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Baroness Hollis of Heigham: I shall write to the noble Lord on that point. The benefits changed and ICA came in quite late. I shall need to check that precisely as I do not want to mislead the noble Lord. Obviously, when we discussed the state second pension, we built that in so that for every year of caring a person would receive a year of pension. Therefore, if one completed 40 years of caring, one would receive a £40 pension. Currently that is not the case. However, perhaps I may check how far back those records go. Certainly the noble Lord is right that we are covered following the introduction of ICA and also following the introduction of the appropriate benefits. I shall check on that point and write to the noble Lord.
Lord Higgins: I am most grateful. This point had been raised with me by an outside body which is obviously fairly expert on the matter. By now, the people concerned must be fairly old and are probably very few in number. Therefore, I am content for the noble Baroness to make absolutely sure that that is so.
Perhaps I may return to the main point which I believed she was making, although I shall need to read carefully exactly what she said. I tabled a Written Question which she kindly answered in time for today's debate. I am concerned that the Written Answer that I received today refers to a "pay-as-you-go" principle. Nevertheless, in regard to individuals there is a distinction. What proportion of the state pension would a pensioner receive if the calculation were carried out on an actuarial basis as a result of his contributions?
One would have great difficulty convincing anyone who receives the basic state pension that the following is so: if, over the years, they had simply invested their contributions, the answer is that they would receive nowhere near the basic state pension. A big element of the basic state pension is not covered by contributions. It is at least arguable that those with deficient contribution records are at least entitled to some part of that compared with those who have paid full contributions.
Another point I was seeking to make is that I do not understand why someone who suffers because he does not have a full contribution record and so receives a lower state pension should not be entitled to have at least some recognition of the fact that he has a small amount of savings. As I understand it, under the Bill
as drafted, he does not have that because his small savings are not compensated for in any way. They are used to bring up the pension to the levels that the Minister has mentioned. I am not clear why it is that those who have a deficient contribution record should not receive something from the Government because they have a small amount of savings, if those who have a full contribution record benefit when they have a small amount of savings.
Baroness Hollis of Heigham: This is not exactly a theological argument, but it touches on a wider debate about the relationship between national insurance and the taxation system. The noble Lord knows perfectly well that although funds go into the national insurance scheme, the state retirement pension is a funded "pay-as-you-go" scheme, as opposed to a money purchase scheme, and in that sense it is funded by today's taxpayers. In turn, the pensioners have funded a previous generation of pensioners.
This matter would depend upon age, gender, work records and the like, as to what actuarial proportion would apply. That is where we are, and the noble Lord knows that as a result the national insurance contributions are levied from an employer and an employee with the availability of a Treasury contribution, if necessary, to make good what GAD forecast is required to have a national insurance fund in balance. That flow of money effectively comes in from different generations of people. Perhaps the noble Lord will accept that description. If we go beyond that we shall be in the realms of theology, if not heresy.
Lord Higgins: I understand all that, but that is not the point that I was making. Is it not the case that those drawing a pension now would receive that pension if all they had done was paid their contributions and received the actuarial result of those contributions?
Baroness Hollis of Heigham: That is true. The basic retirement state pension is the same level irrespective of whether one has been a non-taxpayer or a taxpayer or whatever the level of national insurance contribution one has paid. Technically, some people may have over-funded their pension and others may have under-funded it. There is a cross-pooling effect, across each generation as well as between generations. I do not see anything wrong with that. One may be able to do the sums suggested by the noble Lord, but I do not see that that matters because society pools money for old age.
I return to the second of the noble Lord's questions. If Frank has a retirement pension of £77 and a private occupational pension of £30, he should be in the same financial position as Roy who has a retirement pension of £50 and an occupational pension of £30. That is basically what the noble Lord is saying. One has a full RP of £77 and the other has an RP from incomplete contributions of only £50 and they both have occupational pensions of £30. The result is that under the pension credit Frank's pension will go up from £77 to £100 because his £30 will take him past that, and it is 60p in the pound thereafter. Is it right that Roy's
pension should also go up to £100? His retirement pension record is incomplete but he is poor, and therefore he needs to go up to £100, which is the fulcrum point, and he will still enjoy a proportion of the savings credit in exactly the same way as Frank.The noble Lord is saying that what is currently MIG should carry the strain between where Roy is with his retirement pension, however modest that may be—£10 worth, £50 worth or £77 worth up to £100—and whatever else he may have; he will still receive a savings credit. That is what the noble Lord suggests and I do not believe that that is right. He is saying that such a person should be rewarded twice over, once with a MIG element, a guarantee element that takes him up to £100 with possibly £20, or £30 or £50 of retirement pension—far more than the first person—and on top of that that he should enjoy his savings credit. Those two people with different retirement pension contributions records would end up receiving the same income. That cannot be right. That is not fair to the person who has worked hard, paid the contributions and saved in other forms—through an occupational pension or through savings.
I do not know whether that helps the noble Lord. We may have to agree to disagree on that. That would be the consequence under his case of someone with an incomplete retirement pension record who would receive all the £100 deemed through the MIG element and would enjoy a savings credit on top. I do not believe that it is right to deal with those two people in the same way. I hope in the light of that explanation that the noble Lord will feel able to withdraw the amendment.
Lord Hodgson of Astley Abbotts: I am grateful to the Minister for the full attention that she has paid to this amendment. The counter argument from my noble friend Lord Higgins is whether someone should receive no benefit at all—it is not a matter of full benefit—from having some state retirement pension. I look forward to receiving from the Minister's department the capital calculations. In any way that I try to work this out I cannot work it up to £35,000 or £60,000 to be eligible under the proposals now before the Committee.
I am grateful to the Minister for having dealt with some of the cases. I did not hear much about women who take a career break to care for children, but these were probing amendments designed to discover the position of the Government. We have had much juice out of the orange. I may want to see whether I can extract some more juice on another occasion, but for the time being I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Lord Bassam of Brighton: I beg to move that the House do now resume.
Moved accordingly, and, on Question, Motion agreed to.
Nurse Prescribing
7.28 p.m.
Lord Soulsby of Swaffham Prior rose to ask Her Majesty's Government, in the light of their responses (Cm 4172 and 5245) to the reports of the Science and Technology Committee on Resistance to Antibiotics (HL Paper 81, Session 1997–98, and HL Paper 56, Session 2000–01), what precautions they will propose to guard against increasing the prevalence of antibiotic resistant organisms in the proposed nurse prescribing regulations announced on 4th May 2001.
The noble Lord said: My Lords, in providing a brief background to this Unstarred Question I shall explain that in 1998 I had the honour to chair a sub-committee of the Select Committee on Science and Technology on resistance to antibiotics and other antimicrobial agents. After its deliberations the sub-committee came to several conclusions of which I shall mention two. The first was,
- "This enquiry has been an alarming experience, which leaves us convinced that resistance to antibiotics and other anti-infective agents constitutes a major threat to public health and ought to be recognised as such".
The second conclusion was that,
- "there is a dire prospect of revisiting the pre-antibiotic era".
I cite those two conclusions to emphasise the serious nature of antibiotic resistance. It is not an issue to be taken lightly. The Government have been very positive in their response to the report. That has resulted in a number of publications. The Path of Least Resistance was published by the Standing Medical Advisory Committee (SMAC). A series of patient-information pamphlets was produced by the National Health Service to dissuade inappropriate use of antibiotics for simple infections, such as the common cold, coughs, viral sore throats, earache and so on; in other words, the more prudent use of antibiotics. Also included was the setting up of the long-awaited Specialist Advisory Committee on Antimicrobial Resistance (SACAR).
Since 1988 there has been a welcome decline in antibiotic use in human patients—and in animal patients too. Prescribing is down by 23 per cent. That is a very good record. Nevertheless, when the sub-committee revisited the issue of antibiotic resistance in 2001, we reiterated the need to educate professionals to practise even more prudent prescribing. Recently the Department of Health addressed the issue of antibiotic resistance in a publication entitled Getting ahead of the curve: a strategy for combating infectious diseases. As recently as 4th January 2002 the Department of Health published a leaflet entitled, Got a cold—don't ask for antibiotics. There is little doubt that officially and professionally one of the major factors influencing the spread of the resistance to antibiotics is the inappropriate prescribing of antibiotics. It is now intended to extend prescribing of prescription only medicines (POMs) to independent nurse prescribers by amending the prescriptions-only medicines order 1997 to include antibiotics.
The proposals are very worthy. They are intended to enhance patient care by providing quicker and more efficient access to healthcare, making better use of
nurses' time and skills, and allowing doctors more time to deal with the more serious cases presented. That is an admirable concept to be supported by adequate training of nurse prescribers to prescribe the POMs listed—there are more than 100—by the Committee on the Safety of Medicines. Fifteen antibiotics are also listed. Therein lies the concern.Antibiotics differ from all other POMs in that the needs of the individual patient must be balanced against the need to preserve their usefulness for the general population. Unlike other POMs, the use of antibiotics in one patient may influence the efficacy and efficiency of that antibiotic in another patient, related or unrelated. That does not occur with non-antibiotic POMs.
In its response to the proposed regulations and lists put out by the Medicines Control Agency, the Specialist Advisory Committee on Antimicrobial Resistance firmly believes that systemic antibiotics should be excluded from the list of POMs with the exception of a very few where their use can be easily and accurately diagnosed and proposed. Those include urinary tract infections in young women and bacterial vaginosis.
The extension to nurse prescribers of the ability to prescribe is based on the concept that nurses should prescribe for minor infections; yet it is those very minor infections which have led to the imprudent prescribing of antibiotics by doctors. Will independent nurse prescribers perform better than doctors have done? Will they be able to resist the demands for antibiotics by patients when the nurse prescriber judges that a prescription is unnecessary and yet is pressed by the patient to prescribe? That will not only be a problem for the nurse prescribers; it is a very real problem for medical practitioners. Will the period of training—a three-month programme of 25 taught days—be sufficient for all POMs but including those antibiotics?
The response of the British Society for Antimicrobial Therapy to the proposals recommends limiting the list of oral antibiotics to be prescribed to only the two infections I have mentioned; namely, urinary tract infections and bacterial vaginosis. It has listed the antibiotics which might be used. It points to a very clear role for nurse practitioners by serving as a gateway between patients and medical practitioners. I support that. It is also clear that the programme must be carefully audited especially for any increase in antibiotic resistance. The Public Health Laboratory Service should be brought into play.
I am aware that further discussions have been held with the Chief Nursing Officer, Professor Wise, chairman of the specialist advisory committee, and Dr Martin Wood, consultant physician and President of the British Society for Antimicrobial Therapy. Perhaps the Minister can inform us of the progress made.
In conclusion, I believe that the overall proposals will be a major advance in nursing, provided there is adequate instruction and supervision. I do not cavil with the extension of prescribing by nurses to the 100
or more POMs. The concern is with antibiotics. We have made welcome progress in cutting back on antibiotic prescribing. I believe that that has led to a reduction in antibiotic resistance. Let us not reverse that trend without due caution.Finally, other nurses such as veterinary and dental nurses handle POMs. Will they, too, be included eventually in this proposal?
7.39 p.m.
Baroness Pitkeathley: My Lords, in thanking the noble Lord, Lord Soulsby, for giving us the opportunity to debate the issue, I confess immediately that I have no expertise in prescribing—unlike many noble Lords who will speak. What I do have though is considerable experience and expertise as a patient. Since patient benefit or otherwise must be a central theme of our debate tonight, it seems to me that that gives me leave to make a brief contribution.
For seven months of last year I was a patient at the Middlesex Hospital. I had total body sepsis, peritonitis, an open abdominal wound and, for about half my stay, MRSA. Your Lordships will see that I have a very strong interest in the administration of antibiotics, painkillers, fluids, artificial food and practically every other substance which can be administered to a bedfast patient, the names of which I have now mercifully forgotten.
Your Lordships will perhaps understand that it is a bit of a miracle that I survived at all; that I did so is due in large measure to the fantastic care which I received from the NHS and the fact that no effort was ever spared to save my life even when all hope of saving my life seemed to be gone.
We talk a lot about putting patients first and that it is easy to say and hard to put into practice, but I must go on record as saying that not once in all those long months, at least while I was conscious, did any doctor, nurse or other practitioner do anything to me without explaining the procedure, its process, its effects, asking me if it was all right to proceed and generally putting my thoughts and wishes at the forefront. It is perhaps worth also saying, particularly today, that never once was I treated with anything other than respect and dignity.
The co-operation and trust between the doctors, nurses and the allied professions were also exemplary. For example, a special team of nurses had been set up to ensure that there was the utmost co-operation between the ward and the intensive care unit to ensure that no focus on the patient was lost when the lower level of care provided by the ward was substituted for the one-to-one nursing in ITU. The advice of this nurse team on all matters, including prescribing, was taken by consultants, doctors and nurses on the ward.
This caring and concerned atmosphere alleviated what was inevitably a distressing experience. Some of the worst moments were waiting for an on-call doctor to arrive—usually at night, in the small hours—to prescribe more pain relief, more antibiotics, a new IV line and/or more anti-nausea drugs. It is for that reason that I am speaking strongly in favour of
extending nurse prescribing tonight. Who did I want to prescribe for me at these times—the charge nurse or the night sister, with whom I had constant contact, or a new and often inexperienced doctor who had never seen me before? Your Lordships will conclude that it was of course the nurse. In any event the doctor would take the nurse's advice because she knew more about me.As the size of my notes grew—and noble Lords will appreciate that they eventually filled four folders and stood almost a foot high—who was seriously going to read through all that? No one of course. My history was given to the doctor by the nurse or by me and it was on that basis that the prescription for whatever it was was written out. The delay was sometimes considerable and it caused distress not only to me but to the staff. How much better for the nurse to have prescribed in the first place. Indeed, I am very much in favour of extending nurse prescribing. When it came to putting in lines, the nurses who did so were frequently more skilful and tender to my poor sore veins than the doctor, who, however well-meaning, was often just learning.
I must emphasise that the advice of the nurses resulted from long connection with me, wide knowledge and experience of my condition and close co-operation with the consultant and registrar who saw me daily. Speaking as a patient, I certainly would not want anyone to be prescribing for me without adequate training. So I very much welcome the emphasis placed by the Government on training and on the commitment of £10 million to support this extra training for nurses.
For the proposed extension of prescribing to be successful, trust and respect for each other is vital. That applies not only to the relationships between doctors and nurses but to the relationships with those other professions who contribute so greatly to the welfare of patients, such as physiotherapists and OTs.
I am sure that the new arrangements for prescribing will bring enormous benefits in terms of time and money saved, but I principally support them because of the benefits to patients which I am sure will result from well trained and well informed nurses prescribing as proposed.
7.44 p.m.
Baroness Finlay of Llandaff: My Lords, I am grateful to the noble Baroness, Lady Pitkeathley, for relating a pleasant experience of being in hospital. As a medical practitioner I found it most welcome.
I should like to confine my remarks to antibiotic prescribing and the extension of that to nurses. Antibiotic and anti-fungal resistance are modern phenomena. Stored strains of bacteria from 1915 to 1950 show no transferable resistance, so Darwinian natural selection is very active among micro-organisms.
Currently, it has been assessed that in Wales about half of all antibiotic prescriptions are unnecessary. There are wide variations in antibiotic prescribing across Europe. High rates in Spain correlate with high
levels of penicillin resistance. The noble Baroness has already mentioned the problems of resistance in bacteria.Interestingly, in Finland, a major campaign to decrease macrolide antibiotic use resulted in significant falls in resistant Group A streptococci. Decreased tetracycline use has also been linked to a fall in the amount of resistant strains. So natural selection comes into play and resistant strains of organisms do not emerge.
Nearer to home, there are powerful data from Howard and colleagues. They have looked at antibiotic prescriptions dispensed from a GP practice and the presence of antibiotic resistance in specimens from patients from that practice. When the prescribing rates of antibiotics were high they found high rates of resistance to that antibiotic. The other worrying finding was a cross-correlation between usage of one antibiotic and antibiotic resistance to another. For example, Trimethoprim was associated with multi-resistance in coliform to up to four different antibiotics.
They also demonstrated higher levels of resistance in areas of social deprivation, which strongly supports the hypothesis that the pool of bacteria in a practice population develop resistance. When a member of that community becomes immuno-compromised for whatever reason, he is more likely to be ill with a resistant strain. So the data on resistance relating to the number of prescriptions for antibiotics are strong.
Next, perhaps I may comment on the drugs themselves. They are potent and potentially dangerous. For example, some patients prescribed Minocycline for acne have developed severe lupus-type liver damage. Life-threatening hypersensitivity reactions are well recognised with many antibiotics.
As well as antibiotics there are anti-fungal agents on the list, which I would like to address. Candida albicans used to account for over 95 per cent of all fungal infections, but it now accounts for only about 60 per cent in the UK and 50 per cent in the USA. Resistant strains, particularly glabrata and kruisei have become prominent. Systemic fungal infection is notoriously difficult to diagnose and the anti-fungals anphotericin and Miconozole must be reserved for life-threatening fungemia.
Dental stomatitis and gingivitis needs good oral hygiene and denture-cleaning, not anti-fungals or antibiotics. Dental abscess, which is normally due to prevotella, which is an organism found in the mouth, develops penicillin resistance very readily by Beta Lactamase production. I would remind your Lordships that some dental abscesses have been fatal.
I return to social deprivation because nurse practitioners in walk-in centres in areas of deprivation have been providing a service which evaluates well. It is precisely in the more deprived areas that resistant strains of bacteria are prevalent. Compliance with completing courses of antibiotics is notoriously low and poor social conditions mitigate against care at home of serious infection.
Nurse management protocols, which include prescribing of items as on the current approved list, indicate when to refer on to a doctor those infections that may need systemic antibiotics. That would include the oral antibiotics, obviously.
This nurse contact undoubtedly prevents some patients going straight to the GP for antibiotics. The noble Lord, Lord Soulsby, has outlined current major initiatives to decrease antibiotic prescribing and maintain a list of hospital only antibiotics in the Armementarium against life-threatening infections. Minor infections will get better with good nursing care, especially cleansing and topical measures. Antibiotics systemically should not be used for them anyway.
Serious infections, such as cellulitis, need a serious diagnostic medical workup, for they are potentially fatal. The amount of antibiotic in every community must be decreased to avoid that individual community developing more and more antibiotic resistant strains of organisms.
That is why I would like to see antibiotic prescribing more restricted and not extended to the initiation of antibiotics by more people, and therefore that is why I oppose nurse prescribing of antibiotics. But I should like to make it clear that I do not oppose nurse prescribing of the other items.
7.50 p.m.
Lord Rea: My Lords, the noble Lord, Lord Soulsby of Swaffham Prior, is right to ask this Question, which has caused concern to many clinicians. He is a veritable terrier in the tenacity with which he has warned us of the dangers of emerging resistance to antibiotics, since he so ably chaired the Science and Technology Committee in 1998.
I would say that there are two golden rules for antibiotic prescribers: first, as far as possible, restrict the prescription of antibiotics to moderate or severe infections whose duration can be significantly reduced by antibiotics, or where there is significant risk that they will otherwise become more severe, or where complications will develop; and, secondly, most infections should be treated initially with one of a small range of effective, well understood "first line" antibiotics. "Second line" antibiotics, which are usually more expensive, should be reserved for infections that do not respond to the first-line drugs, or where there is a known resistance to first-line antibiotics. I hope the noble Lord agrees with those principles, which, as he indicated, are not always easy to live up to in the heat of a patient consultation.
MLX 273—the extended list of drugs that has, I gather, been agreed by Ministers—contains 15 antibiotics. I would classify six of these as second-line, to be held in reserve, and nine as first-line drugs. The short list proposed by the Committee on the Safety of Medicines (the CSM) is composed of these first-line antibiotics In fact, they are exactly the ones that I, as a GP, used in the great majority of patients who needed antibiotics. I do not think that the longer list of 15 is appropriate as it stands.
In all cases where treatment fails with first-line drugs, it would be reasonable for nurses to seek a medical opinion, or agreement, before using one of the six second-line preparations on the extended list. I do not suggest that they should not be able to prescribe these, but that the decision to do so should be a shared one.
The extended MLX 273 list, which actually contains 143 drugs, also includes nine anti-fungal preparations. As this was covered by the noble Baroness, Lady Finlay, I do not propose to talk about fungi, except to say that the same considerations apply to them as to bacteria.
Nearly half of the total list consists of newer or more expensive second-line preparations. These are other than antibiotic drugs: they are alternatives to well-tried drugs. Again, I believe that the rule should be that they be used mainly as second-line drugs. They are usually considerably more expensive than first-line preparations. If a first-line drug is ineffective, it may well be that the diagnosis is wrong rather than that the condition is not responding to the prescribed treatment. Therefore, I believe that a shared decision would be appropriate.
One of the considerations that is not clear when reviewing this list of drugs is how often the nurse prescriber will be signing a repeat prescription for a patient on long-term treatment. If the decision to initiate the treatment was a medical one—or part of a team decision, or protocol—then it would be quite legitimate for a nurse to sign a wide variety of prescriptions if he or she were caring for the patient; but as a completely independent practitioner, I think that the current list is too extended.
As the noble Lord, Lord Soulsby, said, we have seen general practitioner prescriptions for antibiotics fall by 23 per cent between 1995 and 1998, which is very gratifying. But, as the noble Lord indicated, we could do better. If nurses are to prescribe antibiotics, their training must—and, I believe, does—include very specific knowledge of the problems of microbial resistance and how to minimise it. I am confident that, with this training, nurses will be as prudent in the use of antibiotics as the best general practitioners; and much better than many. There is evidence in the United States to show that nurses prescribe high-cost antibiotics much less often, and more appropriately, than physicians.
7.55 p.m.
Baroness Cumberlege: My Lords, before beginning my speech, I should just like to declare an interest. I am a vice-president of the Royal College of Nursing, and of the Royal College of Midwives and patron of the Association for Nurse Prescribing. I thank my noble friend Lord Soulsby for initiating this debate, not least because it has given us the opportunity to listen to the noble Baroness, Lady Pitkeathley. I have to say that the NHS clearly played a very important part in her survival, but I suspect that the noble Baroness's personal courage and determination played an equally important part in the process.
I am one of those very sad people. I have only ever had one original idea; namely, nurse prescribing. I am really passionate about the subject, and, I have to say, slightly unhinged. In 1986, I was commissioned by the then government to review community nursing for England. As I undertook the task, I visited parts of England and was appalled when I witnessed some of the enormous discomfort, suffering and pain that patients suffered at that time, although they were well attended by a qualified nurse. The nurses were unable to vary the medication both in its duration and in its strength. These people were actually dying; and community nurses were trying to keep them at home. The situation seemed to me to be simply dreadful.
I then visited doctors' surgeries and saw district nurses and health visitors—highly-qualified professional nurses—standing outside the consulting room doors of GPs, waiting for prescriptions to be signed. They had actually written the prescription, but had to wait for a doctor's signature. That seemed to me to be pretty humiliating. When undertaking the review, one of the recommendations produced by my team was that nurses should be allowed to prescribe from a limited list, provided that they were qualified as district nurses and health visitors and undertook the training.
After a huge effort in winning cross-party support, bouncing the Treasury, persuading other health professionals that this was a good idea, and setting up the first Crown committee (which, among other things, reviewed nurse prescribing) the scheme came into being. There is now a national roll with 23,000 nurses being allowed to prescribe. That is terrific. But throughout the process two severe criticisms have been made. The first related to training. Initially, it was thought to be too thorough. The second criticism was that the Formulary was too restrictive. However, over the years both those issues have been addressed. The training is now realistic: it is well founded and appropriate. Until now the standards have been set by the UKCC, and the curriculum has been approved by the English National Board.
I understand that mechanisms are now in place to ensure that when these bodies cease to be, the new bodies will take on the scrutiny and the leadership of this particular part of training. The training programmes will continue to be set at degree level. They not only involve higher education, but also practical supervision for three months. It is a very solid training regime. The point that I should like to make is that the people about whom we are talking—those who are being trained and who are prescribing—are not fresh-faced school-leavers: they are experienced, professional men and women. Most of them have additional qualifications as nurse practitioners, clinical nurse specialists, or nurse consultants. They are individually accountable for their actions and they are required to work within their competence.
All the research, including three randomised control trials of over 4,000 patients in 35 GP practices, show that nurses are not cavalier when prescribing. Originally, the limited list was a sop introduced in order to get other professionals on board. My vision
for the future is that we should not have a limited list, that nurses should have the full range of the National Formulary.When I look at what nurses are doing in areas such as diabetes and asthma, I find that once the doctor has made the diagnosis it is the nurses who are the experts and who have the knowledge to manage the care. Many GPs are only too willing to let them do so. I believe that there is scope to go much further than we are at the moment.
I wish to give your Lordships one example where I believe it is so obvious that nurses should be allowed to prescribe antibiotics. Currently, a highly trained nurse may take a history from a patient, examine her, carry out diagnostic tests and diagnose a urinary tract infection. But that patient has to wait for the nurse to find and speak to a doctor, get a prescription signed, often without the doctor even seeing the patient, before the patient can receive the antibiotic treatment she needs. I believe that that is nonsense. In the interests of responsive services to patients we should look at the evidence here and in the United States of America and Australia and recognise that nurses are responsible professionals and we should entrust them to prescribe antibiotics.
8.1 p.m.
Lord Turnberg: My Lords, I, too, am grateful to the noble Lord, Lord Soulsby, for bringing this important matter to the attention of the House. Perhaps I may also say how moved I was to hear the eloquent speech of my noble friend Lady Pitkeathley. So I am particularly pleased to have the opportunity of speaking in the debate not only because I believe that bacterial resistance to antibiotics is particularly problematic as a major health hazard—and here I would like to express an interest as chairman of the board of the Public Health Laboratory Service—but also because I have always supported the idea of nurse prescribing; not all nurses, perhaps, and not all drugs. But the principle of nurse prescribing has always seemed very reasonable to me.
But with antibiotics we have a dilemma because, as we have heard, the prescription for one patient has implications for others when resistant bacteria emerge. How, then, can we square the circle of restricting antibiotic prescribing, as we have been trying to do across the medical and veterinary professions, while at the same time widening access to nurses? Blanket approval and blanket disapproval of nurse prescribing does not seem to be appropriate and, as always, resolution depends on the detail. Not all infections are the same and neither are all antibiotics.
At one end of the spectrum we have a patient seriously ill with a high temperature and looking very sick. As a doctor, as I once tried to be, my response to that patient would have been a thorough history and a careful examination for clues about a diagnosis. Then perhaps a chest X-ray, a blood culture and possibly other tests. After that, I might or might not have prescribed a first-line antibiotic while I waited for the
results. That case clearly sounds primarily like a medical rather than a nursing problem, at least to start with.At the other end of the spectrum is a patient with a seemingly minor illness, perhaps a sore throat or a boil, and here again an antibiotic will not be the first line of attack by a doctor or nurse. We would be stepping into areas of inappropriate prescribing where we have begun, as we have heard, to make progress among general practitioners. So if severe infections require medical skills and knowledge before the prescription of antibiotics—and minor infections do not generally require them—what is left for nurses to prescribe?
It is those kinds of considerations that made the specialist advisory committee on anti-microbial resistance look very critically at the long list of conditions which were thought to be appropriate. It felt that many of the proposed infections and antibiotics were inappropriate because they fitted into one or other of the categories I have described. Where it might be reasonable, however, is in one or two unusual or small examples. Urinary tract infections have been mentioned, but even here the types of antibiotics which are used should be limited to first-line treatments, leaving out entirely those second-line treatments which should be reserved for serious infection.
The dangers of emerging antibiotic resistant organisms are spelled out very clearly in the document The Path of Least Resistance which was produced by an excellent group under the chairmanship of Dr Diana Walford of the PHLS at the behest of the standing medical advisory committee. It is worth reading because at the very least it emphasises the need for caution in extending the ability of anyone, not just nurses, to prescribe antibiotics without careful attention to the details of what can be prescribed and for what diseases. It is the detail of which antibiotic and which condition rather than the principle, which I am sure the Minister will consider very carefully when he replies.
8.5 p.m.
Baroness Northover: My Lords, I, too, would like to thank the noble Lord, Lord Soulsby, for raising this important subject. We have heard some very cogent cases tonight for nurses prescribing, with some reservations and some opposition. It seems to me that what we have to ensure is that prescribing is safe not only on an individual basis but also in the wider public health context.
Public health measures such as sanitary reform made the key difference to health in the 19th century: antibiotics played this part in the 20th century, especially as regards hospital medicine. Yet these miracle cures, these magic bullets, do not operate against some static, unchanging enemy.
As the Select Committee on Science and Technology starkly stated in its report of 22nd March 2001:
- "We cannot eliminate [antibiotic] resistance. We can however slow it down, by using antibiotics only when necessary, and by rigorous infection control and basic hygiene, both informed by thorough surveillance".
General practitioners have responded by decreasing their prescription of antibiotics. As a mother of school-age children, I was part of the Government's target audience in their 1999 campaign. I certainly found that that campaign struck a chord among other mothers at the school gates: when their children went down with coughs and colds they were much less likely to rush off to the doctor. I trust that this campaign will not be a one-off.
It has to be alarming though that hospitals have not improved in this regard. I gather that most hospital trusts now do have protocols for what are to be used as first, second or third-line antibiotics and advise on the restrictions in their use. All should have such protocols.
But I also hear that up and down the country the same debates are going on in the various trusts about the low level of compliance with these protocols. I wonder whether the Minister has suggestions on what sanctions there could be to ensure that there is compliance.
One microbiologist tells me that in his experience surgeons have proved more compliant than physicians. He says that is because surgeons know the names of only two antibiotics and can spell only one. As the wife of a surgeon, I could not possibly comment.
But how are we to know what is being done where and by whom in any systematic way if the information systems are not in place? That has to be the key to the proper understanding of this problem and tackling it more effectively.
If hospitals still have much room for improvement but in general practice things are looking a little better, how will nurse prescribing fit in? After all, it has long proved to be the case that it is easier to prescribe than not to prescribe.
I have a copy of the outline framework for nurse prescribers which was produced by the NHS National Prescribing Centre in November 2001. When it comes to listing the kind of clinical and pharmaceutical knowledge to be expected of nurse prescribers, it may be that the issue of resistance to antibiotics is implied but I certainly did not find it stated.
I note that on 9th January 2002 the Medicines Control Agency reported that Ministers agreed that they wish to give more detailed consideration to nurses prescribing oral antibiotics. I also note that on its website the RCN states that it is,
- "mindful of the need to ensure appropriate prescribing as a means of minimising resistance".
Nurses are at the beginning of a new and exciting era, which I support. However, now is the time to set in place the guidance and the monitoring systems to ensure that what should be a positive development in the NHS is indeed such.
8.10 p.m.
Lord Astor of Hever: My Lords, it has been a great privilege to hear such an informed debate on such an important subject, involving all parts of the House. We have heard both sides of the argument. We have heard from a patient, from prescribers and from experts, particularly my noble friend Lady Cumberlege. I do not think that she is at all unhinged on the subject of nurses prescribing antibiotics. I am grateful to my noble friend Lord Soulsby of Swaffham Prior for introducing the debate.
It would certainly seem to be a good time to review the strategies that we have in place to try to halt the march of resistance and guide us in our approach to future regulations. One of the chief problems confronting any effort to reduce the spread of resistance is the lack of information available. Policy development is surely hampered by our not knowing the true extent of the problem with regard to individual strains of bacteria and individual types of antibiotic.
In preparing for the debate, I came across the work of the MYSTIC surveillance programme, which has provided some insight into the link between prescribing rates and resistance patterns. MYSTIC researchers have found that usage does not always affect resistance. Professor Richard Wise has said:
- "What we know about the link between prescribing and antibiotic resistance is fairly crude. The finer points are lost, but this information is necessary to deal more effectively with the problem of antimicrobial resistance".
On a broader scale, it appears that the existing surveillance tools are fairly blunt. They do not provide good quality information that not only monitors resistance patterns but provides relevant data on antibiotic consumption. Until we have a standardised national data collection system, any monitoring of the situation will be limited. I understand that it is not a problem peculiar to the United Kingdom and that matters may improve significantly with the introduction of the electronic patient record. However, I should still be interested to learn when we might see some discernible improvement in the surveillance of resistance in terms of individual drugs and individual infections.
The cost of antibiotic resistance cannot be overestimated. One hundred thousand people pick up antibiotic-resistant infections in UK hospitals every year. Treatment costs the NHS about £1 billion. It costs 100 times more to treat a patient with drug-resistant TB than one with normal TB. At present, the problem is more pronounced in other countries. In Estonia, Latvia and parts of Russia and China, more
than 10 per cent of patients with TB are infected with strains that are resistant to the two most powerful medicines used to treat the disease. In Thailand, three of the most common anti-malarial drugs are now useless.It is of increasing concern that in less wealthy countries patients are often unable to complete a full course of antibiotics, which allows the stronger bacteria to survive and develop resistance to the drug. We should be concerned by those developments, which seem so far removed from our hospitals. Bacteria do not recognise international boundaries. International travel introduces infections that are difficult to treat.
In Britain, we have our own problems to contend with, the best publicised being the superbug, MRSA. Vulnerable patients become infected, and the sheer numbers involved mean that the infection spreads rapidly. It is a worrying situation, and we should think about it internationally, as well as concentrating on our own hospitals.
Where are we in our efforts to slow down the spread of resistance? In 1998, the Select Committee on Science and Technology recommended that the public should be educated in the prudent use of antibiotics. I believe that that recommendation has been taken seriously. I hope that, in accordance with the Select Committee's report of last year, specific campaigns will be repeated frequently and regularly, in addition to the phase 2 mentioned in the Government's response.
One of the greatest problems is public expectation. Patients should know why they are not being prescribed antibiotics when they might have been in the past. The non-prescription form has been effective in helping to reassure patients that they are being cared for and not simply ignored.
For all its worrying prognosis, there is a positive thread running through the discourse on antibiotic resistance. Antibiotics can still provide an effective means of dealing with infection. Accurate diagnosis and immediate treatment are reducing the number of what may be termed needless doses. It is now essential that multidisciplinary initiatives and partnership play their part.
8.16 p.m.
Lord Filkin: My Lords, I am pleased to respond to the noble Lord, Lord Soulsby of Swaffham Prior, in this important debate. It could hardly have been more timely. Although the process of consultation has nearly been completed, it is not finalised, and Ministers have not yet made their decisions. Therefore, although my noble friend Lord Hunt of Kings Heath cannot be here, due to other pressing business, he will read the debate with considerable care and interest, prior to coming to a view on the issues.
The issue of antimicrobial resistance has been well covered. The noble Lord, Lord Hunt of Kings Heath, and I welcome your Lordships' continuing interest. The House's Science and Technology Committee has made a first-class contribution to public health in this
respect. The noble Lord, Lord Soulsby of Swaffham Prior, was a powerful contributor to both the first report and the subsequent report. On that basis, the Government have been able to move forward in developing our own strategy. As the noble Lord, Lord Astor of Hever, signalled, it is not just a national problem, it is an international one. In that respect, if no other, we are not an island, as we are open to infection from elsewhere.In the light of the Select Committee's report, the United Kingdom developed a strategy. I am grateful for the acknowledgement from the noble Lords, Lord Soulsby of Swaffham Prior and Lord Astor of Hever, that concerted action has been taken and that there has been a systematic attempt to address this serious problem. There are, however, no grounds for complacency. We have seen a significant early improvement. The 23 per cent reduction between 1996 and 2000 is good news. One expects that, as with all such initiatives, it will be tougher getting the next 10 per cent down. The noble Baroness, Lady Northover, rightly said that it was not just a GP issue. It is also a matter of whether hospitals are doing it, and I have noted the comments about data records and the importance of hospitals. The monitoring system, to which I shall refer later, will help, at least in part.
Several speakers remarked on the importance of public information on antibiotics and resistance. We have an educated public. It is not the case that people cannot understand an argument that is put to them. It is extremely important, therefore, that the public are aware of the special nature of antimicrobial agents, not least because it helps to reduce the pressure on prescribers. The Department of Health ran a media campaign in autumn 1999. That was not a one-off; there will be subsequent campaigns for the general public and for schools.
The noble Lord, Lord Soulsby, also kindly mentioned the recent announcement made by the Chief Medical Officer in the report, Getting Ahead of the Curve. This is not only about the reduction of inappropriate prescribing, it is also about reducing the need for antibiotics in the first place. Therefore concerted action is required to control the growth of infection and, where appropriate, to consider vaccination. Clearly that must form a part of any sensible strategy for dealing with this major problem.
It is clear that the prudent prescribing of antimicrobials is central to our debate tonight. Noble Lords have repeatedly stressed the importance of prescribing antimicrobials only when it is really necessary to do so, in the right dose and for the right length of time, and seeking to cut down on the unnecessary and inappropriate use that undoubtedly still continues to occur. The noble Baroness, Lady Finlay, gave the House a frightening statistic which she believes reflects the level of inappropriate prescribing taking place in Wales.
The issue for our debate is whether, if nurses—suitably selected and suitably trained—are allowed to prescribe a limited range of antibiotics, that will lead to an increase in resistance. We need to address the
question of whether nurses are likely to make more inappropriate judgments than other medical professionals. Nurse prescribing is not new. Fundamentally, it has come about through the pioneering work of the noble Baroness, Lady Cumberlege. Many in this House concerned with these issues have great pleasure in acknowledging the power and force of her pioneering work in this area.What has been interesting to note in our debate is that no one has argued against the extension of nurse prescribing. How the world has moved on. The debate has concerned inappropriate prescribing, or whether nurses would be more likely to prescribe antibiotics inappropriately. I hope that the noble Baroness will take some comfort from that, although she will not get full comfort because I am not going to go as far as she would like me to in regard to what the Government are likely to do.
My noble friend Lady Pitkeathley made very clear the advantages to patients of nurse prescribing: convenience, immediacy and the assurance of having someone who knows your whole history, has your confidence and is a person you know will be an advocate for your needs. I should like to be able to cite examples, but time will not allow. Let us focus therefore on the key issue of whether nurses would be more injudicious than doctors. I think that one would hope that in fact nurses would be more cautious, more prudent and more keen to follow protocols. That, of course, is the challenge facing the Government in terms of how these proposals should be implemented.
Such evidence as there is was found in three randomised control trials held over the past two years. They involved a total of almost 4,500 patients in 35 general practices. They were tested to see what GPs prescribed and what was prescribed by nurses for a range of common conditions. Those tests revealed no statistical difference between what was prescribed by GPs and what was prescribed by nurses.
The debate does not cover all nurses. Clearly it covers only a limited range of nurses. Not all nurses will want to train. Only first-level registered nurses and registered midwives would be eligible to train. In response to a question put by the noble Lord, Lord Soulsby, there are no plans currently under consideration by the Government to go further than that. In general, one would expect at least three years' experience before nurses were in a position to take up the training that has been developed. The education and training programme comprises 37 days' training in total, 25 days spent at university level along with a further 12 days' supervision in practice spread over three months, plus self-directed learning. That is then followed by an assessment on both theory and competence in practice.
I can confirm the point made by the noble Baroness, Lady Northover, when she asked whether the training would contain a specific focus on prescribing in the context of public health, including teaching on antimicrobial resistance, and the importance of compliance with local antimicrobial policy. As the noble Baroness so rightly remarked, the training will need to cover those points.
Since October 2000, the Department of Health has consulted widely on the extension of nurse prescribing, and again since the summer of last year on the particularly hard issue of the prescribing of antimicrobials. For many reasons of time and skill I shall not attempt to debate the specifics of the lists of antimicrobials for which conditions, because I do not think that we would be able to do justice to those issues at this point. Having said that, however, the Government will look with care not only at the thoughtful advice provided by SACAR and that by noble Lords during the course of this debate, but also at the specifics of what type of antimicrobials might be appropriate in what circumstances. Arguments relating to that were put forward clearly by my noble friends Lord Rea and Lord Turnberg.
The Committee on the Safety of Medicines, which is the statutory consultee on the Government's part, when consulted on the prescription of antimicrobials, lent its support to allowing a limited range of antimicrobials to be prescribed by suitably trained nurses.
A number of noble Lords commented on the importance of monitoring and evaluation. The Government strongly agree with those views. There will be a research programme to monitor the practice of nurse prescribing and we shall certainly wish to consult with SACAR over the findings of that research as it rolls out from 2003 onwards.
Ministers have now decided that first-level registered nurses and registered midwives can prescribe a broad range of medicines, including 130 prescription-only medicines, following the successful completion of a specific programme of extended training. There appears to be no substantial or significant opposition to that which, again, should give some pleasure and comfort to the noble Baroness, Lady Cumberlege.
On the specifics of which antimicrobials should nurses be able to prescribe, the noble Lord, Lord Soulsby, referred in passing to further discussions taking place between the Department of Health and senior representatives of SACAR. I have heard positive noises from those discussions, but those have not yet been put to Ministers and therefore I cannot comment on the detail. However, one would expect to be able to do so in the future.
A number of noble Lords raised questions about future developments. Perhaps, to some extent, let us see how we go with the current arrangements. I have signalled that there are no thoughts for further nurse prescribing. However, there are strong arguments for looking at supplementary prescribing, whereby nurses operate as part of a health team and operate under strict protocols, thus improving service to the patient without straying into areas of risk. However, as I have signalled, we shall not be going as far as the noble Baroness, Lady Cumberlege, would have liked.
In conclusion, as was said last week by the Secretary of State for Health, the NHS Plan published 18 months ago sets out our vision for the future of healthcare in our country, where patients always come first. The extension of nurse prescribing by suitably trained nurses operating within defined circumstances, with access to advice where needed, and properly monitored, will form an important part of improving the health service for the public. I am confident that, as long as we move on in the ways on which noble Lords have given advice, we shall have the support of the House and of the public in so doing.
State Pension Credit Bill [HL]
House again in Committee on Clause 3.8.30 p.m.
Baroness Noakes moved Amendment No. 29:
Page 3, line 4, leave out "qualifying"
The noble Baroness said: In moving Amendment No. 29, I shall speak also to Amendments Nos. 33 and 37. We have already looked today at some examples of the complexity of the Bill. This was a theme among many of those who responded to the Government's consultation document. One of the complexities is the treatment of income in the calculation of the components of the pension credit. The guaranteed credit uses the word "income" and we must look for the definition of that in Clause 15, which we shall come to in due course.
The savings credit is calculated using the claimant's "qualifying income". Of course, we do not know what is in that because it is to be dealt with by regulations under Clause 3(6). The concept of income is further complicated later in the Bill by something called "retirement provision", which is another shot at defining income.
So we have three separate concepts of income in the Bill. If that is not complicated, I do not know what is. Even if noble Lords think that they understand the differences between the concepts, does any noble Lord think that the average pensioner will understand them? The way in which the Bill is currently drafted places barriers to comprehension.
My amendments seek to cut through this complexity and to insert one definition of "income" for both the guaranteed credit and the savings credit, both looking to the definitions in Clause 15. As there is no concept of qualifying income, subsection (6) becomes unnecessary and can be removed from the Bill, which is what Amendment No. 37 seeks to achieve.
I hope that this further attempt at simplification commends itself to the Minister. If it does not, I hope that she will explain why this multiplicity of income
concepts is necessary and what differences the Government envisage between the different types of income. I beg to move.
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