Antimicrobial Resistance

Gary Streeter Excerpts

Tuesday 7th December 2021 Westminster Hall

[Sir Gary Streeter (in the Chair)]

Before we begin our next debate, I remind Members that they are expected to wear face coverings when they are not speaking in the debate. That is in line with current Government guidance and that of the House of Commons Commission. I remind Members that they are asked by the House to have a covid lateral flow test twice a week if coming on to the parliamentary estate. That can be done either at the testing centre in the House or at home. Please also give each other and members of staff space when seated, and when entering and leaving the room.

[Kevin Hollinrake (Thirsk and Malton) (Con)]

I beg to move,

That this House has considered the health impacts of increasing levels of antimicrobial resistance.

It is a pleasure to serve under your chairmanship again, Sir Gary. Mark Twain once said:

“I am an old man and have known a great many troubles, but most of them never happened.”

This is not a trouble that will not happen. This trouble is happening now; this trouble will get much worse. The UK Health Security Agency chief medical adviser, Dr Susan Hopkins, said that antimicrobial resistance, or AMR, was “a hidden pandemic” and that it was important that

“we do not come out of COVID-19 and enter into another crisis.”

What I fear most is that, as Warren Buffet once said:

“What we learn from history is that people don’t learn from history.”

There can be no excuse this time if we do not prepare well for a future pandemic of AMR.

This is not the first time I have raised the issue in the House, and it will not be the last, because AMR is simply too important to ignore. Antibiotics are one of the most powerful tools in healthcare, underpinning every aspect of modern medicine. We need them not just when we are poorly at home with an infection but when we are going through significant life-changing procedures such as chemotherapy and hip replacements. Antibiotics work by killing bacteria but, in the same way that the covid-19 virus can mutate and evolve, so can bacteria, developing resistance to antibiotics.

Right now, this year, about 700,000 people will die from antibiotic resistance infections across the world. It is estimated that by 2050, AMR could claim as many as 10 million lives a year. It is not a hypothetical or vague threat that is happening elsewhere; it is happening in the UK, is getting worse and will get much more so. Professor Jennifer Rohn of University College London has said:

“AMR has very much not gone away, and in the long term the consequences of AMR will be far more destructive.”

The latest report from the English surveillance programme for antimicrobial utilisation and resistance found that antibiotic resistance increased by 4.9% between 2016 and 2020. That means that one in five people with a bloodstream infection in 2020 had one that was antibiotic resistant—a serious, potentially life-threatening situation.

I want to tell you about a mother named Helen. Helen experienced resistant infections in 2013 and 2018, which caused her a great deal of anxiety and pain. She was to experience a third resistant infection shortly after giving birth. When her baby was just six weeks old, Helen developed mastitis, an infection of the breast tissue. She soon developed flu-like symptoms, and a GP prescribed her an oral antibiotic. The infection was resistant and two days later it was getting worse, and she could barely hold her baby. She started vomiting and was sent to A&E, where she was kept on heavy-duty intravenous antibiotics for two nights. Luckily, the sepsis was caught early and she recovered, but it could have been a very different story. Sepsis causes 48,000 deaths in the UK every year, many of them due to resistant infections.

AMR is the next pandemic. It is a hidden pandemic, but that does not mean that we can treat it any less seriously than covid-19. We must have the right plan in place. First, we need a strong system for monitoring the impact of rising AMR here in the UK. I welcome the fact that the Government have been looking into recording AMR or antibiotic resistance as a cause of death on death certificates and I had a welcome update from the Minister on where we are with those proposals. However, it is surprising that not many parliamentarians are focused on the problem, given its context and scale. It is good to see my fellow parliamentarians here today who are taking an interest, but until we have a proper register and until more parliamentarians are made aware of the issue through their constituents, I do not think the levels will be sufficiently high to raise awareness as often as we need in Parliament to make sure we take the matter forward and take action against it. Secondly, we need to support only the appropriate use and prescription of existing antibiotics. Thirdly, we need to ensure that we incentivise the development and research of new antimicrobials and antibiotics.

We need to take a one-health approach across all three issues that recognises the link between resistance and use in humans, animals, agriculture and the environment. The Government’s five-year national action plan on AMR set out the steps we need to take, but we are now just about halfway through and have yet to see any clear update on progress. The UK has been a trailblazer on AMR, but that lack of reporting is not where we need to be. We must be at the forefront of taking domestic action, not least because we are trying to maintain our leadership position as an example for other countries.

It was pleasing to see that the UK made AMR a centrepiece of our G7 presidency. We are long-standing global leaders in AMR and this is hugely important work, but we cannot afford to let our attention drop from what we can also do here and at home. The Minister and I shared many conversations on this matter as Back Benchers and I know she is very focused on and aware of the context, particularly in diagnostics, which I will talk about shortly. Will she consider introducing annual reports for all the partners on the actions in both this plan and in the next five-year action plan?

As has already been mentioned, one of the biggest issues facing us is the fact that there is not enough research and development of new antimicrobials. I would be interested to see what metrics of success we can use to judge the outcomes of the National Institute for Health and Care Excellence’s AMR project, formerly called the pilot, which is trialling a new model for valuing and paying for antibiotics. This is a world-leading, first-of-its-kind subscription-style payment model that will help incentivise companies to develop new drugs needed to tackle resistant infections and is supported by NICE.

The reasons we need a new model are complex. Bacteria naturally evolve to become resistant to certain drugs, but that evolution is happening faster than new medicines are reaching healthcare systems. That is partly because developing antibiotics is a long, complex and risky process, with many products failing along the way. At the end of that process, we do not have a viable commercial market for the new products. That is the key problem and that is because antibiotics are not like other medicines. Often, we want to reserve the new antibiotics for the patients who really need them, meaning the new products could just sit unused on the shelf. In that scenario, the cost of development could way exceed the return, undermining future research. The commercial model for developing antibiotics is broken.

I pay tribute to the UK’s leadership in introducing the AMR project in the first place. I know it is the result of many years of work by the Government, NHS, NICE and the industry sector, but we cannot afford that leadership and drive to slacken off now, because the price is simply too high if we do not succeed. As the Minister knows, the pilot looks at only two antibiotics and, as yet, there are no concrete plans to evolve into a new permanent model for all new antibiotics that come after them. Even though we are world leaders, we must urgently start thinking about the next steps and that must be built into the next action plan. The next steps must consider how we evolve the pilot and implement its learnings at scale and pace. Will the Minister comment on what conversations she has had with NHS England and NICE about how best to do this and what the timeframe might be?

We must also remember that the world is watching the world-leading AMR pilot. NICE has always been regarded as the gold standard and its actions have always carried weight, but now it is running one of only two pilots in the world considering this issue. It is therefore important not only that we get the project right, but that we also get right how we talk about what happened, the results and, indeed, what went wrong. Given that the goal is to incentivise private research and development, I urge the Minister to work with industry on that communication to ensure we are all aligned on the successes and learnings.

In 2019, in their five-year national action plan, the Government committed to reducing hospital-acquired infections by 2024 and halving gram-negative bloodstream infections in the NHS long-term plan. However, there is increasing concern that the covid-19 pandemic will have pushed those targets into the background. I would welcome the Minister’s comment on that issue, too.

As a final action point, in his landmark report, Lord O’Neill describes diagnostics as the most important of his 10 commandments to tackle AMR. The launch of the community diagnostic hubs represents an important opportunity to combat an increased incidence of AMR through accurate and targeted prescription. However, we need to tackle the false economy of simply prescribing antibiotics because they are cheaper than a diagnostic test.

I know other Members want to come in, so I will close by recognising those who do tireless work on this issue and with whom I work closely. First, Antibiotic Research UK or ANTRUK, which is in my constituency, is the world’s first charity specialising in antimicrobial research and education. It provides vital research and support services for patients impacted by resistant infection. Secondly, the British Society of Antimicrobial Chemotherapy provides the secretariat to the all-party parliamentary group on antibiotics, of which I am a member. Without its efforts, the efforts of the Minister and her team and the work of many others, we would not have achieved so much in our fight to stop the next pandemic, but that must be our challenge, to make sure that this time we prepare properly for a pandemic that absolutely will happen if we do not put the right steps in place.

[Sir Gary Streeter (in the Chair)]

Before I call Theresa Villiers, we are expecting three Divisions in the House in a moment. When we get to that point, Members should perhaps think about adjusting their diaries, because it will be 25 to 35 minutes before we come back.

[Theresa Villiers (Chipping Barnet) (Con)]

It is a pleasure to serve under your chairmanship, Sir Gary, and to follow my hon. Friend the Member for Thirsk and Malton (Kevin Hollinrake), whose track record on this important issue is second to none. I warmly congratulate him on securing more time in this Chamber on this important issue.

“Before Alexander Fleming discovered penicillin in 1928, an infection from a simple cut could mean the end of life. Nearly 100 years later, the antibiotic safety blanket we live our lives with is being pulled from us.”

That is a quote from the former chief medical officer, Dame Sally Davies, on the threat posed by antimicrobial resistance. She and many others have spoken out in apocalyptic terms about the catastrophe ahead of us if we do not stem the tide of infections resistant to treatment with antibiotics, as my hon. Friend has so articulately put it.

[Sir Gary Streeter (in the Chair)]

Order.

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On resuming—

[Sir Gary Streeter (in the Chair)]

We will get under way. I know Karin Smyth is not here, but I am sure she will pick up the pace of the debate when she returns. The debate may now continue until 5.55 pm.

[Theresa Villiers]

I started my speech by referring to the remarks of the former chief medical officer, and I was about to say that she is entirely right to have spoken out on this issue. It is not just some millennium-bug anxiety about something that might or might not happen in the future, because people are already dying. Every year, an estimated 50,000 people die from drug-resistant infections, and that number will grow massively unless we deal with the problem.

During lockdown, many of us will have viewed the video of Bill Gates’s warning about a global virus pandemic, which was made years before it actually happened. If action is not taken now on a global scale to deal with AMR, people will look back on Dame Sally’s predictions in the same way. They will say that leading scientists highlighted the potential return to the days when routine surgery, childbirth, a cut in the arm or even an insect bite could give rise to a serious risk of death, and they will ask why we did not act. The good news is that a great deal of action is under way. The O’Neill report, commissioned by David Cameron, was groundbreaking. It was highly influential around the world, and 135 countries have finalised action plans on tackling AMR.

This year, it is very welcome that the UK Government have been using their G7 presidency to try to deliver more tangible progress, as they did last time they held the presidency, in 2013. However, the fact is that developing new antibiotics is massively expensive. The attempt to do so has already forced a number of smaller firms into insolvency and caused some bigger companies to exit their research and development programmes in this area. The fact is that many hundreds of millions of pounds can be pumped into R&D, with no return on that investment whatever if a project turns out to be unsuccessful.

The high failure rates of antibiotic development apparently leave just 40 antibiotics in clinical trials globally. The problem is compounded by the fact that if a new antibiotic is successfully discovered, we want to use it as sparingly as possible, keeping it for serious conditions and to head off potentially worsening AMR problems in the future. That creates even more problems with the risk-return ratio. There is therefore an urgent need for policy reforms to create market conditions that enable sustainable investment in antibiotic innovation, including properly valuing and paying for new antibiotics.

It is very encouraging that the industry has set up a £1 billion investment fund to try to bridge the funding gaps, particularly for smaller biotech companies, that will have a strong focus on drugs that could have the maximum impact in securing and safeguarding public health. Also welcome is the AMR project, which we have already heard about from my hon. Friend the Member for Thirsk and Malton. The project, launched by the UK Government, NICE and NHS, is trialling a new subscription-style model for antibiotics. Under the model, payment is based on the product’s overall value to the NHS, rather than on just counting the pills dished out to patients. Two medicines have been selected, and contracts are expected to commence in April 2022.

It is very welcome that the project has continued despite the pandemic, but we now need to press ahead with wider implementation in order to cover more research and bring in the devolved nations, so that we have a whole-country approach. We need the project to get beyond the pilot stage, and we need to learn from it to ensure that a sustainable solution is put in place for new antibiotics that reflects their long term value to society as a whole.

In conclusion, I very much welcome the leading role that the UK Government have taken on this issue on the world stage. However, if we are to succeed in addressing this great challenge of our time, there is still a lot of work to be done. For example, we need to increase public understanding of the dangers of over-prescribing or misusing antibiotics. We must also tackle the overuse of antibiotics in farming. I do not see that as a domestic problem with our sector—we have strict rules to prevent that from happening in UK farming—but we need to use our trade and foreign policy to raise standards on antibiotics use in agriculture all around the world.

Above all, the Government need to be bold and ambitious in putting in place a long-term market solution that changes how we pay for antibiotics, so that we can reward and incentivise the scientific research that can save us from the nightmare we face: a return to Victorian medical outcomes, where 40% of our population have their lives cruelly cut short by infections we cannot treat. I look forward to hearing from the Minister what action the Government are going to take to drive this crucial issue forward.

[Julian Sturdy (York Outer) (Con)]

It is a pleasure not only to serve under your chairmanship, Sir Gary, but to speak in this important debate. I warmly thank my hon. Friend the Member for Thirsk and Malton (Kevin Hollinrake) for having secured it. I share his view on the priority of keeping the Government’s focus on this very important subject: as a co-chair with my hon. Friend of the all-party parliamentary group on antibiotics, I urge the Minister to reflect very carefully on the suggestions my hon. Friend has made and that continue to be made in this debate. I also want to highlight a few other important points that we need to consider.

First, the Government need to carefully assess how covid has impacted on the global and national antibiotic resistance challenge. Unsurprisingly, the once-in-a-century scale of the pandemic has generated concerns that the increased prescribing of antibiotics worldwide on the back of covid will amplify the problems of growing resistance. The scale of the virus disaster and the variety of global health systems has led to a huge, unco-ordinated and large-scale use of different antibiotics, and we need to know how the nature of the AMR threat has evolved as a result.

The covid experience and the size of the Government’s response also offer lessons for the AMR debate by indicating that, when necessary, we can rise to the challenge and assign huge resources to protect the public. The costs involved in developing the new drugs needed to beat the resistance are enormous, as has already been touched on in this debate, but arguably our perspective on that has shifted somewhat when we consider the scale of the fiscal firepower deployed against the covid virus—some £378 billion in this country alone, as of October’s Budget.

Given the potential of AMR to equal or surpass what covid has done, as my hon. Friend the Member for Thirsk and Malton mentioned, with the very plausible prediction of 10 million dead annually across the world by 2050, it seems reasonable to increase our national financial commitment now. With a much more significant—but still relatively small—investment, we can really make a difference. As has already been mentioned during this debate, and as the Association of the British Pharmaceutical Industry has called for, raising the £10 million cap for the Government’s AMR project subscription trial could be one such investment.

The Government should also explore whether they can build more laboratory capacity in middle income countries and the developing world, as part of our public health and wider aid strategies. The lack of significant medical microbiological facilities in such nations is a significant factor in the mistaken prescribing of antibiotics that fuels the growth of AMR around the world. These labs are necessary to generate the guidance on which antibiotics best fit which disease.

The source of the deficiency is an absence of quality, accredited training and the lack of medical microbiological biomedical scientists, producing a situation in which under-informed prescribing practices simply spread resistance. Building that capacity would be a helpful addition to the UK public health and aid policy, because, as the pandemic has shown, disease mutations that develop abroad do not stay there for long.

Growing antibiotic resistance in lower income countries is both a disaster for them and a serious threat to lives in this country. I urge the Department of Health and Social Care to engage closely on this aspect of the problem and listen to calls, such as those from the British Society for Antimicrobial Chemotherapy, for the creation of a global antimicrobial stewardship accreditation scheme to ensure co-operation across health and research systems and to generalise global good practice. Ministers should constantly remember the need to address the challenge of resistance across Government—I mean making sure that other Government Departments know the impact that AMR has.

I want to touch on one example of that. At the APPG on antibiotics, we recently connected scientific researchers at the University of Exeter with Ministers at the Department for Environment, Food and Rural Affairs, so they could share the case for amending the Environment Bill so that it took account of the issue of antimicrobial residues in water and sewage. I understand DEFRA’s decision that although it should not adopt the specific University of Exeter recommendations, it will continue to listen to this research work, including through the new shared outcomes fund pilot project on AMR surveillance, which is in the Environment Act 2021, but we need to see a level of engagement across the board, from all Departments. A Government assessment of whether a further statutory basis is needed to step up action on AMR should be welcomed.

I finish on this brief point, Sir Gary. Many of us in the Chamber now have sat here before, talking about AMR. We are constantly raising the same arguments and the same points, but we really need to spread that message wider. The biggest disappointment is that it is the same few Members raising the same points: the subject does not seem to be getting the political traction it needs. Given where we have been with covid, that might be slightly understandable, but we have to remember, as my hon. Friend the Member for Thirsk and Malton said: if we take our eye off the ball, AMR has the potential to be a much larger pandemic than we have ever seen before.

[Sir Gary Streeter (in the Chair)]

The winding-up speeches will begin at 5.32 pm. We are now going to have seven and half minutes of pure gold from Jim Shannon.

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[Karin Smyth (Bristol South) (Lab)]

It is a pleasure to serve under your chairmanship, Sir Gary. I congratulate the hon. Member for Thirsk and Malton (Kevin Hollinrake) on bringing this very timely debate to Westminster Hall. It is timely because if we do not learn from the situation that we are in, we will end up in a very bad place; it is with that in mind that I give my remarks.

This is a really unusual subject; I have not been involved in a debate on it before, but it is one on which there is so much agreement. We have a problem, we have evidence of a problem, we agree that we have a problem, we have solutions that we generally agree on and we are genuinely world leaders. I think the Government sometimes bandy around the fact that we are world leaders when we are not; but we are genuinely world leaders in this area, and that is something to be proud of. We have some fantastic people in this country. However, why is the situation not improving? What more needs to be done, and, crucially, has enough been done in recent years? How do we know what has been done? As the hon. Member for York Outer (Julian Sturdy) said, why is there not greater interest and political pressure on this subject?

It was 2013 when Professor Dame Sally Davies described this as a

“catastrophic threat”.

She said:

“If we don’t act now, any one of us could go into hospital in 20 years for minor surgery and die because of an ordinary infection that can’t be treated by antibiotics. And routine operations like hip replacements or organ transplants could be deadly because of the risk of infection.”

It was in 2014 that the estimated figure of 10 million people dying as a result of AMR by 2050 was mooted. I was working in the health service when that discussion was being had, back in 2013-14. I vividly remember the concern of specialists, particularly colleagues in pharmaceuticals, about that, and the actions that were being taken to support clinical practice to make sure that did not happen. However, I do not think that most people walking the streets are aware of the catastrophic prediction made then.

We have a problem—we agree on the problem—and we know the causes of the problem: inappropriate use of antimicrobial drugs in healthcare; poor infection prevention and control practices; use of antimicrobial drugs in agriculture, and accelerated spreads of AMR infections through global trade and travel. Additionally, as the right hon. Member for Chipping Barnet (Theresa Villiers) and other hon. Members have said, there are limited numbers of new drugs available to replace those that become ineffective. The former Prime Minister, David Cameron, launched a review in 2014, and the list of 10 recommendations was published in 2016. In 2017, the cost of global action was estimated at $40 billion. That is an eyewatering sum, but when compared with what is being described as the incalculable cost of covid, which reaches trillions of dollars, that $40 billion estimate starts to look quite small. Others have indicated that in reality the cost of this could be unimaginable to most of us.

There was an excellent debate in Westminster Hall on 26 April 2016, in which my hon. Friend the Member for Ellesmere Port and Neston (Justin Madders) addressed the hon. Member for Mid Norfolk (George Freeman), who is also an expert in this area. My hon. Friend said:

“Although I welcome the renewed focus that today’s debate brings, I fear we are no closer to a solution than we were two and a half years ago.”—[Official Report, 26 April 2016; Vol. 608, c. 540WH.]

I think there is concern in the Chamber that that remains the case today.

The Government have targets, although they are not terribly specific. Many are for the period 2021 to 2025—for example, being able to

“report on the percentage of prescriptions supported by a diagnostic test…by 2024.”

On the eve of 2022, I expect the Minister to be able to outline how meeting those commitments is going. The hon. Member for Thirsk and Malton made some helpful suggestions for what we should be measuring, how we should be measuring it and how that should be reported, which I am sure the Minister will address.

On animal use, which the hon. Member for Strangford (Jim Shannon) highlighted, the investment required by farmers was yet to be formally evaluated in 2019, so it would be useful to know whether the Minister has evaluated that cost. It would also be helpful to have an understanding of how we are collaborating with our European neighbours, now that we have left the European Union, because we know that collaboration is really important, particularly in the agricultural industry.

We should be prepared, and we should certainly be on track, but I fear we are not, so the crucial issue is: what do we need to do? I pay tribute to Dame Sally Davies, our special envoy on AMR, and her work to highlight this issue, which, as she has said in the last year, is a silent pandemic. As she has told us, covid needs to be a wake-up call to the warnings that she has issued over the years. I have listened to her speak on this issue, as has another all-party group, and she has recently used quite a vivid image to describe the situation: covid is like putting a lobster into boiling water, but AMR is like a lobster in cold water. It is a silent pandemic.

One of the issues is that fewer adults know about this. I absolutely agree, and I think that is also true of Members of Parliament. We need to learn from covid, including about things such as altering behaviour, washing our hands and access to water. We also need to support those on the frontline much better, including through clinical direction, to help them in the way that they need in order to treat patients.

[Sir Gary Streeter (in the Chair)]

I call the Minister. Please remember to leave two or three minutes for Kevin Hollinrake to respond.