as dust mites and damp housing, have been implicated in the genesis of allergy. But, as was pointed out to us, everyone lived in damp, cold housing 100 years ago and there was much less allergy. Even the hygiene hypothesis which has featured a lot in the press, we discovered, may be somewhat inconclusive. So we recommended that long-term cohort studies warrant support to explore the effect of environment on the inception, prevention or exacerbation of allergies.

School poses particular hazards for children with allergies. Eczema is itchy and disfiguring and treatment creams are potentially stigmatising. Hay fever sufferers under-perform in summer examinations, dropping a grade compared with their winter mocks at times, and support varies widely between schools. For food allergic children, casual contact with food allergens can precipitate fatal anaphylaxis. Some suffer terrible bullying when other children put nuts into their pockets or lunchboxes to try to contaminate their food, yet school staff do not necessarily know how to deal with anaphylactic emergencies. That is why we called for a review of the care of hay fever sufferers, particularly schoolchildren during exams, for approved allergy training of staff and a review of the case for schools holding generic adrenaline auto-injectors.

So why did the Government brush these aside quite so dismissively? Hospital admissions for anaphylactic shock rose sevenfold from 1990 to 2004 but the true number of deaths remains unknown. Potentially fatal anaphylaxis can occur anywhere and probably a fair number of drug reactions are actually allergic reactions to the medication given. For people with food allergy, eating out is particularly hazardous and food shopping presents a minefield because food labels are inconsistent, confusing and offensive, with warnings so overused that teenagers tend to ignore them. So we recommended greater accuracy on food labels to clearly specify known allergens in the product.

Almost 26,000 people in England have known peanut allergy and yet, on one of our visits to the Evelina children’s hospital, we learnt that in countries such as Israel peanut in weaning foods seems associated with low rates of peanut allergy. This evidence has inspired Professor Lack’s study. His hypothesis is that the avoidance of peanuts during pregnancy and infancy may be contributing to the epidemic. That led us to recommend the Department of Health to withdraw its out-of-date advice on peanut consumption. No other Government advise peanut avoidance in pregnancy. I ask the Minister when the review commissioned from the Food Standards Agency and the Committee on Toxicity will be available. I understand that those bodies have been charged with reviewing the subject.

About one-third of the population will develop symptoms due to allergy at some time, and these are not trivial problems. Today’s debate is particularly timely as the seasonal problems of hay fever, insect stings and plaque dermatitis resurge to join the perennial food and other allergies. I have been able to cover only the areas that the committee felt required the most urgent action, particularly the need to cluster expertise together to form centres of clinical excellence. Many groups are anxious to see the report’s recommendations implemented. The allergy epidemic continues and people are demanding better clinical services, reliable advice on food and better support at school for children with allergies. We hope the Minister shares our vision to improve allergy services. I am sure that he recognises the enormous public interest in the subject and I look forward—as does the committee—to his responses today. I beg to move.

Moved, That this House takes note of the Report of the Science and Technology Committee on Allergy. 6th Report, Session 2006-07, HL Paper 166.—(Baroness Finlay of Llandaff.)

My Lords, I put on record my appreciation for the work of our clerk, our special adviser, my colleagues and our chair. It has been a wonderful experience to work with them. It is sometimes quite daunting to be a member of your Lordships’ Committee on Science and Technology. There are many eminent and highly qualified people serving on the committee. Participating in this debate are eminent physicians who are experienced in diagnosing allergies; eminent scientists who know all about the little that is known about allergies; and people who, unfortunately, suffer from allergies. They are all well qualified to speak. Of course, there is the Minister, himself highly qualified.

What are my qualifications? My qualification is that I am a strong supporter of this Government and wish them well. More than ever, I am anxious that they should keep in touch with the public, address people’s concern and, as they say, be a listening Government. Working on this inquiry, one thing came across loud and clear: people are concerned about allergy. Every time I told friends about our inquiry, inevitably they would respond with an account of their experience of allergy or that of a family member. My children are young parents, and they responded with concerns about their children. Every few days somebody would bring to my attention media items about allergy. There was a supplement last Sunday, mentioning our report and, indeed, the noble Baroness, Lady Finlay. As the Minister knows, the media make it their business to reflect people’s concerns. Teenagers tell me that allergies are now a topic appearing in the social networking sites. The concern seems to be that allergies are a feature of modern life. The noble Baroness, Lady Finlay, spoke about there being fewer allergies 100 years ago. As we raise our standards of living, so, apparently, allergies increase. It would appear that they are not going to go away.

The noble Baroness spoke about regular warnings. Yes, the Royal College of Physicians reported in 2003; the House of Commons reported in 2004; the Department of Health itself reviewed the services for allergies in 2006; and your Lordships reported in 2007. All showed concern. I do not know about the other reports but I can confidently tell the Minister that the British public listen to House of Lords reports. How do I know? I have the privilege of being a member of the Lord Speaker’s outreach team. I have also moderated young people’s debates. Invariably, people tell me how much they value your Lordships’ reports for their authority and impartiality. This is why I ask the Minister to listen more carefully to our report. The public are certainly listening to it. One day the Minister may have to explain why it was ignored.

It is not going to go away. This year there have been letters in the Times, one from medical experts and one from the public, represented by the Surrey Women’s Institute. As we know, you ignore the Women’s Institute at your peril. I am not suggesting that the Minister jumps on a passing bandwagon. That activity is reserved for the Opposition. I am suggesting that the Government should listen and hear. If they do not, others will, and the public will want to know why.

There is another reason why the Government should listen: money. As the noble Baroness, Lady Finlay, explained, nobody really knows what allergy costs the economy. As we explained in our report, this is all to do with record-keeping. There are a number of straws in the wind which indicate that the amount could be substantial. For instance, the Royal College of Physicians states in its report that contact dermatitis accounts for half of all days lost from work through sickness. That in itself would amount to an awful lot of money. There are indications that one in five of the UK population suffers from hay fever. That must be a considerable cost to the economy, as well as affecting children’s performance at school or during exams. The House of Commons has tried to put a number on this: it states that allergy accounts for primary care expenditure of £900 million a year.

Although these costs may not be exact, they could be considerable—and when they relate to a matter of public concern, costs have a horrible habit of achieving major significance. So it will come as no surprise to the Minister that when I read the Government’s response I was disappointed that they did not seem to share the concern of the public and the experts. Certainly, the response dealt with our recommendations; they were sent down the line for action and consideration in a most efficient manner. Any sign of shared concern with the public, however, was absent. Dealing with public concern is rarely a matter of administration. It involves political will.

Perhaps we were at fault in addressing our concerns to the Department of Health. Allergy issues are much broader than that. The Government’s response includes contributions from other departments: business, regulation, children and families, communities, local government, environment, food, work and pensions, health and safety. It is a very broad topic. That is why so many people are aware of it and why so many of them are concerned. Will the Minister look at this report again, not from the point of view of administration, but from the point of view of a Government who are in touch with the public, listen to their concerns and want to know what is being done by all those different parts of government to deal with those concerns? If the Government do not do that, it will come back to bite them.

My Lords, the whole House will be grateful to the noble Baroness, Lady Finlay, for introducing the debate with such authority and for having chaired the inquiry so skilfully. We all learnt a lot. Like the noble Lord, Lord Haskel, I do not feel myself as qualified as some of the great experts we have on the committee. I cannot say, however, that I feel I have the same qualifications to speak that he feels he has speaking from those Benches to urge the Government from behind, but I agree with him that this is an issue of concern for the wider public. The committee has articulated the concern that was apparent to me as a lay member.

I shall deal with the research issues arising from this allergy epidemic. We have already heard that we have one of the highest prevalences of allergic diseases in the world. The costs for the National Health Service are rising. We have already heard what the figures might be, but let us just say that the direct cost to the NHS is around £1 billion while primary care prescribing costs are around 11 per cent of the total drugs budget. Something like 17 million working days have been lost due to asthma alone, at a cost of another £1 billion—you can just talk about round billions with these figures.

The most startling thing of all for me—I say again that I start from a position of total ignorance on this subject—is that we do not seem to know why the incidence of allergy and allergic disease is rising. As the noble Lord, Lord Haskel, reminded us just now, it is clearly linked to some aspect of the more prosperous living conditions we have enjoyed since the 1960s. Dramatic increases were seen between 1964 and 1980, and there have been continuing increases since then. In Germany following reunification, and in other parts of Eastern Europe, there has been an increase in the incidence of allergic diseases right across the former Iron Curtain countries. It seems that there is a critical window of exposure in the first year of life during which the child’s immune system can be influenced, and their risk of allergic disease substantially reduced. Yet once children pass their first birthday, the same factors that would have prevented them from becoming allergic no longer operate, implying that any intervention to change the prevalence of allergy would have to target that very early phase of life and not be brought in some five years later.

There is still uncertainty on whether avoidance of specific allergens during pregnancy is desirable, or whether exposure to some allergies in appropriate contexts actually helps to protect children. A lack of research into the development of the immune system and the establishment of allergy means that the scientific community is still not able to answer fundamental questions, such as whether peanut avoidance protects the child from peanut allergy.

To answer such questions, we need broader studies; as the noble Baroness, Lady Finlay, said, long-term cohort studies are required. Those are not easily funded and do not produce specific conclusions. As Dr Egner of the Royal College of Pathologists advised us,

“In a competitive research environment, it is a brave person who goes into a messy area with no clear outcome”.

Professor Burney, who is a Professor of Respiratory Epidemiology and Public Health, said that it was a dilemma for those funding research to choose between good, basic science that will,

“find the exact answer”,


“a more speculative bit of work that is going to advance general knowledge but is not going to give you the same kind of precise answers”.

The majority of research funding, from the research councils and other public funding streams, focuses on the basic allergy mechanisms; indeed, this research is strong in the United Kingdom. We have research groups that are world leaders in research into the underlying mechanisms of allergy and allergic diseases. High-quality research of that nature in this country has significantly advanced our understanding of the molecular mechanisms of allergy. Where we fall down is in funding, adequately, epidemiological research and research into the development of the immune system.

Research in academia is hindered because of that separation between clinical work and the research centres. If the recommendations of our report help those specialist allergy centres, it would certainly help enormously to bridge the gap, as it is difficult at present for the academic researcher to access patients’ data from general practitioners. Indeed, those are sometimes impossible to obtain. Without access to a good, representative sample of the population at reasonable cost, epidemiological research is hamstrung.

In supplementary evidence, recorded on page 60 of the second volume, Professor Burney explains how the patients’ data are now regarded as confidential and access is denied—in marked contrast to such countries as Germany where data are more accessible. The professor said:

“Under the current rules, because we cannot have access to the names and addresses until the patients have replied to say that they are willing to participate, we are unable to help with any of this process. For a busy general practice this is an all but impossible task and it is amazing that we have any volunteers”.

He went on to ask, not unreasonably, for permission to use names and addresses of patients registered with GPs, together with their dates of birth and gender, providing; first, that the programme of work—including the letter of invitation to participate and the questionnaire—had ethical committee approval and, secondly, that the staff were adequately trained and had honorary contracts with the health authority or trust. Professor Burney ended his letter to the committee,

“The irony is that a properly designed and well vetted study to improve our knowledge of public health is forbidden, but any company can ring me up at home and conduct surveys or try and sell me whatever they please. If your committee were able to find a solution, this would be greatly and widely welcomed”.

We address this issue in paragraph 7.26, which states:

“It is imperative that further research should focus on the environmental factors, such as early allergen exposure, which may contribute to the inception, prevention or exacerbation, of allergic disorders. Long-term cohort studies are a vital part of this research … We look to the … Office for Strategic Coordination of Health Research to improve the co-ordination and funding for these types of projects”.

The Office for Strategic Co-ordination of Health Research arose from the Cooksey review which addressed this issue, which has been a problem for so long that the Medical Research Council undertakes research into it, as does the National Health Service. But before the Cooksey review the two lacked co-ordination. This is a challenge, if ever there was one, for the new Office for Strategic Co-ordination to try to ensure that there can be an exchange of data and a seamless join between the two funding research streams.

The Department of Health claims to be increasing its support for research into the environmental factors that contribute to allergic disorders. It would be encouraging if the Minister could add his support not just for increased funding but for putting in place improved co-ordination so that researchers can be granted adequate access to the relevant data that they ask for.

My Lords, this Select Committee report is particularly timely. Under the excellent chairmanship of the noble Baroness, Lady Finlay, it produced a thorough, thoughtful and constructive review of the rising incidence of allergies in the United Kingdom and, helped by its excellent secretariat and its specialist adviser, Professor Kay, produced a set of constructive and sensible recommendations. However, I found the Government’s response disappointing in parts and in some cases dismissive.

I strongly endorse the remarks made by all the previous speakers, particularly by my noble friend Lady Finlay in opening the debate, and join with the noble Lord, Lord Haskel, in asking for the report to be read again, recognising that it contains important comments expressed thoughtfully by a lot of well informed people.

I wish to relate my next point to a somewhat wider area that the noble Earl, Lord Selborne, covered in detail and elaborate on the decision made nine years ago to recommend to women that they avoid eating peanuts when pregnant and avoid exposing their children to peanuts. I thought then that the advice was not well founded but I recognise that that was debatable at the time. I am given to making gestures in the Chamber as a substitute for using PowerPoint, but this time I shall not distribute my papers all over the Bench in front of me. Since then we have seen a linear rise in the incidence of peanut allergies. I understand as well as the next person that correlation is not causation. There is also the hygiene hypothesis—we have heard about this and I shall not elaborate on it further—that we live in an excessively hygienic environment and people’s immune systems are more disposed to develop pathologies. I recognise that that is not proven, and even if it were, it would not necessarily conclude that eating peanuts was advisable. None the less, careful epidemiological studies show that in Israel, where infants are exposed to peanuts, there has been no corresponding rise in the incidence of peanut allergies. The rate is low and flat, whereas our incidence of such allergies has risen even with the advice I mentioned.

In Africa, children are also commonly exposed to peanuts and have no allergies. There could be genetic differences. I realise none of those points amounts to a proof that you should tell people to rush out and expose children to peanuts, but in my mind they amount to a powerful argument for reviewing the advice not to. The Government’s response to that particular recommendation was to say that they did not think it appropriate to withdraw the advice without having alternative advice to replace it. Fair enough, but I think the advice that ought to be given now, in the light of the additional facts we have gathered over those nine years, is that we do not understand this well enough to issue advice definitely one way or the other, but the indications are that there is no harm in eating peanuts.

From my five years as chief scientist, I realise how uncomfortable Governments are with saying that they do not know, and yet the protocols for science advice in policy-making—issued under John Major in 1996, reviewed by myself under Blair in 2000 and further strengthened by my successor—say that you consult widely and openly, you review changing circumstance and you admit uncertainty. That, in fact, engenders confidence in the public.

That leads me to my final brief point. The noble Earl, Lord Selborne, elaborated very cogently the other piece of evidence that receives generally less attention—namely, that research into the fundamental aspects of how the immune system first creates itself somatically in the first three years of life is difficult and not fashionable. On the molecular details of some of the actual allergies that have arisen, we are among the world leaders, but the world as a whole finds it unfashionable to look at this question. The immune system is not coded in the genome. What is coded in the genome is a programme to assemble itself. The conjecture is that if it is not appropriately sufficiently challenged, it goes looking for inappropriate work to do, hence a rise in allergies. Maybe that is right; maybe it is wrong.

This requires a fusion of people who work on non-linear dynamical systems with people who do careful clinical epidemiological work. As we heard in the report, and as was emphasised by the previous speaker, one of our recommendations is that it receives more attention. If I were the Secretary of State for Health, I would bring together an informal group of people from research in the National Health Service, the Wellcome Trust and relevant research councils—because this is not just a Department of Health responsibility—to ask whether there may not be some kind of coalition that puts a little bit more effort into soliciting this kind of unfashionable, multi-disciplinary research, where the potential researchers have told us they are finding difficulty getting funding.

My Lords, I, too, would like to pay tribute to the noble Baroness, Lady Finlay, both for opening this debate so expertly today and also for her chairmanship of the sub-committee. She has a degree of energy and expertise from which we were all able to benefit and she became a very close friend to every member of the sub-committee under her guidance. I recognise the splendid support that we had from our clerk, but would like to pay a particular tribute to our specialist adviser Professor Barry Kay, whose extensive knowledge and extremely experienced wealth of time in the field so greatly enhanced our work.

I would like, in the brief time available today, to reflect on one aspect of our report—that is, the impact of allergy on children in school—and to highlight some of the problems and solutions which we proposed in our recommendations. As other speakers have commented, allergies can cause a very severe reduction in the quality of life for school children. Think for a moment about children with eczema. Ms Sarah Day, our witness from the Royal College of Nursing, spoke to us about the image problems of children with eczema, which can be deeply distressing to the child or young person, and can often lead to teasing and bullying from other children who do not understand the illness that causes the extraordinary appearance that many of them can exhibit.

A survey by the Department of Dermatology at the Wales College of Medicine showed the devastating impact that severe eczema might have on the lives of children. Beyond the embarrassment, which for them is often the key part of the thing, there is also evidence of sleep disturbance and therefore impaired school performance. Think of children with severe asthma. They, too, suffer great underperformance in school, for many causes. Some 38 per cent of allergy sufferers had missed a considerable part of their schooling due to their asthma problems. Their sleep disturbance also made it hard for them to concentrate at school.

Though less severe, the prevalence of hay fever among children also has a demonstrable effect on their performance, particularly in examinations. As we all know, GCSE and A-level examinations mainly fall in the peak hay fever season. A study of the impact of hay fever on exam performance by teenagers in the UK found that sufferers could drop a whole grade in their summer exams compared to the results of their mock examinations, which were taken in winter when their hay fever was not present. That drop in achievement can be caused both by the symptoms of hay fever and by the sedating antihistamines that are often given to them and which affect their long-term prospects, both of higher education and career development. This is not a small matter; children who may drop from a B to a C in their A-level results, for example, can fail to meet the offer that they have had from a university, and so miss out quite substantially on the university experience that they had planned for, and therefore be affected in their long-term future careers.

Dr Paul Harrison, the director of the Institute of Environment and Health at Cranfield University, told us that children with asthma and allergic rhinitis often also opt out of sporting activities, so compounding their fitness problems. However, we received evidence that the awareness of the problems of hay fever sufferers and other allergy sufferers varied greatly, as did the way in which they were treated by their schools and local authorities. Some local authorities and schools allow special examination arrangements for sufferers, while others simply take no account of it at all. We recommended, therefore, that the Department for Children, Schools and Families should review the care given at school to hay fever sufferers and reassess the way in which they are supported during the exam season. Consistency of provision across schools and local authorities is a responsibility of the department; it is not enough simply to leave it to individual schools. We also feel very strongly that school nurses have a role in ensuring that children are not automatically given sedative antihistamines, which can impair their performance. I will return to school nurses in a moment or two.

There are a small number of children whose allergies are even more life-threatening; children who are at risk of anaphylaxis, for example, a reaction to food such as nuts or to insect venom. The peanut allergy alone has increased dramatically in recent years, creating a real challenge for schools, where teachers may find themselves dealing with a life-threatening emergency of which they have absolutely no knowledge. The representative from what was then the Department for Education and Skills said rather dismissively that, “It is a head teacher’s responsibility to ask themselves whether the cadre of teachers and support staff they have is able to deal with such an emergency”. I do not think that is good enough. I say to the Minister that to leave it to a lay head teacher to make such an assessment is not a response that one would expect from a responsible government department.

Children at risk from anaphylaxis usually carry an adrenalin auto-injector. We usually call them EpiPens, although I understand there are also AnaPens. Under current DCSF practice, only the EpiPen prescribed for the child is held in the school.

However, many of our witnesses felt strongly that schools should keep a stock of those generic auto-injectors available, for example, for a child who may have forgotten their EpiPen on that particular day or one who needed a second dose. We recommend that there should be clear guidance regarding the administration of auto-injectors to children with anaphylactic shock in the school environment. We also recommend to the Government that they should review the case for schools holding one or two generic auto-injectors.

Overall, however, we were concerned at evidence that allergies were poorly managed in the school environment. At the heart of this is the lack of training, most crucially for school nurses but also for teachers, support workers and heads themselves. That we felt was the heart of the problem. The evidence we would have given showed that there was a real problem in the training of school nurses. The department representative seemed to assume that school nurses were the answer to all the problems and could deal within the school with any emergency that arose and could also help with the training of the lay staff.

However, the evidence we had from the Royal College of Nursing spoke of funding cuts and shortage of staff among school nurses. There is also a problem where some school nurses are employed by the school directly and others are employed by the PCT and therefore their training needs can be dealt with in different ways: particularly those employed directly by the school have no one competent to assess their training needs and little money made available for them to update themselves in allergy treatment.

There is a lack of expert knowledge within the school system of how to deal with this huge problem. The Government document Managing Medicines in Schools and Early Years Settings suggested that every child who suffers from any form of problem that leads to them needing medication during the school day should have an individual healthcare plan. While we welcome that suggestion, we note that the heads have insufficient medical knowledge themselves to know whether their staff can deal not only with the routine medicines but with emergencies. We think it is simply not enough to leave it up to the school and to the head to draw up this individual healthcare plan and then to implement it.

We believe that the responsibility lies with Government to ensure that a health professional is available to make the assessments and to provide training where necessary. In the current shortage of school nurses and the difficulty of funding for their training, we fear that this is unlikely to happen. Our recommendation therefore is that the Department for Children, Schools and Families should audit the level of allergy training that school staff receive and should take urgent remedial action to improve this training where it is required. The impact of allergies on school performance as the life chances of many young people is immense and far-reaching. It is therefore disappointing to find that, as with most of the sub-committee recommendations, the Government response was so half-hearted. While agreeing with the Committee’s conclusions, no action was proposed, whether on the training required by staff, the storing of generic auto-injectors or the timing and arrangements of key examinations. It is not good enough. If, as we were told by our expert witnesses, allergy among children is of epidemic proportions and likely to grow, there is no excuse for us to stand back and leave it to lay people in schools and an overstretched school nursing service to deal with a national problem affecting thousands of children’s lives.

For me, the saddest comment that we heard from one of our continental experts on our visit was,

“We are simply amazed at the contrast between the world-class quality of your UK allergy research and the dreadfully low quality of your UK provision to patients”.

My Lords, before my noble friend Lord Bhattacharyya rises, I apologise to the noble Baroness, Lady Perry, for interrupting her excellent speech with my mobile telephone. I apologise to her and to the rest of the House.

My Lords, while I am no medical expert I am glad that this debate has been scheduled for today as I recently experienced serious allergy problems and can offer a layman’s perspective on this excellent report. There is great interest in this debate and I believe that I know why. I was reading the committee’s report this morning when my daughter asked me what I was doing. When I told her that I was going to speak on allergies she laughed and said, “Well, everyone is allergic to politicians”.

My own allergic experience was in line with the report’s analysis. Last year, I noticed a rash on the left of my forehead which I assumed was an insect bite. As I often visit the tropics, one gets a lot of bites. However, within a fortnight a blister developed, so I went to my GP, who thought I had shingles. The treatment for shingles did not help and the lesion worsened. I was diagnosed with cellulitis and treated with intravenous penicillin, but the lesion did not fully heal. In addition, I developed a rash all over my body. My GP referred me to a consultant dermatologist who diagnosed me with an allergy, probably to the original insect bite. Penicillin was replaced by steroids and my skin improved. I then decided to get tests to find out what I was allergic to.

I will not bore the House with the details of my treatment, but as Birmingham has only two immunologists, I went to a specialist London clinic to fully identify my allergies and have immunisation treatment. I was lucky to be diagnosed with an allergy relatively early on, but my case illustrates that a full diagnosis of allergies still requires a significant delay, private care, a lot of travel or all three.

I want to be clear. I am proud of what the Government have achieved in the NHS. The West Midlands Strategic Health Authority under the leadership of Cynthia Bower has transformed the landscape of medical care in my region. We have made great strides in the past few years, with new hospitals and improved patient care. Wanting services to improve is not a criticism of the NHS. There should always be a debate about how public services should improve next. Allergy treatments currently have waiting times that are too high and a quality of diagnosis which is too low. As Dr Pumphrey of Research Councils UK stated,

“patients are unlikely to get ideal advice from any but the best informed of specialist clinics”.

The Department of Health began its report on allergies with a summary of the problems. It said:

“People can wait 3 to 9 months for an appointment to see a consultant in secondary care ... some may be passed around a number of different clinical departments for the different symptoms ... which can make diagnosis and optimal treatment difficult”.

I had no problems. I went to one clinic and very quickly all the experts were there and I was diagnosed early.

The Government tell us that 81 per cent of GPs say NHS care for allergies is poor quality and only half of GPs are trained in managing allergic problems. My experience backs that up. These issues define the problem. Doctors do not have sufficient expertise to diagnose allergies and there are not enough specialists to treat the patients that are diagnosed. This means that patients who go to a GP with asthma have to attend seven times before they get a diagnosis, while only a third of those with asthma are given an allergy test. I was born in India, so I never had all the benefits of hygiene when I was young; therefore, I never had any allergy problems until I faced this one.

Therefore, I endorse the conclusion that we need more training for GPs to diagnose allergies and an increase in clinical specialists based in a regional allergy centre. If we do not do that within the regions there are travel problems. I could afford private care, but the majority of people will have an enormous problem in accessing the sort of expertise that I experienced.

We have strengths in allergy research and courses for diagnosis in the UK—for example, at Southampton and the medical school at my own University of Warwick. I am struck by paragraph 7.27 of the report, which states:

“We are concerned that the knowledge gained from cellular and molecular research is not being translated into clinical practice. We therefore regard allergy research directly related to healthcare as an area of unmet need that requires greater priority”.

Perhaps we should kill two birds with one stone by combining the regional allergy centre with an existing training location. This would best relate allergy research to treatments and GP training.

The Government are right to say in their response that,

“Local need is what will determine how allergy services should be provided”.

We should not be recreating a “command and control” system in the NHS. I hope that Ministers also accept that local commissioners sometimes respond best to a strong lead from the centre. The Government have proved that successfully with waiting times. Launching the first regional allergy centre would be a strong lead from the centre. I welcome the Government’s conclusion that a lead strategic health authority is a worthy idea and I urge action on it.

We also need to help consumers by making it easier to detect any allergies that they might come into contact with. I now know what I am allergic to, both in chemicals and food—but it is a hell of a job to find out. When it comes to products such as aerosols, shampoos and detergents, one avoids all of them; because there is no clear labelling, one is scared.

When you suffer from an allergy, you first look for a cure from those you trust. But if none is forthcoming, you look anywhere. If the NHS makes the correct diagnosis and identifies the right treatment, patients will not require the dubious remedies that have exercised the committee. If we ensure that labelling is clear to those who suffer from allergies, consumers will not be susceptible to the pedlars of snake oil.

I hope that the Government respond constructively, so that we can make great strides in the treatment of allergies. Otherwise, we will see more patients fall into the arms of anyone who will offer them relief, no matter how far-fetched their claims.

My Lords, many speeches today have stressed the seriousness of what can be described justly as an epidemic of allergy. We learned in committee that, among six and seven year-olds, one in five suffers from asthma. Some 5 million people suffer to some extent from allergy to grass pollen. There is some suggestion that the number of people affected by allergies is levelling out. However, there is no doubt that millions of people—possibly an increasing number—suffer severe impairment to their quality of life because of some form of allergy. It was therefore deeply depressing to discover how backward we are in the United Kingdom. No doubt there are centres of excellence, but the overall picture was described by the World Allergy Organisation Specialty and Training Council, which is quoted on page 89 of our report. It highlighted the paradox that in the United Kingdom, a country with an outstanding record in allergy research, there is a remarkably poor clinical service for allergy sufferers.

I was disappointed that when the Committee pointed out how backward we were, the Government reaction seemed to lack the appropriate urgency—they seemed relaxed about our deficiencies. Yet, as our chairman stated, we are considered the laughing stock of Europe in this field. By the way, I add my tribute to the noble Baroness, Lady Finlay, for her chairmanship. In a previous committee on which we served—on physician-assisted dying—I found myself in profound opposition to her views. However, after learning more about her activities and, in particular, after experiencing her chairmanship of this committee, I have become an admirer and feel that she is one of the most valuable Members of this House.

There are at least three respects in which we are backward compared with many of our European partners. The first is in training and education. The diagnosis and treatment of allergies is not part of the basic training of medical students—an astonishing situation. Nor are there adequate general clinical postgraduate courses in allergies for nurses and doctors, which is most important in the case of GPs. Most GPs are not properly equipped to diagnose allergies or recommend appropriate treatment.

A second result of this inadequate training and education is that we have an appalling shortage of specialists. As the noble Baroness, Lady Finlay, pointed out, we have 26.5 specialists—I am not sure who is the half. Spain, with a much smaller population, has 1,300 specialists—50 times as many. Equally unfavourable comparisons can be made with Denmark, Germany, Sweden and many other European countries.

One of the most damning comparisons concerns the very limited facilities we offer for immunotherapy. I quote figures given to committee members who visited Germany. They appear in the appendix to the committee’s report, on page 128. Germany prescribes about 700,000 courses in specific immunotherapy, France about 500,000 and the UK about 5,000, yet the evidence that we received was quite clear. Immunotherapy is a standard and effective way of managing allergies in other European countries. It allows patients to lead much more normal lives, especially in the case of hay fever, asthma and allergies to wasp and bee stings, and it has a more lasting effect than treatment with drugs such as antihistamines or steroids. Immunotherapy can be administered either subcutaneously by injection, involving a lengthy and expensive form of treatment, or more cheaply and conveniently sublingually, by oral tablets. Sublingual treatment is very common in France but is almost unavailable in the United Kingdom. However, even the more expensive form of subcutaneous treatment saves costs in the end because it is much longer lasting and much more effective than drugs.

Why do we neglect desensitisation or immunotherapy? We do so because the MHRA has created the strictest regulation in Europe. Its attitude seems to be determined by safety concerns based on 27 deaths from anaphylactic shock between 1956 and 1982—over a quarter of a century ago. A Danish company gave evidence that it had product licences for subcutaneous immunotherapy in many European countries but had given up seeking licences in Britain because of the attitude of the MHRA. We were also told that NICE has no plans to appraise immunotherapy products. However, the evidence that we received was clear. If administered by specialists in a proper environment, the treatment is safe. If there is a severe reaction, it can be promptly recognised and dealt with. The MHRA has simply not kept up with the evidence and it has apparently not looked at the experience of the rest of Europe.

There is no justification for that defensive attitude. We seem to be unique in our view of the safety of the treatment. Not only other European countries but also the WHO regard immunotherapy as the most effective treatment—the only one that can influence the natural course of allergic disease. Its views are found at page 131.

Therefore, I return to the question of why we are so backward and why we refuse to learn from the experience of other European countries. I fear that it is part of a wider disease—a certain insularity and a refusal to accept, because of insular attitudes, that in many ways other European countries are more civilised than we are. That is certainly the case in their approach to crime and penal policy but it is also the case in many aspects of health policy. Our National Health Service has many virtues and is often unfairly criticised, but our public attitude towards the scourge of allergy is, frankly, a national disgrace.

My Lords, the noble Baroness who initiated this debate and chaired the committee which produced this important report has, not for the first time, rendered a very considerable service to the House, to medicine and, above all, to those afflicted by illness.

This allergy report was produced by the Science and Technology Committee before I joined it but, invited by the noble Baroness to participate in the debate, I said that I would speak of the experience of my own family and of the difficulty of finding general practitioners with the knowledge and time needed to provide the right diagnosis for a wide range of complaints. On reading the report, I found that the experience of my wife exactly bore out some of the most crucial evidence received by the committee and underlined the importance of some of its key recommendations.

Going back to the early 1960s, after the birth of our first child, my wife felt the kind of pain all over her body that one suffers from a poisoned finger. Our unsympathetic GP said that it was probably postnatal depression and that she should see a psychiatrist. She was finally diagnosed by a patient and understanding doctor as suffering from an allergy to cow’s milk. She consulted Professor Jonathan Brostoff, who gave evidence to the committee, one of the leading experts on food allergy and food intolerance. Some years later, after I had become an MP, she suffered from sores in her mouth, constant sore throats and swollen glands, was fed with antibiotics and told to lead a less stressful life. A wise doctor in Abergavenny, feeling sure that it was a food allergy, questioned her closely and suggested that it might be tomatoes. He was right. A long time later, suffering muscle weakness and aching joints, she finally found that she was suffering from an allergy to wheat. Today, when vineyards and wine companies are speeding up the maturing process of wines by adding sulphites, my wife has joined many others unable to drink wine.

Talking to friends about these experiences I have often referred to the doctors who did come up with answers as being members of an increasingly rare breed, the first class diagnostic physician with the knowledge and time to come up with the right diagnosis. The committee, in Chapter 9 of the report, identifies the poor clinical service provided for allergy sufferers in this country. It quotes the 2004 report of the House of Commons Select Committee on Health which said:

“Those working in primary care lack the training, expertise and incentives to deliver services … Many of the deficiencies in primary care are matched by weaknesses in secondary and tertiary care”.

The Commons committee recommended that the GP curriculum should include allergy training and that specialist allergy clinics should be developed across the country as centres of good practice for the training of primary care staff.

The report we are debating today reveals a shocking state of affairs. It is astonishing that it should be necessary for parliamentary committees to suggest that allergy training for GPs should be necessary. It is disturbing that witnesses report that the knowledge of allergy in primary care is poor and refer to minimal training. As if that was not bad enough we are told that there is a shortage of allergy consultants—and of expertise among consultants to whom GPs are likely to turn.

On a visit to the allergy clinic at Addenbrooke’s Hospital, committee members were told that it was a struggle to convince local commissioners to invest in allergy training and services because allergy was not yet recognised as an important subject.

Allergy UK, a leading allergy charity, reported that for patients,

“the major problem is the lack of knowledge at primary care level. GPs do not recognise allergic symptoms when presented with them due to a lack of training in allergy”.

A consultant allergist at the Royal National Throat, Nose and Ear Hospital told the Committee that:

“‘In medical schools the amount of allergy training is absolutely minute, if it exists at all’”.

Another doctor, making the same point, went on to say that when it comes to postgraduate training,

“‘there are so few allergy specialists in the country, there is no one to undertake teaching’”.

Paragraphs 9.28 to 9.31 of the report provide a damning indictment of the current situation. Its second volume, which contains all the evidence received, adds powerfully to that indictment. The key recommendations on allergy centres—those described by the noble Baroness when opening the debate—in Paragraphs 9.40 to 9.46 of the report, on NICE clinical guidelines in Paragraph 9.47 and on education in Paragraph 9.48, demand a full and adequate response.

However, the Government response to all these recommendations is deeply depressing. They refer to a review carried out by the Department of Health and then make use of that review to justify one of the most inadequate responses ever given to a report by a Select Committee of this House, made much worse because, effectively, it is also a response to a committee of the other place that came to similar conclusions. They argue that,

“lack of baseline data … published examples of whole systems modelling of services … analysis of the effects of active demand management of patient flows in allergy care … absence of agreed service models and protocols”,


“the presence of differing perspectives of professional groups”,

make it impossible to make meaningful comments on the existing and desirable capacity of services for allergy. Surely that is not an adequate response to the recommendations but an admission that the Department of Health has failed to do its job.

If all those business jargon phrases that I have quoted identify work that should have been done, the question is why it has not been done and why the information is not available when provision of services is identifiably inadequate and huge sums of taxpayers’ money is being put into the health service. One thing is absolutely certain: with that kind of guidance, few with regional responsibilities will make a positive move to improve the service and provide the allergy centres that the report recommends.

We are told that none of the allergy-related,

“topics has been judged to be of sufficient priority against other proposals to warrant inclusion in NICE’s ... programme”.

That represents a combined failure by both NICE and the department to address priorities that have been identified by two parliamentary committees on the back of a mass of evidence. As to education, I suppose that we are expected to find comfort from the statement that the Department of Health,

“does share a commitment with statutory and professional bodies that all health professionals are trained, so that they have the skills and knowledge to deliver a high quality health service to all groups of the population with whom they deal”,

even though the department first washes its hands of responsibility for setting curricula for health professional training. However, it really is not good enough to be fobbed off with the feeble comment that the department,

“would encourage the Royal Colleges to work together with the bodies responsible for medical training at all levels, in order to ensure that the knowledge and expertise of those working with people with allergies are enhanced”,

and with the recommendation that,

“early attention should be focused on the knowledge and skills of all clinical staff”.

If I appear angry and impatient, it is because I am. That anger and impatience are shared by a large number of professors and consultants in the field, many of whom signed a devastating letter to the Times, which appeared on 31 January. Today we are considering a report that identifies grave shortcomings in the knowledge and training of a large number of health professionals, who as a result are unable to provide the quality of service that is, I am sure, their ambition and the understandable and justified expectation of their patients. It is the job of Ministers to ensure that shortcomings, when identified, are remedied. It is they and not others who should be held responsible if remedies are not found. With a Minister rightly described in the debate as highly qualified, perhaps at long last there is hope.

My Lords, as always it was a great privilege to serve on your Lordships’ Science and Technology Committee. We were extremely lucky to have such a cheerful and energetic chair. She has already paid tribute to our specialist adviser, but I should like to pay special tribute to our clerk, Sarah Jones, who came through her initiation as a committee clerk with flying colours. I also thank our hosts on external visits, who went out of their way to make us feel welcome and arranged fascinating and informative programmes.

I am not an allergist or an immunologist but, as a general practitioner without special training in allergies, I saw many patients with allergy problems. The great majority of these could be helped by simple measures to mitigate the symptons. Inhaled, topical and, occasionally, systemic steroids were extremely useful, as were antihistamines and cromoglycate. I usually referred more severe or intractable problems, mostly asthma or severe skin allergy, to the appropriate chest or skin specialist. It was difficult to get an early NHS appointment to see our one allergist in the catchment area, who always had a long waiting list. I was fortunate never to have to deal personally with a severe anaphylactic reaction, though one of my patients died as a result of a wasp sting while on holiday in Greece.

I have suffered a moderately severe reaction myself as a result of a wasp sting, dealt with competently and effectively by the A&E department at the Royal Sussex Hospital in Brighton. Subsequently, I received a long drawn-out but effective course of desensitisation at Professor Stephen Durham's unit at the Royal Brompton. I know that it was effective because, a year or so later, I was stung eight times at once after treading on a wasp nest in the dark—an experience not to be recommended. Thanks to my desensitisation, it was not a fatal experience—as it might have been, because I had left my EpiPen at home.

In my practice, it would have been extremely useful if one of our practice nurses had received training in the use of patch testing and other allergy diagnostic procedures. As it was, we had only empirical knowledge of the allergens that triggered allergic responses in patients. In many cases, no single factor seemed to be responsible and control of the symptoms—whether a skin rash, wheezing attack or rhinitis—was the doctor’s sole aim, rather than finding out exactly what was causing it.

The main recommendation of the report—to establish a network of specialist allergy centres similar to the one that the committee visited in Cambridge—would make that much more possible. Not only could patients with troublesome allergies be referred there, but GPs and practice nurses could be trained in allergy procedures, as the noble Lord, Lord Crickhowell, suggested. Already, at the Cambridge centre, GPs have improved their allergy skills through their correspondence through referrals. My noble friend will know of the new allergy centre proposed for Manchester, which the noble Baroness, Lady Finlay, mentioned, which consultants want to set up and requires only modest funding. I understand that my noble friend’s colleague, Ann Keen, has agreed that the Manchester Centre should be supported, but so far, no funding has been agreed. Can my noble friend give us good news here?

The rise in allergic disease in the past few decades—which all our witnesses mentioned and which is well understood to be real and not simply due to changes in clinical awareness or diagnostic criteria—has occurred in all modern industrialised countries, not merely in Britain, although we have perhaps had the highest rise. It has not occurred among the populations of developing countries living a traditional lifestyle but, interestingly, it has increased to some extent among the better-off members of those societies, whose standard of living is similar to ours. As we have heard, that phenomenon has been labelled the hygiene hypothesis: those at greater likelihood of exposure to more infections, infestation, environmental pollution or certain foods very early in life—possibly even in utero—are less likely to develop allergies as older children or adults. The clean, the hygienic, thus has a downside. That is perhaps another way of saying, “A bit of dirt never harmed anyone”—and may even do some good.

An example of research carried out in Berlin and Munich on whether the hygiene hypothesis applied was described to us; it has already been alluded to. Before the unification of Germany, the incidence of allergic disease was lower in poor children in the east, where there were higher levels of atmospheric pollution than in the west. After unification, which led to less pollution and higher living standards in the east, levels of allergy gradually rose, so that there is now no difference between east and west. In rural Germany, children brought up on farms, exposed to animals and drinking unpasteurised milk, had lower levels of asthma and other respiratory problems than children in the same area not living on farms. Research that has been described to us, as noble Lords will have heard, by Professor Gideon Lack at the Evelina Children’s Hospital demonstrated that the prevalence of peanut allergy in Jewish children living in Israel was much lower than in genetically similar children living in the UK. As my noble friend has described, the Israeli children had been weaned on to a food based on peanuts. I will not describe the study known as LEAP—Learning Early About Peanut Allergy—which Professor Lack is conducting because it has already been well described.

As its name suggests, the hygiene hypothesis is a hypothesis rather than a full explanation, as there are many exceptions to the rule. It is not much help being allergy free if, as a result of living in an unhygienic environment, a young child were to get seriously ill and fail to survive to enjoy its allergy-free status. However, the hygiene hypothesis may be helpful in understanding the origins of allergy. The mechanism of the immune response to certain bacilli—possibly in the gut flora—in early life appears to enable an individual to deal more efficiently with potentially allergenic challenges later.

Research to identify and understand the processes involved in the acquisition of tolerance early in life has far-reaching potential, and hopefully it will be possible to identify and isolate at a molecular level the factors in the “unhygienic” environment initiating this process. Thus “clean dirt” could be given to vulnerable individuals, enabling tolerance to develop without the long process involved in a desensitisation course. Here, however, I am speculating beyond the evidence that we received. The purpose of my remarks is to underline the importance of stable or increasing government funding to enable the high-quality basic and epidemiological research in this country to continue. The noble Earl, Lord Selborne, and the noble Lord, Lord May, described this very well.

Food allergy is an increasing problem. Although many who think they may be allergic to certain products—according to some estimates about a quarter of the population at some time in their life—may in fact be suffering from food intolerance or ascribe a variety of symptoms to certain foods, encouraged by some complementary practitioners and the media, rather than having a true allergy mediated by IgE or T helper cells. Five to seven per cent of infants are thought to have some manifestation of true food allergy, but the figure is not precise due to diagnostic difficulties. This prevalence reduces to about 1 to 2 per cent of adults, according to the Institute of Food Science and Technology. As has been said, peanut allergy has increased in prevalence so that about 25,000 people may now be affected. New food allergies are being described, such as to kiwi fruit and certain other fruits, tree nuts as well as ground-nuts, chickpeas, sesame, mustard and soya. Dr Clare Mills of the Institute of Food Science and Technology ranges potentially allergenic food products in a hierarchy of severity, with peanuts and hazelnuts at the top of the list and carrots, tomatoes and melon at the bottom.

To conclude, the European Union is reviewing its food-labelling legislation. This should provide an opportunity to rationalise what is at present a confusing set of regulations that cover only 12 known allergens added to food. The list is constantly changing. The review should provide the Food Standards Agency with an opportunity to influence the rationalisation of EU food labelling legislation. Our report recommends that food labels should specify the amount of each allergen listed if it is contained in the product, and we support the FSA in discouraging vague, defensive warnings which can severely restrict the choice of those with possible allergic tendencies, especially if they are of a cautious disposition.

My Lords, much of the fundamental research on allergy and its management has been done in the United Kingdom, and yet with allergy reaching epidemic proportions, this report of the sub-committee so ably chaired by the noble Baroness, Lady Finlay of Llandaff, and guided by our expert adviser, Professor Barry Kay, identifies major deficiencies in allergy services in the country, including a shortage of specialists, lack of training and deficiencies in management when compared, for example, with the continent of Europe.

I wish to focus on immunotherapy in allergy. Immunotherapy, or desensitisation, can lead to a potential cure for an allergy rather than merely alleviating the symptoms with drugs. Immunotherapy has been found to be highly effective in numerous rigorously controlled clinical trials. Importantly, desensitisation treatment has scored well at the highest level of scrutiny such as meta-analysis using the Cochrane database. The treatment, which consists of administering graded increasing doses of whatever the person is allergic to, such as pollen, dust mites, bee and wasp venom, is a specialist procedure that is best undertaken by a specialist. Immunotherapy, given either by subcutaneous injection or drops under the tongue, is the standard treatment for common allergies in virtually every country in the developed world with the exception of the United Kingdom. We found that it is hardly used at all, and there appear to be two reasons for this.

The first is simply a lack of UK allergy specialists. The second seems to be reluctance bordering on obstruction by the Commission on Human Medicines to approve licence applications for allergen immunotherapy given by injection, bearing in mind that, world-wide, immunotherapy is still mainly given by injection, and at present most allergy products are only available in injectable form.

The sub-committee was informed in written evidence from the Medicines and Healthcare Products Regulatory Agency that the UK uses the mutual recognition procedure for immunotherapy products in the same manner as other treatments. Yet we were told on our visit to a Danish vaccine company, ALK-Abello, that this appears to be far from the case. For example, one of that company’s products, Alutard SQ, used to treat grass, tree, cat, dog and house dust mite allergies, has been licensed for use in many European countries for decades. The company told us that in December 2005, Sweden as the reference member state approved Alutard SQ for grass allergy and submitted the file to six European member countries for approval, including the United Kingdom and Ireland. All the countries approved Alutard for use in hay fever with the exception of the United Kingdom. Furthermore, when a revised application was submitted to the MHRA, the company was informed that the position had not changed and, as a consequence, ALK-Abello had withdrawn its file. In other words, this company and no doubt other allergy product companies think it simply not worth their while trying to get an allergen immunotherapy product licensed in this country.

So one might ask why the bar for approval of these products in the UK as opposed to all other European countries is set so high. Is it still the mindset of the 1980s when deaths occurred because this specialist treatment was being administered by untrained personnel to poorly selected patients using crude vaccines in GP surgeries? That is possible, but we have moved on. We must now remove the obstructions to effective allergy practice by making immunotherapy to a range of allergens widely available for UK allergy sufferers. The obvious place for immunotherapy clinics is at our proposed allergy centres. Perhaps MRHA would be more flexible in granting licences for a wider range of allergy products when they are administered by experts in these centres of excellence, rather than continuing with the present unsatisfactory situation in which most products are imported on a named-patient basis.

We also urge NICE, the National Institute for Health and Clinical Excellence, to evaluate those products currently on the UK market which have been subjected to thorough, controlled clinical trials. For example, bee and wasp sting anaphylaxis accounts for several deaths a year and remains often undiagnosed. For these patients, venom immunotherapy by injection can give life-saving protection, but few centres have the facilities for offering this treatment. Endorsement by NICE of bee and wasp venom vaccines would go some way to raising the profile of allergen injection immunotherapy.

Finally, there is the question of oral immunotherapy, in which the allergen is given under the tongue as sublingual drops or tablets. This is safe and effective treatment which can be self-administered by the hay fever sufferer at home. Mr Andrew Dillon, the chief executive of NICE, said in evidence that he had no plans to evaluate the oral hay fever vaccine Grazax. Why is this? The popularity of sublingual immunotherapy is growing year on year, especially among European and American allergists. Why do we have such a negative response to a treatment which has been subject to a Cochrane review and evaluated by numerous robust clinical trials?

The Government’s response to our submission on immunotherapy occupied five lines and concluded:

“If immunotherapy is given sufficient priority by the Department of Health, Ministers will consider it for referral to NICE”.

This in a situation where, as the noble Baroness, Lady Finlay, said, we are the laughing stock of the European Union with respect to allergy treatment. The irony is that although allergy immunotherapy was pioneered in the United Kingdom more than 100 years ago and many of the landmark clinical trials have been performed in this country, it seems to be the rest of the world, not us, which have benefited from that research.

My Lords, as this debate has shown, yet again, there is no subject on which there are not a number of people in your Lordships’ House who are highly expert—many, in this case, as a result of serving on the committee so excellently chaired by the noble Baroness, Lady Finlay. I bring a different expertise, which has been shared by at least one other noble Lord, that of a sufferer.

Because one likes to excel in life, I was rather chuffed when I went into my doctor’s surgery three years ago and he said, “My God, David, that is by far the worst case of hay fever that I have ever seen in all my years of practice”, and he packed me off to the Hereford Eye Hospital. I am half-way through a course of immunotherapy which is, so far, working for grass but not for tree. In order to be in your Lordships’ House this afternoon, I am on 20 milligrams a day prednisolone steroids—nasty stuff steroids, incidentally; 180 milligrams of fexofenadine, which is a strong antihistamine; hourly doses of sodium cromoglicate eye drops; four doses a day of antihistamine eye drops; nasal steroid spray; and piriton to send me off to sleep at night. So it is obviously not trivial going through all these treatments, especially if you still look like a living monster. I mention that not only to get the sympathy of the House, although that is always nice, but more seriously to make three points.

First, the only reason why I am here this afternoon is that I am receiving treatment at Guy’s Hospital from Professor Chris Corrigan and his wonderful specialist allergy team. They gave me new heavy-duty antihistamines, which would not be known to many GPs. My GP is excellent and he had only just heard about them. It is only because I am able to receive that specialist treatment that I am not lying down in a dark room, moaning, at this moment.

My second point is more important, goes to the heart of the debate and is about the importance we tend to attach to allergy. There is a feeling that allergy, even if you get it quite badly, does not rate highly in the league table of human suffering. It does not really matter and the health service should be concentrating on things that save people’s lives, rather than things that make their daily existence more comfortable. I make one or two points on that. A noble Lord, whom I will not mention because he is not in his place, quite often sits next to me in the allergy clinic because his life is threatened without immunotherapy. One bee sting could do for him. Therefore, he has to be there; that makes his treatment high-priority. These are, of course, terribly difficult questions of priority.

In addition, this is something that you can start having at an early age and which, without treatment, can knock you out for four months of every year, right through your lifetime, until you die. Sometimes, quite seriously, you wish when you have it that you were dead. There is a case for priority to be given to that, even over things that are life-threatening but may only be so to people who will have relatively short spans of additional life if they are treated. There is a case to be weighed there.

I pick up a point made by the noble Lord, Lord Taverne. A balance has to be struck in weighing risks. I had a first symptom-free period of eight or ten years when I was injected with immunotherapy by my GP. That was made illegal after one or two people had dropped down dead in doctors’ surgeries. Doctors’ surgeries are now much better equipped to cope if somebody keels over as a result of the treatment they are getting, and will be even more so when the Minister has finished his report. I am not quite clear, delightful though it is to be in the allergy treatment room, that sitting there for an hour after each jab is absolutely essential to my survival, and could not equally well be done in a doctor’s surgery, with greater convenience in many cases. To take another example of risk, there was a very good drug, from which many sufferers benefited, called Triludan Forte, which was banned after a few bad reactions in a million had occurred in the United States. There was a suspicion that it was associated with heart disease. It was worth the risk as far as I was concerned. We must not let risk stand in the way of important advances.

Thirdly, in my experience, everything I have seen underlines the importance of the recommendations made by the noble Baroness, Lady Finlay, and her committee in their excellent report, particularly about the availability of centres of excellence. I am at a centre of excellence. The lady sitting next to me travels for two and a half hours every week to go to that centre because it is the nearest to her. She sits there for two hours and then travels back for two and a half hours. She will have to do that for three years and more than 30 sessions. This is not a negligible price to impose. It is worth it for her, but it shows that, where possible, we should have centres nearer to people’s homes. She does not live anywhere very obscure. What would it be like if you lived, say, in the north of Scotland? I hate to imagine. The necessity of having these core places with the core skills available, led by a consultant but with the right team of people with the right experience, cannot be overestimated.

Some disobliging things have been said—I understand that, having read it—about the Government’s response to the noble Baroness’s report. I did not feel that the response was wicked or dismissive so much as that the department felt that with so many things on its plate, understandably, it did not really wish to grasp this one. It was just a step too far—too much to take on. The same has clearly been true of NICE, as we have heard. No one seems to want to give this the small but decisive push that it requires to be treated properly. I say to the Minister and to the House only that there are hundreds of thousands, maybe millions, of people like me who wish that they would.

My Lords, the noble Lord, Lord Lipsey, should be congratulated. Without being too light-hearted, I must say that if he is on that cocktail of drugs, I am surprised that he managed to stay awake during his own speech today let alone others.

I also thank the noble Baroness, Lady Finlay, for her chairmanship, Professor Barry Kay for his specialist advice and Sarah Jones and Cathleen Schulte for their backup on this inquiry. The key theme that has emerged from the report is that allergy in the UK has reached epidemic proportions, with more complex and sometimes life-threatening new allergies emerging almost daily. Advice to sufferers varies: should the hygiene theory, as described by the noble Lord, Lord Rea, be supported or rejected—cats and dogs and dirt—or should we take every opportunity to isolate our children from possible allergens? The noble Baroness, Lady Finlay, and the noble Lords, Lord May and Lord Rea, have already discussed peanut allergy and advice given for very young children as a good example of that.

About 20 million children and adults in the UK suffer from a form of allergy, and from April 2006 to March 2007 there were 67,077 emergency hospital admissions for people experiencing just an asthma attack, 40 per cent of whom were children under 15. A simple allergy can be an early step on the allergic march towards more serious allergies, and the critical impact of allergy on health and quality of life and its potential to cause fatalities, usually in older children and adolescents, should not be ignored. Allergic disorders are usually chronic and low-intensity but can have serious effects on quality of life for both patients and their families, and in extreme cases can even lead to death. The prospects of unexpected allergic catastrophe or anaphylactic death are real issues for many families and should not be underestimated.

Many common modalities of treatment are outdated and put sufferers at significant risk of side effects, when modern, safe treatments are more effective but not widely available. Allergy treatments are a significant cost to the NHS, and symptoms can have a detrimental impact on lifestyle, the education of children at school or the performance of adults at work. Many lifestyle factors are specifically associated with allergy and must be considered in the context of known or suggested risks for allergic diseases.

Good health and the ability to fight off disease are a function of the immune system, and there are daily references in the media about how that can be improved. It has been suggested that pregnant women who lead a sedentary lifestyle may cause an increased risk of asthma in later life. Recent studies have shown that levels of vitamin D, found in food such as oily fish and boosted by natural sunlight, can influence the development of a child’s lungs and immune system while in the womb. There is also a possible link between asthma and obesity; the numbers of people with both problems have soared in recent decades. It has been suggested that handling rubbish that has been left out for two or more weeks before being collected can increase the risk, as the level of bacteria and fungal spores above bins that have not been emptied is more than 10 times higher than in locations where there is a weekly collection. Keeping a cat can allow the onset of allergic symptoms: a study from Imperial College found that increased exposure to cat allergen was associated with greater sensitivity of the respiratory system.

Blame has been put on the possibility of a defective gene that plays a key role in the appearance of allergic symptoms that occur when the immune system wrongly identifies allergens such as dust mites, pollen, peanuts or cat hair as being dangerous. Scientists have also identified a cold-fighting protein which asthmatics lack. The common cold triggers about 85 per cent of asthma attacks in children, and 60 per cent of those in adults. A study by US scientists has shown that sufferers of allergic rhinitis appear to be at much greater risk of the degenerative brain condition, Parkinson’s. About 5 million Britons are affected by perennial allergic rhinitis, usually triggered by indoor allergens such as dust mites, pet skin flakes and spores, causing inflammation and irritation to the delicate linings of the nose and eyes. A further 3 million suffer from a mix of perennial and seasonal rhinitis, or hay-fever.

We need accurate data, so I commend our recommendation that the Department of Health should ensure that the Systemised Nomenclature of Medicine system, supported by appropriate training, ensures efficacy as a simple, consistent classification system to record allergic disease, monitor its prevalence and inform the commissioning of allergic services.

Whatever measures are taken to minimise the risks of allergen contamination, ultimately some responsibility must lie with the allergic consumer. Social difficulties can make sufferers reluctant to take necessary precautions, and many young people take risks with foods carrying a “may contain” label, believing that food companies are covering their backs with a generalised warning. Children at school risk contact with allergens such as nut proteins, which are easily transferred between surfaces, and if their understanding of their allergy is poor, they can suffer high levels of anxiety. That sometimes leads to a panic-attack reaction. Although minimal, the possibility of anaphylaxis at schools causes great worry to children and their parents, while placing a burden on the school by requiring members of support staff and teachers to be able to deal with emergencies.

In the year to 30 September 2006, about 165,000 prescriptions were dispensed in England for Epipens, at a cost of about £8.2 million. The quick dose of adrenaline which these automatic injectors provide can be life-saving for people suffering an anaphylactic shock to food, insect stings or allergens known to the patient. We had evidence that these auto-injectors were not being used effectively. I agree with my noble friend Lady Perry that it might be a good idea for schools to have their own supply of adrenaline injectors, for use by a trained member of staff or a school nurse, rather than relying on children to carry their own medicine. The prescription of such auto-injectors requires specialist allergy knowledge that is currently lacking among many general practitioners and needs to be coupled with patient training. The establishment of allergy centres and the further education of practitioners in allergy should improve the quality of training provided to patients about administering their treatments.

Many patients turn to complementary therapy to diagnose and treat their allergy, usually because they are unable to obtain proper diagnosis from their GP or stand no chance of being referred to a specialist. Many patients are worried about the side effects of conventional drugs. As president of the All-Party Group for Integrated and Complementary Healthcare, I was disappointed by the lack of response from complementary practitioners to this enquiry. Homeopathy, herbalism, acupuncture, cranial osteopathy, applied kinesiology and methods of self-testing, including Vega hair and blood testing, were dismissed as having no scientific evidence or mechanistic base to suggest that those treatments and tests could be remotely effective. Although I know that that is not true and I have sent patients for these treatments with success for many years, there was little evidence to present to the Committee to back up my belief.

We heard the argument that complementary practices may delay accurate, valid and pressing diagnosis, leading to medical harm. I regret that the lack of evidence did not enable us to assess the beneficial effects of complementary therapies, which are harmless when compared to those of conventional drugs on the thousands of people who are harmed or die needlessly as a result of idiopathic reaction.

I am delighted that the Government accept that research into the effectiveness of complementary treatment should address the outcomes that we have identified, and I hope that the Minister will give serious consideration to the points made today.

My Lords, as I am the last Back-Bencher to speak, what is there left for me to say? Not a lot, unless I repeat matters raised by other noble Lords, and I shall do that occasionally.

The Select Committee of which I was a co-opted member, chaired very efficiently by the noble Baroness, Lady Finlay, investigated the subject before it with great enthusiasm. Numerous knowledgeable witnesses were questioned in great detail. Most of them were helpful but one or two who tried to impress us were not. What impresses me is the almost universal lack of understanding of what allergy is, and this includes people who are medically qualified. This came over loud and clear when witnesses were questioned.

In response to a question last week in another place about the small number of allergy specialists, the Minister listed the large numbers of consultants in dermatology and respiratory medicine and of GPs. The stark reality is that very few of these treat allergy. The services they offer are complementary to allergy but cannot be a substitute for allergy treatment. These doctors do not make an allergy diagnosis or identify an allergic trigger; they diagnose only the single, specialised area covered by them.

Of course, the key problem in providing allergy care is a lack of doctors trained in allergy, and the fact that there are only a few allergy specialists. Currently, only a few doctors are being trained as allergists—a specialty in which it takes some years to become fully trained—and few places are available for those interested in this specialty. More posts for doctors to train in allergy need to be created and funded and there need to be more posts for consultant allergists.

I believe that existing allergy centres are somewhat fragile because most operate on academic funding and there is insufficient NHS funding. This means that when the head of department retires or leaves, the service can disappear. A small amount of NHS funding is needed in these centres to secure them long term. The cost need not be great—two extra consultants, a trainee in allergy, two half-time allergy specialist nurses and a part-time dietician. This would produce trained staff who could then be seeded out to set up centres in areas of the country where there are poor allergy services.

In relation to the large patient need these costs are extremely small. In addition, improved services would result in cost savings for the NHS. Identifying allergic triggers will stop further allergy such as episodes of anaphylaxis, severe asthma and many other conditions. This, in turn, would result in reduced use of health service resources; for example, fewer A&E attendances, hospital admissions, GP consultations and a reduced need for drugs. I very much hope that the Minister will acknowledge that.

Last week I was invited to a reception hosted by the Spinal Injuries Association. I spoke with a senior consultant about the specific areas she covered and about many other matters. When I raised the subject of allergy her immediate response was that there are not enough trained allergists around—I am almost inclined to use that old-fashioned cliché “north of Watford”—with most of the country being without any at all. I found her knowledge refreshing and, at the same time, sad. She knew that there is little happening to alleviate the problems caused by the epidemic of people with allergies.

But at least there is a start in addressing the problem. A new regional allergy centre is being created in Manchester. If this is adequately funded and if those working there are suitably trained, the benefit to the public purse and to the patients will become patently obvious very quickly.

The report of our Select Committee has, I hope, highlighted the requirements of those suffering from allergic conditions. I am one of them. Fortunately, I am being tended by a consultant allergist nearby but many are not, and that is what concerns us all.

My Lords, when the hunting legislation was going through your Lordships' House I was asked by another Peer whether I had ever hunted. When I said no, that Peer was rather disparaging. I redeemed myself only by saying that I had not done so because I am severely allergic to horses. The one and only time in my life I have been on a horse I looked about as good as the noble Lord, Lord Lipsey, does today. As I have that very common battery of allergies, I was delighted to spend last weekend reading the noble Baroness’s excellent and thorough report.

I want to focus on the issues that noble Lords have raised but put them into a context. The context is that there will in future be nothing like the level of funding in the NHS that there has been in recent times. Therefore, for any service, particularly a specialist one like this, it is a question of how we redesign services in order to make what we have more effective. From data gathering and management at the beginning of this report right through to the end, the noble Baroness and her committee have offered the House and the noble Lord, Lord Darzi, an excellent blueprint for how services can be redesigned.

I am not a scientist or a historian, but other noble Lords have referred in their speeches to population conditions 100 years ago. Forgive me if I am wrong, but I think we need to be a bit careful. The survival rates from anaphylaxis 100 years ago would have been pretty near to zero. Although great advances have been made, the noble Baroness is right that the overall picture on prevalence is, when set against advances in public health, truly disappointing. I would go further and say that, if anything, some of the figures in this report and in previous reports by the Royal College of Physicians and the Health Select Committee are probably underestimates. Why? Because most people, like me, do not have severe and acute reactions and manage the condition themselves. Therefore, I suspect that the NHS really gets to see only those who are towards the more acute end of the spectrum. Moreover, those who have allergies are increasingly using the internet to find ways round and manage things for themselves.

The report is a disappointment in that very little appears to have changed in the 40 years since I sat in my GP’s surgery with pinpricks up my arms, watching all the reactions take place, and was sent off home with a list of things to avoid and a tin of Betnovate for when the eczema got really bad. The only thing that has changed is incidence. I thought one of the most interesting findings in the report was the observation by Professor Custovic of Manchester University that the genetic background of the population has not changed dramatically and yet the incidence of allergic disease has. That is worth noting.

I know something else anecdotally; I have tried desperately to find data on it but have been unable to. I understand that in the Italian population there is a high and growing incidence of coeliac disease. As a very good friend of a member of my family has coeliac disease, I know that you can go to Italian restaurants even in this country and find gluten-free pasta. That is increasingly the norm in Italy. It is interesting because in the past 20 years people in this country have adopted a diet with a lot of Italian food in it. I just wonder whether it is another form of allergic disease for which we should be taking preventive action.

I agree with the noble Lord, Lord Rea, that the issue of food labelling is tremendously important. The only thing that one can do with a food allergy—and they tend to be very violent—is avoid the substances that you know you are allergic to. It is useful that EU directives are increasingly updated, but they are unclear. The food industry needs to know that it is not in its interest to have unclear labelling. I hope that, with the FSA, work can be done to improve that.

As somebody who frequently has reactions to skin products and soap, it was a delight to have my own anecdotal feelings set down as being right—namely, that the terms “hypoallergenic” and “dermatologically tested” are meaningless. There is absolutely no way of knowing whether a particular product will set off an allergic reaction. I shall make one point which for obvious reasons is not in the report. As someone who experiences such reactions, I have always wondered why it is impossible, when one has a mild allergic reaction to a product, to draw that to the attention of the manufacturer. I suspect that I am like thousands of other people; I do not want any kind of redress, I do not want money and I do not want to pursue them through the courts. I simply want to tell them that something has happened to me in the hope that they will record that systematically and begin to build up a picture that, somewhere down the line, will either make their product better or help other people. I wish that somehow the Government could encourage especially the cosmetic industry to do that.

I speak at some risk about alternative therapies, because I know that my noble friend Lord Taverne has very strong views on them. A large number of people are turning to alternative therapies, principally because they fear prolonged use of steroids. I cannot blame anyone for seeking relief from some of the symptoms of allergy. If they choose to do that, they should do it in a way that is integrated with conventional medicine. I hope that the department responds to that.

In the National Health Service, we have an unprecedented facility to study allergic disease and not only to conduct trials, but to do population-controlled trials. This morning, someone in my house asked me what I was going to do today, and when I told them about this debate, they said that they developed an allergy when they went to a particular university. Apparently it happens to loads of people who go to that university, because it is surrounded by fields of rapeseed which is a very potent allergen. If we can do nothing else with the regional allergy system, we could look at the incidence of that kind of condition.

Regional allergy centres are important, and they will have to be formed not by the creation of specific new posts but by drawing together and clustering experts who already exist across the field. The key importance of regional allergy centres is twofold. First, they deal with those who have acute and life-threatening conditions, as the noble Lord, Lord Lipsey, said. Secondly and importantly, they can increase the skills in primary care, because that is where the bulk of people who have such conditions go for diagnosis, reassurance and treatment. I wish the report well, and I hope that the Minister accepts its recommendations.

My Lords, this is a first-class report, as has been mentioned several times; it is highly professional, lucid and well illustrated, and the House is rightly grateful to all those who have taken part, especially to the chairman, the noble Baroness, Lady Finlay of Llandaff.

The report draws attention to the centre for the study and treatment of allergy, which emanated from Guy’s Hospital, which is where I continue to work. The centre is directed by Professor Tak Lee, and it is known as the MRC-Asthma UK Centre. It is the only centre of its kind in the country. It is a collaboration between the MRC, Asthma UK, King’s College, Imperial College, the hospitals of Guy’s and St Thomas’s, King’s, Royal Brompton and St Mary’s. As the report says,

“all the organisations had been able to combine their research strengths into one cohesive strategy for the first time”.

The centre also works with general practices in east London. It focuses on teaching, research and patient care. Many more similar centres are required urgently throughout the country, as has been said, and that has been the verdict of several recent reports. All have emphasised that there are fewer allergy centres in the UK than in Europe and the USA yet nothing seems to have been done to increase capacity. Ministers have made the excuse that it is the fault of the PCTs whose job it is to make these decisions.

But Ministers know that PCT's have never been accused of understanding complex subjects like allergy. As has been mentioned, the Times newspaper headline of 26 September stated,

“Britain ‘is the laughing stock of Europe’ for its neglect of allergy cures”.

Ministers need to give a lead. We desperately need a big drive from the top.

Irrespective of any single centre that may be created in the future, right now there are some departments around the country that have critical mass and already fulfil many of the criteria that the report recommends for a centre; for instance, Cambridge, Southampton, the Royal Brompton with St Mary’s, and Leicester. For a relatively small amount of extra investment one could create a number of allergy centres as envisaged by the report: for example, the extras that would be required would be a half-time dietician, one full-time specialist nurse and one paediatric and one adult allergist.

We also need to put money into trainee slots; there are only 12 of these, known as SPRs, in the whole country—one for every 5 million of us. That is totally inadequate to provide, first, a network of NHS services uniformly across the UK and, secondly, the leadership for training a future generation of allergists. While some academic allergy trainee posts have been created—this is very welcome—the numbers are still insufficient to make a significant impact on clinical allergy service provision especially in paediatrics, as the noble Viscount, Lord Simon, mentioned. The numbers simply could not meet the recommendations of their Lordships’ report. Why not move some of the excess unfilled training numbers in other specialties into allergy? Will the Minister tell the House why that cannot be done in the next month?

Of course, any increase in trainee numbers needs to be matched by an increase in the number of consultant posts to build capacity. The charity Asthma UK has drawn attention to the large number of hospital admissions in England for patients with an asthmatic attack. My noble friend Lord Colwyn mentioned that from April 2006 to March 2007 there were over 67,000 emergency admissions, 40 per cent of which were for children under 16. It estimates that 75 per cent of those admissions could be avoided with good asthma care.

Professor Tak Lee emphasises that there are many professionals treating patients with asthma but they concentrate on treating the symptoms but fail to look for the cause of the asthma, failing to hunt for an allergic basis for the problem. That is why it is so important to have allergy experts involved in the care of these patients. Accurate diagnosis is so important, as the noble Lord, Lord Bhattacharyya, stressed. I was especially interested in the section on allergy in the school environment, where the problem of hay fever during examinations is discussed and mentioned by the noble Baroness, Lady Finlay, and the noble Baroness, Lady Perry. For many years I have advocated that one solution would be to hold the examinations in March or April. However, the congenital snag hunters have always dismissed this out of hand, as is done in paragraph 5.25 of the report, where a senior civil servant stated that,

“the structure of the school year is based upon centuries of history … It would not be practical to suggest an alteration of the examination timetable purely to benefit hay fever sufferers”.

Have we not heard that before? That civil servant seems to have forgotten that the examination system has been radically altered dozens of times in the past 60 years. Perhaps he is unaware that the baccalaureate exam is held in May, and the GCSE drama examination was held in April this year by some of the examination boards.

It is not only hay fever sufferers who would benefit from that change, but the thousands of candidates who suffer intolerable heat in the height of summer in poorly designed examination halls, even in quite expensive public schools. A sauna can be an enjoyable experience but not in the middle of a crucial examination which will determine one’s career for life. There would be other advantages—for instance, the summer term could be spent by pupils engaged in more practical work to prepare themselves for citizenship, charitable enterprises and so on. And the examiners could complete their tasks before the summer holidays. This would have a further advantage in that it would allow the universities to make final decisions on their entries before August and do away with the need to allocate provisional places—which creates chaos.

Another aspect of the report deals with the most dangerous of all allergies; namely, anaphylactic shock. This may be caused by many different antigens, including peanuts, drugs, insects and so on. In order to deal with this hazard and forestall disaster, those who are known to be susceptible are provided with the devices that have already been mentioned—EpiPen and Anapen. There is confusion about who can help the child in school and whether anyone should do. The report rightly recommends that staff should be taught about how to deal with these emergencies and have clear guidance. Potential sufferers have to carry the adrenalin themselves, as well as it being available in school. As this is so important, can the Minister assure the House that what must be a relatively straightforward matter is sorted out quickly without resorting to umpteen meaningful, ongoing working parties and committees, which the Minister and I used to call group psychotherapy meetings when we worked together in surgery?

This subject brought to the surface some strange comments in the report. One witness, at paragraph 5.35 suggested that these adrenalin auto-injectors were overprescribed. He said,

“of countless prescriptions I have written over the last 12 years for such devices only one has ever been used”.

Perhaps that witness should have been asked how many of the fire extinguishers in his area had been used in the past 10 years. I always have in my pocket ampoules of adrenalin and hydrocortisone with a syringe and needle. These are probably the only drugs that are required immediately—and there is never time to get them. Recently, I was presented with two patients in anaphylactic shock due to the stings of French hornets. Had I not been carrying these essential drugs, one of the patients might well have died; although of course one can never be certain. Medicine and prophecy are two quite separate subjects.

To many people it is a puzzle how anaphylactic shock actually kills the patient. The cardiovascular system is greatly impaired, blood pressure drops to the boots, and the excess fluid which rapidly collects in the tissues obstructs the larynx because the fluid cannot escape downwards, as the lining is firmly attached to the vocal cords.

Finally, several noble Lords have described the key recommendations of the report in detail. My question is: when will the Government implement these recommendations, so that Britain will no longer be the laughing stock of Europe?

My Lords, I greatly enjoyed the debate. As my noble friend and others have declared their allergic reactions, I probably should declare my own. I am a hay fever sufferer and, for years, living from April to July has always been hell, although my asthma is certainly not as severe as that of my noble friend.

First, I congratulate the noble Baroness on securing today’s debate. I also congratulate her on the excellent work on allergy produced by the House of Lords Science and Technology Committee, which she chaired so ably. As my noble friend Lord Haskel pointed out, allergies affect the lives of millions of people in this country. Around one third of the population suffers from an allergy at some point in their lives and there are people in the House today, as we have heard, for whom this issue is of personal as well as national importance. The establishment of the All-Party Parliamentary Group on Allergy, of which the noble Baroness is a vice-chair, will help us make further progress. I wish the group success for their reception on 14 May.

As the noble Baroness is aware, allergies are common and on the increase. In addition to the obvious health effects, allergic reactions can make unavoidable daily activities very difficult. They can compromise a sufferer’s performance at work and, as we have heard, hinder children’s educational progress. Clearly, allergic conditions represent a huge challenge, not just for our healthcare system, but for society as a whole. It is for these reasons that the Government welcomed the committee’s report, which highlighted very clearly that allergy is an issue that needs to be addressed by a wide range of stakeholders.

Noble Lords will be aware that in 2006, the Department of Health published a report of its review on allergy services. The review looked at the epidemiology of allergic conditions; the demand for, and provision of, treatments; and the effectiveness of interventions. This review was a crucial first step in building a programme of improvements that would be based on sound evidence, and would reflect the views of patients and healthcare providers. We are pleased that it was published in time to inform the inquiry led by the noble Baroness.

Our review concluded that one key lever for changing allergy services in future will be local rather than national action. However, I sympathise with what I have heard today and the reasons so eloquently articulated throughout the House. I will take forward some of the suggestions made, but I still believe that we need to engrave in the NHS at a local level a self-improving system to deal with today’s problem of allergies, as well as with other challenging long-term conditions such as dementia that we have debated in this House and that our NHS will face over the next decade.

The report of the inquiry led by the noble Baroness made a number of recommendations to improve allergy services further. In their response, the Government committed themselves to taking action. Ann Keen, the Minister with lead responsibility for improving allergy services, recently met the noble Baroness to explore how we can work together to take forward the recommendations in the report. As we heard, she made a personal commitment to this report.

Due to the pressure of time today, it will not be possible to run through every recommendation and all the actions that have been taken. I shall therefore focus on the committee’s key recommendations and on some of the specific issues raised today, setting out what we are doing to address them.

A lead strategic health authority should be established to take forward the development of a pilot allergy centre on a hub-and-spokes model. We agree that services need to be better organised if they are to meet patients’ needs. Long-term conditions such as allergies are on the increase, and the Government feel that it is vital to change the disease management pattern in primary care if services are to be fair, safe and effective. Noble Lords are aware that, as part of my ministerial commitment, I spend most of my time providing leadership to the next stage review. I assure the House that that review will be looking at how we can build an infrastructure in primary care to take advantage of some of the innovations discussed here today.

We are also in the process of exploring the feasibility of that approach with interested parties. As part of the consultation process, Professor Sir Bruce Keogh, our recently appointed NHS medical director, has written to all SHA chief executives asking them to declare whether they are interested in taking on this very important role. I have no doubt that Manchester will be a very strong contender. However, there are 10 strategic health authorities and I think it is only fair that they are all asked who should take on the leadership role. The process has started and will be completed soon.

I turn to the issue of workforce planning and education and training, in which my noble friend Lord Bhattacharyya has personal experience. The noble Lords, Lord Taverne and Lord Crickhowell, raised the issue of our educational needs and competences in the service. The noble Lord, Lord McColl, highlighted the fact that last year we were able to create an additional five centrally funded training posts for allergy and a further five for immunology. In total, that is 10 posts. If the current figure is 12, that is near enough a 90 per cent increase in our training numbers. I have no doubt that we need to do significantly more, and we will continue to remind the workforce review team of the need to consider increasing training numbers in relation to allergy as part of its annual review programme.

We have also encouraged the royal colleges to work with other bodies responsible for medical training to enhance the knowledge and expertise of those working with people with allergies. No doubt we all agree that the first contact that a patient makes is in the primary and community services, and if the competences for managing some of the demand from our patients out in the community are lacking, we have to do something about that. That issue is very close to my heart. I feel strongly that it should be part of our reform of primary and community services so as to meet some of the future demands on the service.

As part of the annual review process, we have also endorsed the need for more training numbers for allergy. I have asked deaneries and trusts to examine whether they need to commission more local training posts for allergy.

We also commissioned Skills for Health to work with stakeholders to develop national occupational standards for allergy for the UK in order to improve the quality and consistency of patient care. We anticipate that the standards will be published and implemented this summer.

As well as training, health professionals need the tools to enable them accurately to diagnose and treat patients. We commissioned the Royal College of Paediatrics and Child Health to scope and develop care pathways for children with allergy symptoms. These will help to ensure that children displaying possible allergic reactions are given timely and appropriate care.

I now turn to another area close to my heart, that of research. I have no doubt that I should declare my interest, still working in a university and carrying out research. The noble Earl, Lord Selbourne, eloquently highlighted the importance of research and reminded us of the committee’s recommendation that further research should be undertaken to increase understanding of allergic causes. Work is being taken forward across government to increase our knowledge of these conditions. For example, the Medical Research Council and the Food Standards Agency are collaborating to fund a major new clinical intervention study on the effects of early weaning on food allergy. In addition, the National Institute for Health Research has provided some £4.7 million over five years for research on asthma and allergy.

The noble Earl also raised the issue that more research needs to be carried out on early exposure and long-term cohort studies. Again, the NIHR has funded a project on primary prevention of asthma by allergen avoidance in infancy. The subjects were recruited antenatally and are now 17 and 18 years old. The occurrence of asthma and allergic diseases will be assessed and reported in due course.

The other issue raised by the noble Earl, which again is extremely important and very much part of the next stage review, is how we can get a closer interaction between clinical need and the research excellence that we have achieved and in which we lead in this important field, not just nationally, but internationally. One of the review’s enabling themes is to see whether we can find the right incentive for closer collaboration. Most of us know that we have created the first academic health science centre in this country. I have no doubt that your Lordships will agree that in a further such collaboration, bringing the two together, the power will be much greater than the sum of its parts. We need to exploit that for the future.

Over the past few years, the National Institute for Health and Clinical Excellence has also produced a number of appraisals of allergic conditions and clinical guidelines for atopic eczema. Immunotherapy was another issue that was strongly debated today by the noble Lord, Lord Soulsby. We are and will be working with NICE to develop more focused allergy topic proposals, which will feed back into the NICE topic selection process. These include proposals for health technology appraisals of immunotherapy, as the committee recommended. I am sure that the committee's report will strengthen the proposals and I will liaise with my ministerial colleagues to make sure that they are given the high level of ministerial commitment that they deserve.

The fourth set of recommendations focused on food. The Food Standards Agency has been running training workshops to raise awareness of food allergy issues among enforcement officers. The noble Lord, Lord May, also raised the issue of the peanut allergy. The evidence base on avoidance of peanuts in early life and the subsequent development of peanut allergy has changed since the Government issued advice in 1998. The Food Standards Agency has therefore commissioned a review of the scientific evidence that has become available since that time. This adds to the study being conducted by Professor Lack—until recently, a colleague of mine at Imperial who has now moved to King’s—which is due to finish in 2012.

The noble Lord, Lord May, also raised the issue of how we could get a stronger coalition to tackle some of the research needs in this area. The UK Clinical Research Collaboration exists to co-ordinate strategic approaches to research funding. The major funders include the Department of Health, industry, research councils and charities—including the Wellcome Trust. I have no doubt that, through the leadership of OSCHR, we can bring the debate around research and development in allergy very much to the forefront of the URCRCs.

Finally, the committee recommended that the Department for Children, Schools and Families should review the care and support that children suffering from hay fever receive in schools, particularly through the exam period, as the noble Lord, Lord McColl, highlighted. The Joint Council for Qualifications already advises examination boards that pupils who suffer from hay fever may be given special consideration when taking examinations. We may have to reinforce that. Government guidelines clearly exist; the matter is addressed in Managing Medicines in Schools and Early Years Settings.

Let me move on to some of the other issues that were raised during this informative debate. The noble Baroness, Lady Perry, referred to EpiPens in schools. Managing Medicines in Schools and Early Years Settings states that early years settings, schools, local authorities and primary care trusts should,

“review their current policies and procedures”,


“ensure that all school staff are clear about what to do in … a medical emergency”.

In relation to allergies or anaphylactic shocks in the school setting, it says that, although the Government do not expect school staff to be medical professionals, those giving or helping with medical treatment should be trained and insured to do so. It is for local authorities and schools to work with primary care trusts to ensure that staff, including school nurses, are trained in the appropriate methods.

The noble Lord, Lord Rea, and the noble Baroness, Lady Barker, asked how we could improve food allergen labelling and referred to the UK’s influence on the EU review. The Food Standards Agency will negotiate the new EU proposal on behalf of the UK Government to ensure that allergic consumers are able to make informed choices about the foods that are safe for them.

The noble Lord, Lord Colwyn, and the noble Baroness, Lady Barker, talked about the important role of complementary medicine in relation to allergic conditions. Some might be aware of the steering group on the statutory regulation of acupuncture, herbal medicine and traditional Chinese medicine, chaired by Professor Pittilo, which is due to report to Ministers shortly. We will consider the next steps forward in light of the working group’s recommendations. I have no doubt that its recommendations will also be of great interest to the all-party parliamentary group.

The noble Lord, Lord Colwyn, talked about SNOMED—systemised nomenclature of medicine—clinical terminology. The training requirements to ensure the proper use of SNOMED CT relate to the development of detailed care record systems by local service providers as part of the national programme for IT. SNOMED CT is being built into the systems and training will be a local responsibility associated with their deployment. I have no doubt that that will also capture the incidence of allergies out in the community.

The noble Lord, Lord McColl, also asked about the availability of EpiPens. In the year to 30 September 2006, which is the most recent year for which I have figures, up to 165,000 prescriptions for EpiPens were dispensed in the community in England at a cost of £8 million. EpiPens are out there but I have no doubt that we can do more to ensure that they are there when the need arises, rather than just being prescribed in the community setting.

In conclusion, the debate this afternoon has raised many important issues about allergies and how the NHS could meet the high standards that patients have a right to expect. I hope that our response to the House of Lords inquiry and the actions that we have taken demonstrate our continued commitment to improving allergy services. I have no doubt that there is more to be done, but I can assure your Lordships that the Government will continue to provide support and encouragement to the health service to ensure that this happens.

My Lords, I am most grateful to all noble Lords who have spoken and covered so many aspects of our report in their excellent speeches. I am also grateful to the Minister for having addressed in detail so many aspects of our debate. Indeed, his speech, which I plan to reread several times, sounded more optimistic than the government response that we received in November last year. For that I am grateful. I am sure that the committee is also grateful to hear that the nettle has been grasped over putting out bids to request a strategic health authority to step up to the plate and consider developing an allergy centre following the hub-and-spokes model that we recommended in our report.

We heard today that the allergic march continues, and we are coming from a long way behind. Our excellence in research at the basic scientific level needs to be built on and translated into clinical practice. There is an enormous educational job to be done. I pay tribute again to all the committee, who worked absolutely unstintingly. For us, this was not an abstract academic exercise; everyone on the committee worked so hard because they genuinely want to make a difference. The more we went into the subject, the more we were aware of the size of the problem. We were ably supported, especially at the outset, by the scientific analysis from Cathleen Schulte, by Sarah Jones—as was said, this was her first Select Committee and she handled us admirably—and the wise and guiding hand of our special adviser, Professor Barry Kay.

I reiterate my thanks to everyone and I hope that when a follow-up report is done in a few years’ time, we will see a different story being told and that we have turned the corner from the abyss that we found when we started our inquiry.

On Question, Motion agreed to.