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Antimicrobial Resistance - Motion to Take Note

– in the House of Lords at 2:52 pm on 2nd May 2019.

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Lord Lansley:

Moved by Lord Lansley

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

Photo of Lord Lansley Lord Lansley Conservative

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.

Photo of Lord Crathorne Lord Crathorne Conservative 3:08 pm, 2nd May 2019

I congratulate my noble friend on getting this debate. Prior to this has been a debate on climate change, but this is just as important. We know from my noble friend’s fine speech the importance of finding a solution to AMR. I will certainly not repeat any of the things he has said so eloquently, but it is good news that the Government in their five-year plan are taking this extremely seriously.

First, I declare an interest as having a small number of shares in a company called Helperby Therapeutics, which is involved with trying to find a solution to the AMR problem. There is no question that the world is facing a crisis. Although there are still some climate change sceptics, I do not think that there is anyone who does not believe that we are facing a catastrophe on this.

Margaret Chan, the former director-general of the World Health Organization, said that,

“antimicrobial resistance is a global crisis—a slow motion tsunami. The situation is bad, and getting worse”.

The problem has really arisen because pharmaceutical companies have thus far failed to find a solution. What is particularly worrying is that many of the big pharmaceuticals have left the field, basically because of the massive costs of bringing a drug to the market and the prospect of not being able to make it economically viable.

A documentary film called “Resistance Fighters” has just been made. I mention it so that noble Lords can keep an eye out for it, as the hope is that it will air on television in England. The film shows how much the problem has been ignored for a long time, against better judgment, and makes it clear how new resistance mechanisms could emerge that were hardly conceivable until recently. It also looks at how the mass use of antibiotics in animal fattening can lead to the uncontrolled release of resistant germs into the environment. Negligence and powerful economic interests, which put profit well above the well-being of people, have been putting lives at risk.

I know that the noble Lord, Lord Trees, will talk about the use of antibiotics in animals, but I will quote one set of statistics which I found particularly interesting. In 2016, 80% of all antibiotics administered in the USA were used in animal feed. That is a total of 15 million kilograms, which is equivalent to 300 milligrams of antibiotics per kilogram of produced meat. All hearings on the topic of antibiotic growth promoters were completely blocked in the US Congress for 40 years, despite scientifically proven correlations. Most recently, the US pharmaceutical industry made an annual turnover of $13 billion with antibiotics in animal feed. I think that is quite something.

There was an interesting article in the Times on 14 February, entitled “Rise of superbugs puts everyday surgical operations in jeopardy”. It said that:

“Tens of thousands of patients in Britain are struck down by superbugs because antibiotics to protect them during surgery have failed, a global study says.

One in five infections picked up during common operations worldwide is resistant to standard antibiotics, suggests research that reveals how far resistance to drugs has advanced towards a so-called doomsday scenario”.

I had a successful operation for colon cancer 18 months ago and was given a large course of antibiotics to ensure that no infection developed—and none did. It was quite a thought that if antibiotics did not work, in the worst-case scenario, that antibiotic treatment would no longer be possible. Dame Sally Davies, the Chief Medical Officer, has warned of a “post-antibiotic apocalypse”.

The Times article describes a study which looked specifically at gastro-intestinal surgery,

“which is carried out a million times a year in British hospitals”, and where infection is really quite common. The study showed that antibiotics were becoming measurably less effective. According to the article, Dr Harrison of the University of Edinburgh said that,

“the results could apply to many more of the five million surgical procedures carried out in Britain each year”.

That is an astonishing number—5 million procedures. The article continues:

Nicholas Brown, a consultant medical microbiologist at Addenbrooke’s hospital in Cambridge and director of the campaign group Antibiotic Action, said the findings were a sign that standard preventative antibiotics were failing. He said: ‘The doomsday scenario, the end of the antibiotic era, is in some countries only a theoretical possibility but in other countries it is beginning to have a very significant impact’”.

Professor Anthony Coates, who started Helperby Therapeutics, told me that, as the big pharmaceuticals leave the field, it leaves just a handful of small companies, including Helperby, to “fight on alone”. If that were not bad enough, one of the most promising pharmaceutical companies filed for bankruptcy a few weeks ago—my noble friend Lord Lansley referred to this. This was because it had developed a new antibiotic entity, which cost $500 million to develop. To recuperate these high costs, the company marketed its product for nine months at a price of $10,000 per course. Basically, that price is too high for the antibiotic market, although cancer drugs sell successfully for a lot more than that. The company sold only 50 courses in nine months, and this was not viable.

Professor Coates told me that he was very concerned that all the rest of the handful of small companies developing antibiotics were in the same boat. In other words, they are developing expensive new chemical entities, so when they get to market, they will struggle to survive. Interestingly, Helperby is going down a slightly different route by experimenting with the combination of existing drugs. If it can make that work, that will be marketable at a much more reasonable price.

Professor Coates also said that he thinks the thing that is missing from this key market is market-entry rewards. This is a reward to companies which reach the market with a new antibiotic or combination. The Government introduced NHS incentives for new antibiotics, which is a good start, but unfortunately it did not make any difference to the company which has just gone bankrupt. Professor Coates also said that he thinks that this will make no difference to other small companies, including Helperby, because they nearly all launched in the USA. Apparently the NHS does not have a very good reputation for welcoming new drugs. Perhaps that is one of the things that the Government could look at.

Photo of Baroness Greengross Baroness Greengross Crossbench 3:17 pm, 2nd May 2019

My Lords, first, I congratulate the noble Lord, Lord Lansley, on securing this very important debate. My interest in this issue is partly due to the work I do through the International Longevity Centre UK, which I established 20 years ago. It is one of 16 organisations across the world which looks at these sorts of issues. The ILC-UK, following the UN’s high-level meeting in 2016, held its Jack Watters memorial debate on the subject and produced a report on antimicrobial resistance in 2017. That report links to one of the ILC’s other key workstreams: the promotion of vaccines. I chaired a meeting on that vital issue in this House only last month.

This debate is very timely given that the Government published their new five-year plan in January of this year. There is now renewed vigour from the Government to tackle this issue. I hope that it will be tackled because, as noble Lords have said, this is a major, worldwide challenge and it needs to be taken very seriously. I cannot overemphasise that. The health of our whole population is at risk, but especially that of older people, who are more vulnerable to illness and disability than younger people. I was grateful to receive certain facts and figures from the British Society for Immunology, which points out:

AMR could turn back the clock a century on medicine”.

It is of course alarming to read in the action plan that AMR might already cause 700,000 deaths every year worldwide and that this could rise to 10 million by 2050, which is partly why I welcome how seriously the Government are taking this issue. The UK has been a world leader, from David Cameron taking the issue so seriously back in 2013 to the review from the noble Lord, Lord O’Neill, in 2014 and the work of Dame Sally Davies, which we have mentioned, as well as useful scrutiny from both Houses of Parliament. Now at last we have the new action plan.

In my brief remarks I will focus on the action plan’s acknowledgement of the importance of vaccination’s preventative role and how we might better stimulate R&D into vaccines. While encouraging the development of new antibiotics is obviously sensible, as the noble Lord, Lord O’Neill, recommended, the ILC report agreed with his other recommendations to develop new vaccines and use existing ones more effectively as a way of reducing dependency on antibiotics.

The World Health Organization has calculated that, if coverage of existing vaccines was increased, millions of days of antibiotic use could be prevented. For example, if flu vaccination rates increased, antibiotic use would surely reduce as the incidence of flu fell, as well as from a decline in secondary infections caused by flu, such as ear or sinus infections. In the ILC’s Jack Watters debate, Professor David Salisbury argued that there was “no debate” about whether more should be done to increase the coverage of a wider range of vaccines across the life course. I very much agree with that. I note that the O’Neill review calculated that vaccine programmes save society 10 times their original cost.

The list of potential new vaccines that Professor Salisbury hoped to see developed in coming years ranged from Alzheimer’s to respiratory syncytial virus, as well as more obvious ones such as norovirus and TB. As the British Society for Immunology has pointed out, vaccines are the most preventative health tool in human history. Like me, it also wants to see significant investment in novel vaccine research, in particular into bacterial infections such as pneumonia and sepsis—I am a member of the All-Party Group on Sepsis.

This is why I hope the Minister can reassure me that the action plan will help to create the right environment to incentivise the science community on vaccine development, which historically has a poor commercial return on such investment. I was struck by what the Society for Immunology said in its briefing: that less than 5% of pharma venture capital investment over past 10 years went into AMR. I hope that research on vaccine development is not held back by the focus on developing an AMR of “last resort”, the return of which is uncertain, and that recognition that a co-ordinated cross-government approach across all relevant sectors is urgently required if this is to be achieved.

Photo of Baroness Miller of Chilthorne Domer Baroness Miller of Chilthorne Domer Liberal Democrat 3:23 pm, 2nd May 2019

My Lords, I congratulate the noble Lord, Lord Lansley, on securing this debate. My contribution will focus on just the farming aspect of the issue.

I thoroughly agree with the noble Lord that the whole point of this issue is that it is a one-health problem. One of the lessons is that we cannot divide human health from the health of the animals we eat. If animals are kept in a way that requires them to be dosed with antibiotics on a frequent and routine basis, then of course we should expect to affect human health as microbes learn to find ways around being killed.

The problem is very well exemplified in the pig industry, because when piglets are weaned very early, after say just 20 days as opposed to 40 plus days, they are likely to suffer from diarrhoea and lose natural resistance, so of course they are dosed. I praise the pig industry for making efforts to reduce the use of antimicrobials by about 50% in the last two years, which is a pretty big reduction. However, data from the Veterinary Medicines Directorate shows that in 2017, the last year I have data for, the UK pig sector still used about 130 milligrams of antimicrobials per kilogram of pig. Compared to our neighbours in Holland or Denmark, that is still very high. Why is it so high still? I am not sure; perhaps the Minister will know why. In the Dutch and Danish pig sectors, use of antimicrobials is less than half the UK’s use, at 53 milligrams per kilogram in the Netherlands and 46 milligrams per kilogram in Denmark. There is quite a big room for improvement. Moreover, reduction in the use of antimicrobials in the UK pig sector has in part been achieved by relying on extremely high use of zinc oxide in the feed. Perhaps the Minister can tell me whether it is true, but I understand that there is a link between such zinc oxide use and the rise of MRSA.

Turning to chickens, broiler chickens in particular, ionophores are the antimicrobial compounds that specifically target bacterial populations in chicken production. Those of your Lordships who have been around a broiler chicken plant will have needed a strong stomach to do so since they are kept very intensively. Ionophores are routinely added to the feed of the most intensively farmed chickens to prevent the serious intestinal disease coccidiosis. No veterinary prescription is required. This disease occurs when chickens eat other chickens’ droppings, so intensive systems where tens of thousands of birds are kept permanently indoors in overcrowded conditions are likely to need to be dosed frequently.

One of the issues for the Government is that, if Brexit happens, they will be looking at with whom to make trade deals. The Government should consider the effect of making deals with people who are encouraging intensive farming when looking at agricultural trade deals and where our food will come from. I do not think that it is any coincidence that antimicrobial resistance is much higher in the USA when we look at how much of its food comes from intensive farming. The Federation of Veterinarians of Europe is concerned about the overuse of ionophores in poultry production and has called for the drugs to be made prescription-only. I wonder whether that is something that the Government are considering.

I am pleased that the Government have brought in their five-year action plan, but there is an issue that I would like to ask the Minister about this afternoon. The plan fails to give a clear commitment to carry over and incorporate into domestic UK legislation, should we leave the EU, the EU’s recently agreed legislation that bans routine preventive use of antimicrobials. I am particularly worried because a Question was posed in the House of Commons by Kerry McCarthy MP as to whether the Government will ban routine preventive use. The answer was simply:

“Ministers have confirmed the Government’s intention to implement restrictions on the preventative use of antibiotics in line with new EU legislation”.

That does not sound like a ban to me. There will be a couple of problems with that. First, it will be in conflict with the new five-year plan. Secondly, if we try to export any food products to the EU, they will of course be unacceptable in EU terms. The Government need to come off the fence and say that they will entirely implement the ban as envisaged by the EU.

Finally, I turn to the remarks made at Portcullis House on 13 February by Professor Mark Woolhouse, who is the professor of infectious disease epidemiology at Edinburgh University. He makes the point that in the context of this, an issue is that the UK Government’s emphasis on actions and research is still happening in silos when it comes to surveillance. The challenge is joining up the surveillance across the human, livestock and environmental sectors. Cross-sectorial transmission studies have been unsuccessful because they are not large enough in scale, and research access to routine surveillance data will be crucial for understanding the spread of AMR. Coming from such an expert, this is a very serious issue, and one that the Government need to address by supporting research that is bold and, as he says, mission orientated, and funding it sufficiently so as not to undermine their five-year action plan.

Photo of Baroness Masham of Ilton Baroness Masham of Ilton Crossbench 3:31 pm, 2nd May 2019

My Lords, I thank the noble Lord, Lord Lansley, for this most necessary debate, which covers vital aspects of life and death. So much parliamentary energy and time has been spent on Brexit that a subject as important as antimicrobial resistance has not been as prominent as it should have been on the parliamentary agenda. However, I congratulate Professor Dame Sally Davies, the Chief Medical Officer, for what she has done to help the UK become one of the world leaders in the subject. Antimicrobial resistance is a world dilemma. Governments across the globe should work together and treat this as an emergency problem which must be solved.

The World Bank has predicted that globally, AMR will lead to increases in morbidity and mortality, increase the burden on healthcare systems, increase extreme poverty and could inflict heavy losses on the global economy. The European Medicines Agency’s leaving London for Amsterdam does not give a good message to the world about our status in leadership, new medicines and safety. We will not have voting rights. We will be second-class members if we leave the EU.

I must declare an interest. I had sepsis last June, and know only too well the difficulties of combating infections. Sepsis needs quick diagnosis and antibiotics, but there is a problem getting the correct antibiotic for the appropriate infection. One needs accurate, rapid tests. After nearly a year, I am still battling an infection which persists in going up and down—even though I have the help of three hospitals and the advice of a cousin in Australia, who is a professor of microbiology. I mention this to illustrate how challenging these infections are, especially if they are resistant to treatment. During the year, I have witnessed the stress and pressure some hospital departments are under. The shortage of experienced staff and the difficulties of communication are of concern. There is no doubt that Brexit is not helping. Many much-needed nurses and doctors come from Europe. Many of our doctors and nurses go abroad, where the grass seems to be greener. One never knows what infection will emerge.

I would be grateful if the Minister could tell your Lordships what the Government recommend about Candida auris. The Sunday Times has said that:

“Eight patients in hospitals in Britain have died after becoming infected with Candida auris, the deadly Japanese super-fungus”.

The revelation by Public Health England illustrates the scale of the threat from the super-fungus, which emerged just 10 years ago in Japan, equipped with the fearsome biological armoury that lets it flourish in hospitals and resist most drugs and disinfectants. To date, the microbe has been found in at least 25 British hospitals. What seems to make Candida auris unique is that it spreads so easily from person to person. Once in the bloodstream, it circulates and multiplies, causing sepsis. I congratulate the UK Sepsis Trust for trying to make Parliament, hospitals, GPs, schools and the general public at large aware of sepsis.

With antimicrobial resistance, it is vital that we get new antibiotics. However, a disaster is unfolding in the antibiotics market. In the global struggle against superbugs, Achaogen is a biotech at the front line. Its failure is the latest symptom of an ailing antibiotic market. Its antibiotic, plazomicin, was, in 2018, approved by the UK food and drugs administration for treating complex urinary tract infections caused by drug-resistant bacteria. It is a vitally needed drug, and just one of many new antibiotics we need to replace drugs that are rapidly losing their effectiveness against superbugs. Its loss, for lack of funding, is a tragedy. This was mentioned by the noble Lord, Lord Lansley, and I think it is worth mentioning again.

On a more hopeful note, Carb-X, a global partnership dedicated to accelerating research to tackle the global rising threat of drug-resistant bacteria, with up to £550 million to invest, is said to fund the best science around the world. Its portfolio is the world’s largest development pipeline of new antibiotics, vaccines, rapid diagnosis and other projects to prevent and treat life-threatening bacterial infections. It is encouraging that the UK, the USA and Germany, and several trusts and foundations, are working together. The headquarters are at Boston University. I hope they have great success in helping to protect humanity from the most serious bacterial threat before us. We need better preventive measures as well as alternative treatments, including innovative ways to use the body’s own immune system and healthy bacteria.

I am trying a new treatment for wounds—Acapsil. It is micropore particle technology, a white powder applied to the wound surface. It consists of small particles composed of a network of very fine pores. It removes the toxins, and enzymes are excreted by the wound surface. It does not kill the micro-organisms. It is hoped that it is effective on antimicrobial-resistant infections. Another exciting discovery is that golden kelp, the common seaweed from the rocky shores of Mindelo in northern Portugal, has been found to contain microbes that could bolster the war on superbugs.

I would like to ask three questions. First, what are the Government doing to speed up detection of AMR throughout the NHS? Secondly, do the Government recognise the value of accurate antimicrobial susceptibility testing in safeguarding the remaining effective antibiotics, while accurately monitoring the newly emerging AMR and screening potential new antibiotics? Thirdly, are they aware that the Central Public Health Laboratory in Colindale is involved in an international consortium that has developed a rapid antimicrobial susceptibility test, but that in over two years it has received no direct funding to establish that test capability here?

I have a farm and pony stud. I support vets by saying that they should have the right to prescribe and dispense veterinary medicines, including antimicrobials, according to their responsible clinical judgments. The welfare of animals, as well as humans, must be paramount.

Photo of Baroness Redfern Baroness Redfern Conservative 3:39 pm, 2nd May 2019

I thank the noble Lord, Lord Lansley, and congratulate him on securing this debate on the incredibly important topic of addressing AMR. It is absolutely essential to see AMR as the economic and security threat that it is.

I will talk first about animal husbandry. The Government must make a clear commitment that any future trade deals will require any meat and dairy produce imported into the UK to meet at least the same standards relating to antibiotic use that apply to meat and dairy products produced in the EU, because over 40% of the UK’s total antibiotic use is in animals.

Contamination can occur from animal waste, human waste, pharmaceutical manufacturing and the use of antimicrobial pesticides on crops. There is no doubt that more funding is needed on AMR to kick-start early research into new antimicrobials and diagnostics. We must conduct in-depth research to better understand the impact of AMR pesticide exposure on humans, animals and the surrounding environment, and identify and promote best management practices to minimise exposure when applying antimicrobials as pesticides. There should also be more global transparency over antimicrobial use on pesticides, by collecting and sharing information on the amount and types used on crops each year. Sharing knowledge is so important.

We now see antibiotics reaching the environment in many ways, such as through sewage run-off and the run-off from food producing units such as farms. In particular, there is the impact of effluent from factories on our nearby water systems. Action is needed, too, so that regulators can set at least minimum standards for the treatment and release of manufacturing waste, and drive much higher standards through supply chains. It is vital that we have better commercial return on R&D; it is little wonder that firms are not investing in antibiotics, despite the very high medical needs. We need new ways to reward and enhance innovation.

What matters now is that action should support reducing the unnecessary use of antimicrobials and, I emphasise, and should revive investment in their development. Rapidly growing global demand for antibiotics is necessary to improve access to life-saving medicines, along with economic development. But all too often it reflects excessive and unnecessary use, rather than genuine medical need, so by reducing unnecessary consumption we can have a powerful impact on resistance. Educators, farmers, the veterinary and medical communities and professional organisations need to pledge to make better use of antibiotics and help save vital medicines from becoming obsolete.

The rise and spread of antimicrobial resistance is, as we have heard this afternoon, creating a new and potentially dangerous generation of superbugs. The UK needs to help ensure that AMR remains a global priority by continuing to lead international policy. As we have been informed, by 2050 it is estimated that AMR will kill 10 million people per year—more than cancer and diabetes combined. That is the scale of the threat that we face. The ambition for AMR is, by 2040, to have new diagnostics, therapies, vaccines and interventions in use, together with a full AMR research and development pipeline for antimicrobial alternatives, along with diagnostics, vaccines and infection prevention across all sectors.

Government and other funders must act to ensure that the market can offer sufficient commercial incentive to keep pharmaceutical companies active in this space. They should conduct studies to evaluate the effectiveness of existing wastewater treatment processing in the removal from it of antimicrobials before its discharge into environmental waters, and investigate and identify the factors that result in treatment inefficiencies and failures in processing methods, or the infrastructure failures. Studies have found APIs in rivers, treated and untreated manufacturing wastewater, and sediment downstream of industrial wastewater treatment plants.

We have evidence, too, of the clear priorities that will support greater progress in addressing antimicrobial-resistant microbes in the environment. As I mentioned earlier, high-risk areas, such as the disposal of waste from healthcare facilities and manufacturing, could be prioritised and addressed at local and global levels to reduce the potential risks to human health posed by having those microbes in the environment. Unfortunately, we have not seen a new class of antibiotics for decades, because an overuse of antimicrobials has increased the rate at which resistance is developing and spreading. Again, we lack the new drugs to challenge these new superbugs. Governments and other funders must act to ensure the antimicrobial market can offer sufficient commercial incentives to keep pharmaceutical companies active in this space. Where testing is clinically appropriate and recommended by NICE, action should be taken to address the perverse financial incentives that may discourage use. I emphasise that we must work in collaboration to improve national and international understanding. We have a major global challenge ahead of us.

Photo of Lord Trees Lord Trees Crossbench 3:46 pm, 2nd May 2019

My Lords, I too am grateful to the noble Lord, Lord Lansley, for securing this debate. Like him, I commend the new national action plan on tackling antimicrobial resistance. There is no doubt that antimicrobial resistance—that is resistance to microbes—is a major global challenge. The O’Neill commission’s final report in 2016 warned that, if unchecked, by 2050 AMR could lead to 10 million deaths and a $100 million cost to the economy globally. That has been referred to earlier. There is no question that antimicrobial resistance is a truly major issue.

These figures are frequently used in the introduction to discussion of antibiotic resistance. That is the resistance of bacteria to particular drugs. I emphasise, perhaps needlessly, that while all bacteria are microbes, not all microbes are bacteria. This is significant when considering drugs, which are often specific. As a veterinary scientist and in the context of the involvement of animals in this issue, I will focus on antibiotic resistance. I declare my interests as a long-standing member of the BVA and a former president of the Royal College of Veterinary Surgeons.

The first point is that the AMR figures that headline my contribution, quoted in the O’Neill report, include the consequences of drug resistance in malaria and in viruses, notably HIV and the human tubercle bacillus. These are undoubtedly major causes of mortality in humans globally, but in none of them is there a connection to drug use in animals. I make this point not to diminish the problem of AMR, nor that of antibiotic resistance, but it is important when addressing this problem to accurately distinguish its component parts in order to rationally tackle it.

Having clarified that, and excluding the above three infections, the resistance of some bacteria to antibiotics is still a substantial problem in human medicine. While it is generally accepted that this is primarily a result of the use of antibiotics in humans, there is undoubtedly some connection to the use of antibiotics in animals. These situations particularly involve food-borne infections transmissible between humans and animals, such as E. coli, campylobacter—which is the biggest cause of food poisoning in the UK, usually non-fatal but debilitating—and salmonella. They also involve some other directly transmissible infections, to which those who work with or keep animals may be particularly exposed, such as MRSA.

There is still much uncertainty, in many of these situations, about the extent of the flow of resistant bacteria between animals and humans, and indeed the environment, and its direction—because we must remember this is bidirectional. We badly need more research on this, but molecular typing methods are increasingly helping to elucidate these questions. There have been some important results recently from several groups using molecular characterisation, which have shown that bacterial populations of E. coli and salmonella in animals and humans may remain more distinct than hitherto suspected.

Notwithstanding this, the veterinary profession and livestock industries have taken the issue of antibiotic resistance very seriously, and have made huge progress in reducing or restricting antibiotic usage in animals—I am talking about Europe and the UK particularly—to safeguard human health, while maintaining animal health and welfare, and livestock productivity. There has been a concerted effort by animal industry bodies—particularly in fish farming, but also the poultry and pig industries, to be fair to them—and the British Veterinary Association, the British Small Animal Veterinary Association, the British Equine Veterinary Association, the Responsible Use of Medicines Agriculture Alliance and the National Office of Animal Health. These bodies have variously produced literature, information, posters, training courses and toolkits, and have set voluntary targets and restrictions.

This has all been strongly supported and monitored by the Veterinary Medicines Directorate and the Royal College of Veterinary Surgeons, which introduced guidance some time ago in its Code of Professional Conduct requiring veterinary surgeons to be responsible in their use of medicines and antibiotics. For the avoidance of doubt, I make it clear that the use of antibiotics in animals for growth promotion has been banned in Europe since 2006, and antibiotics are available only by prescription from a veterinary surgeon for animals under their care.

The remarkable progress in reducing and restricting antibiotic use in the UK is documented by the latest UK One Health Report, published in January this year. This shows that, between 2013 and 2017, there was a 40% reduction in the use of antibiotics in food-producing animals, achieving below the 2018 target advocated by the O’Neill commission report. This translates to a reduction of antibiotics in animal use to 282 tonnes, and of so-called high-priority critically important antibiotics, as defined for human use, to 2.2 tonnes. In the same year, 2017, the corresponding figures in humans were 491 tonnes for all antibiotics and 17.1 tonnes for critically important antibiotics.

But we must not be complacent. Further voluntary targets were agreed in 2017 for reducing antibiotic use in eight key livestock sectors. Those targets variously include reduced use, particularly of high-priority critically important antibiotics; improved monitoring and data collection; and knowledge-exchange initiatives.

As has previously been said, the issue of antibiotic resistance is global. While good progress is being made in the UK, there is still uncontrolled use of antibiotics in both humans and animals in many countries. In an age of globalisation, the global movement of humans, who carry millions of bacteria with them every time they go anywhere, as well as of animal products, will continue to introduce antibiotic-resistant bacterial strains into the UK no matter what we do here, as was stressed by the O’Neill report. United, coherent global action is required and the UK has been a strong leader in that respect. The importation of resistant bacteria is of particular concern post-Brexit. Like several speakers in today’s debate, the BVA and others have called for rigorous standards requiring the responsible use of antimicrobials on farms to be incorporated into future trade deals, with certain conditions put in about minimal antibiotic usage. This is a particular issue with regard to the US, for example, to which the noble Lord, Lord Crathorne, alluded. I assure him that I do not defend the scale or purposes of antibiotic use in animals that we see in the US. Can the Minister assure the House that the threat of importing antibiotic-resistant bacteria on meat products will be carefully considered in negotiating future trade deals?

The new UK five-year action plan sets out ambitious measures nationally and internationally in both human and animal usage to tackle AMR. In animals, a target is set to reduce antibiotic use by 25% between 2016 and 2020, with new objectives set beyond that for the next five years. In the longer term, and in addition to the reduction and restriction of antibiotic use, it is essential that we seek better ways of dealing with bacterial infections to avoid drug use, such as improved hygiene, biosecurity and other measures, particularly the development of vaccines—that has been mentioned, so I shall not emphasise it further. Vaccines against endemic disease are particularly needed. The Government are to be congratulated on mentioning the importance of endemic diseases in their Health and Harmony policy statement in 2018.

Will Her Majesty’s Government consider making available financial support under the public money for public goods agenda that we see in the Health and Harmony document and in the coming Agriculture Bill for measures that will reduce the development and spread of antibiotic resistance?

I, too, pay tribute to the efforts of the Chief Medical Officer, Dame Sally Davies, and the O’Neill commission, which have been hugely important in galvanising national and international attention on this subject.

Photo of Baroness Walmsley Baroness Walmsley Co-Deputy Leader of the Liberal Democrat Peers 3:57 pm, 2nd May 2019

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?

Photo of Baroness Thornton Baroness Thornton Shadow Spokesperson (Health) 4:07 pm, 2nd May 2019

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.

Photo of Lord Lansley Lord Lansley Conservative

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

Photo of Baroness Thornton Baroness Thornton Shadow Spokesperson (Health)

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.

Photo of Baroness Blackwood of North Oxford Baroness Blackwood of North Oxford The Parliamentary Under-Secretary for Health and Social Care 4:19 pm, 2nd May 2019

My Lords, I thank my noble friend Lord Lansley for securing a very important debate which has been filled with expertise and wisdom from all sides. I am grateful to him for saying that, if he could, he would have chosen to make this a “take note with approval” debate, which is not always the case when debating a government strategy.

My noble friend is right that antimicrobial resistance is one of the most pressing global challenges that we face in this century. Unchecked AMR threatens the achievement of many of the sustainable development goals, including those affecting health, food security, trade and labour supply. The World Bank estimates that an additional 28 million people could be forced into extreme poverty by 2050 through shortfalls in economic output unless resistance is contained.

In recognition of the threat of AMR, we published the strategy in 2013 and, as my noble friend has rightly said, we can count many significant achievements over the five years since. I pay tribute to him for the role he played in developing it before he moved on. We have seen unprecedented levels of research investment and collaboration, with £350 million having been invested since 2014. We have also reduced antibiotic use in humans by 7.3%, as he noted, and as the noble Lord, Lord Trees, who is an expert in this area, rightly pointed out, sales of antibiotics for use in animals have reduced by 40%. However, the noble Baroness, Lady Masham, said that this is of value only alongside the development of comprehensive surveillance systems, which we have also been putting in place.

Finally, resources and campaigns have been delivered for front-line staff. As the noble Baronesses, Lady Redfern and Lady Walmsley, said, they have an essential role to play in changing the culture and communicating with the public. I would like to point to a particular tool which has been developed, known as “Treat Antibiotics Responsibly Guidance, Education and Tools”. It turns into a fantastic acronym—TARGET—which I know the noble Baroness, Lady Thornton, will like. It is a toolkit of evidence-based resources to help clinicians and commissioners in England to reduce inappropriate antibiotic prescribing. Some 99% of CCGs promote this to their GP practices. I hope that responds to the question raised by the noble Baroness.

However, we must be up front about the scale of the challenge that AMR presents here at home, let alone in developing countries. As has been noted in the debate, resistance continues to increase. Between 2013 and 2017, we saw a 35% increase in resistant infections in humans here in the UK. Just as my noble friend says, this is a dynamic problem that requires a dynamic response. However, I would like to reassure the noble Baroness, Lady Masham, on her questions about Candida auris. It can establish itself within the hospital environment and be difficult to control, but currently the NHS has no persistent outbreaks. It is an uncommon fungus in the UK and our surveillance shows a low risk to patients in healthcare settings. No multi-drug resistant strains have been identified and there have been no deaths in NHS hospitals.

In order to respond to the dynamic challenge we face, the Government have recognised that no single five-year plan could deal with it, so we have set out our vision for a world in which AMR is contained and controlled by 2040 and we will continue to play our part in tackling the global problem of AMR by modelling best practice at home. Further, by supporting progress internationally through strong action to prevent infection generally, we will contain the emergence and spread of resistance. Alongside this vision we have published a five-year AMR national action plan which sets challenging five-year ambitions that will begin to fulfil the vision.

I would like to reassure the noble Baroness, Lady Thornton, on the question she raised regarding the workforce. Unlike the NHS Five Year Forward View, the NHS Long Term Plan commits to implementing the AMR national action plan which sets out to assess current and future workforce needs for strong infection prevention and control as well as antimicrobial stewardship. This should ensure that we develop the correct workforce targets. This is reassuring in terms of hoping we can achieve the priorities we have set out in the plan.

Our new plan includes a strengthened focus on infection prevention and control, renewing our commitment to halve levels of healthcare-associated Gram-negative bloodstream infections by 2023-24. It includes a world-first target to reduce the actual numbers of resistant infections, with an aim to reduce them by 10% by 2025. We will go further on our previous ambition to reduce antimicrobial prescribing, reducing it by a further 15% by 2024, strengthening stewardship programmes and raising public awareness, while ensuring rapid and timely treatment with antibiotics where it is essential to save lives. Through greater interoperability of data, we will develop real-time, patient-level prescribing and resistance data to inform antibiotic treatment, optimise life-saving treatments for serious infections and help develop new interventions to reduce AMR.

The noble Baronesses, Lady Masham and Lady Walmsley, are absolutely right that better use of diagnostic testing is essential. However, we found many challenges in this area over the last five-year period with the previous plan. We believe that, through data linkage work, by 2024 we will know which diagnostic tools and tests have been used in support of every prescription for antibiotics and will be able to target improvement. There is also further research work going on, which I will come back to.

The noble Baronesses, Lady Greengross and Lady Walmsley, and the noble Lord, Lord Trees, raised the important issue of vaccines for humans and animals, which play a key role in tackling AMR. One of the nine ambitions for change set out in our 2040 vision is to minimise infections in humans and animals. Optimising the use of effective vaccines will be critical in achieving this ambition. The national action plan includes commitments to stimulate more research into and promote broader access to vaccines. One of the ways in which we are doing this and supporting the development of the uptake of vaccines in lower and middle-income countries is through the Global AMR Innovation Fund and the UK vaccine network, as well as through our significant contributions to Gavi, the Vaccine Alliance and, more recently, through CEPI, the Coalition for Epidemic Preparedness Innovations—which, we understand, is having a significant impact on the pipeline.

My noble friend Lord Crathorne raised the question of the use of antibiotics as growth promoters. He was rather put right by the noble Lord, Lord Trees, but I will just repeat for the sake of certainty that since 2006 antibiotics for use as growth promoters have been banned in the UK and Europe, and they will continue to be.

This brings me on to a point raised by the noble Baronesses, Lady Miller and Lady Thornton, and a point of clarification on the response to Kerry McCarthy. The Government have confirmed their intention to implement their restrictions on the preventative use of antibiotics in line with EU legislation, but this will require a consultation with all interested stakeholders following the usual processes when amending domestic legislation. I hope that is a reassuring clarification. If noble Lords would like to follow up in writing, I shall be happy to respond on that.

I will respond to a follow-up point that also came from the noble Baroness, Lady Miller, and the noble Lord, Lord Trees, regarding trade agreements and AMR. I assure the House that any future trade agreements must work for consumers, farmers and businesses in the UK, and we will not water down our standards on food safety, animal welfare or environmental protection as part of any future trade deal. I hope that is a reassuring response.

I hope the noble Lord will forgive me, but following the debate I shall raise his point regarding AMR funding associated with the Agriculture Bill with the Minister and return to him.

I will now move on to the question regarding research and treatment development. Building on our research co-ordination and collaboration, we must continue to invest in research and to support the development of new, alternative treatments, vaccines and diagnostics. As noted by noble Lords from across the House, this is clearly essential if we are to make progress on the aims we have set out in what is rightly an ambitious plan.

Significantly, as my noble friends Lord Lansley and Lord Crathorne point out, the plan includes a commitment to lead the way in testing solutions that address the failure of companies to invest in the development of new antimicrobials. We are the first country in the world to announce that we will test new models that pay companies for antibiotics based primarily on a health technology assessment of their value to the NHS as opposed to the volumes that are used. This is an exciting and important step and we must fight hard to push it forward.

The noble Baroness, Lady Walmsley, asked about timelines. NICE and NHS England are leading on this complex work and a core team of experts and specialists are already in place. There is no delay in pushing forward this work. We anticipate it will take 18 months to two years to complete. The current NICE appraisal processes take about 49 to 60 weeks but this project requires a bespoke process to deal with the complexity of considering the full dimensions and value for antimicrobials. I look forward to reporting back to the House as the project continues.

We are sharing our learning with other countries and encouraging them to do the same or similar. I hope that we can push for this to be raised in international fora, as it is only when these kinds of pilots happen on a global scale that we can hope to see real progress. We hope that the data generated from this work will help other countries to think about how they value these precious drugs and how we can work with the industry to overcome market failure.

A number of noble Lords raised the question of a global fund. We have made some initial progress with the Global AMR Innovation Fund, GAMRIF, which has been set up. We are pushing at every opportunity to improve collaboration and to get support for it. However, it is a challenging picture and I hope to be able to report more progress in coming months.

On co-ordination, the national action plan was co-developed across government departments, agencies, the health family and the devolved Administrations, with an input from a wide range of stakeholders. We intend to continue in that vein as it is the only way in which we will make effective progress. The UK has played a lead role in strengthening international co-operation to tackle AMR, not least in securing the UN declaration at the General Assembly in 2016.

I pay particular tribute to the noble Lord, Lord O’Neill, for his ground-breaking early work and expertise in this area. I join others around the House who have paid tribute and expressed gratitude to Dame Sally Davies in advance of October. She has been a driving force on the global stage on this agenda. I have no doubt that, whatever happens in the autumn, her leadership will continue from Cambridge and beyond. It will be of tremendous value to the United Kingdom and everywhere else that she goes.

Whether it is getting it right with new antimicrobials and getting them through the pipeline or it is supporting the development and testing of rapid point-of-care diagnostics, the Government are clear that we want to improve the whole system. I am pleased to update the House: today I announced a new and expanded accelerated access collaborative to serve as an umbrella organisation for UK health and innovation. The new AAC will work with patients and the system to pull through the best and most cost-effective innovations, to get them to clinicians and patients faster than ever before. This includes the use of digital tools and health tech alongside the best new medicines. From new diagnostic tools to better identify people who need treatment, to improved ways of monitoring usage to ensure that patients complete treatment courses, together these innovations will help to address the growing threat of AMR.

I hope that with this information I have covered the points raised by noble Lords today. We can be proud of the work that we have done in the UK to secure AMR on the global agenda, not only as a health issue but as a “one health” issue with an enormous social and economic impact. We have invested to turn declarations into concrete actions and to support countries to develop their capacity to tackle AMR, improve global surveillance and undertake vital research and development. Through this plan we are setting out our challenge to ourselves and to other countries to continue life-preserving work to preserve antimicrobials for future generations.

In closing, I do not think that I can do better than to follow my noble friend in quoting from the IACG report to the Secretary-General:

“The challenges of AMR are complex … but they are not insurmountable”.

We should take courage from this, but should remember that our success will depend on the urgency with which we drive forward this response and the continued success in securing international collaboration. I believe that together we can achieve that.

Photo of Lord Lansley Lord Lansley Conservative 4:35 pm, 2nd May 2019

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.