Antibiotic Resistance

Lord Goldsmith of Richmond Park Excerpts

Wednesday 15th October 2014 Westminster Hall

[Zac Goldsmith (Richmond Park) (Con)]

I am thrilled that despite my breaking two rules in a short time when I walked into the Chamber you are still allowing me to speak in the debate, Mr Chope. It is a pleasure to follow all the speeches, which have covered virtually all the angles. I am grateful to my hon. Friend the Member for York Outer (Julian Sturdy) for securing the debate, and for the speech he made.

There is a depressing but nevertheless welcome consensus that we are losing our antibiotics to resistance, and effectively losing modern medicine as we know it. Notwithstanding the threat of Ebola it is hard to imagine a bigger health threat. The World Health Organisation has described antibiotic resistance as a bigger crisis than the AIDS crisis of the 1980s. If we lose antibiotics we risk the return of a time when basic operations will be deadly. I used to wonder what it would take to wake up the British establishment to that appalling threat. For years virtually nothing seemed to be done to combat the extraordinary phenomenon of antibiotic resistance. I thought, naively, perhaps, that once the health establishment blew the whistle, everyone else would fall into line and, fortunately, the health establishment has been blowing the whistle very loudly. We have heard various quotations today of the apocalyptic language of the chief medical officer, Dame Sally Davies. I think she has even used the term “apocalypse”. She has said that if we do not take action, deaths will go up and up, and modern medicine will be lost.

That is of course already beginning to happen. It is not a futuristic scenario. In 2006 there were just five cases in which patients failed to respond even to last-resort antibiotics in this country. Last year the number was 600. I know that there has been some action and I do not mean to disparage that. In March last year the Cabinet Office confirmed that it would examine the question of resistance as a national security issue. In September of that year it released an outline UK five-year antimicrobial resistance strategy. The Government have since set up a high-level steering group, chaired by Dr Felicity Harvey, the director general, public health, to implement the strategy once it is released, which I think will be later this year. All that is good news, and it is possible that the strategy will match the urgency of the situation. However, I am afraid that there are worrying signs that it will not.

Yes, there will be renewed efforts to develop new drugs, which is crucial. I was thrilled to hear the Prime Minister’s response to a question on the subject, during Prime Minister’s questions, when he briefly outlined the Government’s commitment to supporting the development of new drugs. That is obviously a prerequisite to solving the problem. There is nothing in the pipeline at all, and, as existing drugs become ineffective, we clearly must hope for new developments and do all that we can to facilitate them. There will also be renewed efforts to limit the inappropriate use of antibiotics in human medicine. That subject has been covered and I shall not dwell on it today. However, so far, successive Governments, including the present one, have resolutely avoided confronting a part of the problem that is not only huge but avoidable.

It is worth repeating that from day one, when Alexander Fleming accepted his part of the Nobel prize, he issued a dire warning. We have heard the quotation and I will not repeat it. The simple reality is that we have completely ignored that warning, more or less from the day he issued it. Instead of treasuring that miracle cure, we have squandered it—not just in hospitals but on intensive farms, and not just to treat sick animals but to keep animals alive in conditions where they otherwise would struggle simply to survive. That is not just a niche concern; 50% or thereabouts of the antibiotics that we use in this country are used on farms and it is even more in the United States and some other countries. Overall use per animal on UK farms is 18% higher today than it was a decade ago. That is disproportionately true of those antibiotics that are critical to human health.

[Graham Stringer (Blackley and Broughton) (Lab)]

The hon. Gentleman is making an important point: since tetracycline and penicillin-based antibiotics have been banned as growth promoters for farm animals, the use of tetracyclines has up gone tenfold and the use of penicillins has gone up fivefold. This is not a party political point: there is something that the Government can do immediately about that situation, which is to monitor and study it with a view to reducing the excessive use of antibiotics on farms.

[Zac Goldsmith]

I absolutely agree with the hon. Gentleman, and will come on to that briefly—I am going to try to keep my remarks short. That is exactly the point. Many people felt that the ban on the use of growth promoters back in—actually, I forget the year, but I think it was 15 years ago, although I may have got that wrong and am happy to be corrected—

[The Parliamentary Under-Secretary of State for Health (Jane Ellison)]

It was in 2006.

[Zac Goldsmith]

It was eight years ago, then. Many people felt that ban heralded the beginning of the phase out of the routine prophylactic use of antibiotics on farms, but, as the hon. Gentleman just pointed out, use has continued to increase across the board and disproportionately with regard to those antibiotics that are critically important. Given that the antibiotics used in veterinary and human medicine are closely related it is impossible to believe that that increase has not contributed to antibiotic resistance and the transfer of resistant bacteria from animals to humans.

The problem is that the industry has dug its heels in and contested the link. We have been told that there is no proof, but we know that resistant bacteria can be passed to humans on food, through the environment, directly via raw meat and so on. Some strains of resistant bacteria can mix with human strains and pass on resistant genes. For example, E. coli in animals is different from E. coli in humans, but we know that resistance can be and is transferred between animals and humans.

The industry also says that levels of resistance on intensive farms are no different from those on extensive farms, but two reports from the Department for Environment, Food and Rural Affairs have shown that resistance is 10 times lower on organic farms. The industry says there is no problem because antibiotics have to be prescribed by vets and everything is handled responsibly, but more often than not it is the feed mills that place orders for antibiotics rather than the farmers themselves. Finally, we are told that the use of antibiotics is necessary for the provision of cheap food. Perhaps that is the case, but that food will feel a hell of lot less cheap if the cost that society has to pay is the loss of modern medicine.

A briefing has been sent out to a number of MPs by the industry body RUMA—the Responsible Use of Medicines in Agriculture Alliance—saying:

“Fluoroquinolones are rarely used in poultry in the UK.”

RUMA has stated that as fact in response to the points that I and others have raised today. But on 8 September, a few days before that briefing was released, I met representatives of the Veterinary Medicines Directorate, who told me that the British Poultry Council has so far refused to provide any kind of data on antibiotic use at all. How the industry body RUMA can make such a bold and plain statement is beyond me—I suspect it is simply nonsense.

The experts take a different view from that of the industry. Sir Liam Donaldson, chief medical officer before Dame Sally Davies, went so far as to say that

“every inappropriate or unnecessary use on animals or agriculture is potentially signing a death warrant for a future patient.”

The European Food Safety Authority said last year that it is a

“high priority to decrease the total antimicrobial use in animal production in the EU.”

The Minister’s predecessor, my hon. Friend the Member for Broxtowe (Anna Soubry), told me after a debate on the same subject last year:

“Routine prophylactic use of antibiotics in both humans and animals is not acceptable practice”

and that she would be writing to DEFRA

“to ensure that existing veterinary guidance makes that very clear.”

I do not doubt the commitment of the chief medical officer—I am a wild fan of hers, as I know many hon. Members here are. I have not read her book yet, but I will do; I have read much of her writing. I have also met Dr Felicity Harvey and seen the seriousness with which she takes the issue. But so far, at least, DEFRA seems to be dragging its feet. There has been no sense of urgency in any of the meetings I have had, and any response I have had from DEFRA has been far more likely to mirror the industry line than anything the experts have said. The body language of DEFRA as a Department is almost completely defensive.

Thanks to the Netherlands and other countries we no longer have any excuse to stall. The Netherlands has seen a 50% reduction in livestock antibiotic use and expects a 70% reduction by 2015. It has phased out almost completely the use in agriculture of critically important antibiotics. There has been similar action in Denmark, Norway and Sweden. As I understand it, even the US, the land of agribusiness—it is where it was invented—has banned the use of fluoroquinolones in poultry.

The UK has no such targets or aspirations, and it is time that changed. We need to stop hearing excuses about lack of data that the industry has not provided and require those data to be collected. That is a prerequisite, as the hon. Member for Blackley and Broughton (Graham Stringer) said earlier. If the five-year strategy is to be taken seriously when it is eventually produced, it must provide a pathway to ending the routine prophylactic use of antibiotics on farms. That is now a black and white issue. In addition, the strategy must provide a pathway to an eventual ban—ideally, sooner rather than later—on the use on farms of antibiotics that are critically important to humans. Those two measures are the least we can expect from the five-year plan if we are to have any hope at all of combating a threat that the World Health Organisation has compared to the threat of AIDS.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (Jane Ellison)]

I thank all Members who have contributed to what has been an extremely good debate. I thank my hon. Friend the hon. Member for York Outer (Julian Sturdy), who led the debate and gave a thoughtful speech. I will try to respond to as many points as possible.

I will not spend much time on the scale of the threat, as many Members eloquently have outlined that. It was brought home to me clearly when, together with my noble Friend Lord De Mauley, on behalf of the Department for Environment, Food and Rural Affairs, and the chief medical officer, I represented the Government at a World Health Organisation conference in The Hague earlier this year. The conference started with a young woman talking to us. Essentially, she was dying: she had been through pretty much every stage of antibiotics available and all had failed. That brought home powerfully what we are talking about now and what Professor Dame Sally Davies has been writing about for some years. The case has been made by other Members and I will not dwell on it. This is an extremely serious global public health threat.

The Government have a “one-health” approach, working together across human and animal health with DEFRA. My hon. Friend the Member for Richmond Park (Zac Goldsmith) made some detailed points that I will probably ask DEFRA colleagues to respond to in more detail. We will be able to respond to some of them, and some will be encapsulated in the strategy, which will be published alongside an implementation plan. Virtually all the points made in today’s debate will be covered, as well as many additional points, in that publication; I will talk to Dr Felicity Harvey and the CMO to ensure that.

In the time available, I will try to outline what the Government have done to date and give Members reassurance that we are not complacent and that we recognise the scale of the threat. In response to questions raised by some Members, we are not waiting for a grand global strategy to try to take action ourselves; we already have many things in hand, because, as Members have said, time is running out.

In September 2013, we published the UK’s first five-year AMR strategy, taking the one-health approach that I have outlined to address the human, animal, food and environmental aspects of AMR, and set up the high-level steering group, to which some Members have referred, to oversee the delivery of that strategy and, importantly, to deliver metrics to assess progress and develop the implementation plan so that our progress can be judged. In June 2014, the steering group published the measures. Broadly speaking, they look at areas such as trends and resistance; antibiotic usage; the quality of antibiotic stewardship; public attitudes, knowledge and awareness; and changes in public and professional behaviour. All of those were touched on in the debate. I confirm to the shadow Minister that the Government published their response to the Health Committee’s report on 12 September.

The first annual progress report will be published later this year, alongside an associated implementation plan, which will pick up many of the points made in more detail. However, let me highlight some of the actions to date. I am delighted that the chief medical officer, Professor Dame Sally Davies, received so many plaudits from Members in the Chamber. I, too, have read her book, which is short but very alarming, and it brings home in graphic detail the scale of the problem we face—it certainly helped to focus my mind. She has led a global campaign of which the UK is right at the forefront.

The adoption in May 2014 of the World Health Assembly resolution on AMR, which was co-sponsored by the UK, was a major step forward. It provided a mandate for the World Health Organisation to develop a global action plan to tackle AMR by 2015. We are actively contributing to support the delivery of that global action plan.

The international nature of the problem was highlighted by many Members. India was mentioned by my hon. Friend the Member for York Outer and other Members, and I confirm that the recently produced Chennai declaration has begun to tighten up on over-the-counter use, so we are beginning to see significant action. India also supported a World Health Assembly resolution on this matter. However, sitting the table and hearing the different contributions at the conference at The Hague certainly brought home to me the fact that there are differing attitudes across the world. It will be a big task to get some countries to where they need to be and we certainly need to lead by example, which is a point that has been well made.

One of the things that we can do in supporting the work at a global level is building capacity and capability. As with so many problems of our developed world, we cannot afford to wait for everyone to go through the same cycle of development, discovery and identification of problems; we need to try to share our understanding. Public Health England is piloting a laboratory-twinning initiative, where high-income Commonwealth nations are working with low and middle-income countries to build up AMR education, training and surveillance capability, rather than waiting for them to develop their own.

The drugs pipeline is a huge issue, which was explained well and in some detail by my hon. Friend the Member for York Outer. That is an area in which we need rapid and concerted international action to stimulate the development of new antibiotics. The O’Neill review, which was commissioned by the Prime Minister in July, was mentioned. It is an independent review looking at the economic issues that cause this problem, and will make recommendations on what collective action can be taken by Governments globally. I confirm to my right hon. Friend the Member for North West Hampshire (Sir George Young) and others that that review will investigate solutions such as pricing and the introduction of incentives. The review is independent, so that team can think what they want—that is what they are tasked with—and we want them to come back with solutions to a problem that we know requires innovation. The interim report is due next summer, with the final report the year after that.

The faster adoption of new ideas was touched on, in particular those brought forward by small suppliers—Bioquell was mentioned. That is integral to the brief of the new Minister with responsibility for life sciences, my hon. Friend the Member for Mid Norfolk (George Freeman), who was recently given a joint appointment to the Department of Health and the Department for Business, Innovation and Skills to look at how we can accelerate the rate of innovation, because, as we know, we must not lose time on this.

Members were concerned to know whether, in the meantime, pending the O’Neill review, work was under way, and I can confirm that it is. Quite a lot of work is going on with the pharmaceutical industry. The industry is working with Chatham House and the Big Innovation Centre to explore issues about the pipeline and to look at possible options to stimulate antibiotic development. We expect the outputs of those initiatives to be published later this year, and they will feed into the independent O’Neill review. Other work is under way, some of which involves making public assistance available to smaller companies where they need it, but I can confirm that the pharmaceutical and biotech industries are fully engaged, as we need them to be, in exploring the issue and working together on the all-important research agenda.

Much of the focus for that research is diagnostics. We have commissioned work to improve our ability to diagnose infections quickly and increase the take-up and routine use of point-of-care diagnostics. That means being able to diagnose much more quickly—at the point of care—without the delay in having to send things away for study, and so on. The more quickly we can diagnose, the more quickly we can use appropriate medication. The Select Committee certainly pressed us on that when we gave evidence and we are aware that it wants us to take action on that issue. That is very closely linked to the work on improving prescribing, which is a key strand of efforts to reduce the overuse of broad spectrum antibiotics. Easy, cheap and accurate diagnoses will enable us to tailor patient treatment much more speedily and improve clinical outcomes, which is obviously a win-win.

Hon. Members have mentioned the award of the £10 million Longitude prize, which happened on the evening between the first and second days of the Hague conference, so it could not have been more appropriate and it was great news that came through while we were all there. It was fantastic on two counts: first, that money will go towards developing a new diagnostic for AMR, on which we expect further details to be announced shortly; and secondly, it felt like a great leap forward for public recognition and public engagement on the issue. That announcement was integral to a popular science programme on television—it was not just done by the scientific community; there was full public engagement, so I am really delighted about that and we have to build on it.

On research, hon. Members will be interested to know that the Medical Research Council is leading an AMR Funders’ Forum to improve the co-ordination of research relevant to all those different aspects of antibiotic resistance. In addition, there are two new National Institute for Health Research, or NIHR, health protection research units—I apologise for all the acronyms—with a focus on AMR and health care-associated infection. They were established in April at Imperial college London and at Oxford university, and they are in the process of agreeing their initial two-year work programmes, so more research is going on in those establishments.

In addition to important work to galvanise international action and stimulate drug development, we are trying to put in place the infrastructure and tools needed to improve infection prevention and control, and diagnosis and prescribing, in order to prevent the development and spread of AMR. That requires thinking about the problem in an entirely different way, because this problem is unique. The scale has been outlined by other people, but because of some unique aspects, we need to do things in a different way, and we are very aware of that.

Infection prevention is, of course, better than treatment, so we are refocusing attention on what more we can do to improve our ability to prevent infections and reduce reliance on antibiotics. To reduce the risk of importing very resistant infections from countries where the prevalence is higher—some of those countries have been mentioned—measures such as screening on admission to hospitals are now recommended and will be taken up.

Improving infection prevention includes work with NICE—the National Institute for Health and Care Excellence—and others to develop clinical guidance, best practice information and resources. We are also strengthening the code of practice on the prevention and control of infections to clarify for providers the measures they need to take to ensure effective infection prevention and, importantly, antimicrobial stewardship. That is being complemented by NHS England looking at the best ways to use levers on commissioning in the NHS and how it can establish local patient safety fellows to champion and help to embed best practice. On the animal side, DEFRA has provided guidance to assist with farm health planning. Work is under way to explore how we can make better use of vaccines and alternative treatments to reduce reliance on antibiotics and minimise the opportunity for resistant strains to develop.

I turn to the recent survey, the English Surveillance Programme for Antimicrobial Utilisation and Resistance —to which the shadow Minister nobly referred; it is quite a mouthful—or ESPAUR. That report from Public Health England was grim reading. It certainly made it clear that we have a long way to go in this regard, and it provided data that showed the enormous variability in the levels of prescribing across the health care system in England. It showed us some areas with extremely high prescribing rates, which often had the highest resistance rates. Although that report was tough reading, it was commissioned precisely because we did not really have a baseline report. We now have that, and it is a really important set of baseline information, from which we can go forward and help to improve practice.

[Zac Goldsmith]

Data are rigorously collected in relation to the resistance and use of antibiotics in human medicine, but they are hardly collected at all in relation to farm use. My understanding is that the whole system is entirely voluntary, and as a consequence, there are virtually no data at all. Is that an area where, at the very least, the Minister’s Department could pull rank on DEFRA and require the collection of data, so that we can have a meaningful discussion, because at the moment DEFRA does not seem inclined to pursue the matter with any great vigour?

[Jane Ellison]

I have already noted my hon. Friend’s concern about that, and I will bring it to the attention of my colleagues in DEFRA and ask them to give a detailed response. Although I had noted it as an area of concern, as I say, we work very closely together on this issue, which is why the UK, I think uniquely, sent two Ministers—one from agriculture and one from human health—to conference in The Hague.

To go back to GPs, we need to get to the bottom of why we have such variation around the country and why there is so much inappropriate use. That work is going on. There are some initiatives to support the optimisation of prescribing—essentially trying to give doctors more tools to enhance their professional skills. One of those is called TARGET—Treat Antibiotics Responsibly, Guidance, Education, Tools—and is being promoted by the Royal College of General Practitioners. Work is under way to develop this area and include it in health care training curricula. We have also developed new antibiotic prescribing measures for both primary and secondary care to try and help drive down that variability.

I think we can do more as MPs—all of us, in all our routine conversations with health and wellbeing boards, GPs and clinical commissioning groups, and with our local trust chief executives. This should be a standard question on our agenda for those meetings. That would really help, because I know, as a Government Minister, and I think we all know as MPs, that when we are aware that someone is going to ask us a tough question, we go away and start thinking about whether we have a good answer, so there is a lot more that we can all do to drive it at that routine level. There is only so much that the Government nationally can do to influence local GPs.

I want to reassure Members, however, that European antibiotic awareness day is on 18 November, and it would be a great moment for all of us to talk to our local health care professionals. I would be delighted if hon. Members here today, who are so interested in the subject, would work with me in putting together something in writing to all colleagues, with great questions to ask their local health care system. I would be delighted to do that and I can facilitate it. It would include posters for GPs’ surgeries as well as encouraging the public and professionals to become antibiotic guardians and to make pledges to undertake individual action in our effort to preserve antibiotics. Some members of the public are beginning to understand the scale of the challenge, but we are certainly not there yet, and I think Parliament has a role in trying to make that clear.

As a result of the work to date in the first year of the Government’s strategy, we have significantly better data and information, which we can use to inform the development of effective interventions. We have begun to define the scale of the problem much more, and I have outlined the action that we are trying to take in an international context to make sure that the spread of AMR is taken seriously across the world.

As I have mentioned, I will report all the points made in today’s debate both to the chief medical officer and to our cross-party high-level steering group to ensure that we have picked them up in the imminent publication. If there are any points that are not picked up, I will come back to hon. Members on them individually, but I want to reassure the House on the matter. I thank my hon. Friend the Member for York Outer for calling this debate and, indeed, the House for such a well-attended and thoughtful discussion. Everything we can do in this House to highlight the scale of the problem and the urgency of tackling it is very welcome, and I thank all hon. Members for their contribution today.