Antimicrobial Resistance

Baroness Walmsley Excerpts

Thursday 2nd May 2019 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I too thank the noble Lord, Lord Lansley, for giving us the opportunity to talk about antimicrobial resistance, because, as we have heard, it is one of the world’s most difficult and dangerous health challenges. It could put back the clock and make many of the treatments which we take for granted, such as the surgery undergone by the noble Lord, Lord Crathorne, far too risky in future.

It is not often that you read a book by an eminent doctor whose findings not only scare you but had obviously scared them too. However, that is what I found when I recently read the book about AMR by the Chief Medical Officer, Professor Dame Sally Davies. Near the beginning of the book she says that the findings of the group of experts she brought together were simple: first, we are losing the battle against infectious diseases; secondly, bacteria are fighting back and becoming resistant to modern medicine; and, thirdly, in short, the drugs no longer work. She admitted to feeling rattled about that, and so am I. Therefore, I congratulate the Government on the latest iteration of their comprehensive plan to tackle AMR, and welcome the fact that the plan outlines actions to control AMR both within and beyond our borders. I also welcome the fact that the plan for the next five years has brought the four nations of the UK together, unlike the previous version.

One principle of the plan is reducing the need for using antimicrobials to limit the opportunity for microorganisms to evolve resistance to them. I will mention three ways of reducing the need for these medicines: immunising the population against the diseases that might require such treatment; tackling the spread of infection; strengthening the natural immunity of patients and supporting their general health so that they can fight off infections themselves.

Vaccines are of course the most effective preventive health tool in human history, and have been able to eradicate entire diseases such as smallpox. As the noble Baroness, Lady Greengross, mentioned, expanding the use of existing vaccines would have a major impact. For example, universal coverage of children by the pneumococcal vaccine would avert 11.4 million days of antibiotic use in children under five each year. However, we also need new vaccines, but no new class of vaccines has been discovered in decades.

The noble Lord, Lord Lansley, was absolutely right to focus on money. There are major financial barriers in the way of developing new antimicrobials. It is now five years since the Health and Social Care Committee in another place urged,

“tangible and rapid progress in this area within six months”.

However, as the House has heard, in the last few years, since discussions have been ongoing between the industry and the Government about the deterrent effect of the current funding model, three multinational pharmaceutical companies have left the market. Significant government investment is also needed in novel vaccine research, to tackle an increasingly urgent global problem.

Although the UK cannot rescue the situation alone, the unique nature of the NHS gives us the opportunity to demonstrate a new funding model that could work for both of these groups of pharmaceuticals and set an example to other countries. I was therefore pleased to see that the Government and the industry have agreed a new funding model for antimicrobial development and supply that will provide more stable income to the companies, while providing the NHS with novel antimicrobials which can be held in reserve by doctors for use when older, cheaper medicines no longer work because resistance to them has been developed. I understand that the new model will delink the payments made to companies from the volumes of antibiotics sold, basing the payment instead on a NICE-led assessment of the value of the medicines and supporting good stewardship.

When will the Minister be able to report on the timeline for the full implementation of this pilot scheme and how will the Government assess whether it has been a success? Will the new model also be used to fund the development of new vaccines, many of which are badly needed in countries that cannot afford to develop them themselves but which are often the source of infection outbreaks in this country?

Infections are spread around the population by many means, via water, food, air droplets and poor sanitation, and we are fortunate in this country on most of those issues. However, what should be most easily prevented are those infections acquired in healthcare settings. This is particularly dangerous because patients are at their most vulnerable and may have compromised immune systems. Healthcare-acquired infections are among the most serious modern public health problems worldwide and many are caused by antibiotic-resistant bacteria, so effective HAI management is vital to slowing the AMR crisis. It is therefore critical that the NHS puts in place system-wide processes, such as screening and surveillance programmes, and the highest possible level of hospital hygiene and sterile practice that can help tackle HAIs and reduce their incidence. The Government must also maintain their focus on HAIs to ensure that infection rates, which have been falling, do not start to rise again. Unfortunately, they have now plateaued.

Across the NHS, there is regional variation in hospital-acquired infection rates. According to freedom of information data, almost two-thirds of hospitals do not offer point-of-care testing, a tool that could help provide real-time information on patients for a range of infections. Only eight out of 50 trusts routinely carry out point-of-care testing for infections such as flu, and less than 10% of trusts test for a full range of infections, such as MRSA and others. Some trusts consistently appear among the best, and some consistently among the worst, for reported cases. Of course, one has to ask whether these trusts have better or worse reporting mechanisms, or whether they have more or fewer cases to deal with. But whatever the answer, can the Government assure me that the focus is still on getting these figures down? Personally, I would be very reluctant to go into a hospital with a poor record on this.

Optimising use—for which read “reducing unnecessary prescribing”—requires both public and medical education. Patients need to know that it is sometimes for their own benefit when their doctor tells them they do not need antibiotics but advises them instead to go home, rest and take plenty of fluids, and not to go to work or school and spread it around. On a system-wide basis we need to be able to report on the percentage of prescriptions supported by either a diagnostic test or a decision support tool. There is a target for this in the plan. Will the Minister say whether there are online learning packages and easily available diagnostic tools, so that GPs can be supported to make the optimum decisions about prescribing?

We should not ignore the potential of strengthening patients’ own ability to fight off infection without the use of antimicrobials. Malnutrition can reduce the body’s own defences, and it is a disgraceful fact that there is malnutrition among the poorer sections of the UK population today, particularly among children and older people. I have even heard of malnutrition among long-term hospital patients because of the poor quantity and/or quality of hospital food, or the fact that no attempt is made to ensure that the patient eats it. This factor cannot be ignored when considering how we can reduce the spread of disease. Will the Minister say what action is being taken to tackle malnutrition?

Another aspect of boosting natural immunity—mentioned, I think, by the noble Baroness, Lady Masham —is the role of microbiome; that is the 39 trillion microorganisms that occupy our bodies. Of course, some can be harmful, but the majority contribute to health. There is some evidence that a healthy, varied gut microbiota can have a beneficial effect on our immune system. Specific bacteria in the gut have been associated with immune development, and we know that germ-free mice have less well developed immune cells. Altered populations of bacteria are associated with a host of diseases, from allergy, asthma, autoimmunity and neurodegenerative diseases to obesity. However, we probably still do not fully understand which specific bacteria are important for health. A better understanding of the community of bacteria that affect our health is needed. This is a promising area of research, so will the Minister tell the House whether the Government are investing in research into the contribution the microbiome can make, particularly to immunity against infectious diseases?