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Community care


Secretary of the EAACI Primary Care Group, Elizabeth Angier, discusses how immunotherapy can be executed in the community, and not just in hospitals


Elizabeth Angier is a general practitioner and secretary of The European Academy of Allergy and Clinical Immunology’s (EAACI) interest group Allied Health and Primary Care, the task forces of which initiate work in developing proficiencies for allied health professionals. A secondary force focuses upon a multidisciplinary team concerned with allergy, and a third concerned with allied healthcare members centres on special products for cow’s milk allergies.

The EAACI 2017 was held in Helsinki, Finland, in June and attended by Pan European Networks. At the congress, Angier debated the importance of implementing immunotherapy within the community against Désirée Larenas-Linnemann, founder of the Clinic of Excellence in Allergy and Asthma, Berlin, Germany.

Mapping calls for community care

Utilising the exemplar of a historic Heineken advert, which utilised the tagline ‘Heineken refreshes the parts other beers cannot reach’, Angier articulated how, similarly, primary care is a “hard place to reach”. She further argues the point that it is vital that cross-border relations are assessed, and that there is a call for such, as well as illustrating that “the allergy community is built on relationships and trust”. In a situational analysis – due to be released under EAACI guidelines and primary care in immunotherapy in autumn 2017 – Angier and the board found that 70% of their colleagues wanted to collaborate with the allergy community.

Within this release, several infrastructural barriers have been identified as key areas of concern in implementing primary care in the community: “we didn’t have knowledge, we had time pressures, there were difficulties with reimbursements, and there were difficulties with communication with specialists.” She added: “We spend a lot of time on guidelines; we spend a lot of time on pathways, but what we don’t look at is … the interfaces and how we communicate with each other as colleagues to implement service delivery.”

© Hans Hansson

Shared and integrated care

In the Finnish capital Angier observed primary care in the community by shadowing a practitioner who visited patient’s houses, and other practitioners, to whom she gave an education programme and brought them to his practice to provide accredited training in order to implement immunotherapy in the community. She added: “If I was to put this forward as something we can do, let’s do it … let’s get the initiation with the specialists.”

In her observations in Helsinki, she saw primary care initiated in hospitals with follow-ups in the community. Currently, subcutaneous care in Helsinki is executed by conducting the up-to-maintenance phase within hospitals, and then healthcare professionals going out into the community to attend to the patients who haven’t experienced specific difficulties. She also stressed the importance of the patient/professional relationship by adding that “a difficulty, something you’re not sure about”, can be addressed by getting in touch with a professional whom you already know, as opposed to a stranger in a hospital.

“Integrated care is built around the patients, and I’d really like us to think about that,” Angier continued. “As a patient, time is important. However, it may be that the primary care sector fails in this argument – health services aren’t allowed to fail because that may be at a detriment to the patient.”

The secretary of the Allied Health and Primary Care Group called for a co-produced humble enquiry in order to provide an integrated care service.

“If we can crack immunotherapy with all the difficulties and subtleties that surround it, then we can crack allergy care.” In order to facilitate this, Angier proposed that a technical and adaptive transition was likely to be required. As a result of adaptive change, she emphasised the emotional attachment associated with this evolution, adding: “it involves feelings of loss and grief, but people have to change their habits.”

Learning from experience

In 1986 the Committee on the Safety of Medicines issued a report which detailed deaths and adverse reactions associated with immunotherapy treatments in allergy patients. There were 26 deaths in 30 years. Angier recognised the importance of remembering those deaths, as well as recognising and understanding why they happened. She added: “We want to look at better value care, increase patient experience and better quality [as well as] staff satisfaction. If we’re delivering immunotherapy in a value-based way, without the perverse incentives of money and tariffs, then we might get a better delivery.”

Looking at the system, Angier suggested that it is currently “designed around episodes of care, rather than patient journey; it’s designed around disciplines coming together rather than the patient’s problem.

“Sometimes, the way we run hospitals is at our convenience, rather than the patients, and also, sometimes, we assume that the patient’s time is free and valueless.”

As a result, she warned that patients may become disenfranchised with the current healthcare system, and may refuse to partake in that system any longer.

Progression for patients

“In delivering healthcare, you want to define hard core principles which would be: patient selection, being aware of asthma, waiting the right amount of time, education, investment and training, looking at infrastructure and looking at referral pathways.” Angier stipulated these principles which would, subsequently, constitute collaboration among healthcare services to deliver immunotherapy care in the community, as well as ensuring the safety of patients in the process.

In volume two of the anticipated EAACI guidelines, readers from the allergy community, and elsewhere, will be able to recognise from primary care survey results that the work being done is a work-in-progress. Angier said that the Allied Health and Primary Care Group has not achieved what they hoped to initially achieve, but with contributions from the allergy community in the future, she remains is hopeful. The general practitioner and secretary extended a call to the allergy community in the audience to talk with primary healthcare fellows, and for the community and professionals to contribute in writing papers on the topic: “This is what’s best for patients,” she said, before concluding on her portion of the debate. “Come and join us and help us with these problems, because I’m looking at this as a system and I’m aware that immunotherapy can be a dangerous thing, but we can learn from it.”


This article will appear in Pan European Networks: Health 2, which will be published at the end of August.

Pan European Networks Ltd