Table 1

Summary of characteristics of the included publications (arranged in chronological order)

Author, (year) (ref)Level
RegionType of studyStudy aimSalient findingsKey recommendationsComments
Isinkaye et al (2016)36UKRetrospective cohort studyTo ascertain what proportion of referrals to secondary care could be managed a by GP with special interest in allergy
  • At least two-fifths of all referrals to specialists (42%) were felt to be appropriate for a GPwSI setting.

  • There was some disagreement between reviewers re: suitability of a further 30% of the referrals

  • Intraobserver variation was also seen (ie, reviewer changed their initial opinion on referral after seeing the letter from specialist).

  • GPwSI in allergy could effectively identify and manage a large proportion of referrals made to paediatric allergy specialists.

  • This service should be introduced alongside other initiatives to improve UK allergy services.

  • The GP referral letters and the clinic letters from specialists were reviewed by three paediatric allergists.

  • Generalisability of results may be an issue, although GPwSI shown to be useful by Levy et al as well.

  • The authors used an agreed set of criteria for the competencies expected of a GPwSI (not provided with the paper).

Krishna et al (2016)37UKReport/non-systematic literature reviewTo discuss the potential use of telemedicine in pathways for diagnosis and management of adult allergies
  • Adult allergy services can potentially benefit from telemedicine. Various pathways are suggested.

  • Algorithms for possible management of allergic rhinitis, urticaria and anaphylaxis via telemedicine are discussed

  • Authors advise that prospective studies evaluating these techniques should be planned

  • Telemedicine used successfully in some areas of medicine, but systematic prospective studies in allergy are lacking.

  • There are potential issues with clinical governance and confidentiality Lack of adequately trained specialists can affect implementation of these measures.

Bousquet et al (2015)38EuropeIntroduction of prospective study using Information and communications technology (ICT) methods.Plan for study with ICT methods in allergy services.
  • Many gaps in allergy diagnosis and management exist which could be addressed using advances in ICT.

  • The use of Visual Analog scoring, e-allergy and MASK aerobiology apps can help in diagnosis, management and monitoring of allergic rhinitis.

  • The systems will be based on ARIA and International consensus of rhinitis guidelines.

  • The use of ICT can facilitate communication between clinicians, patients, pharmacists and other stakeholders.

  • This project aims to use ICT systems to tackle heterogeneity in AR management across Europe.

  • The clinical trial is being planned; but the uptake of ICT in other studies has been poor.

Conlan et al (2015)39IrelandRetrospective cohort studyReview of
  1. New allergy referrals to adult specialist clinic.

  2. A pilot email communication service with non-specialists.

  • A majority of patients referred to secondary care had chronic spontaneous urticaria or angioedema.

  • Food/drug allergy or intolerance accounted for about a quarter of all referrals.

  • The email service did not show demonstrable impact on referral numbers.

  • It was rated as useful by those clinicians who responded to the survey.

  • Studies examining referral patterns can be helpful in planning services locally by targeting education of non-specialists.

  • New models of care delivery should be tried to help ease demand on specialist allergy centres.

  • Study designed to help service planning locally design may be generalisable whereas findings are not.

  • The uptake of email service was perhaps lower than expected. Also the response rate to the survey was poor (35%) which makes the usefulness of the service difficult to gauge.

Chan et al (2015)40Hong KongReportTo discuss the current management of allergic disease in Hong Kong.
  • Despite increasing demand, allergy services and training remain poor. There are dedicated allergy services in public hospitals for adults.

  • Laboratory support for allergy and immunology is inadequate.

  • 2 pilot ‘Hub and spoke’ centres catering for adult and paediatric allergy should be established.

  • Training programme in paediatric and adult immunology and infectious diseases should be extended to allergy.

This is a report from the Hong Kong allergy alliance, whose members include patients, clinicians, academics, industry and other stake holders in allergy within Hong Kong. 
Jutel et al (2013)24EuropeReport/cross-sectionTo provide a contextual patient-centric framework based on opinion of PCPs, specialists and patients.
  • Access to specialist services was identified as the ‘greatest unmet need’.

  • In public health services, waiting time for secondary care is usually > 6 weeks.

  • Current dominant model of allergy care in Europe is specialist based, but this is unsustainable.

  • Groups across Europe need to learn from shared experiences to generate political will to enable change to services.

  • Patient involvement and empowerment should be strongly encouraged.

The authors of this publication belong to the EAACI Task Force for Allergy Management in Primary Care.
Jones et al (2013)41UKSurvey/retrospectiveTo assess patients perception of usefulness of the secondary allergy clinic at Plymouth Hospital.
  • A third of the patients did not find the clinic useful.

  • Half continued to have troublesome symptoms.

  • 10% do not feel confident about managing their allergies.

  • There is a need for follow-up of most patients with allergy to reinforce education.

  • Specialist clinics should try to obtain routine feedback from patients to monitor effectiveness.

  • Patients who attended clinic over a 11 year period were surveyed, 36% response rate (336/933).

  • No description of services offered or the competencies of the clinicians.

Agache et al (2012)7EuropeSurvey/cross-sectionTo assess the actual status of allergy management in primary care across Europe
  • Two-thirds of PCPs do not have ready access to allergy specialists.

  • The average waiting time to see a specialist in a public health service was more than 6 weeks.

  • Referring patients to organ specialists is much easier than referral to an allergist.

  • A thorough assessment needed to understand demands on services and facilities available to PCPs. This can be used to adapt allergy pathways for primary care.

  • To develop a structured development and information platform for PCPs.

  • The study was carried out by an EAACI task force.

  • Surveys sent to the national societies of EAACI member countries and to individual members of EAACI as well as the international primary respiratory group.

Sinnott et al (2011)23UKProspective planning and implementation of care pathwaysDescription of a pilot project undertaken to improve allergy services in the North of England.
  • Poor training of PCPs leads to inappropriate referrals due to lack of confidence in managing allergies.

  • Specialist services are often deluged with patients who could have been managed in primary care.

  • Variable tariffs for allergy pose a disincentive for trusts to develop services.

  • Postcode lottery exists especially for those with severe allergies.

  • Linking clinicians with an interest in allergy is a good way to improve standards and increase awareness of patient pathways.

  • Developments should support existing service provision.

  • Commissioners need to be educated regarding the impact of allergies.

  • Good transition between adult and paediatric services needed.

  • £1.8 million pump priming for services from the DoH, UK.

  • Getting commissioners in the NHS interested in improvement of allergy services was challenging.

  • The project helped formation of a specialist nurse group in the region as well as a good network of clinicians interested in allergy.

Warner and Lloyd (2011)42UKDiscussion/pathway developmentBackground for the development of paediatric allergy care pathways by the Royal College of Paediatrics and Child Health (RCPCH)
  • The pathways are aimed at commissioners, health professionals, patients, parents and carers.

  • They aim to provide a bench-mark for service provision.

  • Eight pathways developed by six multidisciplinary working groups.

  • The authors define competencies rather than criteria for onward referral, so that guidance can be applicable even when there are regional variations in service provision

  • Existing literature was systematically reviewed to identify ideal pathways for care and competencies required.

  • Pathways for anaphylaxis, asthma/rhinitis, drug allergy, eczema, food allergy, latex allergy, urticaria and venom allergy were proposed.

Royal College of Physicians and the Royal College of Pathologists (2010)21UKReport from a publicly funded organisation.Recommendations to stakeholders in allergy for provision of cost-effective improvements in allergy care.
An update on changes to allergy service provision following the House of Lords inquiry (2007) into allergy.
  • Services remain poor and highly inequitable.

  • Some progress since 2007

    • Additional trainees in adult and paediatric allergy were appointed.

    • The Northwest SHA spearheaded a pilot into restructuring of allergy services.

    • NICE had adopted a few projects for issuance of guidelines.

  • Some areas of concern remained unaddressed including:

    • Poor coding of allergy clinical work.

    • Patient engagement underused

    • Governance and training within existing services remains poor.

    • Occupational allergy provision remains poor.

  • Serious deficiencies found in the commissioner's knowledge of the allergy needs of the local population.

  • PCP survey in 2009 showed that most (70%) continued to rate NHS allergy services as poor (similar to 2002 survey).

  • Services should join up to serve the population of a defined geographic area.

  • Validated Patient Reported Outcome Measures (PROMs) need to be developed to evaluate the effectiveness of services.

  • Quality Assurance schemes should be developed for clinical allergy services.

  • Protocols and guidelines should be shared freely between centres.

  • More allergy training should be incorporated into PCP and medical student curriculum (and all other related specialty training)

  • Clinical services should establish good links with the local patient groups.

  • There should be better allergen labelling.

  • Working party for this report consisted of clinical experts and patient representatives from all over the UK.

  • Data from the pilot study in North West were discussed in the report.

  • Selected publications were reviewed (non-systematic).

  • Views from charities supporting patients with allergy also represented.

  • Concerns expressed about the lack of funding for outcome evaluation with allergy service remodelling in the North West.

Levy et al (2009)43UKProspective; no control group.Evaluation of a PCP with special interest clinic in allergy.
  • Two-thirds of the patients would have been referred to secondary care in the absence of this clinic.

  • Less than 10% of those reviewed were referred onto a tertiary clinic.

  • The clinic was estimated to have saved £13,500 in 9 months due to reduced referrals.

  • Second-tier clinic in primary care has the potential to be clinically effective as well as cost-effective.

  • It encourages care in the local community and can reduce the burden of inappropriate referrals to tertiary centres.

  • Referrals proforma provided information on how the clinic was used by other PCPs.

  • Consultation satisfaction questionnaire captured patient experience.

Working group of the Scottish Medical and Scientific Advisory Committee (2009)22UKReport from a publicly funded organisation.To report on the diagnostic and clinical allergy services within Scotland
  • High burden of allergy in Scotland; 30% children and 25% adults are affected.

  • The levels are rising for all conditions (except perhaps asthma) and services have only improved marginally since last report in 2000.

  • There are insufficient numbers of medical specialists, trainees, PCPs, dieticians, nurses and pharmacists trained in allergy.

  • Service is fragmented with no collaboration between primary, secondary and tertiary services.

  • Dietetic services fragmented and patchy and are not always backed up with clinician support.

  • Allergy curriculum in undergraduate and postgraduate medical training needs improving.

  • Primary care staff should have access to basic initial and ongoing training.

  • There is a need to encourage and facilitate standardised and evidence-based practice through shared protocols and pathways.

  • Data collection, audit and research facilities in allergy should be improved to ensure better future planning of services.

  • Regional MCN for adult allergy and a national MCN for paediatric allergy services are needed.

  • Involvement of voluntary sector should be encouraged to publicize the deficiencies in service.

  • The authors commented on the non-availability of trained specialists and the

  • underusage of non-physician services for allergy (pharmacists, dieticians, nurse specialists).

  • Improved motivation via incentives should be planned.

  • PCP with special interest may be a useful resource.

Haahtela et al (2008)32FinlandProspective; intervention; no control group.Nationwide allergy programme being adopted in Finland. Proposed to run between 2008 and 2018.
  • Project is currently underway. Its goals include:

    • Prevention of allergic symptoms.

    • Increase tolerance against allergens.

    • Improve allergy diagnostics.

    • Increase resources for allergy management.

    • Decrease healthcare costs due to allergies.

  • For each of the five identified goals, specific tasks, tools and evaluation methods have been defined.

  • This project is based on very close collaboration between the government, healthcare sector and non-governmental organisations.

  • Emphasis is on tolerance and not on allergen avoidance.

  • The project builds on the very successful Finnish asthma model.

  • Being followed in other countries (Norway, UK), preliminary results are expected soon.

House of Lords Science and Technology Committee, 6th report of session 2006/7 (2007)18UKReport from a publicly funded organisationTo explore the impact of allergy in the UK upon patients, society and the economy as a whole.
  • Allergy exerts a considerable social and economic burden upon the nation.

  • There is a severe shortage of allergy specialists in the UK and the services lag far behind those of many countries in Western Europe.

  • There are problems with data collection rendering statistics imprecise and affecting service redevelopment plans.

  • There has been a chronic lack of training of PCPs and medical trainees in allergy, leading to problems with diagnosis and management at the primary care level.

  • Further research into the basis of allergy is urgently needed to underpin further public health policies to address the rise the allergies.

  • Large, tertiary centres led by allergists should be developed to ensure optimal treatment of patients with complex and severe disease and also as sources for education and training for other clinicians.

  • Improved education of medical practitioners to diagnose and treat occupational allergies needed.

  • Improve undergraduate and PCP allergy training.

  • New centres should build on existing excellence.

  • Some specialist services can be restricted to few centres across the country.

  • Educators and Commissioners should work together to develop generic quality assured clinical post graduate allergy courses.

  • NICE to appraise immunotherapy and cost-effectiveness.

  • A lead health authority should be identified by the Department of Health in order to establish a pilot tertiary allergy centre. A full cost analysis should be integral to its establishment.

  • This report was published by the allergy subcommittee UK House of Lords Science and Technology Committee 2007.

  • Recommendations made for non-NHS management of allergies (eg, training teachers in managing allergic emergencies, supporting children with hay fever during school examinations, helping those with occupational allergies return to work, improving allergen food labelling, etc).

  • Authors visited numerous national and international allergy centres of repute to compile this report.

Department of Health (2007)44UKReport from a publicly funded organisation.Response to the report from the House of Lords Science and Technology Committee 2007.
  • No published whole system models of services for people with allergy.

  • No data on existing skills.

  • There are also no analyses of effects of active demand management of patient flows in allergy care.

  • No data on allergy needs in various regions across the country.

  • The royal colleges should work together to set up curricula for health professional training in allergy.

  • Health commissioners should work with local service providers to ensure best possible service planning for their catchment areas.

  • Much clearer understanding of skills and competencies of the existing workforce needed.

  • NICE advised to provide guidance on allergen immunotherapy.

  • Funding identified for an allergy centre in the North West region of England.

  • Most of the recommendations from the House of Lords report could not be acted upon due to insufficient and unreliable data on the existing state of allergy management, according to this report.

Warner et al (2006)3WorldwideCross-section; Questionnaire survey.To define the current state of allergy training and services in the countries represented within the WAO
  • Prevalence rates for allergies in the responding countries ranged from 7.5% to 40% (mean 22%).

  • Number of certified allergists varied widely from 1:25 million in Indonesia to 1:16,000 in Germany.

  • Formal certification procedure is not available for clinicians in some of the countries surveyed.

  • In most countries, patients are first referred to organ-based specialists before being referred to allergists.

  • There is a very wide gap between demand and provision of allergy services worldwide.

  • Training of medical students, general practitioners, generalists as well as system specialists who deal with allergy must improve to ensure better care provision.

  • More tertiary level centres needed to set the standards, advance research, support training and provide expertise to primary and secondary care.

  • Survey sent to all WAO national society member organisations to be completed by allergists knowledgeable about services within their own countries (61 sent, 34 responses received).

  • Data based on impressions of these experts in some countries rather than on published data.

Department of Health (2006)45UKReport from a publicly funded organisation.Review of allergy services undertaken to fulfil Government of UK's commitment to the House of Commons Health Committee.
  • No compelling evidence on need or on quality of allergy services since relevant research lacking.

  • Patients feel let down by a poor and often inaccessible service.

  • Specialist services are usually not available, resulting in very long waits to see consultants where services do exist.

  • Self-care can be particularly useful in allergy and should be promoted.

  • Some conflict between the main two specialities offering allergy services in the UK (ie, allergy and clinical immunology).

  • Local commissioners need to establish levels of need for services for allergy in their health community.

  • Educators and Commissioners should work together to create additional training spaces for doctors.

  • Guidelines for management and care pathways should be developed by NICE.

  • Data obtained by review of existing literature and also by interviewing stakeholders.

  • Highlights the difficulties in developing national strategy for allergy services without baseline data on needs and costs involved.

  • It is important to understand the skills and competencies that exist and those that are needed from the diverse workforce to enable future development and provision of services.

El-Shanawany et al (2005)46UKCross-section; Questionnaire SurveyTo survey allergy services provided by clinical immunologists in the UK.
  • Immunology centres are the only providers of tertiary allergy care for most of the UK.

  • Consultant immunologists are likely to be providers of tertiary level allergy care in the medium and long term for the UK.

  • Waiting times for allergy patients in these clinics were long, sometimes waiting over a year for urgent appointments.

  • Very few centres benefitted from dietician support.

  • There needs to be a collaborative effort between clinical immunologists and allergists in the UK in order to improve services.

  • Questionnaires sent via three supra-regional immunology audit groups to the various participating immunology regional centres in the country.

  • 17 immunology centres serving a total population of 32 million individuals responded.

Ryan et al (2005)47UKDiscussionTo propose minimum levels of knowledge required for clinicians in order to improve standards of allergy care.
  • Self-care in allergy is problematic due to the poor access to NHS healthcare and the availability of unregulated alternate practitioners.

  • PCPs and practice nurses could be better trained in prescribing drugs for allergy.

  • Intermediate care services (eg, PCP with special interest) should be developed.

  • Pharmacists, primary care nurses and physicians could be trained in a few allergy-related techniques to vastly improve service provision.

  • The authors suggest that management of allergy in primary care can be improved even when specific tests and other infrastructure are unavailable.

  • Knowledge of pharmacotherapy for allergy can help PCPs manage a majority of patients.

Department of Health (2005)48UKReport from a publicly funded organisationGovernment of UK response to the House of Commons Health Committee report.
  • Good quality data on needs and services for allergy is lacking.

  • Service models for managing allergy in primary and secondary care could be developed.

  • Medical regulatory bodies overseeing physician and nurse training should be encouraged to increase allergy educational content during training.

  •  Self-care should be encouraged; NHS led expert patient programme will be extended to allergy.

  • Food Standards Agency has produced a guide for those recently diagnosed with food allergies.

  • Local commissioners should establish need for services in their local area.

  • It was felt that a review of available data and research on allergic conditions is necessary in order to plan future direction of allergy services. This formed the basis for a separate report (as above).

Levy et al (2004)49UKCross-section; Questionnaire surveyUnderstanding the views of PCPs in the UK regarding the quality of primary and secondary care for allergy.
  • More than 80% felt that the NHS allergy care was poor.

  • Primary and secondary care services were thought to be deficient.

  • Very few (4%) offered skin prick tests at their practice.

  • Most expressed concern regarding managing children with allergies.

  • A majority were confident in the management of urticaria, allergic rhinitis, angioedema, anaphylaxis.

  • National education programmes should be developed for PCPs.

  • Specialist care provision for allergy should be reviewed urgently within the NHS.

  • Randomly selected sample of 500 PCPs from UK General Practice register were contacted.

  • Only 50% response rate.

House of Commons Health Committee (2004)19UKReport from a publicly funded organisationTo highlight the need for allergy service improvement in the UK
  • Primary care skill base for allergy is poor—this is compounded by weakness in secondary care sector as well.

  • Current provision is manifestly inequitable and more allergy specialist centres are required.

  • Better secondary care can help improve primary care knowledge and services.

  • Paediatric services are worse than adult services —school nurse training, transition services, dietary recommendations, etc, all need improving—-specialist services can help improve school staff training in allergy by taking on leadership for this.

  • Poor and sometimes dangerous practice exists in the independent sector.

  • Data on waiting times are flawed, and this adversely affects service planning.

  • Allergy specialist centres need to be developed manned by allergists; allergists cannot be substituted effectively by other specialists.

  • Advocated the establishment of national primary care allergy network.

  • Ongoing training for allergy in primary care needs to improve; services should be peer reviewed.

  • Introduction of clinical quality markers for allergy to incentivise improvement advised.

  • PCP curriculum needs to be modified to include more allergy.

  • Separate coding for allergy needs to be introduced (now available).

  • Investment in allergy training required.

  • Health committee comprising of elected representatives.

  • Expert interviews, statistics from published sources, submissions to panels from individuals – patients or carers (300 letters) were all used.

Royal College of Physicians (2003)20UKReport from a publicly funded organisation.To ensure that allergy services are prioritised for improvement by commissioners and managers in the NHS.
  • Allergy incidence and prevalence is increasing but services are quite poor.

  • Very few allergy specialists in the country and few trainees in the pipeline.

  • General practitioners not trained to cope with the increasing demands for allergy treatment, most do not feel confident about services, but very few patients are referred to specialists, nonetheless.

  • Few centres offer secondary care allergy; six centres UK wide offering tertiary care. Hence PCPs not sure who to refer patients to.

  • Increasing emergency admissions for allergy.

  • Some papers quoted to suggest specialist services may be cost-effective.

  • Need to have increased allergy specialists (rather than other specialists who are untrained in allergy).

  • Important to develop regional allergy centres that can help with education, training and networking between primary and secondary care in the region (‘Hub and spoke’ configuration).

  • More doctors should be trained to become allergy specialists.

  • 40 new training posts in allergy will be required.

  • Patient groups and charities must become more active and lobby for better services.

  • There is a need for more dieticians and nurse specialists in allergy.

  • Working party consisting of clinical experts from all over the UK, patient representative.

  • Selected publications reviewed (non-systematic).

  • Other interested stakeholders interviewed, including clinicians, charities supporting patients with allergy, individual patients.

  • Two parts to the report—one covering allergy services and recommendations for improvements and the other covering common allergic conditions and their management.

Ewan and Durham (2002)33UKDiscussionProposal to improve NHS allergy care in the UK
  • NHS allergy service provision is inadequate and inequitable.

  • Estimate that there is one whole time equivalent allergist per 3.4 million population in the UK.

  • Only six clinics in the UK offer services of full time NHS allergists.

  • Each of the health areas in the UK should have a regional specialist centre to provide clinical expertise and training.

  • More training posts in allergy should be created.

  • Data derived from the BSACI and BAF database.

  • Authors assume that part-time allergists provide 0.3 WTE and other specialists provide 0.1 WTE allergy work per week. This is debatable.

Ewan (2000)50UKDiscussionAn overview of NHS allergy services and suggestions for improvement.
  • There are serious deficiencies in the allergy services within the UK.

  • Training numbers for allergy are not adequate to serve current and future demands on the specialty.

  • Organ specialists (including immunologists) not appropriately trained for the holistic management of these patients.

  • Minimum of 1 regional allergy centre per region needed manned by allergy specialists and nurses, dietician.

  • Organ-based specialists and allergists need to be appointed to more secondary level centres.

  • There should be an increase in specialist training spaces for allergy.

  • Data from BSACI and BAF database as above.

  • Recommendations as per the Allergy task force set up by the BSACI and DoH in 1998.

Brydon (1993)51UKQuestionnaire; retrospectiveA survey to determine the effectiveness of a nurse practitioner service.
  • Nurse led service resulted in fewer general practitioner consultations and also a reduction in prescribed medication for allergy.

  • Most respondents reported an improvement in symptoms.

  • Better results seen in patients who were followed up for longer.

  • Using nurse led services in primary care can be cost saving.

  • There could have been a recruitment bias/criteria for choosing a section of patients not made explicit.

  • Bespoke postal questionnaire before and 9 months after appointment with the nurse.

  • Responses compared with patient notes from PCP.

  • BAF, British Allergy Foundation; BSACI, British Society of Allergy and Clinical Immunology; DoH, Department of Health (UK); EAACI, European Academy of Allergy and Clinical Immunology; MCN, Managed Clinical Network; NHS, National Health Service (UK); NICE, National Institute of Health and Care Excellence, UK; PCP, Primary Care Physician; PROM, Patient Reported Outcome Measures; WTE, Whole Time Equivalent; WAO, World Allergy Organisation.

  • Level: 1° (primary) refers to care delivered by primary care physicians, nurses and other practitioners who are non-specialist and offer services in the home or community.

  • 2° (secondary) services refer to those provided in hospitals by clinicians (doctors or nurses) deemed to have specialist training and knowledge relevant to the management of the condition.