World Antibiotics Awareness Week

Theresa Villiers Excerpts

Thursday 16th November 2017 Westminster Hall

[Theresa Villiers (Chipping Barnet) (Con)]

It is a pleasure to serve under your chairmanship, Mr Davies. I congratulate my hon. Friend the Member for York Outer (Julian Sturdy) on securing a debate on such an important issue.

As we heard in my hon. Friend’s powerful speech, antimicrobial resistance is a significant and increasing public health threat both here and in the rest of the world. It is estimated that, in the United States and Europe alone, antimicrobial-resistant infections currently cause at least 50,000 deaths a year. We can be proud of the fact that the UK Government have played a world-leading role on this issue. David Cameron was one of the first leaders to put it firmly on the international agenda when he launched the review led by Lord O’Neill in 2014.

Despite that determination and commitment, the effective work that the Government are already engaged in and commitments from many other Governments around the world, I am worried that progress is not fast enough, given the seriousness of the risks we now face. Antibiotics have saved countless lives in the 80 or so years since Alexander Fleming’s historic discovery. Ever since their use became widespread in the 1940s, they have ensured that life-threatening infections can be treated effectively and operations that would have previously been very dangerous can be performed safely. Research indicates that the use of antibiotics has probably extended our average life expectancy by around 20 years.

The consequences of antimicrobial resistance are often portrayed as a future threat, but the World Health Organisation is clear that antimicrobial resistance is already detected in all parts of the world and is already causing serious harm. Across the member states of the European Union, it is estimated that AMR currently costs around €1.5 billion in additional healthcare costs and productivity losses.

Those rather dry sounding points can hide the scale of the potential horror we face. The O’Neill review concluded that more than 300 million people are expected to die prematurely because of drug resistance over the next 35 years. As we heard from my hon. Friend, we could see a return to the days when straightforward operations and minor injuries can routinely result in death and childhood mortality is commonplace.

The chief medical officer, Professor Dame Sally Davies, has rightly described AMR as a “catastrophic threat”. She has warned of a “post-antibiotic apocalypse”, where 40% of the population die prematurely from infections that we cannot treat. In her view, that could amount to nothing less than

“the end of modern medicine.”

The worst-case scenarios are frightening. It is therefore vital that we take action to address the threats we face.

We clearly need to improve infection control, not only in our healthcare facilities here but around the world, and I urge the Minister to make AMR, improving sanitation and infection control a priority for our overseas aid projects. We need to bring an end to the over-prescribing of antibiotics in human medicine. That means doing much more to raise public awareness of this issue, so that more people understand the consequences of demanding antibiotics from their GP even when there is not clear evidence that they are needed or justified. It is imperative that we develop better and more accurate ways to diagnose conditions so that we no longer see so many instances of antibiotics being used in cases of viruses and other conditions where they have no effect.

As my hon. Friend the Member for York Outer said, it is crucial that we take action to end the overuse of antibiotics in agriculture. According to a letter from senior medics to the Department for Environment, Food and Rural Affairs in 2016, an astonishing 90% of all UK veterinary antibiotic use is for mass medication of groups of farm animals. As we reflect on reform of our agricultural support system in preparing to leave the European Union, the new system of farm support that we introduce must discourage intensive farming practices where animals are kept in overcrowded, unnatural and unhealthy conditions, which leads to routine prophylactic use of antibiotics. We should be promoting much more health-oriented methods of farming. It is possible to maintain a successful farming sector and at the same time significantly reduce levels of antibiotic use, and we have already seen progress in that direction, particularly in the poultry sector.

We need to ensure that we give priority to this area in Government spending on research and development as part of efforts to expand the pool of effective antibiotics. I agree that we should seek a new approach to rewarding and incentivising medical research in this area as a further means to drive forward the search for effective antibiotics. We need also to significantly improve our knowledge and understanding of the scale of antibiotic use and the threat posed by AMR in this country and around the world.

The O’Neill report made 10 recommendations, and I would welcome an update from the Minister today on the progress made on delivering those. I also urge him to make tackling antimicrobial resistance a key element of our public health policy. I hope the Government will press NHS England, local clinical commissioning groups and local authorities to make it a focus of their sustainability and transformation plans. Moreover, tackling AMR should be an important element of our foreign policy and our international aid budget, because it is self-evident that we cannot solve this problem without concerted action on a global basis.

In conclusion, there are many impassioned debates in the House on different subjects, all of which no doubt seem worth while and important at the time. However, there can be few issues of such huge significance as the one we are considering. If we fail to take action and future generations find their lives blighted by the post-antibiotic apocalypse predicted by the chief medical officer, they will look back on debates such as this and their judgment will not be kind. I say to the Minister and to each and every Member of the House that we need to take action now on antimicrobial resistance if we are to safeguard the health and wellbeing of future generations. I urge the Minister to take that message back to his colleagues in Government.

[Jeremy Lefroy (Stafford) (Con)]

It is a great honour to follow my right hon. Friend the Member for Chipping Barnet (Theresa Villiers) and my hon. Friend the Member for York Outer (Julian Sturdy) in this extremely important debate. As my right hon. Friend said, this issue is both important and urgent; it is not something that we can put off.

I declare my interests as a trustee of the Liverpool School of Tropical Medicine, which does research in this area, and as chair of the all-party parliamentary group on malaria and neglected tropical diseases, the significance of which I shall come to in a moment.

Both previous speakers outlined the importance of this subject. The O’Neill report said that we are looking at the possibility of 10 million deaths a year and the loss to global GDP. However, I do not want to dwell on that, because I want to talk about how we can make progress. We have to make progress because at the moment it is too slow. As the chief medical officer, Professor Dame Sally Davies, has said, we do not have time. “The Drugs Don’t Work”, to quote the title of her book.

There are four areas in which we need to make some progress. I do not claim any innovation in this. I listened to a lecture on the issue just last week and these were the four areas set out; I am just repeating what I have heard. The four areas are public education, drug discovery, the involvement of drug companies, and financial mechanisms such as advance market commitments. I shall take them in turn.

First, on public education, it is extremely important that we work together, that we bring the public with us. This country has had a great record over the years in preserving antibiotics for the most essential use, at least in relation to human health. My right hon. Friend described the problems in the animal health sector, but in the area of human health, we have preserved antibiotics. Compared with most countries in the world, we are extremely prudent in our use: doctors do not prescribe them unless they are really needed.

We can do more, however. We can involve the public—citizens—in the search for new antibiotics. I was introduced last week to a great scheme called Swab and Send, which can be looked up on the internet and which is run out of the Liverpool School of Tropical Medicine now. For a small amount—I think it is £30—people get five swab kits. They are encouraged to send in dust samples or whatever; they are encouraged to swab anywhere in their house where they think interesting cultures might be building up and to send the samples in to be tested in laboratories. I saw some of the results. Young people, children and adults all around the country are sending swabs to Liverpool for them to be tested and cultured to see whether potential new antibiotics can come out of that. The reason for doing it is that, just as with the fortuitous discovery of penicillin, we have, potentially, the answer—it could even lie somewhere in a corner of this room. We do not know, but let us get citizens involved in sending those samples in from all over the country and, indeed, the world and get them tested. We have an army of volunteer scientists and researchers out there who are able to help us to discover the next generation of antibiotics.

The second area is drug discovery. We have heard that it has been extremely difficult to make progress in drug discovery, for a number of reasons. I believe that the last major development was 30 years ago, so we have not had a new antibiotic for 30 years. The problem is that antibiotics are cheap. When drugs are cheap but developing them is expensive—it takes years, we have heard 15 years, and the cost can be in the hundreds of millions of pounds —it is simply not commercially possible for drug companies to engage in this kind of research and development. It needs a combination of public finance and private development and initiative.

At this point, I want to reflect on what has happened in relation to malaria, which I know a little about, over the last 16 or 17 years. The Medicines for Malaria Venture is a fine example of how we can have international co-operation. It supports pharmaceutical companies to develop new medicines for malaria that would not be able to be produced commercially. Seventeen years ago, in 2000, as I know myself having contracted the disease a number of times, the efficacy of standard treatments for malaria was poor, or they were pretty toxic. Resistance to chloroquine, which was the main drug, was high everywhere. Sulfadoxine-pyrimethamine, or SP, which had replaced chloroquine as the main drug in a number of places, was also becoming less effective. New drugs, based on the Artemisia annua plant, were emerging, but much more work needed to be done on them. Drugs were available, but they were not particularly well developed, and because they were single therapies, not combination therapies, there was the great risk that resistance to them would occur very quickly.

The Medicines for Malaria Venture was set up with the specific aim of working with companies to bring potential drugs through research and development to the market. I am proud to say that, since 1999, the United Kingdom has been the second largest provider of funding to that excellent organisation after the Bill & Melinda Gates Foundation, which has funded more than half the total expenditure since then, which is something like $1 billion.

What have we seen as a result of the $1 billion of expenditure over 17 years? We have seen a transformation. In 2000, there were 10 products around and being worked on: six at the research stage and four at the translational stage. There was none at the product development stage and none on the market. Where are we now, 17 years later? There are 21 in research, nine at the translational stage, seven at the product development stage and 10 on the market. That is a huge return on investment. Obviously, it was not just the investment of the $1 billion or so with MMV; it was also investment by private companies working alongside MMV that put a lot of their own money into it.

Now, therefore, we have not only a good range of very effective drugs available globally that have saved millions of lives—one estimate is 6 million; it is possibly more than that—but a very healthy pipeline: 30 drugs at the research and translational stages and another seven at the product development stage. That is exactly what we need to see for antibiotics, and not just in the future but now. There we have a model. It may not be exactly the right model for antibiotics, but it is a model. That shows that it can work and not just in relation to malaria drugs; we have seen it work in relation to drugs for so-called neglected tropical diseases. An equivalent organisation is bringing forward drugs in that area. We have seen it with vaccines. The world has come together to produce better vaccines or more vaccines to cover more diseases through the Global Alliance for Vaccines and Immunisation.

We therefore have models for drug discovery, but we need to ensure that they involve the drug companies. This cannot be done just by the public sector. The drug companies have enormous expertise and great researchers; they just need the incentive to work on the development of new antibiotics to a much greater extent. We are not talking about doing one or two; we are talking about looking at dozens and dozens. That is why it needs a co-ordinated and global approach. I think the drug companies are willing. They are out there, they are able to do it and they want to do it; they just need a bit of co-ordination and incentive—a bit of a push—and also the public encouragement that comes from knowing that this is something that we all want to do and that will benefit the entire world.

We need to look at how that finance could be introduced. I have talked about advance market commitments. That is the possibility that has been suggested to me. It has been done before. Just over a decade ago, advance market commitments were developed for vaccines. We have vaccines available around the world now, inoculating children and preventing them from getting debilitating or killer diseases, because of the commitment made by our Government in 2005-06 and other Governments, with again the UK taking the lead. That is an area in which we have expertise and have already shown commitment. Therefore, it is absolutely right, as my hon. Friend the Member for York Outer and my right hon. Friend the Member for Chipping Barnet have said, that the UK should be taking a lead in this. At this time, when perhaps our global position is changing, what could be better than showing global leadership in an area that is of great benefit to all humanity and showing that global Britain is a reality, not just a form of words?

Just a few words on how advance market commitments work. In the case of vaccines—there is no reason why it could not work in the same way for antibiotics—there is an agreement for money to subsidise the purchase of a future drug at a given price, so that people know that they are going to sell that drug at a certain price, which means that they can invest in the research and development. That gives manufacturers the incentive to invest not only in that R and D, but in capacity. We need to build that capacity. Clearly, in the case of vaccines, that was enormous because vaccine plants are extremely expensive; in the case of antibiotics, the expense would be less, but nevertheless significant. Then there is the agreement that, once a fixed amount of sales, in terms of numbers or value, has been reached, the manufacturer is contractually obliged to sell the drugs affordably in the markets or to license the technology. Let us be frank: these drugs are not going to make large sums of money for people. They have to be available at prices that everybody in the world, whether they get them through a health system or purchase them individually, can afford.

[Theresa Villiers]

Listening to my hon. Friend’s speech, it occurs to me that, in other areas of medical research, we see a hugely positive impact from the charitable sector. Should we be trying to read across the lessons from other areas of medical research and to get these fantastically successful charities involved in raising money for AMR research?

[Jeremy Lefroy]

My right hon. Friend is absolutely right. I referred earlier to the involvement of the Bill & Melinda Gates Foundation in the setting up of MMV, but there are so many other medical charities putting millions and sometimes tens of millions of dollars into these areas. That is the beauty of partnerships such as MMV, the Drugs for Neglected Diseases initiative and other partnerships: they take money from the commercial sector, charities, non-governmental organisations and from Government and everybody is working together—they are not in competition with each other over relatively scarce resources. The partnerships are using the benefits, in the case of companies, of their researchers and facilities; in the case of foundations, of their contacts, ability to deploy drugs on the ground and funding; and in the case of Governments, of the substantial funding that they can put in.

I want to conclude by saying that this is not pie in the sky—this is something we can do. We have proven in the case of malaria and other diseases that we can achieve tremendous results. We know there is a will. We know Government have a will. We know there is a will in other countries. It just needs a lot more urgency and more co-ordination. If the UK, through the Department of Health, and as my hon. Friend the Member for York Outer has said, through the co-ordination of the various Departments, were to take this by the scruff of the neck, we would have something by which the UK could again show world leadership not just in words, but in actions. I look forward to hearing from the Minister the plans that we have in that area.

O’Neill Review

Theresa Villiers Excerpts

Tuesday 7th March 2017 Westminster Hall

[Kevin Hollinrake]

I absolutely agree. The difficulty is that due to the reward mechanisms in the system, such research and development is not happening. I will turn to that shortly.

This is not an apocalyptic prophecy. Antimicrobial resistance causes some 700,000 deaths globally and an estimated 12,000 deaths in the UK every year—similar to the number of people who lose their lives from breast cancer. Quite simply, if the bacteria that cause infections become resistant to antibiotics, people die. This issue is listed in the national risk register of civil emergencies, a five-year Government register, which states that an

“increasingly serious issue is the development and spread of”

antimicrobial resistance and points out that much of modern medicine will become unsafe. Minor surgery such as organ transplants, bowel surgery, cancer treatments and caesarean sections will become high risk—there will be more illness and more deaths.

Dame Sally Davies, our chief medical officer, pointed out that antibiotics have extended life by an average of 20 years—20 years of our lives may therefore be lost—and 40% of our population could die prematurely if this situation is not resolved. Operations would become unsafe due to the risk of infection during surgery or chemotherapy. Influenza pandemics would become much more serious. The national risk register states:

“The numbers of infections complicated by AMR are expected to increase markedly over the next 20 years. If a widespread outbreak were to occur, we could expect around 200,000 people to be affected by a bacterial blood infection that could not be treated effectively with existing drugs”.

[Mrs Theresa Villiers (Chipping Barnet) (Con)]

Does my hon. Friend agree that it is vital that we heed the O’Neill review’s recommendation that antimicrobial use in farming must reduce if we are to address the frightening consequences that he is outlining? In particular, we need to move away from intensive farming, which is reliant on the prophylactic use of antimicrobials.

[Kevin Hollinrake]

My right hon. Friend is right that bacteria can move from animals into humans, and the O’Neill review was clear that we need to take action in agriculture as well as our health services.

The national risk register states that we will be unable to treat some 200,000 people with existing drugs and

“around 80,000 of these people might die.”

That is a Government report.

Breast Cancer Drugs

Theresa Villiers Excerpts

Thursday 26th January 2017 Commons Chamber

[Mrs Flick Drummond (Portsmouth South) (Con)]

It is a pleasure to speak in the debate, and I congratulate the hon. Member for Mitcham and Morden (Siobhain McDonagh) on securing it. I was really honoured to be able to back the application to the Backbench Business Committee. I also thank her for her powerful speech, which was very moving.

Fighting cancer is not just a top priority for the NHS but one of the great scientific challenges of our time. Treating our illnesses with science rather than superstition is a relatively new idea in the history of medicine. However, the acceleration of better diagnosis, better treatment and more successful outcomes is keeping more of us alive for longer, and with a better quality of life.

The motion mentions Kadcyla, a treatment that NICE is not currently able to recommend for the treatment of secondary breast cancer, and we await the result of its consultation in March. This treatment is a relative of another medicine, which, in its introduction, was also extremely controversial—Herceptin. After a lot of consideration by NICE and a lot of debate and pressure from this House, Herceptin was approved. It has helped thousands of people—men get breast cancer too—in fighting breast cancer.

Kadcyla is a treatment that could help women who have already been on an Herceptin-based treatment and whose cancer has continued to advance. We must be clear when we talk about secondary, or metastatic, cancer that we are talking about people whose lives will be massively shortened by cancer. Kadcyla gives them and their families more time and a better quality of life. It can add months to the life expectancy of patients whose remaining lives are likely to be measured in only a few months. The hon. Lady movingly talked about some of her friends and some of those in the Public Gallery.

I think we all understand that there are ultimate financial constraints on the NHS, even though spending on it has increased. I really welcome the new cancer drugs fund, which provides patients with much better access to the most promising new cancer treatments, while providing value for the taxpayer.

[Mrs Theresa Villiers (Chipping Barnet) (Con)]

I was profoundly moved by the case of my constituent, Rosalie Marshall, who sadly is suffering from breast cancer. She told me that she finds it hard to understand why the NHS can spend such significant sums on conditions which, frankly, are not life-threatening and sometimes seem to verge on the cosmetic, and yet not give priority to vital drugs like Kadcyla. Surely something is wrong, and savings could be made in other parts of the NHS that would more than pay for Kadcyla.

[Mrs Drummond]

Yes, I also get emails on the same subject. We have to remember, though, that there are other considerations such as mental health conditions. Sometimes people do not quite understand why money is being spent on various parts of the NHS, but there are always other reasons behind it. However, I totally agree with my right hon. Friend about drugs like this which seem to make such a difference.

In the case of Kadcyla, there do seem to be questions as to why it cannot be brought into regular use. Some of those questions are for NICE and some are for the manufacturer. Kadcyla is a treatment that has been accepted by a number of European countries, despite the expense. I am reassured to see that many cancer charities accept that NICE has made every effort so far to fund it, and that NICE has been doing its best. However, there remains the question of how NICE’s apparent final position stands up by comparison with other European countries—France and Germany, for instance. France’s equivalent of NICE considered Kadcyla in exactly the same way as NICE has, and has approved it.

Another query is based on the choice of comparator treatment in assessing the quality of Kadcyla as a treatment. There have been concerns that the comparator treatment—Lapatinib and Capecitebine; I hope that Hansard will be able to report that rather better than I can say it—is no longer available on the NHS. The drug’s manufacturer carries the comparison on its own website, with the outcome of a clinical trial codenamed EMILIA. However, it does not seem realistic to base a decision on a drug on a comparison with another drug that is not available on the NHS either. It would help everyone to understand the comparison if it was made with a drug that is generally available.

Can the Minister tell us the status of Roche’s study under the name ESTHER, which is looking at Kadcyla? In the event that NICE does not revise its decision now, will it be open to it to do so when it gets the ESTHER conclusions? That trial is not scheduled to report until 2023, so the immediate concerns about availability remain. However, I recognise that research goes on constantly, and that perhaps the manufacturer will reconsider its position. It is unfortunate that NICE has been subjected to sustained attacks by the manufacturer, Roche, which has risked undermining NICE’s reputation in a most unjustified way. I call on Roche to get round the table with NICE and look again at the pricing of this drug, as it has done with others in the past.

Turning to other treatments, I know that the message is going out to clinical commissioning groups about the options available. Many Members will have had campaign emails relating to bisphosphonates, and I was reassured by the response I had from the Department of Health and the Portsmouth clinical commissioning group that they are being made available. Queen Alexandra hospital in Portsmouth has above-average performance in both treatment times and outcomes, and is becoming, if it is not already, a centre of excellence in cancer treatment.

I know that this is a difficult subject and budgets are limited, but like many others in this House, including those in the Gallery, many of my friends and family have died of breast cancer or are survivors. We need to make sure that we are keeping up with the right drugs to treat them, and that sounds like Kadcyla.

Oral Answers to Questions

Theresa Villiers Excerpts

Tuesday 20th December 2016 Commons Chamber

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

3. How the Government plan to show global leadership in tackling antimicrobial resistance.

[Mrs Theresa Villiers (Chipping Barnet) (Con)]

12. How the Government plan to show global leadership in tackling antimicrobial resistance.

[Chris Green (Bolton West) (Con)]

14. How the Government plan to show global leadership in tackling antimicrobial resistance.

--- Later in debate ---

[Nicola Blackwood]

My hon. Friend is absolutely right that it is essential that we improve diagnostics if we are to tackle this national threat. A routine part of the clinical management of patients showing symptoms of infections is to take a blood sample. When an infection is identified, those samples are indeed tested for resistance. Part of our AMR strategy is to improve diagnostics and to fund innovation in this area.

[Mrs Villiers]

Will the Government commit themselves to ensuring that their strategy will include discouraging the use of intensive farming, given its overuse of antibiotics which contributes to antimicrobial-resistant problems?

[Nicola Blackwood]

I agree that we must focus on that as well, but we are currently focusing on reducing the need for antibiotics by minimising disease risk in animals through good animal husbandry and on-farm biosecurity. At present, antibiotics provide the only effective means of treatment for a number of animal diseases, and are therefore essential to ensuring the health and welfare of animals. However, we are also working on the matter in an international context with the World Organisation for Animal Health, and we will continue to drive forward the agenda.