Antimicrobial Resistance

– in the Scottish Parliament on 21st April 2022.

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Photo of Alison Johnstone Alison Johnstone Green

The next item of business is a debate on motion S6M-04070, in the name of Humza Yousaf, on the Scottish approach to managing the global risk of antimicrobial resistance. I invite members who wish to speak in the debate to press their request-to-speak button now.

Photo of Humza Yousaf Humza Yousaf Scottish National Party

Over the past two years, we have understood what it means to be faced with a health crisis that, at first, we could not treat, and we have seen its impact on so many areas of our lives. What would happen if many more infections could not be treated? What if antibiotics no longer worked to protect patients while they were undergoing surgery or chemotherapy? In reality, that is what could happen if antimicrobial resistance—AMR—was allowed to rise uncontrolled.

Today’s debate on this important global issue is the first in the history of devolution. I do not use the term “global threat” lightly, but AMR is a global threat. I want us all to be under no illusions about the severity of that threat. The World Health Organization has described the rise of antimicrobial resistance as

“one of the top 10 global public health threats facing humanity”,

and

The Lancet has published research that estimates that almost 5 million deaths in 2019 were associated with bacterial AMR. Of those, 1.27 million were directly caused by antimicrobial resistance.

However, there are things that we can do to address the threat and I want to focus on three key ways in which we can contain it. The first involves people, not only recognising the extraordinary efforts of those who are already working in the field in Scotland but looking into the future and thinking about those whom we will need to help us to combat AMR. The second way is through information flows. To address any problem, we must, of course, understand the nature of it, so I will talk about how we gather and share that data, both domestically and internationally, and the rationale for doing that.

Finally, we need to recognise the global nature of the issue. As we know, AMR does not recognise borders, so I will talk a bit about our international work in that regard. We know that AMR does not just spread between humans across borders and around the world but can develop and spread via animals and the environment. I will speak about the people and information flows across health and social care and about our work with global partners.

In closing the debate, my colleague Maree Todd will give some focus on our work in animal health and the environment. We need action in all those sectors and for them to work together to control and contain AMR, taking a one health approach to the problem.

I want to talk about all the people who are involved in helping us tackle AMR, because they are critical to our success in containing it. AMR control starts with infection prevention. Every time we use an antimicrobial drug, resistance has a chance to develop. Therefore, health professionals across Scotland work hard to prevent as many infections as possible and control them quickly when they happen, which not only helps the patients of today but avoids the use of some drugs altogether. That work helps to keep drugs working for the patients of tomorrow.

Sadly, we know that not every infection can be prevented. When infections occur, we need to use our life-saving antimicrobial drugs in the most appropriate and effective way. As a Government, we have invested in specialist antimicrobial pharmacists, healthcare scientists and researchers, who work together to get the right drug to the right patient at the right time. The right diagnostic tests, when they are undertaken promptly in our laboratories, can help identify the right drug for a patient’s particular infection and protect important treatments for the future.

In Scotland, we are fortunate to have groundbreaking organisations that lead the way on AMR. The Scottish Antimicrobial Prescribing Group—a consortium of prescribers from within the national health service—publishes regular guidance and educational materials for colleagues on the best possible use of antibiotics and other antimicrobial drugs. Prescribers have continued that critical task alongside their clinical work throughout the Covid-19 pandemic. With the SAPG’s help, spotting opportunities for good stewardship of those drugs can be part of every health and care professional’s job.

However, we are not just thinking about how to tackle the issue with our current workforce, as important as that is. A long-term problem requires long-term planning, so we are also taking stock of our on-going specialist workforce and staffing needs, building on the lessons that were learned during the pandemic by the infection prevention and control, antimicrobial stewardship and health protection workforces. We are working hard to determine and address our evolving service needs. That workforce not only safeguards antimicrobials but supports health and social care in the prevention and control of existing and new, emerging infections, which is of course critical to any future pandemic.

Every effective workforce needs to have appropriate data to manage their task and our clinicians have shown strong leadership in collecting surveillance data on AMR. In Scotland, we have the uniquely wide-ranging Scottish one health antimicrobial use and antimicrobial resistance reports, which are published every year in November to coincide with world antibiotic awareness week. The reports cover humans, animals, the environment and the food chain and are hugely important to our understanding of AMR. Only with the most accurate and up-to-date information can we keep track of how resistance is changing and evolving, in order to guide our health system continually towards the best possible treatments to use.

However, we want to go further. Learning from the Covid-19 pandemic, Scotland needs and deserves a once-for-Scotland electronic surveillance system for infection, which could support patients and staff on the front line of infection control and underpin our important AMR work. I have asked my officials to start looking into the best systems for Scotland.

Photo of Sandesh Gulhane Sandesh Gulhane Conservative

Although that is important, is it not also important to have communication between healthcare staff, so that they are able to talk to one another and see one another’s notes?

Photo of Humza Yousaf Humza Yousaf Scottish National Party

Dr Sandesh Gulhane raises an important issue—of course, he has first-hand experience in his clinical role—and that is why we have published our data strategy for health and social care. I commend it to Dr Gulhane and anybody in the chamber. Importantly, the strategy talks about not necessarily uprooting every information technology system across health and social care but about creating the cloud-based infrastructure that will be critical for sharing the information that the member talks about.

Photo of Michael Marra Michael Marra Labour

The minister talks about surveillance and issues of stewardship. Is the third leg of the tripod not discovery, and the fact that we need new interventions? Will the cabinet secretary or the minister cover that in their speeches?

Photo of Humza Yousaf Humza Yousaf Scottish National Party

Y es, of course—we will cover that aspect. That is why—I was going to come to this at the end of my contribution—I am keen to accept the Scottish Labour amendment in the name of Jackie Baillie, as it is very important that work is done on research and the various different research streams that exist. It is a very good amendment, and that is why we will accept it later today.

Lastly, I turn to the global nature of the issue that we are dealing with. It is a global crisis—AMR leaves no part of the world unaffected—so it requires a global response, and Scotland is rising to meet that shared challenge. Like climate change, AMR is an issue that does not respect borders. Resistant microbes can and do spread widely through the environment, and via people and animals travelling.

We work closely on the issue with colleagues from all four United Kingdom nations—in fact, I will be attending a ministerial round-table meeting on AMR with my colleagues from the other UK nations next month. With them, we will be discussing a new way to incentivise pharmaceutical companies to invest in research and development for new antimicrobials.

Scottish experts have played a leading role in the development of the UK’s national action plan on AMR, which runs from 2019 to 2024. The University of Strathclyde is undertaking some of the key research and modelling work underpinning the delivery of the plan on the contribution that is made by infection prevention and control. Nevertheless, I take Michael Marra’s point—there are various pieces of work under way, and it is important that we get an understanding of the landscape and bring that work together in a collaborative way. That is why, as I said, we will be supporting the Labour amendment on the role that the Scottish Funding Council could play in that regard.

We are also looking much further afield. Like climate change, AMR is a threat to the achievement of the United Nations sustainable development goals and to the hopes and aspirations of millions, which is why we seek to work globally on the issue. To give one example, the Scottish Antimicrobial Prescribing Group has been working in partnership with Ghanaian colleagues for several years on helping to improve antimicrobial prescribing and practice in Ghanaian hospitals. We are now considering what further work we can do as part of Scotland’s international development work.

I note with slight disappointment that the free trade agreements that the UK Government has concluded since European Union exit have been lacking in ambition on AMR. My ministerial colleagues have written to the UK Government to express Scotland’s regret on that issue and to push the UK Government, perhaps in future free trade agreements, to increase its ambition in that respect.

I suspect that most people in the country have probably not heard of the threat that AMR poses—why would they? However, given the severity of the potential impact of AMR, we have a collective duty to raise awareness of the dangers of antimicrobial resistance. We all have a role to play—we can all listen to our healthcare and veterinary professionals and take their advice on whether we, our family members and our cats and dogs really need that antibiotic. We can take unused drugs back to the pharmacy, where they will be properly disposed of so that they do not end up in our environment.

AMR is an enormous challenge, and tackling it requires conscientiousness and creativity in health and social care, in veterinary surgeries, on farms, in laboratories and when working with international partners. It requires professionals from different sectors and backgrounds to work together, and we in Scotland have been doing that. Despite the threat of resistance and the many ways it can spread, what is happening in Scotland is a positive story, but there is much more to do. As I said, we intend to accept the Labour amendment today. I look forward to what will undoubtedly be a thoughtful and considered debate.

I move,

That the Parliament recognises the extraordinary positive impact of antibiotics and other antimicrobial drugs in the health and social care system; recognises the terrible costs, in terms of morbidity and mortality and wider societal and economic impact, of antimicrobial resistance (AMR), and notes the ongoing risk posed to Scotland and the world if AMR continues unchecked; acknowledges the effective One Health approach to tackling AMR taken by Scotland; welcomes the ongoing commitment of the Scottish Government to contain and control AMR, including through participation in the UK’s 20-year vision for antimicrobial resistance and five-year National Action Plan; recognises the hard work and commitment of those working to contain and control AMR within the NHS and across all One Health sectors in Scotland, and acknowledges that everyone in Scotland has a role to play in antimicrobial stewardship, preserving the effectiveness of antimicrobial drugs in the years to come.

The Presiding Officer:

Before we move to the next speech, members will wish to be aware that there is time for me to give time back for any interventions.

Photo of Jackie Baillie Jackie Baillie Labour

Although I absolutely understand the importance of discussing the global risk of antimicrobial resistance, this debate was supposed to be a chance for us to discuss the impact of long Covid in Scotland. I hope that the Presiding Officer will allow me just a little latitude to mention that first, before I turn to the substance of the debate.

In doing so, I note that the one health approach to tackling antimicrobial resistance was actually adopted in Scotland in 2016. The Government has had six years to bring forward a debate, but it has not done so until now—not once in that entire six-year period. The situation surrounding long Covid could not be more urgent and, for the 132,000 people across Scotland who are living with the condition, the debate could have provided much-needed information and impetus for the Scottish Government to act. This could have been the opportunity for the Scottish Government—

Photo of Jackie Baillie Jackie Baillie Labour

Let me finish my point, and then I will give way by all means.

This debate could have been the Scottish Government’s opportunity to tell us whether it has finally spent any of the £10 million that was announced for long Covid treatment seven months ago, and to share what research it has done on the condition since we first learned about it two years ago. I suspect that the reason why the debate has been cancelled is that few bids have been made for the money, because health boards are too busy fighting the latest wave of Covid overwhelming our hospitals. Perhaps just giving them the money for them to get on with making the provision is the best thing to do, rather than micromanaging help for long Covid sufferers who, in the meantime, have to suffer for even longer.

Instead, the debate was changed at the very last minute. Scared of criticism, and with political spin at the forefront of its consideration, the Scottish National Party Government cancelled the debate. It made the wrong decision. In truth, both debates are required.

I will give way to the cabinet secretary and then I will turn to antimicrobial resistance.

Photo of Humza Yousaf Humza Yousaf Scottish National Party

I thank Jackie Baillie for giving way, but I regret her inaccurate characterisation of why the debate is being held. It is not unusual for business to be revised, but the debate has not been cancelled; it will take place in a few weeks. The reason for that is precisely because we will then be able to put into the public domain the detail that Ms Baillie is rightly asking for. That is what she wants and it is what stakeholders want. To suggest that the debate has been cancelled is incorrect. Subject to the Parliament’s agreement, it will take place in the next few weeks.

Photo of Jackie Baillie Jackie Baillie Labour

I simply say that people will look at the record and will see that we have waited for six years for a debate on antimicrobial resistance, but there has not been anything in that entire time, while a debate on long Covid, which is about people experiencing the most dreadful symptoms now and not getting treatment, has been put off until some point in the future.

If left unchecked, resistance to antimicrobial drugs could have long-lasting and profound effects on global health. Routine surgeries such as hip replacements and organ transplants could become less safe. Childbirth could be more dangerous. A number of infections such as urinary tract infections, pneumonia and tuberculosis could become harder to treat or require a stay in hospital.

A report that was published late last year found that the total use of antibiotics in Scotland has fallen by 17.1 per cent in the past five years. That is positive progress, but the report also found that antibiotic use in hospitals is up by 2.3 per cent since 2016. Despite the statistics showing that the use of antibiotics has generally decreased, it is important to recognise that Covid-19 might have altered the picture. Although antimicrobial usage has decreased in primary care, there have been increases in prescribing by dentists, for example, because of limited options for dental treatment during the pandemic. It is also important to consider greater public awareness of infection prevention during the past two years, including hand washing and mask wearing, and an overall decrease in socialising, which has reduced infection transmission.

However, this is not an issue that is reserved to Scotland or one that can be fixed simply by taking a Scottish approach. Antimicrobial resistance is prevalent across the globe, with countries in sub-Saharan Africa and south Asia experiencing the highest death rates. In Europe, rates of resistance in the south are greater than in the north and, as we saw during the pandemic, the spread of virus and bacteria is not stopped at a border.

If the global spread of a disease is coupled with antimicrobial resistance, there is the threat of future pandemics. The Government must have plans in place to support our NHS and care sector. Scotland’s hospitals are already under great strain. Patients are waiting for up to eight hours to be seen in accident and emergency departments, and we know from the Royal College of Emergency Medicine that there is clear evidence that long waits in emergency departments are directly associated with patient death. We must therefore act to prevent antimicrobial resistance from impacting on the NHS in the future.

As antimicrobial resistance makes infections more difficult to treat and leads to longer hospital stays, the NHS will be faced with higher medical costs and increased mortality, so it is right for us to co-operate across the UK and globally to deal with that. When the MRSA crisis posed a similar threat more than a decade ago, Scottish Labour took action, which was then followed up by the SNP.

We established a system of national mandatory surveillance of MRSA, developed the introduction of an antimicrobial resistance strategy, created new standards for hospital infection control and cleaning services, and invested in better facilities for decontaminating reusable medical devices. Those steps were delivered quickly and effectively, and made the difference between life and death for many people.

The World Health Organization ranks antimicrobial resistance as one of the 10 greatest global public health threats facing humanity. It has highlighted the concerning development of multi and pan-resistant bacteria that cause infections that are currently untreatable. As we come out of the pandemic, many people will be left with weakened immune systems, which means that there is a danger of long-term health problems such as long Covid interacting with untreatable diseases. That is a cause for concern.

Labour’s amendment seeks not just to highlight but to support the Scottish research environment. There is much work being done by Scottish research groups on the key themes of surveillance, stewardship and discovery. We know that their share of research council income peaked in 2012-13 but has declined since then. As we are now outside the formal EU research environment, we must do everything that we can to rebuild the international collaboration and the partnerships across the UK that are so critical to advancing research in antimicrobial resistance. Tasking the Scottish Funding Council with a rapid review of resource options would be a simple yet impactful step.

Eighteen higher education institutions in Scotland already conduct research in this area, which is welcome. The Scottish Government should outline what financial support it can give to ensure that Scotland is on the front foot when it comes to dealing with the looming crisis. How much funding is being allocated to such work? The NHS must also be given the research and development capacity and the funding that are required to tackle the issue effectively, to monitor microbiological data, and to train and educate staff on such issues.

WHO scientists are concerned that Covid-19 has caused greater inappropriate use of antibiotics, which makes the risk of antimicrobial resistance greater still. People in care homes with specific needs are particularly susceptible. I hope that the Scottish Government will make sure that the rise of antimicrobial resistance in our care homes is addressed at pace, because we cannot allow residential care to become the ground zero of antimicrobial resistance.

Antimicrobial resistance is real, it is a threat to modern medicine and it is important that the Scottish Government acts now to fund research and to prepare the health service and our care sector for all eventualities. We need to learn from the mistakes that were made during the pandemic to ensure that Scotland is not once again caught on the back foot.

I am grateful to the cabinet secretary for his support for the Labour amendment.

I move amendment S6M-04070.1, to insert at end:

“, and believes that the Scottish Funding Council should be tasked with a review of domestic and global funding streams available to Scottish universities and research groups to contribute to the global research efforts in AMR and avenues to UK and international research partnerships.”

Photo of Sandesh Gulhane Sandesh Gulhane Conservative

I refer members to my entry in the register of members’ interests. I am a practising NHS doctor. Therefore, I am probably the only member here who can legally prescribe antibiotics.

Photo of Maree Todd Maree Todd Scottish National Party

I declare that I, too, am a prescriber.

Photo of Sandesh Gulhane Sandesh Gulhane Conservative

I said “probably”.

Today’s debate is very important in its own right, and I believe that there is consensus across the Parliament on much of our approach to tackling antimicrobial resistance. That said, the Scottish Government’s motion, like so many of its other motions, is somewhat self-congratulatory, and it does not call for any specific action. That is why, like the Scottish National Party, we will support the Labour amendment.

Before I drill into the subject, I would like to pay respect to the more than 130,000 Scots who are struggling with the debilitating condition that we were supposed to be addressing today, before the SNP-Green Government pulled the debate from the schedule. We received the revised agenda only about two days ago. That move did not go unnoticed by many of the people up and down the country who are struggling with long Covid and are still waiting for the Scottish Government to deliver a credible action plan.

The cabinet secretary has said that the reason for the delay is to allow the Government to make an announcement, but I have been talking about long Covid since I got here and it has been eight months since the cabinet secretary announced money for it. Despite that, we are still apparently not ready for a debate on the issue. We look forward to the discussions that will take place after the elections.

In today’s revised business, we are focusing on Scotland’s approach to managing the global risk of antimicrobial resistance, or AMR. I will start by travelling back some 94 years. Before Alexander Fleming discovered penicillin, in 1928, an infection caused by a simple cut could mean the end of life. The discovery of penicillin was a game changer in medical history. There was a famous case of a surgeon performing the amputation of a limb in which that one surgery killed three people: the patient, the surgical assistant who was holding the patient down and who was cut, and the surgeon, who managed to nick himself with his blade. They all died because of the inability to treat infection.

Why did that happen? When antibiotics kill bacteria, there is a chance that a random mutation—such as the one we see in the Covid virus—will allow the bacterium to evade antibiotics, giving it an advantage from which it profits. The bacteria then reproduce and dominate. As antibiotics lose their ability to kill strains of microbes, and if we cannot deliver new drugs that can beat those bugs, then by 2050 we can expect about 10 million deaths per year worldwide in people aged under 30 to be caused by drug-resistant infections. That would be more than the number of deaths caused today by cancer and diabetes combined.

Back in 2013, seven years before Covid, Dr Susan Hopkins, the chief medical adviser to the UK Health Security Agency, said that AMR was a “catastrophic threat”. She said:

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

Can we imagine a return to the days when childbirth, a cut in the arm or even an insect bite could give rise to the serious risk of death? That might seem far fetched, but did we heed the warnings about a possible respiratory pandemic? We are not working fast enough to deal with long Covid. Warren Buffet once said:

“What we learn from history is that people do not learn from history.”

I hope that he is wrong about AMR and long Covid. We cannot allow ourselves to emerge from the Covid pandemic and enter another crisis, either of AMR or of long Covid.

AMR infections cause an estimated 700,000 global deaths each year. In the UK, AMR causes an estimated 12,000 deaths per year. It was recently reported that antibiotic resistance increased by 4.9 per cent between 2016 and 2020. That means that one in five people with a bloodstream infection in 2020 had an infection that was resistant to antibiotics, which is a potentially life-threatening situation.

There are now strains of tuberculosis that are resistant to almost all lines of treatment. The number of TB deaths has increased for the first time in a decade and global targets are no longer being met. When I was on my infectious diseases rotation during my training, I saw a patient who was stuck for months and months in a small negative pressure room because he had a multidrug-resistant strain of TB. His mental health was awful. He was sick because of the severity of the side-effects of the antibiotics that he had to be given.

What are we doing about AMR? Clinicians are reducing their use of antibiotics, where possible. GPs have decreased prescribing by 20 per cent since 2016, although we have seen a 2.3 per cent increase in hospital prescriptions over the same period.

Can we come up with new drugs to replace the ones that do not work any more? Unfortunately, it is not that easy. No new class of antibiotics has been developed since 1987, and the market for antimicrobials is broken. Developing new antibiotics is massively expensive and there are only 40 antibiotics in clinical trials globally. The problem is compounded by the fact that new antibiotics should be used sparingly, which affects the risk-to-return ratio.

In order to overcome the high failure rate of new antimicrobials, the UK Government has stepped in and developed an innovative solution that is now being tested. The model moves away from paying for individual packs of antimicrobials and towards making an annual payment that is based on the health benefits to patients and the value that the drug adds to the NHS. That new subscription-style payment is a win for the NHS and for industry. Patients benefit from a secure supply of new antimicrobial drugs, while pharmaceutical companies can reliably forecast a return on their investments.

The UK Government is also committed to investing in health research, increasing public research and development investment to record levels equating to £20 billion by 2025, which is an increase of about a quarter in real terms. I take it that the cabinet secretary welcomes that commitment.

In Scotland, we are fortunate to have expert intelligence, evidence-based guidance, clinical assurance and clinical leadership. NHS National Services Scotland has a department that is dedicated to reducing the burden of infection and antimicrobial resistance, and its experts are represented on the UK’s advisory committee on antimicrobial prescribing, resistance and healthcare-associated infection. That four-nation body provides practical and scientific advice to the UK and devolved Governments on minimising the risk of healthcare-associated and drug-resistant infections. I am interested to know whether the cabinet secretary shares my view that AMR and, indeed, other pressing health crises that may emerge are best tackled on a four-nation basis, with not just Scottish data and research solutions but four-nations ones.

In 2019, the UK and devolved Governments set out a joint vision for containing and controlling AMR by 2040. That is supported by a five-year national action plan with clear targets. The commitment to reducing the need for antimicrobials by lowering the burden of infection in our communities, in the NHS, on farms and in the environment is serious. That one health approach has seen antibiotic use in farmed animals decrease by 52 per cent since 2014, and there has been a decrease of 79 per cent in the sales of veterinary antibiotics that are most critical for human health.

The UK plays a leading role in tackling AMR on the world stage. That was witnessed when Britain used its G7 presidency to secure an ambitious commitment on AMR to strengthen the resilience of antibiotic supply chains and develop sustainable, clean and green solutions for antibiotic manufacturing.

AMR is a global problem that requires global action. This is not the time to pat ourselves on the back. We cannot be distracted, and our children would never forgive us if we failed. We must step up our efforts to work seamlessly across the UK to deliver on the national five-year plan and control AMR by 2040. In doing so, we can ensure that Scotland’s world-class expertise maximises its contribution to global research efforts through the UK and international research partnerships.

Photo of Emma Roddick Emma Roddick Scottish National Party

A nyone who works in, or has worked in, the NHS or, indeed, anyone who knows someone who spends a lot of time in hospital or a care home will understand the massive importance of tackling antimicrobial resistance.

I admit that, back in 2020, when we first started putting antibacterial gel on everything, I felt a bit anxious about what that—and the inevitable group of people who, no matter what doctors tell them, insist that amoxicillin somehow makes their viral infection go away more quickly—might do to bolster the other, slower pandemic. It is important to reiterate now what the Scottish Government, health advisers and many others have been saying weekly for the past few years: washing our hands is the best thing that we can do to prevent spreading viruses. Washing for 40 seconds will prevent bacteria from developing resistance, and the overuse of hand sanitiser might do the opposite.

Anti-infectives such as antibacterial spray and hand sanitisers have their place in hospitals and homes in which there is an active infection, for example, but they also deserve real consideration in tackling AMR. Indeed, reducing unintentional exposure to them is a policy in the five-year action plan that we have signed up to. Using them more responsibly may have been quite a difficult circle to square in the peaks of the pandemic, but now is probably a good time to start to educate people better and encourage them to read labels, use the appropriate kind of sanitiser and stick to hand washing when possible. We desperately need to be able to rely on disinfectants and other anti-infectives in hospital, and it is simply not worth risking that to save 40 seconds of our time.

We also have to be able to trust that, when we are prescribed antibiotics, we need them. The reduction in unnecessary antibiotic use due to increased awareness of, and action against, AMR as well as research that has provided better knowledge of when antibiotics are not needed is a key part of building that trust.

Similarly, we have to be able to trust that, when we need antibiotics, those antibiotics will work. That will continue only as long as everyone honours their responsibility to preserve the effectiveness of those drugs. What the Scottish Government needs to do—we have heard from the cabinet secretary that the Scottish Government is doing this—is ensure that the public are armed with the knowledge that they need to understand when antibiotics are simply not useful and why AMR is a very real threat to our future healthcare standards.

It is heartening to see that Scotland’s efforts in tackling AMR are already showing strong results. We have cut the number of post-surgical deaths and we have a patient safety record that is among the best in the world.

It is right that part of Scotland’s approach to managing the risk is signing up to the UK’s five-year action plan and 20-year vision. Alongside in-house efforts such as our world-leading patient safety programme, Scotland is working closely with other countries in the UK on this global issue. That is exactly the sort of international co-operation that Scotland should seek to nurture.

Following Brexit, it is more important than ever to build links and share knowledge, funding and efforts. Resistance anywhere in the world poses a risk to Scotland and the UK, and a global effort is required to overcome that. I am glad to see Scottish Labour’s amendment recognise that, and I am happy to support at decision time its position on the Scottish Funding Council reviewing the funding streams that are available to our universities and research groups.

Whatever constitutional situation Scotland is in, co-operation is vital. The Scottish approach of working closely with other countries to promote best practice and tackle AMR is undoubtedly the right one to take, and I look forward to seeing the trend of better managing antimicrobial resistance continue.

Photo of Michael Marra Michael Marra Labour

I compliment Emma Roddick on her fine speech, which included practical advice on how we can all contribute to tackling AMR. We appreciate her support for and comments on Labour’s amendment.

AMR is, as other members have said, near the top of most lists of global risks that we face collectively. However, so was a pandemic, and our preparedness in Scotland and internationally was chronically limited. Some of the exercises that we undertook to prepare for a pandemic were insufficient. We have to take such big global warnings an awful lot more seriously.

We should be clear that no one anywhere is doing enough to deal with AMR. That point was made clear to me time and time again in my conversations with clinical and research colleagues on the subject in recent days. There has been limited progress in different places, but the pandemic has been a huge distraction for our scientific and medical communities, which would otherwise have been focused on other issues. It is entirely appropriate that that effort was put in, but we know that there has been a lack of progress on AMR as a result. That is just one of many deep and hidden consequences and opportunity costs that come from dealing with the global ramifications of the Covid pandemic.

However, as other members have pointed out, the warnings about AMR are nothing new. The great Scottish scientist Sir Alexander Fleming, who discovered penicillin, the first antibiotic, spoke of microbial resistance in his acceptance speech for the Nobel prize in 1945, which was five years after resistance was first detected. He specifically highlighted underdosing—that is, the need to use a limited and low-level amount of prophylactic antibiotics to prevent such medicine from being rendered ineffective over time. Therefore, as has been pointed out, the analysis of the issue is nothing new.

As colleagues have pointed out, for many, the idea that childbirth, routine surgery or nothing more than a cut finger could result in death is unimaginable. However, that is the day-to-day lived experience for many people across the world. The advances that Fleming and his many collaborators and successors unleashed have transformed health systems across the world, and they have held out the promise of more certain, happier lives to billions.

It is estimated that the retreat of the broad applicability of antibiotics risks global costs of $100 trillion by 2050. Each year, more than 1 million people globally die as a result of antimicrobial resistance. If we do nothing, or continue on the current course, the figure looks set to reach 10 million lives lost a year, which will eclipse the 8 million lives that are lost to cancer each year.

The O’Neill report, which was issued in 2017, was a call to arms on AMR. The review was requested by David Cameron, the then Prime Minister. In my view, he is probably the most incompetent Prime Minister that the country has seen in a more than 200 years—although the incumbent PM is in competition with him in that regard—but that was one of the very few positive things to be issued during his premiership.

Our work in surveillance, stewardship and discovery has been utterly critical and, as a country with highly advanced medical and research infrastructure, it is incumbent on us to do much more. The response to the 2017 report has been nowhere near commensurate with the scale of the threat that was identified.

In my last few seconds, I want to highlight some of the outstanding research work that is being done in our universities. I am keen to draw attention to the work of Professor James Chalmers at the University of Dundee. Professor Chalmers has become a familiar figure on our television screens due to his vital work on the Covid pandemic. He and his research team are having a global impact. Prior to the emergence of Covid-19, his studies included phase 1 and phase 2 studies of non-antibiotic alternative therapies for respiratory infections, diagnostics to reduce antibiotic use and much more.

I would have been citing Professor Chalmers’s work today, if the promised long Covid debate been delivered. His research is proving the high prevalence and debilitating nature of that condition and the various groups to whom it is a particular risk. That is an illustration of the displacement that has been a result of the pandemic and its impact on the research community.

We are grateful for the support of the Scottish Government and the other parties for our amendment. AMR work is vital, and it must be not just put back on the track that it was on previously, but reinvigorated and accelerated.

We are keen to have a health check on the research environment that has been blown off course. We have to acknowledge as a Parliament the fact that our universities have lost their lead in research funding capture over the past decade. As Jackie Baillie pointed out, in 2013 we had a 10 per cent lead on the rest of the United Kingdom, and we are now in a situation of parity.

That analysis by the Scottish Funding Council should focus on surveillance and stewardship, but it must also focus on discovery and the idea that new therapies can be put in place. We can be proud and hopeful that the drug discovery unit at the University of Dundee—the most influential institution on pharmaceuticals in the entire world—is turning its guns on antimicrobial resistance by developing entirely new kinds of drugs.

Our Scottish Government should be doing everything in its power to support those efforts and avoid the terrible and unfortunately predictable consequences of failure.

Photo of Fulton MacGregor Fulton MacGregor Scottish National Party

I am grateful for the opportunity to speak in this very important debate.

As members have said, Scotland has always proudly been at the forefront of revolutionary scientific breakthroughs, and it was of course a Scotsman, Alexander Fleming, who pioneered research into antimicrobials almost 100 years ago. In the century since Dr Fleming’s work, innumerable lives have been saved thanks to the discovery of antimicrobials. It is impossible to put an exact figure on that, but the World Health Organization estimated that antimicrobials have added roughly 20 years to global life expectancy.

For many, antimicrobials have seemed to be a miracle cure, and although that sentiment may be true, it is a double-edged sword, as we have heard today. Overreliance on antimicrobial treatments can encourage evolutionary pressure favouring antimicrobial-resistant organisms. Indeed, the WHO noted that, in 2019, 1.27 million global deaths were attributed to ineffective treatments due to AMR.

Even for less severe ailments and conditions, AMR can lead to longer recovery times, resulting in lengthier hospital stays, higher medical costs for our NHS and prolonged suffering for patients—Dr Gulhane made that point very well. Tackling AMR must remain a key priority for the Scottish Government and our NHS. I am proud to say that Scotland is already a world leader in fighting antimicrobial resistance, and that must continue.

Both the Scottish Government and NHS Scotland contributed to the UK Government’s five-year action plan, “Tackling antimicrobial resistance 2019-2024”. The action plan is a stepping stone towards the aim that, by 2040, AMR will be effectively contained and controlled through strong mitigation. It is important to emphasise that the plan does not foresee the eradication of AMR, as AMR is, by definition, an ever-evolving issue that requires constant vigilance.

A key step taken by Scotland that came from the action plan was the establishment of the Scottish one health national AMR action plan group. The group works in collaboration with UK and European colleagues in conducting research to understand the risk factors for developing new antimicrobials, as well as research into the effectiveness of interventions, aiming to drive behavioural change around antimicrobial use among healthcare professionals and the general public.

I mentioned that Scotland has been a world leader in fighting AMR, and that is evident in the Scottish patient safety programme, which was introduced in 2008. The programme is a national quality improvement scheme that aims to improve the safety and reliability of care and reduce harm. Importantly for this debate, a key facet of the programme is ensuring that patients are treated responsibly and safely with the right medicines across a wide range of care settings. Since the implementation of the programme, the number of hospital and post-surgical deaths and complications has been cut significantly. Two major illnesses that have direct links to AMR—MRSA and C difficile—have seen their numbers fall year on year since the programme began.

There are three methods by which the Scottish Government could continue to mitigate AMR. The first is to reduce the need for antibiotics, which can be achieved by measures such as continuing to hold food standards to the highest level, ensuring animal safety through protection from infection and preventing environmental changes that can cause epidemics to develop.

The second is to ensure that antimicrobial use is optimised and used only when necessary. Programmes such as the aforementioned SPSP are vital in educating healthcare professionals on the matter. However, as the cabinet secretary said, we all need to take personal responsibility for when we, our children or other dependants, and our pets need antibiotics.

The final method is for the Scottish Government to continue to invest in expert research on the topic of AMR. As well as basic research, specialised research into new therapeutics, diagnostics and best practice will be invaluable in our continued fight against the problem.

In 2018, at the start of the previous parliamentary session, I did some work with Christine Bond from the University of Aberdeen. Among her many titles is trustee of Antibiotic Research UK. She said that there was a test that could show whether antibiotics would work and questioned why health authorities around the world were not using it. She has also done quite a lot of research on probiotics. The Scottish Government and others should look at her work, if they have not already done so.

I thank the Presiding Officer for the opportunity to speak in this important debate. There are things that the Scottish Government and our NHS have done very well, but we will need to continue that excellent work to challenge the problem in future.

Photo of David Torrance David Torrance Scottish National Party

Antimicrobial resistance has emerged as one of the most serious public health issues of the 21st century. It poses a threat to the effective prevention and treatment of an ever-widening range of infections caused by bacteria, parasites, viruses and fungi that are no longer susceptible to common medicines. Antibiotic resistance in bacteria makes the problem of AMR even worse. To varying degrees, over several decades, bacteria that cause common or serious infections have developed resistance to each new antibiotic that comes to the market. Faced with that fact, we must all—not just here in Scotland but worldwide—take action to avert a global health crisis.

We have heard warnings from the Wellcome Trust that, without effective antimicrobial drugs, many routine surgeries could become life threatening, with common infections becoming untreatable. Several fields of modern medicine that every one of us takes for granted, including hip replacements, intensive care for pre-term babies, chemotherapy for cancer treatment and organ transplants, depend on the availability of effective antibiotic drugs. Those treatments, along with many other activities, could not be performed without effective antibiotics.

The economic impact of antibiotic resistance is difficult to assess because a number of far-reaching consequences must be taken into account. For example, increased resistance leads to elevated costs associated with more expensive antibiotics, specialised equipment, longer stays in hospital and isolation procedures for patients.

In 2015, the Review on Antimicrobial Resistance estimated that, by 2050, failure to act on AMR could result in 10 million lives being lost each year to drug-resistant strains of malaria, HIV, tuberculosis and certain bacterial infections, at a cost to the world economy of $100 trillion. That is further compounded by startling figures from the World Bank Group, which estimates that, unless resistance is contained, an additional 28 million people could be forced into extreme poverty by 2050 through shortfalls in economic output. The World Health Organization has declared antimicrobial resistance to be one of the top 10 global public health threats facing humanity. With numbers like those, it is clear to see why.

The symptomatic misuse and overuse of antimicrobial drugs such as antibiotics is widely believed to be one of the main drivers for microbes developing resistance. The inappropriate use of antibiotics is also a factor, particularly self-medication, because it almost always involves unnecessary, inadequate and ill-timed dosing, which creates an ideal environment for microbes to adapt rather than be eradicated.

There is also recognition that a substantial percentage of total use occurs outside the field of human medicine, with the use of antibiotics in food-producing animals and agriculture a major contributor to the overall problem of resistance. The one health approach to tackling AMR, adopted in Scotland in 2016, acknowledges that the health of humans, animals and the environment are interconnected and that an efficient approach to tackling the issues must be co-ordinated in a nationwide effort.

“Tackling antimicrobial resistance 2019-2024: The UK’s five-year national action plan”, which supports “Contained and controlled: The UK’s 20-year vision for antimicrobial resistance” and which the Scottish Government and NHS Scotland contributed to, recognises that AMR cannot be eradicated. The planned focus is on three key aims to tackle it—reducing the burden of infection; optimising the use of antimicrobials; and developing new diagnostic therapies, vaccines and interventions with the core ambition of securing a world in which AMR is contained, controlled and mitigated.

The establishment of the Scottish one health national AMR action plan group, which is led by Health Protection Scotland, to co-ordinate the delivery of a UK five-year national plan has seen research undertaken to enable us to better understand the risk factors for acquisition of certain resistant organisms and the outcomes, as well as research into the effectiveness of interventions that are aimed at driving behavioural change around antimicrobial use.

Globally and at home, the progress on AMR is hugely encouraging. Initiatives such as Scotland’s world-leading patient safety programme are delivering substantial results, for which our NHS Scotland staff must be commended.

I welcome the significant work that is under way to develop new evidence-based interventions to prevent infections, decrease the need for use of antimicrobials and, in turn, reduce the potential for the development of resistance. I also applaud the commitment of those who are working to contain and control AMR in our NHS and across the health sectors in Scotland.

This slow-burning pandemic affects every one of us, and awareness must continue to be raised globally, nationally and locally. We all have a role to play in sustained action to prevent the need for antibiotics to be used and reduce drug-resistant infections in order to secure the future delivery of our healthcare.

The Deputy Presiding Officer:

I call Gillian Mackay, who is joining us remotely.

Photo of Gillian Mackay Gillian Mackay Green

Antimicrobial resistance is a global concern and my speech will focus largely on the global situation. AMR threatens our ability to treat common infections and could lead to the rapid spread of so-called superbugs, which cause infections that are not treatable with existing antibiotics. According to a report that was published in January on the global burden of bacterial antimicrobial resistance, an estimated 4.95 million deaths were associated with such resistance in 2019, including 1.27 million deaths that were directly attributable to bacterial AMR.

The World Health Organization has warned that not enough new antimicrobials are being developed and that a lack of access to quality antimicrobials remains a major issue. Antibiotic shortages are affecting countries and healthcare systems all over the world. The UK Government’s five-year strategy states:

“Antimicrobials are crucial medicines in modern healthcare, yet up to two billion people still lack access to them.”

For most antimicrobials, few replacements or alternatives are being developed. According to the UK Government,

“Research and development of the vaccines, diagnostics, tools and tests needed to prevent infections is similarly lacking.”

The WHO has highlighted that greater innovation and investment are required in the research and development of new antimicrobial medicines, vaccines and diagnostic tools. The UK Government must provide greater support for that as a priority.

The cost of antimicrobial resistance to both healthcare systems and patient care is significant as it means prolonged hospital stays and more expensive and intensive care.

If we do not tackle AMR, more people will be pushed into poverty. Although it is true that AMR is a global problem that affects all countries regardless of borders, it does not affect all countries equally. Studies have shown that the burden is disproportionately higher in low and middle-income countries. We therefore have a responsibility to act.

High rates of resistance to antibiotics that are often used to treat common bacterial infections have been observed globally, and they indicate that we are running out of effective antibiotics. A well-known example of a bacterium that is resistant to a number of antibiotics is MRSA, which has caused infections around the world that are difficult to treat.

As we have heard, antibiotic resistance is not purely a health issue. Evidence and research papers continue to be published on the implications of routine antibiotic use in farming, which can expose people to antibiotic-resistant micro-organisms through contaminated food or water. Although routine antibiotic use is less prevalent in Scotland, we should keep it in mind when scrutinising trade deals that the UK Government is seeking post Brexit.

That is also not confined only to terrestrial farming practices. Globally, aquaculture is an increasing contributor to antibiotic use. According to an article in the journal

Nature by Schar et al, global antimicrobial consumption in aquaculture was estimated at 10,259 tonnes in 2017.

While antimicrobial use in Europe is likely to reduce by 2030, in Africa, for example, it is likely to increase. We need to ensure that sufficient protein sources can be produced in developing nations to meet nutritional needs, while tackling the global issue of antimicrobial resistance. That makes it a social justice issue, as well as a health one.

Releasing antibiotics or their metabolites into the environment could increase the emergence of antibiotic genes. That release could be from hospitals or agricultural run-off, for example, and could enter the food chain or water system. Antibiotic resistant organisms can also follow the same path. Another paper by Schar et al, published in

Nature in 2020 says that those types of environments become likely hotspots for the development of new antibiotic resistant genes. Humans come into contact with resistant micro-organisms through numerous routes, including the consumption of contaminated foods, interactions with animals and in contaminated environments. Ensuring that we minimise antibiotic use and explore other therapeutic avenues will, I hope, reduce the instances of those interactions.

Antiviral drug resistance is also an increasing concern among immunocompromised patients, as resistance has developed to most antivirals. Without the tools to prevent and treat drug-resistant infections, more treatments will fail and medical procedures will become more risky. While new antimicrobials are needed now, if the way that we currently use antibiotics is not changed, then they will suffer the same fate as existing ones. Antibiotics have saved millions of lives since they were first invented. We must act now to ensure that treatment with antibiotics remains effective, now and for generations to come.

Photo of John Mason John Mason Scottish National Party

I am happy to confess that the subject is not my main area of expertise, either from my professional background or since I came to the Parliament. However, I did first come across the issue when I lived in Nepal in the 1980s, in relation to both leprosy and TB. I am focusing on the ‘world’ aspect that is mentioned in the motion and I welcome the cabinet secretary’s mention of Ghana in his opening speech.

Leprosy was fairly common in Nepal, and for both that disease and TB, there was and is a problem with people not completing their treatment course and therefore not being cured while also building up resistance. That was entirely understandable as people were having to pay for drugs and many were from a very poor background. It was not surprising that when their symptoms receded they did not continue with treatment that they could ill afford. Money was very tight in the hospital in Tansen where I worked, and we had to assess people before they could get treatment, as sometimes richer people would turn up disguised as poor in order not to have to pay.

I understand that over the past 20 years, global numbers of new leprosy cases have remained stable, irrespective of available effective treatment. In 1981, the WHO recommended multidrug therapy against leprosy. In 1996, the first case of primary multidrug resistance was reported. Reports of mycobacterium leprae resistance rates have ranged from 2 to 16 per cent, while an Indian study of 239 relapses and 11 new cases found 21.6 per cent of cases to be drug resistant and 6.8 per cent to be multidrug resistant.

The TB Alliance reports that about 29 per cent of deaths that are caused by antimicrobial infections are due to drug-resistant TB. There are over half a million cases of drug-resistant TB each year, either because the somewhat complex drug regimen is improperly administered, or because people with TB stop taking their medicines before the disease has been fully eradicated from their body.

Treating a single case of multidrug-resistant TB or extensively-drug-resistant TB can be thousands of times more expensive than drug-sensitive TB. In South Africa, drug-resistant TB consumed 32 per cent of that country’s $218 million national TB budget, despite accounting for only 2 per cent of all cases.

Some of the figures that I quote are slightly out of date but, to give a comparison, for a drug-sensitive TB case, the cost is something like $260. Multidrug-resistant TB costs $7,000 and extensively-drug-resistant TB, $27,000.

Antimicrobial resistance has a worldwide impact. It affects all areas of health, involves many sectors and has an impact on the whole of society. It is a drain on the global economy, as it causes economic losses due to sickness of humans and animals, along with higher costs of treatments. Just as we have seen with the availability of Covid vaccines, that is likely to mean that the poorest countries suffer most.

There now seems to be a global consensus that antimicrobial resistance poses a threat to humanity and, following the pandemic, could be one of the defining health issues of our time. I have seen the figure of 700,000 people a year dying due to antimicrobial resistance, although the figure of more than 1 million has been mentioned in the debate. That shows the need for a united approach across the world to tackle such a complex problem.

The WHO considers that the issue is one of the top 10 global public health threats. If it is allowed to continue, procedures such as caesarean sections, hip replacements, cancer chemotherapy and organ transplantation will all become riskier. The 2015 review on antimicrobial resistance estimated that, if we fail to act on AMR, an additional 10 million lives could be lost each year to drug-resistant strains of diseases such as malaria, HIV and TB by 2050.

The Scottish Government’s action plan accepts that AMR cannot be eradicated, but the core ambition is that it should be contained, controlled and mitigated. I fully accept that the focus of the Government and the Parliament is rightly on Scotland. However, just as with Covid, one country cannot deal with antimicrobial resistance in isolation. As one of the world’s richer nations, we have a responsibility to work with our partners worldwide, not least our closest partners in Malawi, Zambia, and Rwanda.

Photo of Stephanie Callaghan Stephanie Callaghan Scottish National Party

Like my colleagues, I will discuss the momentous global challenge that antimicrobial resistance—AMR—presents in an evolving world. I will attempt to limit repetition, but there will be some.

In 2022, we face the imminent danger of climate Armageddon. The recent Intergovernmental Panel on Climate Change report outlines that current plans to address climate change are not ambitious enough to avoid catastrophic events. We also continue to fight the Covid pandemic—a global health crisis that is far from over. Those existential threats exacerbate inequality, poverty and displacement and tie directly into the battle against AMR.

Antimicrobial resistance is not a new challenge, nor is it on the horizon. It is with us now. As with the climate and Covid, scientists have been raising the flag of concern for years but we have not yet seen robust mitigations or the necessary global leadership.

We recently got the data from the global research on antimicrobial resistance project, which showed that AMR is third among the leading causes of death globally. A few members have already mentioned that, this year, up to 700,000 people will die from antibiotic-resistant infections around the world. That figure is worth repeating again and again.

The latest report from the UK surveillance programme for antimicrobial utilisation and resistance tells us that antibiotic resistance has increased by 4.9 per cent in the past four years. Covid has taught us that preparation is key and that inaction is abdication. Failure to act now means that countless families will be grieving in future.

What is needed? First, we need a strong system for monitoring the impacts of rising AMR in Scotland. The Scottish Government has been looking into recording AMR or antibiotic resistance as a cause of death and I would welcome an update from the cabinet secretary on where we are with data recording.

Secondly, we need to start slowing the increase of AMR through strengthened infection prevention and control, enhanced hygiene and improved sanitation. As Emma Roddick said, washing our hands is key. Scotland’s world-leading patient safety programme is an excellent foundation for managing AMR. For example, in Scotland, infections from C diff and MRSA have dramatically reduced in over-65s—by 80 per cent and 94 per cent, respectively—under the SNP Government.

Thirdly, we need to have initiatives to address the systematic misuse and overuse of antibiotics, which has resulted in microbes developing resistance to antimicrobial drugs. Worldwide, the food sector needs to urgently listen to the WHO and its calls for

farmers and the food industry to stop using antibiotics routinely to promote growth and prevent disease in healthy animals. Going back to the issue of overuse,

my colleague John Mason hit the nail on the head with his comments on TB and leprosy.

A further challenge is the severe lack of research and development for new antimicrobials. The way that pharmaceutical companies operate, with their dependence on sales for returns on investment, is not conducive to addressing AMR.

The UK’s pilot scheme introducing a fixed-fee model to finance the development of antibiotics is innovative and encouraging, but to respond to the existential threat of AMR we need a global scientific response. The rapid development of Covid vaccines shows us what really is possible, and we can and must remove constraints on collaboration between scientists.

I am encouraged that Scotland has adopted a one health approach to tackling AMR since 2016. The acknowledgment that the health of humans, animals and the environment are interconnected is really vital.

I close by recognising those who tirelessly work on this issue. The scientists and public health experts have already achieved so much in the fight to hold back the next pandemic, but they cannot fight the war alone. They need the backing of legislators, big pharma and individuals to make sure that, this time, we prepare properly for the next pandemic. It absolutely will happen if we do not put the right steps in place.

Photo of Annabelle Ewing Annabelle Ewing Scottish National Party

We move to closing speeches. I call Carol Mochan to wind up on behalf of Scottish Labour.

Photo of Carol Mochan Carol Mochan Labour

I thank everyone who has contributed to the debate so far for their very important and engaging contributions.

I must, however, note my disappointment that we have not discussed long Covid, as was planned. I believe that that debate is of the utmost importance and that it needs to take place soon. Tens of thousands of people across Scotland are believed to be suffering from it, so we must speak about it in the chamber. I heard, obviously, what the cabinet secretary has said, but I do not think that the Government has given us an adequate reason why the subject of the debate was changed. That should be noted by Parliament.

I return to the important issue of antimicrobial resistance. In closing the debate, I will reiterate some of the important points that have been made, and sum up my party’s view on this important issue for the future of the country.

My colleague Jackie Baillie and Emma Roddick mentioned that there is some very good news around. It is most welcome to realise that there is reduction in use in many places and, of course, that we are managing to prevent many more infections. Emma Roddick gave an excellent speech on the need to look at prevention first and to make sure that we have the right messaging and training in place to do that. I thank her for her speech, which I thought was excellent.

Sandesh Gulhane was the first to give us some of the history of antibiotics; many other members also mentioned it. His comment about antibiotics being a “game changer” is very important. That fact is why we have to take this issue very seriously. The number of deaths that would be associated with the loss of antibiotics’ function would be, as many members have mentioned, a dreadful step backwards. TB in particular was given as an example of increased infections, and a disease for which we are unlikely to meet our global targets unless we really do something about it.

As a number of my colleagues have remarked, Scottish Labour very much welcomes the efforts to address the risks of antimicrobial resistance—in Scotland and around the world. It is important that we recognise that any attempt to do that must take place on a UK-wide basis and, indeed, globally.

The rapid development of the Covid vaccine was a great example of just how much can be done, in record time, when nations work together with a common purpose. That is the attitude that we should move forward with.

As we all know, any progress in healthcare begins with well-funded and effective research; antimicrobial resistance is no different. Ensuring that there is long-term support for that research is a vital step that we must take in order to preserve the effectiveness of antibiotics and other key medicines for years to come. The Scottish Government should be doing all that it can to support the many universities across Scotland that are doing that work, so that we can play our part in the promising international work on antimicrobial resistance. I am afraid that, at the moment, that support is not as good as it could be.

Unfortunately, Scotland trails behind England in terms of funding, and is devoting a third less per head of the population to clinical research of that kind. The British Heart Foundation estimates that without charitable funding the Government and other public bodies would need to increase direct funding by 73 per cent to make up for that shortfall. That does not sound to me as though the matter is a priority for the Government. That needs to change. If we want to be world leading, we have to put in the funds to achieve that.

It is with that in mind that my party is calling for the Scottish Funding Council to be tasked with a review of the domestic and global funding streams that are available to Scottish universities and research groups, so that we can effectively contribute to the global research efforts into antimicrobial resistance, and of the avenues that are available throughout the UK and in international research partnerships.

As we have heard from other members, effective prescribing also has a role to play in preventing the rise of antimicrobial resistance, but the report from the Health, Social Care and Sport Committee on its inquiry into the supply and demand of medicines across NHS Scotland last year was very critical of the progress that the Government has made in improving prescribing practices in Scotland. In particular, the committee was very critical of the inability of the NHS in Scotland to collect data on the outcomes of medicine use in patients, which will make it much harder to understand antimicrobial resistance better.

Prescribing in primary care makes up the bulk of our NHS medicines spend, despite there being ineffective monitoring of those medicines when the medicines reviews are carried out with patients. Again, that does not sound like the kind of foundation that we want if we are to push ahead with tackling antimicrobial resistance. As the cabinet secretary said, those things have to change. My party wants to fully support efforts to do that.

I reiterate that although the debate has been useful—I have learned a lot and some very important points have been made—it is disappointing that after months of evading the question of support for long Covid patients, the Government still has no answer or solution in place that could give thousands of people some peace of mind. The habit that has been developed of kicking the can down the road and hiding behind unpublished reports is not a healthy one. It really is time that we start to reconsider the way in which we do business, so that we discuss in the chamber the true priorities of the people, not simply what suits the Government at a particular moment.

The Deputy Presiding Officer:

I call Sue Webber to wind up on behalf of the Scottish Conservatives.

Photo of Sue Webber Sue Webber Conservative

I echo the comments that have just been made by my Labour colleague Carol Mochan.

Antibiotics are among the most powerful tools in healthcare, and they underpin every aspect of modern medicine. We need them not just when we are poorly at home with an infection, but when we are going through significant life-changing procedures such as chemotherapy and hip and knee replacements. Antibiotics work by killing bacteria, but in the same way that the Covid-19 virus mutates and evolves, so can bacteria, thereby developing resistance to antibiotics.

Antimicrobial resistance poses a substantial threat to human health. It is estimated that, by 2050, AMR could claim as many as 10 million lives a year worldwide—more than cancer and diabetes combined. Michael Marra made that point earlier. Already, AMR infections are causing an estimated 700,000 deaths each year globally, while it is estimated that, in the UK, AMR causes at least 12,000 deaths per year. AMR is not a vague threat that is happening elsewhere: it is happening in the UK, it is getting worse and it will continue to do so. Professor Jennifer Rohn of University College London has said:

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

Although we have seen a welcome decline in total antibiotic use across the UK and in Scotland, their use continues to increase in hospitals.

The good news is that a great deal of action is under way. The O’Neill report, which was commissioned by David Cameron, was groundbreaking. It has been highly influential around the world, and 135 countries have finalised action plans on tackling AMR. Last year, the UK Government used its G7 presidency to try to deliver more tangible progress, as it did the previous time that it held the presidency in 2013, which was very welcome. As Dr Gulhane said, only 40 new antibiotics are currently in clinical trials, which should concern us all.

The UK Government is working with the devolved Administrations to tackle AMR effectively, including through its national five-year action plan. The five-year national action plan, which was developed in conjunction with the devolved Administrations, identifies three ways to fight AMR. They are:

“reducing the need for, and unintentional exposure to, antimicrobials; optimising use of antimicrobials;” and

“investing in innovation, supply, and access.”

Alongside its five-year strategy, the UK Government also published a long-term ambition for AMR. That document set out a vision

“of a world in which antimicrobial resistance is effectively contained, controlled and mitigated.”

It laid out nine ambitions for the UK. They are to

“Continue to be a good global partner ... Drive innovation ... Minimise infection ... Provide safe and effective care to patients ... Protect animal health and welfare ... Minimise environmental spread ... Support sustainable supply and access ... Demonstrate appropriate use” and “Engage the public”.

With that, I would like to mention Ms Roddick’s comments, which were a reminder to us all that antibacterial agents do not impact on viruses. Ms Roddick also reiterated the instances in which antibiotics are not useful.

In July 2019, the UK Government announced that its investments in combating AMR included £32 million of capital funding to support AMR research, which included £19.1 million for AMR research at four National Institute for Health and Care Research biomedical centres, and £8.8 million for two NIHR health protection research units on healthcare-associated infections and antimicrobial resistance.

The UK is also working internationally on AMR. In September 2019, the Department of Health and Social Care announced a £6.2 million package of funding

“to strengthen existing surveillance systems tracking AMR trends across Africa and Asia”.

In our 2019 manifesto, the Conservatives pledged to turn our attention to the great challenges of our time, including solving antibiotic resistance. In order to do that, we committed to the fastest-ever increase in domestic public research and development spending to meet our target of spending 2.4 per cent of gross domestic product on R and D across the economy. Some of that new spending would go to a new agency for high-risk, high-payoff research, at arm’s length from Government.

Furthermore, at last year’s autumn budget and spending review, the UK Government increased public R and D investment to record levels, which equates to £20 billion by 2024-25, which is why it is important that we reinforce co-operation globally and across the UK, and why a Scottish approach is unnecessary.

However, we will do the same as the rest of the world. Although we will support the Scottish Labour amendment today, we need to reduce the gap in funding between Scotland and England, and come up to and match what is done elsewhere. We have to play an equal part.

The progress that we have seen in recent years is welcome, especially the UK Government’s new subscription-style payment model for antimicrobials, which will incentivise companies to invest in the area. The new subscription-style payment model is a win-win for healthcare systems and industry. It demonstrates that NHS patients can benefit from a secure supply of new antimicrobial drugs, while pharmaceutical companies can reliably forecast their return on investment.

AMR is a serious issue and one on which we must continue to work together. It is heartening to see the UK Government taking positive steps to ensure that not only is action taken now, but that plans are put in place for the future.

Photo of Maree Todd Maree Todd Scottish National Party

My colleague has vividly described why we must keep antibiotics working. When modern medical procedures are so reliant on the ability to treat bacterial infections, the threat that antimicrobial resistance poses must not be underestimated, and we cannot afford to be complacent in our response to that risk.

I look forward very much to debating long Covid in a few weeks’ time, but I have to say that, as a pharmacist and—as Sandesh Gulhane would say—a legal prescriber, I have spent my professional life promoting the rational use of medicines and good stewardship of antibiotics, so I welcome the opportunity for the Parliament to give its attention to that global threat.

Photo of Jackie Baillie Jackie Baillie Labour

I absolutely agree with the minister on the importance of the subject. Could she perhaps explain to members why, in the past six years, there has not been one Government debate about it?

Photo of Maree Todd Maree Todd Scottish National Party

A ctually, in the past 23 years—is it 23 years?—since devolution, there has been no debate on antimicrobial resistance, and I for one am delighted that we are finally debating it. When I was a student at university, my honours project was on antibiotic prophylaxis for caesarean section.

Photo of Jackie Baillie Jackie Baillie Labour

The record will reflect that there were debates on C diff, MRSA and a variety of different diseases that are caused as a result of antimicrobial resistance.

Photo of Maree Todd Maree Todd Scottish National Party

Indeed, but not on the specific topic of antimicrobial resistance.

In fact, I was going to highlight that back in my days at university—because I am decades beyond qualifying—C diff was called antibiotic-associated colitis. That highlights the change in perception over the decades. I am very proud that Scotland has made such massive progress in treating that particular hospital healthcare-acquired infection.

However, we need to recognise that AMR does not affect only humans. Bacteria with the potential to become resistant to antibiotics exist in animals and in the environment. For that reason, we require a one health approach to the threat that recognises that the health of people is closely connected to the health of animals and our shared environment. In short, we cannot tackle AMR in humans in isolation, and I will step outside my usual brief to say more about that.

The Scottish Government has committed to a one health approach to combat AMR. In 2015, as Ms Baillie said, we formed the Scottish animal health and antimicrobial resistance group. That forum features representation from Government, industry bodies and both the human health and veterinary sectors, truly encompassing our one health vision. It provides leadership and engages with key stakeholders in taking a co-ordinated, quality-driven approach to anti-AMR measures, which include promoting good infection prevention and control practice for animal keepers; improving veterinary prescribing practice for both pets and livestock; and learning from the data that we have on AMR in animal populations.

A vital tool in tackling AMR is the provision of coherent, consistent advice for the animal-keeping public, including farmers and pet owners. We have established the Scotland’s healthy animals website to centralise guidance for animal keepers and veterinary professionals and to promote responsible antimicrobial stewardship. Monitoring levels of antimicrobial usage and rates of resistance is also essential. To that end, as my colleague mentioned, NHS Scotland produces an annual Scottish one health antimicrobial use and antimicrobial resistance report. That provides information on the use of antibiotics by humans and in veterinary practices in Scotland, and on levels of antibiotic resistance that are found in a range of important human and animal infections and in the environment. Bacteria of particular interest are those that can potentially transfer between animals and humans, including bacteria that are common causes of food poisoning, such as salmonella and E coli.

Although I accept that there is much more to do in the battle against AMR, the achievements with regard to overall usage of antimicrobials in the animal sector should be acknowledged. On-going monitoring demonstrates an overall decline in the usage of antibiotics in livestock species; that is significant and demonstrates the hard work of producers and veterinarians to safeguard the efficacy of our antibiotics. We also aim to harness the power of genomic technology—something that, thanks to the pandemic, we are all much more aware of—to identify and track food-borne pathogens and antimicrobial-resistant organisms through the agri-food system and the environment.

I previously mentioned that one health includes the wider environment in which humans and animals live, and that is why we convened the AMR in the environment in Scotland stakeholder group, including representation from the Scottish Environment Protection Agency.

I will address some of the points that were made about research. The Scottish Government is fully engaged with a research programme within the national action plan and across research categories of evidence generation, implementation, evaluation, co-ordination and guidance. Active Government-funded research is being done in many areas, including food safety, sustainable investment, environmental contamination, and diagnostics.

I will highlight just one of the environmental contamination research projects. Our efforts to combat AMR in the environment have led to the formation of the One Health Breakthrough Partnership, which is an initiative based in the Highlands that seeks to address environmental pharmaceutical contamination. That unique partnership is driven by NHS Highland, Scottish Water, SEPA and the environmental research institute.

Scottish universities and research institutions make a significant contribution to AMR research. We have ensured that the breadth of that contribution is captured by commissioning a register of all Scottish one health research into AMR from the previous five years. We will maintain that register as an active and updated resource, and it will continue to inform our evidence-based policy making in the future.

Michael Marra made a point about the pandemic creating immediate challenges in the past two years and derailing research. The pandemic has absolutely been at the forefront of everyone’s minds for the past couple of years, and there will undoubtedly be transferable learning from this episode in history. We have seen strides forward in infection prevention and control in all settings, including hospitals and care homes, and there has been an astonishing level of global collaboration in everything from developing vaccinations to understanding the genomic sequencing of new variants of viruses.

Photo of Michael Marra Michael Marra Labour

I fully acknowledge the minister’s point about the long-term potential benefits in the changes to the research environment and the collaboration that she has described. I would not say, however, that the research agenda has been derailed by the pandemic. It was more that there was some displacement and that some members of the research community were doing other work. If we are going to get back on track and accelerate that work, the SFC review that we have asked for and the minister has graciously agreed to is critical to making sure that additional resource can be identified to allow that work to take place.

Photo of Maree Todd Maree Todd Scottish National Party

Absolutely. I agree, and that is a fair point. We are committed to taking action on AMR throughout our work, including via international trade. As the coronavirus pandemic has also demonstrated, diseases do not recognise national borders, and that is also true of AMR.

As the UK embarks on trade negotiations with prospective third country trading partners, Scotland continually presses for measures to be taken to tackle the development and spread of AMR in all UK free trade agreements. My ministerial colleagues have written to their counterparts in the UK Government several times to ensure that AMR is recognised during such negotiations.

I am grateful to the experts in many areas who lead Scotland’s efforts to contain and control AMR but, as my colleague said in his opening speech, we can all help to support that work. For example, we can all listen to those who are treating us or our pets when they advise us that an antibiotic is not the best course of action. I am coughing furiously at the moment and I am living proof that antibiotics do not treat viruses. We can all ensure that we stay healthily hydrated, for example. That helps to reduce urinary tract infections and can prevent the use of some antibiotics and the development of further complications. We can all make sure that we never flush away unused medicines into the environment. As a pharmacist, I would of course tell people to take them back to the pharmacy for safe disposal.

I thank everyone who works to control AMR in their daily life, whether in a hospital, a GP surgery, a pharmacy, a lab, a farm, a veterinary surgery, a research institute or one of the many other settings in which such work is done. We recognise your efforts to keep our drugs working, and we all support you.

We in Scotland are vigilant to the threat that is posed by AMR. We are ready to meet that challenge and we have made great strides forward, supported by experts and by the Scottish public. However, we must not become complacent. We must maintain our focus and energy on ensuring that our antibiotics continue to work. To that end, we will continue to adopt a one health approach, which involves tackling AMR in humans side by side with protecting the environment that we exist in, and protecting the animal and plant life that we share it with.