Antibiotics (Primary Care)

Jane Ellison Excerpts

Monday 23rd November 2015 Commons Chamber

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

Let me begin by congratulating my hon. Friend the Member for Erewash (Maggie Throup) on securing this very well-attended debate on a very important issue. The hour is late, but there are a number of hon. Members in the Chamber, reflecting the importance of the debate, and they have made well-informed interventions. I will attempt to address all the issues raised, but if there is anything I do not get to I will look to write to hon. Members.

This debate is timely. Antimicrobial resistance awareness week, a news item in The Lancet and news from other countries, in particular China, have helped to underline the issue that, on occasion, can sound quite dry. If people wonder what the issue is, it has been aptly illustrated in recent weeks. The prescribing and use of antibiotics has a direct impact on antimicrobial resistance. As my hon. Friend made clear, it is one of the biggest global health challenges we face and I spend a lot of time talking about it to Health Ministers from other countries. The costs of antimicrobial resistance are very significant. The O’Neill review on antimicrobial resistance, commissioned by the Prime Minister, estimates that a continued rise in resistance by 2050 would lead to millions of additional deaths worldwide each year and an economic cost of up to $100 trillion worldwide. This is a really big issue.

My hon. Friend described exactly the problem we face in terms of the appearance and spread of bacteria that are resistant to treatment by current antibiotics, and the threat that poses to modern medicine. She provided some examples of that threat. Without effective antibiotics, medical advances such as organ transplants, and even minor surgery and routine operations, will become high-risk procedures. Procedures we assume can now be done as minor day surgery will suddenly become again a serious threat because of serious resistant infection. Antimicrobial resistance is a global problem that needs to be tackled at a national and global level to ensure antibiotics are used wisely.

As my hon. Friend and others will know, in 2013 we published the “UK Five Year Antimicrobial Resistance Strategy” to address this significant threat. It takes a “one health” approach, addressing human, animal, food and environmental aspects of antimicrobial resistance. The hon. Member for Strangford (Jim Shannon) is, as ever, in his place. On many occasions I disappoint him by saying that matters are England-only, but I am delighted to be able to confirm that this is a UK-wide strategy. We are working on it in close collaboration with Scotland, Northern Ireland and Wales. At the heart of our strategy is the need to use antibiotics more effectively. The key is how we change both public and health professional behaviour, and my hon. Friend described the challenge we face.

The English Surveillance Programme for Antimicrobial Utilisation and Resistance—just another one of those catchy little titles we come up with in the health world—is a very important programme. The 2015 surveillance report shows that general practice accounts for 74% of prescribed antibiotics. The number of antibiotic prescriptions in primary care has declined for the last two years and are now lower than in 2011. However, analysis of the data suggests that although there have been fewer prescriptions, higher doses or longer courses of antibiotics are being prescribed. Total use of antibiotics continues to increase in the NHS, albeit at a slower rate. We still have a significant challenge. It is a challenge for all of us and, as my hon. Friend said, behaviour change is right at the heart of how we tackle the problem, both for those who prescribe and for those who use antibiotics—both are crucial to our response.

In August, the National Institute for Health and Care Excellence produced its stewardship guidelines for the health and social care system, which covered the effective use of antimicrobials, including antibiotics. We understand the pressures, as have been well described here, that primary care prescribers face every day. We know, as my hon. Friend the Member for Torbay (Kevin Foster) illustrated, that sometimes people expect to leave their doctor with a certain prescription, even if it is not the right thing. To support GPs, therefore, we have been working with the Royal College of General Practitioners to provide them with suitable tools to reduce levels of inappropriate prescribing.

Last week, research by Antibiotic Research UK found that doctors prescribed 59% more antibiotics in December than in August, despite many of the illnesses treated by antibiotics not being seasonal. That, too, touches on the challenges. One of the key resources doctors have at their disposal is TARGET—treat, antibiotics responsibly, guidance, education, tools—which is hosted on the RCGP website and aims to increase primary care clinicians’ awareness of the importance of antimicrobial resistance and responsible use. Health Education England continues to work with Public Health England to ensure that the competence and principles of prescribing antimicrobials are embedded throughout the professional curricula.

In a recent trial, the chief medical officer, Dame Sally Davies, wrote to a sample of high-prescribing GPs in England, explaining that their prescribing rates were significantly higher than those of other similar GPs and asking them to reassess their prescribing protocols. This intervention resulted in a 4% reduction in levels of prescribing in those practices. That is encouraging and more trials are planned. I put on the record the gratitude of this Government and Governments around the world to Professor Dame Sally Davies for the work she has done in spearheading not just our national AMR campaign but the international campaign. I have watched her galvanise whole countries to action on this subject. We are extremely lucky that she is leading the charge.

NHS England’s introduction of a quality premium on antibiotic prescribing for 2015-16 is another significant step. The purpose is to act as an incentive to reduce levels of antibiotic prescribing in both primary and secondary care. We are encouraged by the early results and expect a reduction in levels of antibiotic prescribing in the next set of data covering 2015-16.

We are not overlooking the consumers of antibiotics: the public. We need to improve their understanding about their appropriate use and are active participants in European antibiotic awareness day, which has just passed and which looks to engage the wider public. My hon. Friend the Member for Erewash highlighted the extremely important antibiotic guardian programme. We have set a target to reach 100,000 antibiotic guardians by next March. We also urge all colleagues—this is where MPs can be extremely helpful—to bring this up with their local NHS. If they ask about it, people will realise its importance, so I ask them to do so as part of their routine contact with local NHS institutions.

Public Health England, working in conjunction with the RCGP, has developed a range of patient information materials to help them think about how they care for themselves when they have a self-limiting infection, such as a cold, and when to consult a health professional. Critically, my hon. Friend referred to diagnostic testing, particularly the C-reactive protein test. I understand her frustration—sometimes it feels like things move rather slowly—but I hope that the attention the strategy has received illustrates our desire to move faster. In fact, the driving force behind the UK-wide strategy is about gearing up the whole health system to react more quickly.

Most antibiotic prescribing is done in the absence of a test to determine the nature of the illness and whether an antibiotic prescription is likely to help. Making better use of technology is a key part of our work. Greater access to and use of rapid diagnostic tests will help us to avoid unnecessary treatment and provide more targeted treatment where infections are diagnosed, which, of course, will mean better outcomes for patients.

[Jeremy Lefroy (Stafford) (Con)]

My hon. Friend might note that, in the case of malaria, the introduction of rapid diagnostic tests has substantially reduced the inappropriate use of important antimalarials.

[Jane Ellison]

That is an excellent illustration of the potential of rapid diagnostic tests, and of course we had exciting news on malaria recently.

In December last year, NICE recommended that GPs should consider carrying out C-reactive protein testing for people presenting in primary care with symptoms of lower respiratory tract infection if, after clinical assessment, a diagnosis of pneumonia has not been made and it is not clear whether antibiotics should be prescribed. I understand that the test is increasingly being used in primary care, although the evidence for its use is mixed and the role of normal clinical diagnosis remains critical.

We want the right test available in the right place, from patients’ homes and the high street to primary and secondary care. That work is being undertaken as part of the implementation of the UK antimicrobial resistance strategy. To further develop the use of diagnostics in clinical practice, we are investing £1.3 million of research funding through the National Institute for Health Research. That research is being undertaken by Cardiff University, focusing on GPs’ use of the C-reactive protein test to help to target antibiotic prescribing to patients with chronic obstructive pulmonary disease. It will be interesting to see how that research goes, and I am sure we will return to it.

In addition to the important work to improve appropriate prescribing, we should not forget the vital role of infection prevention and control—it was good to hear my hon. Friend the Member for Erewash note that. We have made significant progress, with dramatic reductions in some infections in recent years, but there is always more to do. We can make a significant contribution to that agenda by improving our ability to prevent infections in the first place. That includes work with NICE to develop clinical guidance and best practice information.

We have strengthened the code of practice on the prevention and control of infections to clarify for providers the measures needed to ensure effective infection prevention and antimicrobial stewardship. We will also improve infection prevention and control by introducing an indicator, as part of local antimicrobial resistance implementation plans from April next year, to help CCGs. That will be another good opportunity, from the spring, to ask CCGs how their plans are going and whether they can explain what they are doing locally. It was good to hear Erewash CCG being cited. I am sure my hon. Friend will hold its feet to the flames, as will others.

Let me touch briefly on the international scene. It was good to hear my hon. Friend the Member for Thirsk and Malton (Kevin Hollinrake) talk about India. I had the pleasure of talking to the Indian Health Minister about this very topic at the World Health Assembly in Geneva in May. Tonight’s debate is not about the international aspect, but I would be delighted if any Member wanted a debate focusing on that, because the UK can be proud of our record in that regard. To give one example, as part of our focus on global antimicrobial resistance, the UK has committed £195 million over five years to the Fleming fund, which will support antimicrobial and infectious disease surveillance in developing countries, where we know drug resistance has a disproportionate effect. We were delighted to see all 194 member states agree to the World Health Organisation’s global action plan at the World Health Assembly earlier this year. The Government are now working towards the UN General Assembly in 2016 and are continuing to champion this agenda there.

Let me conclude by reaffirming our commitment to delivering improvements in the way antibiotics are used in the NHS. I take the challenge that my hon. Friend the Member for Erewash has highlighted and we will make sure that the NHS hears that from tonight’s debate. The work we have undertaken, and are continuing to undertake, means that we now have significantly better data and information on how antibiotics are used in both primary and secondary care, but we have much more to do. I welcome tonight’s debate as a reminder of the task that lies ahead of us.

Question put and agreed to.