National Survey of United Kingdom Paediatric Allergy Services

Abstract Background Comprehensive national assessments of paediatric allergy services are rarely undertaken, and have never been undertaken in the United Kingdom. A 2006 survey estimated national capacity at 30,000 adult or paediatric new allergy appointments per year and identified 58 hospital clinics offering a paediatric allergy service. Objective The UK Paediatric Allergy Services Survey was the first comprehensive assessment of UK paediatric allergy service provision. Methods All 450 UK hospitals responded to a survey. Paediatric allergy services are provided in 154 lead hospitals with 75 further linked hospitals. All 154 lead paediatric allergy services completed a detailed questionnaire between February 2019 and May 2020. Results The 154 paediatric allergy services self‐define as secondary (126/154, 82%) or tertiary (28/154, 18%) level services. The annual capacity is 85,600 new and 111,400 follow‐up appointments. Fifty‐eight percent (85/146) of services offer ≤10 new appointments per week (no data provided from 8 services—2 no response, 6 unknown) and 50% (70/139) of the services undertaking challenges undertake ≤2 food or drug challenges per week (no data from 3 challenge services). Intramuscular adrenaline is rarely used during challenges—median annual frequency 0 in secondary services and 2 in tertiary services. Allergen‐specific immunotherapy is offered in 39% (60/154) of services, with 71% (41/58) of these centres treating ≤10 patients per annum (no data from 2 immunotherapy services). The 12 largest services see 31% of all new paediatric allergy appointments, undertake 51% of new immunotherapy patient provision and 33% of food or drug challenges. Seventy percent (97/126) of secondary and all tertiary services are part of a regional paediatric allergy network. Only nine services offer immunotherapy for any food (3 for peanut), 10 drug desensitization and 18 insect venom immunotherapy. Conclusions There has been a fourfold increase in paediatric allergy clinics and an approximately sevenfold increase in new patient appointment numbers in the United Kingdom over the past 15 years. Most services are small, with significant regional variation in availability of specific services such as allergen immunotherapy. Our findings emphasize the need for national standards, local networks and simulation training to ensure consistent and safe service provision.


| INTRODUC TI ON
The atopic conditions asthma, eczema, allergic rhinitis, anaphylaxis, conjunctivitis, food allergy and urticaria/angioedema collectively affect over one in three children in the United Kingdom and are estimated to cost the NHS over £1 billion per annum. 1 The United Kingdom has one of the highest rates of allergic disease and whilst the prevalence of hay fever and eczema has plateaued or decreased, 2 in contrast admissions for anaphylaxis, food allergy, urticaria and angioedema have increased significantly. 2 4 This was based on data from the BSACI website clinic finding service, but this is neither complete nor up to date. 5 We have therefore undertaken the first comprehensive survey of every UK hospital to establish which are providing a paediatric allergy service and what that service consists of. The intention of the survey is to also act as a repository so that health professionals and patients and their families can identify the location of services appropriate to their needs. Furthermore, by identifying areas where inconsistencies exist, the information may be used to help drive publication of national standards for paediatric allergy services, similar to those in adult allergy services. 6 The results will also allow individual services to benchmark themselves against other paediatric allergy services and may help inform decisions regarding the structure and development of services and networks.

| ME THODS
The survey was completed in two stages. In the first stage, the contact details of all 450 hospitals in the United Kingdom were found from online searches. Each hospital was contacted to establish whether the hospital provides a paediatric allergy service. If a paediatric allergy service is provided, the respondent was asked for the contact details of the person best placed to answer more

| RE SULTS
All 154 lead services seeing paediatric allergy patients nationally completed the survey between February 2019 and May 2020. The two last respondents completed their surveys after the start of the Covid-19 pandemic and were asked to record the configuration of their service prior to any impact of the pandemic. Respondents were asked if they provide a secondary or tertiary allergy service or both.
The terms were not further defined and interpretation was entirely at the discretion of the respondent. Responses were as follows: 126 • Most paediatric allergy services are relatively small, suggesting a need for national standards and networking.
• There is significant regional variation in provision of some paediatric allergy services such as allergen immunotherapy.
F I G U R E 1 UK Paediatric Allergy Services -Configuration map. The UK Paediatric Allergy Services -Configuration Map webpage includes a Map Legend within which ten different "layers" can be selected: Paediatric allergy services (denoting the Lead and Link paediatric allergy services in the UK); Allergy Network membership (specific network); Nurses undertaking Allergy Consultations (i.e. instead of a doctor); Dieticians undertaking Allergy Consultations (i.e. instead of a doctor); Dietician Support; Joint Clinic -Gastroenterology; Joint Clinic -Dermatology; Joint Clinic -Respiratory; Adolescent Clinic; Transition Clinic. In this Figure,  (82%) secondary only and 3 (2%) tertiary only and 25 (16%) secondary and tertiary level paediatric allergy care. For subsequent analyses, tertiary only and secondary and tertiary respondents were combined. Seventy-one (46%) were providing paediatric allergy services in one or more other hospitals.  and prior to oral food challenges (9). One individual reported that the decision to perform component testing is made in the laboratory. Ara h2 is the most routinely tested component (98%, 106/108), followed by ara h8 (85%, 92/108), ara h1 (55%, 59/108), ara h9 (50%, 54/108) and ara h3 (40%, 43/108). Hazelnut components are tested routinely on all children with suspected hazelnut allergy by 9%

| Desensitization Programmes
Desensitization is offered by 16% (24/149) of services. Eighteen services offer desensitization to insect venom (5 secondary, 13 tertiary), 9 to food (3 secondary, 6 tertiary) and 10 to drugs (2 secondary, 8 tertiary). For services offering food desensitization, peanut is offered by 3, milk by 7 and egg by 4 centres.   3.4.9 | BSACI secondary care and specialist paediatric allergy service standards Few secondary care services fully adhere to all the secondary care standards set out by BSACI 7 and similarly few tertiary services to all the service specification standards for paediatric allergy specialist centres published by NHS England 8 (Tables 1-3).

| Follow-up and transition arrangements
3.4.10 | Regional variation in paediatric allergy service provision

| Small services predominate
Clinic capacity is heavily skewed towards smaller services with one in four secondary services and one in five tertiary services undertaking only one clinic per week seeing exclusively paediatric allergy patients. There are no requirements within either the BSACI standards for secondary care or the NHS contract for specialist paediatric allergy services with regards to the number of patients that must be seen within the service, beyond stating for the former that the service should be undertaking at least one allergy clinic per week.
The consequence of many services being small is that they undertake very low numbers of challenges and, in general, there was very little reported use of intramuscular adrenaline. This raises a concern about confidence in managing anaphylaxis. Further investigation as F I G U R E 3 Regional differences in paediatric allergy services. Data shown are the regional differences in four metrics: (1)   to whether this reflects under usage of intramuscular adrenaline, or selection of very low-risk patients is warranted.
Three-quarters of all secondary services and all tertiary services are part of a local network. This has the potential benefit of allowing sharing of guidelines, protocols, teaching, education and support.
However, it needs to be determined whether being part of a network results in improvements in paediatric allergy care.

| Provision of multidisciplinary paediatric allergy services
With regards to specific staffing of paediatric allergy services, dietetic input is essential for the management of paediatric allergy patients 9 and BSACI secondary standards state that a paediatric dietician should be available and competent to support patients with food allergy.

| Diagnostics capacity
Thirty thousand four hundred and sixty-five challenges are performed per year in food-allergic children in the United Kingdom. This number has to meet the needs of those children from the outpatient consultations who require a challenge and as well as children already known to the paediatric allergy service requiring challenges. We did not specifically ask about waiting list for challenges, but from our own experience, and discussion with peers, low capacity and long waiting lists for challenges is commonplace across allergy services.
Significantly, pressure could potentially ensue from the multiple-day visits required for Palforzia, the newly licensed therapy for peanut immunotherapy, and from the increasing provision needed for selective nut introduction and early introduction challenges.

| Regional provision for less common allergyrelated activity
The aspiration for there to be at least one regional centre providing the full spectrum of specialized paediatric allergy services remains appropriate but is not being fulfilled. The number of services offering highly specialized diagnostic and treatment facilities remains low, for example diagnostic testing for and investigation of drug allergy, particularly to intravenous antibiotics and local and general anaesthetics.
Few services offer adolescent and/or transition clinics. EAACI recently published guidelines for the management of adolescents and young adults with allergy and asthma that will help ensure ensure that services are providing for this group of children, either within existing clinics or in separate clinics. 15

| Strengths and limitations of study
The strength of this survey is the 100% response rate from all services seeing paediatric allergy patients across the United Kingdom, providing the first comprehensive assessment paediatric allergy service provision. The principal limitation is that the responses to the survey are unverified and hence our interpretations of the data are dependent on the accuracy of the responses. Furthermore, for some questions, the response given in the survey reflects an individual clinician's personal practice and may not reflect the practice of other colleagues within a service. We also did not include private practitioners offering paediatric allergy services. In some parts of the country, such provision is significant. However, the paediatric allergy training of individuals providing private paediatric allergy services is often minimal to non-existent and the quality of care provided is extremely variable. The data from this survey are contributing to an ongoing international comparison of paediatric allergy services.

| CON CLUS ION
In summary, there has been a welcome increase in paediatric allergy service provision, but much of this is provided in small services.

ACK N OWLED G EM ENT
The authors thank all the individuals from services across the United Kingdom who responded to the survey.

FU N D I N G I N FO R M ATI O N
RW received funding from Wellcome Trust ISSF Academic Collaboration Fund.

CO N FLI C T O F I NTE R E S T
The authors have no conflicts of interest to declare.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are openly available at: https://doi.org/10.24376/rd.sgul.20292489.

E TH I C A L S TATEM ENT
Ethical approval was not required for this service evaluation.