Antimicrobial Resistance

Lord Lansley Excerpts

Thursday 2nd May 2019 Lords Chamber

Moved by

[Lord Lansley]

That this House takes note of Tackling Antimicrobial Resistance 2019-2024: the UK’s five-year national action plan.

[Lord Lansley (Con)]

My Lords, it is my privilege to move that the House takes note of this government publication. I am very grateful for the opportunity to secure this debate and, in my case, to return to the issue of antimicrobial resistance. I was fortunate enough to have a debate on this subject about three years ago, and indeed other noble Lords have also initiated debates on it. It is important that we do so. Today is a powerful illustration of where we can give ground to the climate change debate. However, there is more than one issue on which it is really important that we have these opportunities for debate, not least because they give us the chance, over a slightly longer period, to realise the complexity and multifaceted character of the challenges we face and the need for us to work intensively and consistently to deal with them.

I am grateful to noble Lords for participating in the debate. It is evident from conversations I have had and communications I have received that, for every one of us here, there are two or three more who would have liked to be here and to have contributed. I hope that future opportunities will offer themselves.

It is not in the custom of this House to say so but, if it had been down to me, I would have been “taking note with approval” of the Government’s national action plan. I say that very straightforwardly. My purpose is not to criticise the national action plan but to commend the initial five-year plan and the refresh published in January. The timeliness of this debate was further illustrated by the fact that on Monday the United Nations Interagency Coordination Group on Antimicrobial Resistance reported to the Secretary-General with a document that said:

“Unless the world acts urgently, antimicrobial resistance will have disastrous impact within a generation”.


In many debates we have understood the scale of the threat that we face. Indeed, when I was in the coalition Government, we included, for the first time, AMR as one of the top-tier risks in the national risk assessment and we understood its character. I was proud of the fact that shortly after I ceased to be Secretary of State—although none the less the work had begun—we saw the publication of the first five-year action plan, which ran from 2013 to 2018.

An illustration of the nature of the problem we face is that UK data—the Minister may refer to some of it later—clearly shows that there has been a significant reduction in antibiotic prescribing for animals and there is clearly some reduction in the extent of drug-resistant infections that animals for food production are harbouring. In human health, there has been something like a 6% reduction over five years in the prescribing of antibiotics, which compares with about a 6% increase in the preceding five years. None the less, the burden of infection and antibiotic-resistant infections among the human population in the United Kingdom is not going down. It is at best stable and some specific drug-resistant pathogens are increasing.

That tells us—it is something that I think we all know—that we are dealing not with a static problem but with a dynamic threat. The problem is that bacteria are rapidly evolving and adaptable, and the number of drug-resistant pathogens will rapidly increase. They have the capacity to swap DNA, so they will be able to acquire resistance to new antibacterial agents. We are also seeing the emergence of some drug-resistant pathogens; they are resistant to a number of antibiotics. Indeed, I noted that about three and a half years ago America was particularly worried about the presence of a pan-resistant infection. I think it was resistant to about 21 different antibiotics. Therefore, it is not simply a case of increasingly having to combine antibiotics and other treatments to deal with these drug-resistant infections; we have to try to ensure that we reduce the threat.

The UN document, published on Monday, also said:

“The challenges of antimicrobial resistance are complex and multifaceted, but they are not insurmountable”.


That goes to the heart of this debate. From looking at the list of speakers, I know that this afternoon we will understand that there is a range of approaches, all of which have to be pursued. I do not for a minute say that the issues I propose to focus on are more important than others on which we have to work. Antimicrobes in the environment and so on are very important but I do not propose to dwell on them. None the less, it demonstrates that the original national action plan published in the United Kingdom and the international work that has been done have focused on a one-health approach. However, it is terrifically important that we understand that we have to work across the environment, animal health and human health to make progress. The joint publication by the Secretary of State for Health and Social Care and the Secretary of State for Environment, Food and Rural Affairs demonstrates the Government’s commitment to working on a “one health” basis.

I will focus on one sentence from page 74 of the Government’s January report, which relates to the development of new therapeutics. The report says that one of the Government’s objectives is the development of “alternative strategies” to try to ensure that we can bring forward new therapeutics to deal with and combat antibiotic resistance. Part of that means that we therefore need to understand how we can develop new therapeutic agents. Part of that is academic research; it is not just about therapies, but diagnostics—I think in the last debate the noble Lord, Lord Rees, instanced the Longitude Prize which Nesta was pursuing. That continues, four years later, with the objective of delivering additional diagnostics. Prizes for academic research seem to be stimulating a range of teams to try to respond. Not only do we have to promote and fund academic research but pull the fruits of that initial academic work through to therapeutic agents we can deploy in practice for human health.

We seem to be going backwards on this. I think three major pharmaceutical companies have ceased their antibiotic research activity in the last 18 months—including Novartis, which is notable given its scale and reputation. In America a start-up company was developing a therapy that was given FDA approval in July 2018 for the use of plazomicin in complex urinary tract infections. This company filed for bankruptcy in early April. Over the course of last year, it secured no more than about $1 million of business. What is happening here? A new drug is approved for use and there is no revenue to support it. This is exactly the problem for antibiotics. Novel antibiotics such as these get a relatively narrow indication for use, because antibiotics are not broad-spectrum—they are very targeted. Also, as they come into use, they are pretty much a last-line therapy for use in rare circumstances, so they do not get bought very much. This company, like many pharmaceutical companies starting out, could be supported across the so-called valley of death by the funding support of CARB-X, only to find that there is a desert. There is no funding to make this happen.

That is where the Government in this country are looking to develop a new business model that helps bring through those new therapies, but that is a way off. A project team is being established and it will probably be something like another 18 months beyond that before we see what this business model may look like. We need more urgency. We need to think about what this model looks like, and at least put preparations in place, even if we have to add data and specifics to it as the work goes along.

The noble Lord, Lord O’Neill of Gatley, published a seminal review and report on this. First, he said that we want play and pay. That is, those in the pharmaceutical industry should be either engaging in this research—that is, playing—or paying. Frankly, I do not think that will work. It will just be treated as a tax on the pharmaceutical industry. He now seems to have said that he is rather giving up on this and that therefore the Government should take it over. I am afraid there is no evidence to support the proposition that Governments are better at innovation than the private sector. We need to combine in public and private partnerships. In that context, we need, as I think the Government intend, to recognise that this is about giving those bringing forward new therapeutics the confidence that they will be paid for. From the Government’s point of view, that has to be a proportionate and reasonable amount, and it has to be attractive.

The UK represents 3% of the global drugs market. We will not be able to do this on our own. That is why I return to the point in the Government’s national action plan that we have to work internationally—not just as the Government do with the Fleming Fund, promoting national action plans and better prescribing globally, which is absolutely right and very valuable, but through the richest countries coming together. They have to establish, effectively, a global fund. We have a global fund for HIV/AIDS and tuberculosis at the moment; perhaps they could enhance and add to that— it would be a substantial enhancement—to pull through the new therapies that will enable us to combat antibiotics.

That will require action from America, Japan and ourselves. I should declare an interest as chair of the UK-Japan 21st Century Group, and I particularly mention Japan because it has the presidency of the G20. In Osaka at the end of June, for the first time Health and Finance Ministers will meet together shortly before the Heads of Government do. Health and finance should be talking together, because in so many contexts the economy and the health of the nation fundamentally depend on each other. That is a moment. I know my counterpart in Japan—who, as it happens, is a former Japanese Health Minister—and his colleagues would be very interested in working together through the G20 in Osaka to launch an initiative that would enable us to deliver on a major programme for issuing prizes for research and determining the price that will enable us to pull through new therapeutics for the future.

With apologies for the many other issues that need to be covered—I know that many noble Lords will want to raise them—I will focus on that one. I hope the Government will use the global leadership that the United Kingdom has already demonstrated, not least with the marvellous work done by Professor Dame Sally Davies, who is due to retire in the autumn—knowing her, I do not think she will be letting go of this at all. We will welcome her to Cambridge in the autumn, but I suspect that she will continue to travel the world pushing this issue forward. We have the research, the capacity, some of the resources and the ability to take a lead internationally to bring new therapeutics and diagnostics through to the marketplace, and demonstrate that we can stem the tide of antibiotic resistance. I beg to move.

--- Later in debate ---

[Baroness Thornton (Lab)]

My Lords, this has been a fascinating debate and revealed again the depth and breadth of the knowledge and passion your Lordships’ House has on this issue. I thank the noble Lord, Lord Lansley, for initiating the debate and the Library and many other organisations for their helpful briefings. I feel I should declare that I am a member of a CCG. I say that because it is rare to see a subject that is the victim of as many acronyms as the NHS, but this field certainly challenges that, combining as it does health, farming and the environment, the research and science communities, pharma businesses and international organisations. I was very grateful for the list of acronyms at the front of the Government’s five-year paper.

As noble Lords have said, we know that AMR currently results in 700,000 deaths globally every year, that by 2050 that could be 10 million, and that it threatens to turn back the clock on a century of medicine, rendering modern surgery, organ transplantation and chemotherapy too dangerous to use. Preventive treatment is needed, as the report says, to curb the spread of bacterial diseases requiring antibiotics. As the noble Baroness, Lady Walmsley, said, vaccines are the most effective preventive health tool in human history. We therefore need to expand the use of existing vaccines to have a better impact.

One of the most serious issues in the fight against AMR, which almost every noble Lord mentioned, is that no new class of antibiotics has been introduced for more than 30 years. Antibiotics are quite unlike any other category of drug, because every dose of antibiotics poses the risk of encouraging bacteria to adapt and develop resistance. That was illustrated by the noble Baroness, Lady Masham, in her description of the fight she has been having, which we have discussed on several occasions over the past year.

The Government’s five-year action plan is indeed an impressive document and a step along the road. I join the noble Lord, Lord Lansley, in saying that we may not be moving as quickly as we should. That has been echoed across the Chamber. Of course, it is not the complete solution, and serious questions have been asked in the debate. I join the noble Baroness, Lady Miller of Chilthorne Domer, in saying that the plan is disappointing in that it fails to give a clear commitment to incorporate into domestic law the European Union’s recently agreed legislation that bans routine preventive use of antimicrobials. It is a pertinent question at this point. Article 107.1 provides:

“Antimicrobial medicinal products shall not be applied routinely nor used to compensate for poor hygiene, inadequate animal husbandry or lack of care or to compensate for poor farm management”.


That is not being incorporated into UK law, as far as we can tell. I agree with the noble Baroness that the answers given to questions in the Commons were ambiguous, to put it mildly. Perhaps the Minister could take this opportunity to clarify the issue.

When I discussed the five-year plan with my noble friend Lord Winston, who regrets that he cannot join us this afternoon, he said two things to me. The first was that meeting this challenge will be well-nigh impossible given the dearth of lab, technical and science staff in the NHS at this moment. Secondly, he said that investment in research needs to be much greater and the follow-through more effective. My noble friend would have put those points more eloquently and, probably, more forcefully than I have, but neither of those issues is new; they have been articulated in your Lordships’ House over a long period.

Part of the NHS long-term plan talks about the delivery of the five-year plan we are discussing today. Will the staffing review address technical staff, of which there is a terrible shortage? They are essential for the delivery of both the NHS long-term plan and this plan. We know that the issue of research is not just about funding to deliver ground-breaking research. The UK does a great job in training PhD students, but loses a lot of talented people because the post-doctoral period is so unstable. We need continued support for interdisciplinary networks to strengthen research and develop capacity. Does the strategy address that issue as robustly as the emergency that we are facing requires?

Many noble Lords mentioned market failure, which the noble Lord, Lord Lansley, dwelled on in his opening remarks. According to Professor Dame Sally Davies, the reason for that is in part that the easy wins have been made and there is now a fundamental failure of the market for new antibiotics. Given the growing threat of AMR and the need to conserve and use current and future antibiotics carefully to preserve their effectiveness for as long as possible, it is clear that pharmaceutical companies are aware that any new antibiotic they bring to market will be prescribed only very sparingly rather than as a first-line treatment during its patent life, thereby reducing its profitability. I found that idea very dispiriting because it seems that we must address market failure. The report of the noble Lord, Lord O’Neill of Gatley, also recognised and addressed this issue.

That is even more discouraging when one realises that, over the past five years, we have seen pharmaceutical companies withdraw further and further from the development of antibiotics. In June last year, the latest company, Novartis, exited the market, bringing the total number of companies involved in antimicrobial drug development to six. The issues of market failure and disinvestment are incredibly important; therefore, the Government’s scheme to delink the price paid for antimicrobials from the volume sold is also crucial.

Even more depressingly, Professor Dame Sally Davies argued that the industry needed to step up and act in a socially responsible way, pointing out that tackling AMR was also in its interest. In her evidence to the Commons Select Committee, whose report I found extremely useful, she said:

“I am disappointed by the number of them”—


pharmaceutical companies—

“who have said quietly over a drink, ‘Well, Sally, we know you’re going to solve this. The Government will have to pay, so we’re waiting until you pay’”.

Where is the social responsibility? What terrible short-sightedness. To go back to the point about losing modern medicine, what is the point of developing the world’s greatest cancer portfolio if there are no antibiotics to rescue the patients? Yet industry expects us in government and the public sector to fund this, or that it will happen through somebody else being corporately responsible.

This market failure might lead to catastrophic consequences, as referred to on pages 74 and 76 of the five-year plan. It rightly states:

“The UK cannot solve such market failures alone”.


I question that because I should not like to think that the idea that we cannot solve this alone because we are 3% of the world market means that we do not try to do things in this country to turn this round. Our NHS has huge purchasing power: it pays billions of pounds to pharma, which makes billions in profit from these sales, for the drugs and treatments we need. We must have some leverage here. I ask the Minister: if a UK university or small pharma company found a new antibiotic, surely our Government would find a way to make sure that it was developed and brought to market. They would not wait for this to happen on the world stage, would they? I really want to hear that we will not have a repeat in the UK of the situation described in the MRC report, as referred to by the noble Lord, Lord Lansley. I received that report; the story of Achaogen was a graphic one of market failure in developing a new antibiotic. However, the noble Lord did not ask something that I wish to ask: what will happen to that drug? Achaogen developed a drug that can treat the most serious superbugs; therefore, it is not much needed so the company did not make enough money and went bankrupt. Where has that drug gone? What has happened to it? That is an important question.

[Lord Lansley]

As I understand it, the company is up for sale so, effectively, people would buy the patent and the drug.

[Baroness Thornton]

Let us hope that the people who buy it are public-spirited enough to know that they need to develop it and that that can be done. That puzzled me when I read the fascinating article, which I recommend to noble Lords. I thought, “A new antibiotic is out there and it is not available to us, for goodness’ sake”.

I congratulate the Government on the five-year plan. It is important, however, that the impetus behind it works, that the incentivisation schemes unlock investment in AMR, that we do not face the same issues being faced in America, and that implementation of the plan is speeded up.

--- Later in debate ---

[Lord Lansley]

My Lords, I thank the Minister for her excellent response to a really good debate. I am very grateful. I said at the outset that I hoped that the debate would bring forward a range of expert views relating to the “one health” concept, and it did exactly that. I am most grateful to all those who contributed to enable that to happen. The debate demonstrated the complex and multifaceted character of the problem. I share the Minister’s hope that it is indeed surmountable.

I shall say just a couple of things. First, on growth promotion and trade, the issue is that only now are some countries beginning to recognise that they have to stop antibiotic use in growth promotion and its widespread prophylactic use in animals. That happened in Europe in 2006, but it happened in 2017 in America for growth promotion and only now are the Indian Government bringing forward proposals in this respect. There is an international aspect that we need to work on.

My final point is that I entirely understand what the noble Baroness, Lady Thornton, said. The point of the national action plan is to be the best in the world—the best in class—and to demonstrate what can be achieved. If we can achieve those targets, it will be fantastic, but it has to happen elsewhere. Not only turning a national action plan into its equivalent in other countries but creating international global action, which was the burden of my contribution, will be central to a more effective response overall, which we all want.

Motion agreed.

House adjourned at 4.37 pm.