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Raising awareness and ensuring safety: A conversation with Dr Nasreen Khan
24 June 2024

IQAS clinical lead - Dr Nasreen Khan

Improving Quality in Allergy Services (IQAS) is discussing all things accreditation and allergy in this edition’s blog for World Allergy Week. I had the honour of speaking to Dr Nasreen Khan, our IQAS clinical lead, who is a passionate advocate for allergy awareness and accreditation. Nasreen leads the adult allergy service at University Hospitals of Leicester NHS Trust and is a consultant allergist and respiratory physician. This year’s theme for World Allergy Week is food allergy; this affects millions of people worldwide, and it is crucial to shed light on the importance of proper diagnosis, management and public awareness.

What is the importance of IQAS and becoming an accredited service?

Our specialty, allergy, unified with clinical immunology into a single field in 2021 because of the small size. It is vital to share experiences and best practices to ensure high standards in allergy care, enhancing quality through a collaborative, dynamic process. The IQAS programme emerged in 2003 from a paper about the unmet needs in allergy, which revealed significant geographical disparities in allergy care. IQAS aims to ensure consistent, high-quality allergy services and maintain rigorous standards by sharing best practices, ultimately ensuring that patients receive excellent care whenever and wherever they are treated.

How does being accredited make a difference to allergy?

Drawing from her personal experience with achieving accreditation for her own service, Nasreen looks at the accreditation process as a fantastic opportunity to highlight their exceptional teamwork and team spirit. While it required her service to demonstrate compliance with all the standards, this didn’t mean that they weren’t already providing superb care to their patients. Instead, IQAS has enhanced the quality of care that is offered. The accreditation process necessitates strong teamwork and as doctors you can’t operate in isolation, so it’s important to collaborate with nursing, pharmacy and dietetic colleagues as well as administrative staff. Nasreen recently met with someone who organises and ensures that patients attend for her day case procedures, underscoring the importance of seamless teamwork for smooth operations. The IQAS programme is about providing assurance that services run effectively, universally requiring everyone to understand their roles, take pride in their work and communicate efficiently within the team. Achieving the necessary standards is crucial, but the essence of the accreditation process is fostering teamwork. Nasreen believes that this is the cornerstone of any successful accreditation programme.

How can accreditation improve patient safety, care and quality within allergy services?

The key to providing exceptional care, Nasreen explained, is that it lies within being open, honest and transparent about processes. It is crucial to learn from mistakes; understanding that mistakes will happen will allow services to handle them constructively. When errors occur, Nasreen’s service analyses them using a routine branch method, using a no-blame culture that emphasises learning from every incident.

Mistakes can range from mild to severe, much like the spectrum of anaphylaxis – by placing emphasis on learning from adverse events, Nasreen’s service is able to enhance patient safety. Sharing best practices, especially those based on nationally or internationally recognised standards, further reduces the likelihood of problems. In allergy care, as in other hospital practices, they often see patients with complex needs. Primary care colleagues help manage less complex cases, allowing the service to focus on patients with multiple allergic comorbidities. This complexity increases the risk of complications, making robust standard operating procedures (SOPs) and treatment protocols essential. Ensuring that these protocols are ratified by the entire team, kept up to date and regularly reviewed is vital for managing risk and ensuring patient safety.

How can patients and families verify whether a hospital is accredited?

The British Society for Allergy and Clinical Immunology (BSACI), our national allergy society, provides a link on its website to accredited allergy services. It guides patients to both accredited services and those working towards accreditation. Nasreen understands that achieving accreditation is time-consuming, and we appreciate the commitment of services that register and work through the process.

Patient groups such as Allergy UK and Anaphylaxis UK also link to IQAS on their websites, which significantly extends outreach. Patients frequently use and value these resources, making it easier for them to find reliable allergy services. Accreditation offers assurance to patients that a service meets high standards; for example, 29 services are engaged with the IQAS programme. Nine are accredited, one is being assessed and a further 19 registered services are working towards achieving accreditation. The nine accredited allergy services represent an important portion of our small specialty.

The goal of accreditation is inclusivity, aiming to help services work together to provide high-quality care without placing blame. This is especially crucial given the geographical inequities in allergy services. For example, Scotland and Wales have limited services and Northern Ireland faces its own challenges; within England, there are significant regional disparities. While there is still much to do, these efforts mark an important start toward ensuring that all patients receive excellent allergy care, no matter where they are.

Why is bringing awareness to food allergy so important?

This year World Allergy Week is focusing on food allergies, which are becoming more common. There is an ongoing debate about whether this rise is due to increased awareness and reporting, or a genuine increase in cases. Current statistics confirm a real increase in food allergy incidents. Several hypotheses explain this rise; one prominent theory suggests that children born into highly hygienic environments have a higher incidence of allergic diseases. For example, children raised in inner-city areas with less exposure to allergens have more allergies than those in farming communities, who are exposed to various allergens early on. This supports the idea that early exposure to allergens, such as peanuts, can reduce the likelihood of developing allergies.

There are nuances to this argument, especially regarding children of allergic parents and the timing of allergen introduction. As an adult allergist, Nasreen focuses on the increasing number of food allergy cases and the importance of understanding these issues. One major concern is overdiagnosis – many people mistakenly believe that they have food allergies, leading to unnecessary dietary restrictions and, in extreme cases, malnutrition. For example, avoiding essential food like milk without a true allergy can have serious consequences. Conversely, some patients with severe food allergies may not receive a proper diagnosis. This can lead to life-threatening reactions upon exposure to allergens. Unfortunately, the media frequently report tragic deaths from food allergies, highlighting the need for proper diagnosis and awareness. It is crucial to strike a balance between avoiding overdiagnosis and ensuring that those with genuine food allergies understand the risks and implications. Proper diagnosis and education are key to managing this growing issue effectively. 

What are some common misconceptions about food allergy?

One of the most common issues Nasreen encounters is patients mistakenly believing that they have a food allergy when they actually have a food intolerance. Unlike food allergies, intolerances are not life-threatening. Until recently, much of the workload involved diagnosing ‘not allergy’ rather than nut allergy, helping patients to understand that they don’t have an allergy and encouraging them to reintroduce foods into their diet.

Nowadays, we see fewer of these cases because we triage referrals more carefully. Patients without a strong history of allergies are often managed by their GPs with a special interest in allergy.

Food intolerance is a major one. Just recently Nasreen reviewed a patient who had had symptoms of nut exposure since childhood but had never received a formal diagnosis. After testing, they were found to have multiple positive results, indicating dangerous peanut and tree nut allergies – cases like theirs highlight the importance of accurate diagnosis. For patients with multiple food allergies, a dietetic assessment is crucial. These individualised nutritional assessments ensure that these patients avoid dangerous foods while maintaining a balanced diet to meet their nutritional needs. This specialised care relies heavily on dietetic colleagues.

The key is balancing underdiagnosis and overdiagnosis, ensuring that patients get the right diagnosis as soon as possible. This approach, often referred to as ‘getting it right first time’ (GIRFT ), is essential in providing best care for all patients.

How can individuals with food allergies advocate for themselves in these situations?

Patients can seek advice from patient societies and the BSACI. Ideally, the standard route for accessing allergy care is through the NHS – when the system functions well, patients contact their GP surgery, either by email or phone, for a risk assessment. Healthcare providers can then determine whether the patient is at risk for a severe allergy or if it’s more likely to be an intolerance.

Nasreen’s service is fortunate to have GPs with extended roles (GPwER) in allergy, and they hope that more primary care colleagues will join this field, especially with the new GPwER accreditation framework for allergy within the Royal College of General Practitioners. Ideally, patients would be assessed by these specialised GPs. Education is crucial, and the BSACI offers primary care and allergy educational symposia, regularly advertised on its website. BSACI encourages GPs, nurse specialists and other allied health professionals (AHPs) to attend these sessions to help patients and identify those at risk for severe allergies.

When a potential severe allergy is identified, the GP or AHP may initially seek advice and guidance from an allergy service. Most trusts provide advice and guidance services, allowing quick email correspondence with a consultant. Additionally, there is an electronic referral system, where qualified health professionals can refer patients for allergy assessments. These referrals are triaged by the allergy service, ensuring that patients in need are seen promptly, or advice given to help the primary care practitioner manage the patient in the interim.

From what Nasreen and I have spoken about, you can see how managing the complexities of allergy diagnosis and management can be challenging, but with the right resources and support, both patients and healthcare professionals can work together to ensure the best outcomes. Accreditation plays a crucial role in this process, offering assurance that services meet high standards and encouraging continuous improvement. As more services receive accreditation in allergy care, we can better address the needs of our patients and reduce the risk associated with misdiagnosis. By utilising patient societies, staying informed through education programmes and making the most of NHS resources, we can continue to improve the quality of care for those with allergies.

Chloe Shields

IQAS and QPIDS programme coordinator 

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