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NHS'. (r3) Assuming that thespecialist community dietitianhas the necessary competenciesand follows protocols statingwhen to refer a patient on forfurther investigation. then incombination with new andeffective evidence-basedtreatments they potentiallyhave an innovative recipe forsignificant NHS savings. dS

(9) British Dietetic AssociationGastroenterology Specialist Grou p'Professional Guideline: UK evidence-based practice guidelines for thedietetic manaoement of iritable bowelsyndrome (lBS) in adults': Birmingham.September 2O1O

Q0) Skudacher H, Whehn K, lNing PM,Lomer M (201 1 ), Comparison of symptomresporee following advice for a diet low infementabte carbohydrules (FODM APs)ve6us standard dietary advice in patientswith idtable bowel syndrcme. Journal ofHuman Nutritian & Dietetis:24: 487-4gs

(l 1) Gupta R et al. e004. Review: Burdenof allergic disase in the UK: secondaryanalyses of national databases. Clin ExpAilergy: 34; 520-526

(12) Levy ML, Walker S, Woods A, SheikhA (2009), Seruice evaluation of a l.JKprimary cffi-based ailergy clinic: qualityimprovement repoft: Pimary CaeBspiatory Journal: 1 8; Ahead of pint- Micle in pres

(13) Depaftment of Heahh" NHS White Paperpresented to parliament by the Secetaryof State for Health by Command of HerM4esty July 2010. 'EquW and exellence:Liberating the NHS'; The StationeryOffice: Repotl No: Cm 7881; ISBN97801017881 20

'e fffi,stroe,yrterotoffW e,(i *ti*

care referrals, unnecessaryinvestigations, complicationsand associated conditions andmedicatjons. ln addition, treatingpatients who have been givena diagnosis of IBS after red flaginvestigation can also reducethe substantial 'revolving door'costs. This is a potential win-winscenario, with a proportion of themoney saved being channelledto support the new communitygastroenterology dietetic service.

Should this service includeGI allergy?Allergy effects 1-2% ot the adultUK population. (r1) Allergy as awhole costs the UK NHS overt1 billion pounds per annum(rr) with a significant proportionof referrals to allergy clinicsbeing related specifically to foodallergy. r- However. there is aUK-wide lack of specialist adultallergy servicesl,'and there is noadult allergy service in Somerset(with the nearest solutionbeing expensive secondary ortertiary care referral to Bristol orSouthampton). Despite the new201 1 NICE guidelines on allergy,

which clearly state that allergydiagnosis and treatment couldpredominantly take place inprimary care (a), speclalist allergyclinics within primary careremain almost non-existent.

lnterestingly, all the patientsin our audit were referredwith IBS and yet almost B%improved when given dietaryintervention for Gl allergy andnot lBS. A further 26%o weresuccessfully treated usinga combination of advice forfood allergy and IBS (althoughfollow-up needs to be donewith this group to determinethe true cause of theirimprovement).

Not only is there a need forspecialist adult food allergytreatment within primary care,but there also appears to bea significant issue with thediagnosis of Gl symptoms. TheSomerset audit results highlightthat it is vital to run a clinic thatcovers both disciplines with aspecialist dietitian who has theskills and competencies to beable to differentiate betweenthe conditions.

FinallyAs the pressure increasesthroughout the NHS to reducereferrals to secondary care,dietetic community services areideally placed to set up specialistclinics to bridge the gap. Wecan "challenge the way thingsare done", fitting perfectly withthe 2010 White Paper, 'Equityand excellence: Liberating the

References(1 ) Beltlini M, Iosetfl C, Costa E B/agt S, Stasl

C, Del Punta A, Monicelfi e Mumolo MG,Rlcchiuti A, Bwi n Marchi S (2005)'The genetal pactlioneri appr@ch toiriable bowel sydrome: From intention topectice , Jourrut of Dig5tive and LiverDisease: 37(7 A: 934-939

'2t Boyal College of Physicians Allergy: Theunmet need'. London: Royal Colege ofPhysicians of London: (200q. Repoft No:/sBN 7 86076 783 9.

& NICE: ltritable Bowel Syndrcme: Costingrepoft implementing NICE guidan@.February 2008. Londan

4) NICE: Food alergy in children and youngp@ple: NICE clinical guideline 116;February2011, London

6) lnadomi JM etat. (2003). Systematicreview: the economic impact ot iftitablebowel syndrcme. Alirent PmacolTher:1 8; 671 -682

(6) Thompson WG, Hffiton KW SmylhGT Smyth C (2000)'hitable bowelstndrome in gensal pructice: prevalence,characteristics and referaf , Gut 46; 78-82

A Greig E (201 1), Audit of gastroenterotogyoutpatients clinic data fu May 201 1;Taunton & Someret NHS Irust

(8) Gore S (201 1 ), Audit o! gastroenterologyoutpatients clinic data for May 201 1 ; Y&vilNHS Foundation Trust