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Lord McNair: My Lords, I am grateful to the noble Lord for giving way. At the beginning of my speech, I should have said that I was sitting on the Front Bench only incidentally because my noble friend could not be present then. My remarks were not Liberal Democrat policy in any sense; they were merely ideas which I felt may be useful to the debate.
Lord Lucas: My Lords, it is my experience that almost every policy is a Liberal Democrat policy at one time or another.
As has been said by many speakers, there is a great deal that needs to be done on the practice of microbiology in hospitals, ranging from the simplest matter of personal hygiene through to organisation and the raising of the status of clinical microbiology so that it becomes a profession that people seek to follow. An important part of that is making sure that research funds are available. Quality people follow money for research because they want to achieve something. If one cannot get money for a decent research programme, one will choose to do something else. There is little money for research in this area, but there is so much to be done, not only in basic research and in making sure that we have a continuing armoury of chemicals to deal with infection but also in diagnosis (to make sure that we have a quicker and better ability to understand what is happening to patients) and in practice, so that we know the best ways of dealing with infection control and can make use of all the data that we should like to see coming from better surveillance practices.
I share with at least one of the Liberal Democrat spokesmen a perception of what is the most important aspect of the report. I refer to the suggestion that the recommendation of the Swann Committee be taken up and that there should be an overarching government committee on antibiotics and infection generally.
I should like to look at that rather more deeply than considering just antibiotics. These questions are immensely complex. They cross not only departments, but run deep into the depths of individual departments. One example which has been quoted several times is the use of antibiotics as growth promoters in animals. The simple answer is to ban them, but we must consider also animal welfare. We must take decisions on which antibiotics we shall allow to be used on animals. We need curatives for animals. We need people who develop curatives for animals to know that they will not be taken away three years later because someone wants to use them for humans. Considering all the regulations these days, it still costs perhaps £100 million to produce
a curative for animals. People involved in that need to know that they will have a continuing market and that there is some structure to ensure that if the curative has been "okayed" for animals, they will be able to keep it for animals. It is no good looking at virginiamycin and saying, "We have found something else; we have found a use for a similar chemical; we now want it for humans", because nobody will ever develop a substitute for virginiamycin because they always think that it will be used for human patients.We must look at the costs to the industry of taking away such products. Under the World Trade Organisation regulations, we cannot prevent the import of a large quantity of, say, chicken from China or Thailand which has been produced using such substances. There is no way of detecting them by the time the chickens reach us. They will come in at a low cost. If we build a high-cost industry, as has Sweden, like Sweden we shall have to give it immense subsidies to survive. If we want to do something that allows us to make the change without incurring that cost, we have to plan for it long term. We have to consider tripling or quadrupling the amount of space allowed for chicken houses. That means that the Department of the Environment, Transport and the Regions will have to ensure that planning permission is granted. No one wants a chicken shed next to them. It is difficult to get planning permission for that.
Other questions relate to the alternatives. Sweden uses zinc compounds. That causes considerable problems with heavy metal wastes in the litter from chicken houses. Germany uses arsenic on pigs. I do not suppose that that is something that we want spread on our fields. All of the alternatives have consequences and require a great deal of thought and consistent and coherent planning.
One of the great lessons from the BSE disaster is that waiting until a problem hits you in the face is extremely expensive. We have spent something like £4 billion on taking out a disease which will kill seven people a year--a figure has been pretty consistent over the past four years--whereas we are here looking at a problem which could kill tens of thousands of times that number of people with the greatest of ease as soon as MRSA acquires a solid form of vancomycin resistance. All it takes is some daft scientist in a hospital to decide to see whether he can give MRSA vancomycin resistance because he wants to know if it can be done. Indeed, it has been done in a hospital not very far from here. The only good thing about it is that it was stopped before the scientist had time to drop the test tube. It will not be long before we have this animal with us. We must be prepared for it.
This Government have a considerable reputation for complacency. When faced with a difficult question they do not seem able to see further than a focus group can think. The astonishingly fatuous response of this Government to the report of this House on the medical uses of cannabis is but the most recent example. I expect nothing from the Minister but flannel and prevarication. Why else would the Government have taken seven months to reply to this report when it quite clearly
demands urgent and multi-faceted action? I expect nothing, but the lesson of this report is that you should always prepare for the unexpected, and I shall be delighted if I am wrong.10.31 p.m.
Lord Hunt of Kings Heath: My Lords, today's debate has demonstrated once again the seriousness and complexity of the antimicrobial resistance problem. I am very grateful to noble Lords for their contributions which have been both constructive and helpful and are, as already stated, a demonstration of the valuable work of your Lordships' House.
The Government are well aware of the healthcare problems presented by antibiotic resistant strains of micro-organisms. The Government therefore welcome and commend the report of the Select Committee on Science and Technology. The report is comprehensive and far reaching and has found a wide and receptive audience. Indeed, the document has done much to stimulate the increased national and international attention this subject is now receiving. I pay particular tribute to members of the sub-committee and to the noble Lord, Lord Soulsby of Swaffham Prior, for the enormous amount of work they undertook.
The Government will be giving their formal response to the report shortly. The Government are not complacent. We did not reply earlier because we want to ensure that the response gives the full depth and breadth of consideration that this important issue rightfully merits. My right honourable friend Tessa Jowell wrote to the noble Lord, Lord Phillips of Ellesmere, at the beginning of July making that point. He responded saying that he was content with the reasons for preferring to delay the response until the autumn. The Government will of course take particular note of the points raised by noble Lords in today's debate, although I doubt that I shall be able to respond to all of them tonight.
This is an important issue. Microbial resistance is a major public health threat that the Government take most seriously. I shall briefly summarise some of the major issues and outline the Government's strategy in tackling them.
The first antibiotic--penicillin--was discovered 70 years ago. Since that remarkable discovery, a variety of other antimicrobial agents have been added to our armoury against the effects of infectious disease. The efficacy of these agents has inevitably resulted in their widespread use, frequently reducing suffering and death. The noble Lord, Lord Perry of Walton, provided some graphic descriptions. It is of great concern therefore that the increasing resistance of micro-organisms to antibiotics jeopardises many of the medical advances made in the treatment of infectious disease. Although the problem is not so widespread in the UK as in many other countries where antibiotics are more freely available and infection control procedures may be less effective, it is nonetheless a very serious problem, and we are treating it as such. My noble friend Lord Winston had some very important points to make in that respect.
The message from the Science and Technology Committee, behind which the Government stand four square, is that there is no room for complacency. Our
past heritage will not itself protect the future. As the noble Baroness, Lady Masham, said, bugs have no boundaries. The world is becoming smaller and international travel more commonplace. The organisms which cause infection do not respect international boundaries and are able to move quickly and unseen among our communities with the ability to jeopardise healthcare. We must all be ever-vigilant in our fight against them and not relax our guard. If hard-to-cure infections are not to become more widespread and if treatment is not to become more difficult and expensive, action must now be taken to slow down or delay the emergence of antimicrobial resistance and limit its spread. But there is no quick or easy solution.It is clear that resistance is to some extent an inevitable consequence of antimicrobial use, a point identified by the noble Lords, Lord McNair and Lord Dixon-Smith. However, apparent over-use and misuse of antibiotics is fuelling the proliferation of resistant micro-organisms. Some antibiotics are being prescribed when they might not be needed. Some patients are adding to the problem by expecting antibiotics for every infection, needed or not. Each unnecessary use of an antibiotic for a viral infection, like a cold or influenza, increases the chance that resistant strains might proliferate and spread among the body's naturally occurring bacteria.
Even when antibiotics are prescribed appropriately, many patients fail to use them as directed. Stopping antibiotics too early kills the weak micro-organisms, leaving the strong to develop resistance, flourish, and perhaps spread through the community.
By their very nature hospitals are significant sites for the development of antibiotic resistance. Noble Lords have referred to that point frequently during the debate. Hospital patients typically receive several, and often intensive courses, of antibiotics, creating ideal conditions for resistant strains to emerge and thrive. Resistance moves easily between hospital and community settings.
We cannot just rely on hopes of successful development of new antibiotics with appropriate efficacy to solve the problem, even though there may be new antibiotics or novel therapies on the horizon. Resistance problems have always existed and probably always will, no matter how many classes of antimicrobial agent or new mechanisms are developed.
What can be done? Slowing down or delaying the emergence of resistant micro-organisms and limiting their spread will not be a simple matter. But much can be done. In the UK the Government have already commenced a strategic plan of attack. An interdepartmental multidisciplinary steering group has already been set up with responsibility for co-ordinating and driving forward work on antimicrobial resistance. There is a need for continued outside advice from experts and we are actively considering how best to put this in place.
Our strategy is based on three key elements: better surveillance; prudent antimicrobial use; and effective infection control. This strategy continues to evolve as
expert advice becomes available and an action plan for taking forward specific projects of work is being developed.Across these areas a number of initiatives have already been undertaken or are under way. These include enhanced surveillance--a point made by my noble friend Lord Winston--a review of the clinical use of antimicrobial agents; a review of antimicrobial agents in the food chain; measures to improve infection control management and practice; and the promotion of research in the field and into the development of new antimicrobial agents and vaccines.
Last year the Chief Medical Officer asked the Standing Medical Advisory Committee to examine the issue of antimicrobial resistance in relation to clinical prescribing practice and make recommendations. The committee set up an interdisciplinary sub-group with cross-representation from the standing committees for nursing, midwifery, pharmacy and dentistry and it included veterinary and consumer representation. The final report entitled The Path of Least Resistance was produced and published in September. As my noble friend Lord Rea said, the main report is a comprehensive scientific source document, with summary and synopsis versions, that has been widely distributed in the UK and made available on the Internet. As an immediate step copies of the synopsis version were sent to all doctors. Alongside the Select Committee's report, the Standing Medical Advisory Committee's recommendations are key to the Government's future strategy and work programme.
Refinement of the use of antibiotics must be the key feature of the strategy to tackle the antimicrobial resistance challenge. The Government have an important role to play but they need support from, and action on the part of, healthcare professionals, expert groups and many others who have an interest in this important public health issue.
Reducing the unnecessary prescribing of antibiotics is likely to prove a significant factor in combating the development of resistant strains of bacteria. Patients, too, have a significant role to play by not pressurising their clinicians to prescribe them in circumstances where they are not effective, such as for colds and influenza. The noble Lord, Lord Soulsby, and my noble friend Lord Winston spoke clearly about the pressure on GPs.
Clearly, we have to get the balance right. When swiftly and appropriately prescribed, antibiotics can unquestionably be life-saving. We must scrupulously avoid discouraging people from visiting their GP when they feel unwell. Such a balance cannot be achieved overnight but is one which, in partnership with the profession, we can aim to achieve. The Department of Health is working on proposals for a public campaign. It is worth reporting that in 1997 GPs in England prescribed 6 per cent. fewer courses of antiobiotics than in 1995. Happily, that trend continued in the first half of 1998.
I turn to education, a point raised particularly by my noble friend Lord Winston. Educational initiatives for both health professionals and the general public are of major importance for improving the use of antimicrobial
agents. The Government have brought the Select Committee's report to the attention of the professional bodies. These include the General Medical Council, the medical Royal Colleges, and the English national Board for Nursing, Midwifery and Health Visiting. It is clear that increased attention needs to be paid to antimicrobial therapy in their programmes of postgraduate education and vocational training.The noble Baroness, Lady McFarlane, offered some valuable insight regarding the contribution of nurses, and specifically infection control nurses. Her comments will be studied with great interest.
A number of noble Lords raised the very serious issue of infection control in hospitals. The noble Lord, Lord Fitt, spoke movingly of his own experience in that regard. Improvements in hospital infection control arrangements are an important part of the action being taken by the Government. The responsibility for ensuring that effective arrangements are in place for the control of infection in trusts rests with the chief executive of the trust. Hospital infection control is an important part of an effective risk management programme to improve the quality of patient care. I wish to stress the chief executive's personal responsibility for the quality of care as part of the new clinical governance framework for which the chief executive is responsible to the NHS trust board.
All hospitals should have an infection control team which has primary responsibility for, and reports to the chief executive on, all aspects of surveillance, prevention and control of infection.
In 1997 the NHS Executive asked regional epidemiologists to survey communicable disease control arrangements at health authority level throughout England. The survey identified a number of shortcomings which have now either been addressed or are being addressed.
The NHS White Paper, A First Class Service, set out the detailed responsibilities of chief executives of NHS trusts for the quality of care to which I referred. That will include infection control services and will pick up many of the issues raised by noble Lords. For instance, as I said, as part of the clinical governance framework, infection control teams will be expected to produce regular reports to trust boards, but these could include hospital hygiene reports to bring deficiencies in cleaning standards to the attention of the trust board.
The noble Baroness, Lady Masham, asked whether MRSA targets could be established for each hospital. The Government agree that much work needs to be done to develop performance indicators and/or targets on hospital infection control, including MRSA, and are actively considering this recommendation alongside their proposals on clinical governance, to which I have just referred.
The noble Baroness also said that issues to do with infection control are as important in the community as in hospitals. The Government agree that there is a need for national standards and guidelines for community infection control management. The Department of
Health is taking the lead in ensuring their development, working in partnership with many others who will be involved.The noble Lord, Lord Soulsby, and my noble friend Lord Winston asked about funding for the PHLS. I can assure your Lordships that we shall be discussing the long-term funding of the PHLS with that body when it has completed the strategic review which it is currently undertaking. I am unable at this stage to say what the outcome of that review will be, but, in order to give the PHLS time to undertake the review, present its conclusions to Ministers and agree their implementation, £2.3 million in additional resources will be made available to the PHLS in the 1999-2000 financial year.
A number of noble Lords, including the noble Lord, Lord Lucas, referred to the recommendation of the committee that a single multi-disciplinary government committee should be set up to oversee all aspects of antibiotic use. The Government have established an interdepartmental multi-disciplinary steering group to develop the recommendations of your Lordships' Select Committee and the Standing Medical Advisory Committee to turn that into a wider government strategy and to steer and co-ordinate activity in this area. Consideration is currently being given to the need to set up an expert group to provide advice on scientific aspects of antimicrobial use.
My noble friend Lord Rea asked about vaccine research. The Government are involved in establishing a national framework for co-ordinating vaccine research. We intend that the UK population should have available at the earliest possible opportunity safe and effective vaccines. I should like to reassure noble Lords of the high priority which the Government give to this area.
The noble Lord, Lord Jenkin, asked about the Government's position in relation to over-the-counter antibiotics. I can reassure him that the Government will continue strongly to promote adherence to prescription-only status for all antimicrobials within the EC and elsewhere.
My noble friend Lord Rea asked about advice to general practitioners on prescribing. I can confirm that all health authorities continue to employ both pharmaceutical advisers and primary care medical advisers to provide advice on the use of medicines. As an important part of this role, they continue to visit GPs to discuss their prescribing. A number of studies have confirmed the effectiveness of their activities in this regard. My noble friend Lady Hayman announced last week that PRODIGY, a computerised prescribing-decision support system, is to be made available to all GPs without cost. Shared doctor-patient information screens and patient information leaflets can be printed to advise patients on management of their illnesses, which I think is a great advance.
My noble friend Lord Rea also raised the issue of the new primary care groups. With their establishment, subject to legislation, the Government will expect them to take an active role in professional development in this area. We also have examples of good prescribing practice in the use of antimicrobials in primary and secondary care. These will be identified and
disseminated through health authorities, primary care groups, hospital trusts and post-graduate educational networks.A number of noble Lords, including the noble Lord, Lord Dixon-Smith, referred to deficiencies in information in the health service. In September this year my right honourable friend the Secretary of State for Health launched the new information strategy for the NHS. This is part of a £1 billion investment to get the information systems right and to make information work for NHS patients and staff. Over a period of time it will ensure that we provide lifelong electronic health records for every person in the country, and instant access 24 hours a day in every hospital and GP surgery to patient records and best clinical practice. The whole emphasis is to bring together outcomes, activity and prescribing data. I believe that that will very much help the health service meet the very difficult problem that it faces.
There have been widespread concerns in the medical community and elsewhere that problems of resistance are being fuelled particularly in respect of foodborne pathogens such as species of salmonella by the use of antibiotics in animals. Much has been said about this by noble Lords today, particularly by the noble Lord, Lord Soulsby, in his introduction to the debate. I am not able to respond directly to that issue today. However, noble Lords will be aware that the Government have set up an investigation into microbial resistance in relation to the food chain which is being carried out by a working group of the Advisory Committee on the Microbiological Safety of Food. The noble Lord, Lord Clement-Jones, referred to the matter. As he suggested, the working group is expected to report to the committee before the end of the year. The committee will then offer advice to the Government on a range of issues concerning the responsible use of antimicrobial agents as veterinary medicines and growth promoters.
A number of noble Lords referred to the international dimension. The Government are determined to give constructive support to international initiatives and to take a leading role if required to ensure that effective systems for monitoring antimicrobial resistance can be set up without delay. We shall press for this to be given priority in the World Health Organisation's next global and regional biennial work programmes and in the future framework for European Union action in the field of public health.
With UK support the World Health Assembly adopted a resolution in May 1998 which urged member states to take measures broadly in line with the planned UK strategy and called on the director general to promote international co-operation. Within Europe, too, the European Commission in its communication of April 1998 on the development of pubic health policy in the European Community identified the growing problem of resistance to antibiotics as one of the new risks to health. The Commission's scientific steering committee has set up a working party to examine all aspects related to this question.
I would be failing in my duty to your Lordships' House if I gave the impression that there was a quick solution in sight. Tackling antimicrobial resistance is a long-haul task that requires partnership between government and a wide range of organisations and individuals across many disciplines in both the UK and internationally. There is no doubt that antibiotic resistance presents one of the greatest challenges to us all. It is an unending battle, according to the noble Lord, Lord Dixon-Smith. The UK Government are rising to the challenge and taking action to help tackle the problem. They are playing a leading role both nationally and internationally but alone they cannot do all the things that need to be done. If they are to succeed they need a strong spirit of partnership, co-operation and determination among healthcare professionals, expert groups, communities and every individual citizen.
Today's debate and the reports of your Lordships' committee and the Standing Medical Advisory Committee present a very clear message to us all. The Government will be resolute in their response.
10.53 p.m.
Lord Soulsby of Swaffham Prior: My Lords, the hour is late and I shall not detain the House much longer. I thank all noble Lords who have contributed to the debate. They have supplemented one another's contributions to an extent and provided important information both from their experience and the report. They have expanded on areas that I have failed to deal with adequately.
I do not think that anyone who has heard the noble Lord, Fitt, describe the tragic end to his wife's life can now doubt that antibiotic resistance is a very important entity to which we must attend. We should thank him for so bravely bringing the information to us. It must put an indelible mark on our minds that he is a person who has experienced at first hand the tragedy of antibiotic resistance.
The noble Baroness, Lady Masham, identified the problem of pressure sores to individuals like her who have to sit in a wheelchair. All these are very important matters which may well miss the attention of those of us who consider ourselves to be reasonably normal, although at times that is under challenge by various people.
Perhaps I may briefly identify some of what I believe to be the headlines of this debate. Surveillance has been identified by a number of noble Lords. To my mind that is particularly important. I was pleased to hear from the Minister that the Government are going to attend to some of deficiencies in the public health laboratory service, which have been identified with the input of several million pounds. I did not deal with research in my opening comments, but it is particularly important. If we had more research so that we could identify antibiotic resistant organisms in a clinical environment such as in a doctor's surgery it would be a major step forward.
The education of the doctor at the undergraduate and postgraduate level has been identified. The noble Baroness, Lady Platt, who, unfortunately, is not in her
place, identified the education of young mothers and children as regards the use of antibiotics. In committee she was very keen to identify the fact that women's magazines would be an excellent medium for getting over that message. Indeed, that has happened.The use of alternative medicine has been identified by the noble Lord, Lord McNair, and my noble friend Lord Clanwilliam. That area was touched on only briefly in the report. Some evidence was given to us about alternative medicine. I am delighted that my noble friend Lord Lucas takes probiotics every morning in order to repopulate his intestines with beneficial bacteria instead of antibiotic resistant bacteria. I do the same occasionally, but not every morning. That is an area for future development. The noble Lord is a little ahead of the game in that respect.
He mentioned the Swedish system for the control of the use of antibiotics in animals. Initially, that was not viewed very favourably; but after 10 years, and due to the fact that the Swedes depended very much on the use of antibiotics in animal husbandry for the control of disease, that has now been improved and the benefit of the withdrawal of antibiotics in animal husbandry has been shown to take place. The amount of antibiotics used is now very much reduced, but, as mentioned by several noble Lords and the Minister, that cannot happen overnight. It takes quite a long time.
We had a very good input from the noble Baroness, Lady McFarlane, on antibiotic and infection control in hospitals. In committee her experience and knowledge of the matter was very valuable and put into perspective the problems that we have and which we identified.
I am delighted to hear the Minister say that there is no place for complacency. We were aware that the response was to be delayed but, with due respect to the Government, we did not expect it to be this delayed. The response may well be the better for that delay; I do not know. However, the publication, The Path of Least Resistance, is welcomed. It details effectively how to handle the situation.
Education is welcome too. I have mentioned the £2.3 million additional funding to the Public Health Laboratory Service--that is also welcome--and its strategic review. It is good news that there is to be, I hope, an overarching committee, and progress is being made on that. We find that important in dealing with the problem of antibiotic use and resistance.
Finally, we are delighted to hear--as I am sure is my noble friend Lord Jenkin--that the Government will abide firmly by the principle of no over-the-counter antibiotics.
We have had a good debate. It has been a prolonged debate, but much of importance has been said. I commend the Motion.
On Question, Motion agreed to.
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