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World Antibiotics Awareness Week

Volume 631: debated on Thursday 16 November 2017

I beg to move,

That this House has considered World Antibiotics Awareness Week.

It is a privilege to serve under your chairmanship, Mr Davies. Exactly one century ago, Ernest Rutherford split the atom and humanity entered the nuclear age. The groundbreaking discovery represented a momentous step forward for human progress, but at the same time it unleashed a challenge for those beyond the laboratory and academia—the avoidance of mutual assured destruction. As this debate is about World Antibiotics Awareness Week, some might wonder why I started with the splitting of the atom, but I believe that there is an equally strong argument for the aforementioned period to be referred to as the antibiotic age. It was 11 years after the splitting of the atom that Sir Alexander Fleming discovered penicillin, here in this very city of London.

No one can deny the profound impact of antibiotics on medicine, and their widespread use represents a watershed moment in our evolutionary story. However, as Fleming himself understood, shortly after making his discovery, giant leaps in scientific progress produced wholly new challenges. As antibiotics were readily available, it appeared that we had invented miracle drugs of sorts. The snag is that we now face the real and severe threat of antimicrobial resistance.

Across the globe this week, scientists and healthcare professionals are hosting a wide range of events to make antibiotic resistance a globally recognised health issue. I am delighted that we as parliamentarians are here today to represent the role that lawmakers and Governments will play in facing the challenge of antibiotic and antimicrobial resistance. The week is also intended to raise awareness of the need to preserve the power of antibiotics through appropriate use, to increase recognition that individuals, health and agricultural professionals, and Governments must play in tackling antibiotic resistance, and to encourage behavioural change and convey the message that simple actions can make a difference.

While the threat of antibiotic resistance is often considered a doomsday scenario—one might say a medical Armageddon—we must remember that that menace is all too deadly today. Currently, 700,000 people die each year from drug-resistant infections; the future threat is touted as being so severe and extreme, not because we are not living with the effects today but because of the truly appalling potential scale of the problem if we do not take co-ordinated action. If we do not act now, antimicrobial resistance will be responsible for 10 million deaths per year by 2050. That is more than the number of people worldwide who were killed by cancer in 2015. It is nearly impossible to put a number on the lives that have been saved by antibiotics; some sources put the figure at roughly 2 million, but it is entirely conceivable that we may arrive at a position where the balance tips, and antibiotics pose a greater threat than a remedy.

As I have said previously in this House, we run the risk of returning to a medical dark age, where routine operations such as hip operations cannot be carried out, and infections that are standard today become deadly. This week, the British Society for Antimicrobial Chemotherapy published a report on behalf of the all-party parliamentary group on antibiotics. The report, the briefing for which has been sent to all Members of the House, considers the AMR action plans and strategies set out by the World Health Organisation, the European Union and the UK, and asks, crucially: “Has the world lived up to the challenge?”

The overarching theme of the report is that future strategies to combat antibiotic resistance should incorporate specific, measurable, attainable, relevant and timely—SMART—targets. When the stakes are 10 million deaths each year within four decades, it is easy to become lost in the scale of response that that merits; but as is so often the case, a coherent and clear approach is our greatest weapon. I call on the Government to ensure that all steps are taken to counter AMR and explicitly to incorporate those SMART targets I listed. I believe there is much to be gained from making that standard practice and removing any doubt. I am sure that colleagues will be encouraged to read in the report that

“the UK has taken significant steps to meet the objectives of the EU Action Plan, which in turn satisfies the WHO Europe Strategic Action Plan.”

There are two aspects, however, where our country needs to up its game. First, we need to address education and public awareness, so it is entirely fitting that we meet today during World Antibiotic Awareness Week, an occasion aimed directly at bolstering an understanding of resistance and the threat it poses to humanity. We need to be forthright in promoting the “four rights” when consuming antibiotics: the right drug, the right dose, the right time and the right duration. A survey carried out across Europe in 2016 indicated that knowledge about AMR remains low, and antibiotic consumption has decreased by only 6% over the last seven years. To address that, the British Society for Antimicrobial Chemotherapy advocates the use of simple and clear language in all awareness-promoting material. There is a direct recommendation of

“monitoring the efficacy of education campaigns through online channels.”

Fleming himself was once quoted as saying that the best remedy for a common cold was a dram of whiskey.

I know the Scottish Members would certainly agree with that. As Fleming said,

“it’s not very scientific—but it helps.”

We now need to make the message as clear as day: antibiotics are ineffective when taken unnecessarily and doing so bolsters resistance and endangers mankind.

The second area where significant progress can be made is on the incentives for antibiotic discovery, research and development. It should be noted that the antimicrobial challenge is as much economic as it is medical. We must find an alternative to the reimbursement model, whereby profitability of bringing new antibiotics to the marketplace is linked to volume of sales. That is because we are actually seeking to limit the use of such drugs to preserve their power; to use new drugs as a point of last resort, as it were. To use an analogy, it is almost like the fire service—we need it to be there and to be effective, but we do not want to use it. However, nobody would dispute the necessity of investment and funding for that key emergency service.

To overcome this task, it is essential that measures are taken to co-ordinate a review of progress in new drugs, alongside the activation of research and development by industry for new antibiotics and related products achieved by Innovative Medicines Initiative projects. On the economics, we need to seek innovative solutions, with the pricing conditions and “pull” measures needed for the long-term sustainability of new antibiotic development, so that they are promoted. An example of that is the compact initiative of the European Federation of Pharmaceutical Industries and Associations to promote a sustainable business model and adequate conditions for the introduction of effective new antibiotics.

The O’Neill review, published last year and described last week by a columnist from The Times as

“the best argued and most accessible”

report in his lifetime, was very clear on this matter. Lord O’Neill found that much more needed to be done to close the substantial gap in research and development funding between AMR and the best-funded areas of medical science. The report being launched this week quantifies this further, and states that $40 billion is needed over 10 years, representing about 0.05% of G20 countries’ current healthcare spend. I will not claim that that sum is insignificant, but it is certainly affordable given the magnitude of the threats we face.

For improvement on a global level, the report makes it clear that co-ordinated efforts must be made in the veterinary sector, where I am pleased that tangible progress has been made in the UK. Figures from the Countryside Alliance show that sales of livestock antibiotics across the sector have fallen by an average of 27%—their lowest levels since records began—which is a good start, because a failure to address AMR in livestock has fundamental implications for the treatment of human diseases. For that reason, mirrored co-operation between Government Departments is essential.

While I am delighted that we are joined by my hon. Friend the Under-Secretary of State for Health, this matter also encompasses the Department for Environment, Food and Rural Affairs, the Department for International Development and the Department for Exiting the European Union. We need a clear commitment from the Government that that co-operation is there and that an interdepartmental strategy is on the agenda. Beyond that, we require what Antibiotic Research UK describes as a “grand alliance” to come together, comprising the Government, the pharmaceutical industry, collective medical research charities and academics.

To reduce further the overall use of antibiotics in the veterinary sector, guidelines have been developed for prudent use. The EU road map also proposed the creation of an animal health legal framework, based on the principle that prevention is better than the cure. Take the example of colistin. In 2015, evidence emerged of colistin resistance with the potential for transfer and spread between bacterial species. In order to preserve colistin for human medicine and limit the spread of resistant genes, the European Medicines Agency imposed strict limitations on its use and recommended the withdrawal of marketing authorisations for all oral colistin in veterinary medical products. Professor Galloway, from the Royal College of Physicians and Surgeons of Glasgow, is calling for a full review of the use of antibiotics used in both animal husbandry and human clinical practices, and I believe the Government should actively consider that suggestion.

In the UK, some sectors have conclusively beaten the target set by the veterinary medicinal products directive. Such industries represent very clearly what we are aiming for with the SMART targets I referred to at the beginning of my speech. In many cases, progress has been made through voluntary schemes. I request that the Government look directly into specific sectors in order to investigate best practice and what we can learn from it.

However, we must go further as a global leader and recognise that this is an international challenge. Almost 80% of antibiotics used in the USA are not taken by people but used within the livestock sector, which I find astonishing. In India, people consume an average of 11 antibiotic tablets per year. Only today, data has been released showing that antibiotic resistance is growing in Europe. Progress that Britain makes will be quite simply irrelevant in the absence of a confident international stewardship programme.

The British Government must act as an example in their commitment to tackling resistance head-on globally and, while I recognise it is not in the specific gift of my hon. Friend the Under-Secretary of State for Health to dictate his published ministerial responsibilities, I believe it is timely explicitly to add antimicrobial resistance to those responsibilities. That symbolic act would send a clear message that Britain is committed to remaining at the forefront of the fight against antibiotic resistance.

I share the hon. Gentleman’s concern about the problems with antibiotics, which we see with farm animals. However, there is also now a problem over supply, due to the increased concentration of the pharmaceutical industry—there are new mergers coming along as we talk. Does he think that that is worthy of proper investigation? Those companies can turn the supply on, but they can also turn it off, which can also be life threatening.

The hon. Gentleman makes a fair point. As I said, we have to encourage new antibiotic discovery. In our current system, the big pharmaceutical companies have been reluctant to come forward and put that money in, because the financial model just does not work.

However, encouragingly, we are now seeing smaller companies and spin-outs—from science departments within medical departments within universities—looking specifically at antibiotic discovery. There is something to be said about that, and again we have to look closely at it, because it could be used to our advantage. I encourage the Government to look at that, I encourage all Members who have a university in their patch to talk to them and I encourage those who have any of these small companies to visit and talk to them. It is incumbent on us all as parliamentarians to go out there and promote what is happening on our doorstep.

There is no doubt about it: the big pharmaceutical companies are finding it very difficult to promote new antibiotics. It takes 15 years for a new antibiotic to come to the marketplace from the start of the process of discovery. Companies have to make a huge investment. If that investment leads to a drug that is not actually used, because we are using it as a point of last resort, the financial model as it currently sits just does not stack up. That is something we have to address.

The discovery and development of antibiotics should not be seen as a curse. However, we must recognise that responsible steps now need to be taken to ensure that they persist and that we keep resistance firmly locked down. The antibiotic age can remain a golden one, and our collaborative actions can prevent a fall into what has been described by many as a medical abyss without antibiotics.

In the antibiotic age, we are all on the same side. This is not about politics or what the UK can do; it is about global action. That cannot translate into a lack of zeal and an absence of the will to win. I very much look forward to hearing what the Minister has to say. The UK Government have made great steps forward. The O’Neill report was a great start, but we have to continue that, and we have to be world leaders in this. We have a great opportunity to do that, if not for our generation, for future generations.

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

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

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

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

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

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

“the end of modern medicine.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It is a pleasure to serve under your chairmanship, Mr Davies. At relatively short notice I am standing in for my hon. Friend the Member for Linlithgow and East Falkirk (Martyn Day), who is not very well. I am not certain of the cause of his illness, but I am sure that if he is seeking advice, he will rightly be following the guidance of the theme of World Antibiotics Awareness Week, which states:

“Seek advice from a qualified healthcare professional before taking antibiotics”.

He will also be taking the advice, as I am sure will everyone else, of my hon. Friend the Member for Central Ayrshire (Dr Whitford), who has been impressing on us the importance of the flu jab. I can testify to the medicinal qualities of a hot toddy, from time to time, but in the careful context of appropriate medication with appropriate medical advice.

I congratulate the hon. Member for York Outer (Julian Sturdy) on securing this debate, which gives us an important opportunity to reflect on the issue of antimicrobial resistance and the importance of being aware of the challenges. It is a timely debate, taking place during the World Antibiotics Awareness Week. Any kind of awareness week has a number of important consequences. In this context, improving the understanding of the risks faced, which we have heard clearly from other hon. Members, is key, as is presenting an opportunity to take action in response to the challenges presented.

The challenge is very clear and came through in all the speeches. The right hon. Member for Chipping Barnet (Theresa Villiers) made it clear how difficult it is to overemphasise the scale of the challenge and the risk we face. Some 700,000 deaths a year are attributable to infections from superbugs that are resistant to antibiotics, and that figure is predicted, as we have heard, to rise to almost 10 million in total by 2050.

There are huge challenges in the livestock and veterinary sector as well. I was interested to hear that academics from the University of Glasgow in my constituency are among those taking the lead. I will say a wee bit more about what the university is doing shortly.

As the hon. Member for Stafford (Jeremy Lefroy) has said, the issue also has a big impact on developing countries, where people require access to medicines and the challenge of resistance is huge, and it threatens the progress made in health and tackling poverty. Being aware of the huge risks and then using that as a motivation to action is one of the key opportunities presented by awareness week.

I will reflect briefly on the Scottish Government’s actions. A large amount of health policy is devolved, but there are good examples and good practice on which we can reflect. In March the Scottish Government announced a £4.2 million research grant to investigate the prevention and control of healthcare-associated infections, as well as to research new ways of using existing antibiotics more effectively and efficiently. Some of that funding was provided to a consortium of researchers led, as I have said, by the University of Glasgow in my constituency, working with other Scottish universities to establish a new Scottish Healthcare Associated Infection Prevention Institute, which will conduct important research, bringing together a range of academics, researchers, practitioners and so on.

The Scottish Government have also established the Scottish antimicrobial resistance and healthcare-associated infections strategic framework for between 2016 and 2021. It has a number of aims to do with the containment of antimicrobial resistance; advancing scientific knowledge and innovation; improving efficiency, transparency and accountability; and improved workforce capability. That is important for all environments where healthcare is delivered, such as care homes, community pharmacies and primary care, and for everyone involved in the delivery of care.

There are a number of things we can all do at an individual level. There was a debate in March, I think on the broader issue of antimicrobial resistance, during which we were encouraged to become an antibiotic guardian. In fact, when the sitting was suspended for a Division in the House, many of us signed up online. The number of people signing up to that campaign continues to grow and this is another important opportunity to encourage others to do so. The Scottish Health Secretary, Shona Robison, has pledged to join the scheme and to encourage as many people as possible to do so in order to reach the target of 100,000 people becoming an antibiotic guardian.

This debate has shown that the Government have some challenges and opportunities. Are we ensuring that the right levels of investment are being channelled through the right Departments? The importance of joined-up government across Departments, including DEFRA, DFID and the NHS, has been made clear in this afternoon’s speeches. Towards the end of his remarks, the hon. Member for Stafford touched on the issue of a joined-up global response. There is a sense in some quarters that Brexit might represent some sort of retreat from the world stage. Yet the Government’s response to the O’Neill report in 2016 clearly stated that a global response, including “working closely with Europe”, is required. How do they see that relationship with European institutions in the context of Brexit? How can we be sure that the bonfire of red tape and regulation that so many Brexiteers have dreamed of for so many years will not weaken those efforts? We have already heard about the possibility of chlorine-washed chicken and so on coming into the United Kingdom as a result of potential trade deals with the United States. How can we make sure that meat that comes in as a result of new trade deals is not absolutely overloaded with antibiotics and other treatments that could lead to increased antimicrobial resistance?

In conclusion, this is a significant challenge and awareness is important. Awareness weeks, debates such as this, and the antibiotic guardian scheme play a very important role in tackling some of the challenges. I was interested to hear about the Swab and Send initiative and am keen to sign up to it. I can think of several dusty corners, not just in this Chamber but elsewhere in the Palace of Westminster, where who knows what might be discovered. I think that is a challenge to us all.

We know that there are models out there that can work. The hon. Gentleman spoke about a number of them and some of the many positive actions taken to tackle malaria, as well as the challenges that remain in closing the final gap. The other day I attended an interesting meeting between DFID officials and the all-party parliamentary group on vaccinations for all. We looked at the impact of the near eradication of polio and the challenges that will present for other schemes in the future. Some of the infrastructures that have been built up to deliver that historic achievement of the eradication of polio can perhaps be adapted to meet other healthcare challenges. I am not by any means an expert, but perhaps this is one of those areas.

It is clear from this debate that we can all play our part, and it is also important that the Government lead by example. Once again, I congratulate the hon. Member for York Outer on securing this debate and I look forward to the Government’s response.

It is a pleasure to serve under your chairmanship, Mr Davies. I thank the hon. Member for York Outer (Julian Sturdy) for securing this debate on a really important subject during the week when we are focusing attention on the value of antibiotics and the challenges of antimicrobial resistance.

We have heard some interesting contributions, and I think there is widespread agreement across the Chamber. To reiterate some of the problems, we all agree that antimicrobial resistance is arguably the biggest challenge facing our health system. It is worth taking a moment to reflect on how fantastic antibiotics have been. We take so much for granted. Alexander Fleming’s discovery of penicillin heralded a golden age in health. Penicillin was the first of many antibiotics; it alone has saved countless lives and was rightly hailed as a wonder drug. Wide-scale access to antibiotics changed the nature of medicine forever: wounds would heal and operating theatres became safe places where life-changing and, indeed, life-saving operations could be carried out without fear of deadly infection.

However, that was a long time ago and we now too often take antibiotics for granted. We have become blasé about their use. We have become careless and irresponsible. Too often at the first hint of an infection—a cough, a sneeze or a headache—GPs come under pressure from their patients to prescribe antibiotics. Too often antibiotics are the first port of call. Too often they are made available as a precaution. Through overuse and inappropriate use we have allowed the development of resistant bacteria on a global scale.

That is not just confined to their use on humans, as has been mentioned by several hon. Members. In fact, the use of antibiotics in animal husbandry is widespread and is not just to treat infection, nor even to protect against infection. Until relatively recently it was permissible for sub-therapeutic doses to be added to animal feed to promote growth. That practice was banned globally in only January of this year. Even without that, 44% of all antibiotics used in the UK are used on animals and often inevitably find their way into the food chain and domestic water supplies. Cat McLaughlin, chief advisor to the National Farmers Union on animal health and welfare, stated:

“Arbitrary restrictions on the use of antibiotics…could have a detrimental impact on animal and plant health.”

That might be all well and good; however, the scientific consensus is that if we fail to place restrictions on the use of antibiotics, there will be a catastrophic effect on human health.

It is worth stressing that, as we have heard, antimicrobial resistance is the cause of 700,000 deaths globally each year, and that figure is predicted to rise significantly, to horrific levels, by 2050. Here in England, 5,000 people die every year from infections that have developed resistance to antibiotics. We must not underestimate the full impact of antimicrobial resistance. Let us be absolutely clear: without resort to effective antibiotics, there will be no treatment for complex infections, no chemotherapy for cancer and no treatment for cystic fibrosis, heart transplants or joint replacements. I recently visited the microbiology laboratory at the Royal Blackburn Hospital in Lancashire and the consultant microbiologist I spoke with said, “If you take one thing from your visit here today let it be this: we are so close to being unable to perform even the most minor, the most simple, operations, and so close to being unable to treat commonplace infections.” She impressed on me the need for urgent action.

The World Health Organisation identified the need for co-ordinated global action back in 2011. I am pleased to say that the UK has been a leader in responding and that at the time it published the five-year antimicrobial strategy and commissioned the O’Neill report, which has already been mentioned. It is clear that our focus should be two-fold.

First and foremost, we must raise awareness of the danger of overuse and focus on the reduction of demand. There is a lot that we can and must do. I agree with other hon. Members that we must start with a public education programme to manage expectations and to highlight the issues of inappropriate use and too frequent use. We should increase the use of diagnostic testing so that only efficacious targeted antibiotics are used.

In both those areas we should look to community pharmacists to lead. Qualified pharmacists are well placed to provide antimicrobial stewardship. Every day 1.6 million visits are made to community pharmacies in the UK, which provides ample opportunity to advise the public on appropriate treatments for ailments, to ensure full awareness of remedies other than antibiotics that may in many cases be more appropriate. The Royal Pharmaceutical Society has offered to support its members to take on new and extended roles. Why not take it up on that offer? Why not make mandatory the roll-out of minor ailment schemes in community pharmacies? Why not support community pharmacists to carry out diagnostic testing to support GPs and other dispensing health professionals? Reducing the prescribing of antibiotics is not just the responsibility of GPs.

We must also regulate to reduce the amount of antibiotics used routinely on animals that are not sick. The National Office of Animal Health refutes the call for extended regulations and rejects the call to reduce antibiotic use in food products. However, we must act to promote a global reduction, because we are not talking about insignificant amounts of antibiotic use. Here in the UK, as I have mentioned, 44% of all antibiotic use is on animals. In the USA that figure is more than 70%. Many nations do not even record the figure and there is every reason to suppose that it is far higher. We must acknowledge that this is a global problem and play our part in identifying new incidences of antimicrobial resistance.

We must invest in research and development, promoting innovation to discover the next generation of antibiotics. At the moment, fewer than 100 scientists are working in the pharma industry to develop antibiotics, due mainly to a lack of adequate reimbursements. Not only would that ensure antibiotic protection for us in future, but investment in this sphere has the potential to make a significant contribution to the UK economy. We must see the challenges as opportunities.

The UK has an opportunity to be a world leader in life sciences and antibiotic development, but the reality is that, contrary to the O’Neill report’s recommendations, there has been insufficient progress, and incentives to promote this innovative work are not forthcoming. We should stop focusing on the cost of new antibiotics and focus on the cost of not developing them. The British Society for Antimicrobial Chemotherapy maintains that the UK has failed to address the issues in three main areas: education and public awareness; veterinary and agricultural use; and incentives for antibiotic discovery, research and development.

As we mark World Antibiotics Awareness Week, I ask the Minister to outline what steps the Government will take on three fronts. What steps will he take to reduce the inappropriate use of existing antibiotics in the treatment of human illness? What action will he take to regulate the use of antibiotics on healthy livestock? What action will he take to stimulate the research and development of new antibiotics? Will he demonstrate to us that the Department is determined to take this subject by the scruff of the neck? A world without antibiotics is unthinkable.

In a rare and welcome twist for a Westminster Hall debate, I think I will have time to cover pretty much all the points that colleagues have raised.

Let me congratulate my hon. Friend the Member for York Outer (Julian Sturdy) on successfully securing this debate in World Antibiotics Awareness Week. As everyone has said, it gives us a great opportunity to draw attention to an important issue—or the important issue. On the way in, I said to my right hon. Friend the Member for Chipping Barnet (Theresa Villiers), “I didn’t know you were interested in this subject,” and she said, “This is a critical issue.” It has come on to her radar, so she has come to speak—brilliantly, I thought—in today’s debate. Say to many Members across the House, “We have a debate on AMR this afternoon,” and they would ask what that is. I do not think that will be the case for much longer, nor should it be, and I thank everyone for their contributions. Raising awareness of the importance of preserving antibiotics through their appropriate use and preventing infections in both humans and animals is part of the challenge.

Lord O’Neill has been rightly lauded and much mentioned this afternoon for his review of AMR, which was published last year. I agree that it is an excellent and accessible piece of work. The former Chancellor of the Exchequer, George Osborne, and David Cameron deserve great credit for having the foresight to ask him to do it. His review said that, by 2050, an estimated 10 million deaths a year could be caused globally by AMR if no action is taken. In comparison, cancer causes 8.2 million deaths per year—I am also the cancer Minister for England —and diabetes causes 1.5 million, to put that in context.

AMR is part of the Darwinian process of natural selection, as microbes adapt following exposure to antimicrobials. The problem is greatly amplified by the inappropriate use of antimicrobials—in particular, antibiotics. All Members who have spoken today mentioned public education. It was one of the four points made by my hon. Friend the Member for Stafford (Jeremy Lefroy). While he spoke, I googled Swab and Send—I was listening at the same time; I can multitask, contrary to popular belief—which looks absolutely excellent. I look forward to finding out a bit more about Dr Adam Roberts’ project; he has done excellent work.

If any Members or constituents wish to find out more about the science of AMR, I heartily recommend the new “Superbugs” exhibition at the Science Museum in London. It explains both what AMR is and how we are using science to tackle it. The exhibition is an excellent example of the cross-sectoral collaboration that has enabled the UK to take such a leading role in tackling AMR.

While I am on the subject of science museums, may I give a shameless plug to my constituency—this does not happen often for a Minister? Public awareness is critical and that was a key point in the O’Neill report. A few weeks ago, I went to the Winchester Science Centre, which has just launched a new partnership with the University of Southampton. It has a brilliant new exhibit on AMR called, “The most dangerous game in the world”, which gives children—it is mostly children who visit the centre—the chance to understand what AMR is. They play an interactive game to try to understand the threat it poses to us and what we are doing to tackle it. Through the Association for Science and Discovery Centres—there are science centres all around the country; some will be in the constituencies of Members here today—we have the chance to raise the profile of the public education role that is needed for AMR. I suggest that raising awareness among our young people would be a brilliant place to start.

This debate is timely as it follows the publication last week of the all-party group’s antibiotics report, which was mentioned by my hon. Friend the Member for York Outer. The report made recommendations for us and others to consider in our development of future action plans to combat AMR. I thank the group for the report. Its recommendations will be useful as we develop the refreshed UK AMR strategy and the new action plan; the current one comes to the end of its five-year life at the end of 2018. In addition, the UK strategy makes the commitment to assess the effectiveness of the implementation plan at the end of the five-year period. The policy innovation research unit at the London School of Hygiene and Tropical Medicine is undertaking a full evaluation of the current UK five-year strategy, looking at the evidence underpinning the key mechanisms of change across human and animal health sectors. Its work will further inform the development of the refreshed strategy.

It is World Antibiotics Awareness Week and European Antibiotics Awareness Day is on Saturday 18 November. The two events take a “one health” approach, with human and veterinary health professionals working closely to give a unified message on the subject. They provide opportunities to engage with healthcare professionals and the public on AMR and what we can all do to help to address it. As part of World Antibiotics Awareness Week, letters are sent from the chief professional officers for England and other national leaders inviting colleagues who are working in the NHS, local authorities, universities and professional organisations to support activities for the week. Links are provided to a wealth of AMR-related resources.

Our chief medical officer, the much mentioned—rightly so—Professor Dame Sally Davies, works closely with her opposite numbers in Edinburgh, Cardiff and Belfast. She falls within my responsibility and I see her regularly. We always talk about this, and her book, “The Drugs Don’t Work”, which was mentioned by my hon. Friend the Member for Stafford, is a brilliant piece of work. I recommend it to anybody with an interest in the subject.

The national Keep Antibiotics Working campaign was launched across the country last month by Public Health England, for which I have ministerial responsibility, to raise awareness of AMR and, using TV, radio and social media advertising, to reduce demand for antibiotics by the public. I hope that Members have seen, heard and watched that campaign.

In addition, the antibiotic guardian scheme, which was mentioned by the hon. Member for Glasgow North (Patrick Grady), was launched in 2014, providing brilliant tools for healthcare professionals to raise awareness. That has now signed up more than 50,000 individuals, of whom I am one—people pledge personally to commit themselves to use antibiotics more prudently. When I signed up I did not see in the drop-down options a dram of whisky, but why not? The people behind that website are probably listening or watching, so surely it is only a matter of time.

The debate is also timely in that the Government are due to publish shortly the third annual progress report on implementation of the UK five-year AMR strategy. The report will set out the range of activity that went on through 2016—we look at the year before—to implement the strategy and points to the reduction in antimicrobial use in 2015 throughout the UK. Data for England in 2016, published just last month, show a continuing reduction in antimicrobial use in humans. Significantly, the annual sales data for antimicrobial use in animals, published last month, show a 27% drop in the use of antibiotics in food-producing animals since 2014. That meets the Government commitment two years ahead of target.

At this point I want to touch on colistin, which my hon. Friend the Member for York Outer referred to. Sales of colistin decreased by 83%—below the maximum target recommended by the European Medicines Agency—during the lifetime of the plan so far. On whether a review is looking into colistin use, I am not aware of any specific review, but its use is highly restricted and controlled now; it has dropped by 83%, as I said, and we continue to monitor it extremely closely, I am sure he will be pleased to hear.

This is just the beginning; our work is by no means complete. Last month, Responsible Use of Medicines in Agriculture launched a set of sector-specific reduction targets that we aim to and will deliver by 2020. The Government have also set challenging ambitions to halve the number of healthcare-associated gram-negative bloodstream infections and the inappropriate use of antimicrobials in humans by 2020-21. Gram-negative infections are growing in incidence. Gram-negative bacteria are more resistant to antibiotics and are increasingly resistant to most available antibiotics.

E.coli infections, for example, make up the bulk of the healthcare-associated gram-negative bloodstream infections we aim to reduce. A report published by Public Health England last month revealed that four in 10 patients with an E. coli bloodstream infection in England cannot be treated with the antibiotic most commonly used in hospitals; that relates to a point made by the hon. Member for Burnley (Julie Cooper). In 2017-18 we aim for a 10% reduction in all E.coli infections. Just two days ago, on Tuesday, the Secretary of State hosted an event with over 200 frontline staff from primary and secondary care to share good examples of actions to tackle such infections—I am sure that colleagues from Lancashire were there—and to develop improvement plans for 2018.

The consumption of antibiotics is a major driver of the development of antibiotic resistance. We have implemented a range of initiatives to help prescribers to improve their use of antibiotics, including the provision of guidance and tool kits and the use of behavioural change initiatives and financial incentives. AMR local indicators are provided in the Public Health England Fingertips portal, bringing together local information on prescribing and infection rates to allow local teams to benchmark their performance against others in similar areas so they can develop strategies for improvement that are appropriate for their local circumstances.

That gives me a chance to touch on the point made by my right hon. Friend the Member for Chipping Barnet, who mentioned sustainability and transformation partnerships. We absolutely expect AMR to be included, and it was included in the planning guidance for developing STPs. Take-up in local areas has been limited, but I suggest that MPs apply pressure to their local STPs by encouraging the STP leads to consider AMR. For the record, STPs that are in my good books—the apples of my eye—are Cheshire, Wider Devon and the Black Country. If Members wish, they can refer their STP leads to those as places to look for good practice that are involving AMR in their planning.

Most Members who have spoken have touched on new drugs; my hon. Friend the Member for Stafford certainly did so at great length. Although preventing infections and protecting the antibiotics that we have are the first two pillars of any approach to tackling AMR, the third is promoting the development of new drugs and alternative treatments. However, as has been said, no new treatments have been brought to market for many years. We fully support action to address this market failure through market incentives such as market entry rewards, championed by the O’Neill review, and other solutions, and we welcome the commitment made this year by G20 leaders to consider how such solutions could be implemented regionally and internationally. My hon. Friend’s ideas are welcome, and he is dead right in calling for a co-ordinated approach and for us to give them a bit of a push, to use the expression that he used.

My hon. Friend’s commitment to the subject shines through; it is great to see his leadership. I gently suggest that although global work and co-operation are extremely important and will, in the end, produce the kind of results that we need, we could take a step ourselves as the United Kingdom. The amount of money required to start something like, for instance, the Medicines for Malaria Venture is not great, particularly if it comes from a combination involving Government. The UK has provided 20% of the funding, as I said, alongside the Gates foundation. Sometimes it takes quite a time to get the world to work together. Perhaps we could consider doing something ourselves with as many co-operators as we can, and getting it going right now. As my right hon. Friend the Member for Chipping Barnet (Theresa Villiers) said, we could consider using the official development assistance budget, because this is for the benefit of everybody in the world, and it certainly is for poverty reduction.

My hon. Friend is quite right. I have made a note and passed it back to the team. There are many pulls, of course, on the UK aid budget—that is a topical subject about which he knows far more than I do—but I will definitely take away that point and speak to our colleague, the new Secretary of State.

That point fits neatly into where I was going next. Although it will take time to develop an appropriate global model on the pull incentives, we are making significant progress on the push side. The UK has committed £50 million over the next five years to the global AMR innovation fund, which has been discussed in the House many times. The first tranche of £10 million will fund a bilateral UK-China AMR research collaboration, which we expect to open next spring.

At the same time, we are working with pharmaceutical companies through the joint Government-industry working group. A number of Members have said that this cannot all be left to the public sector, and it absolutely cannot. Through the working group, we are seeking to develop a NICE health technology assessment-based reimbursement model—another snappy title. As my hon. Friend the Member for Stafford said, that means that we would pay for antibiotics based on their value. A team at York University—I know that this will be of great interest to my hon. Friend the Member for York Outer—is working on the evaluation process and will report back to me in the spring. We will then decide on and announce the next steps. I hope that that is useful to Members.

To return to international issues, last week I attended the G7 in Milan—the presidency is held by Italy this year—to discuss international health matters. AMR was one of the three key items that we discussed, which shows the importance of taking a “one health” approach. It was a meeting with many challenging conversations as we attempted to produce a communiqué, which we did in the end, but I can report that the AMR discussion was not one of them. All attendees—the seven Governments, international bodies such as the World Health Organisation and other non-governmental organisations—were in complete alignment that AMR is an urgent global issue and the problems that it raises cannot be solved by individual countries. There was unanimity.

This was the third time that AMR had been prioritised on the G7 agenda, which shows our continued dedication to tackling it and the importance of countries working together. I had an interesting bilateral conversation with the Health Minister from Canada, which will assume the presidency next year in January. I urged her to keep the issue at the forefront of her mind; I hope that that went in. Each country needs to take action to tackle AMR, but we are obviously stronger together.

Our chief medical officer, to refer to Sally again, works tirelessly to raise the profile of AMR in the WHO and international circles. She travels far more than I, and ensures its place not just as a health and agricultural issue but as a political and financial one; a number of Members have mentioned the fiscal cost of AMR. The United Nations declaration secured in September last year made it clear that we will not be able to deliver the sustainable development goals if we do not tackle AMR. As a number of Members have been kind enough to mention, we have been at the forefront of shaping action on AMR through proactive engagement, and Dame Sally has an awfully big role to play in that.

Indeed, at the G7, the OECD recognised and acknowledged that the UK is leading the way in providing experience on how to tackle AMR. Although many challenges will come as a result of our decision to leave the European Union, in this area, as in so many others, we lead the world, and it is very much in the world’s interest to continue working closely with us and benefiting from our experience. The bottom line is: why wouldn’t they?

I will also mention the Japanese, who are passionate about tackling AMR and with whom I had conversations around the G7. I was pleased to learn that they are as dedicated as we are to addressing AMR. This week, our chief medical officer attended an AMR conference that they hosted in Tokyo with other Asian countries. I understand it went well and look forward to getting a formal readout when she returns.

Good global surveillance is essential to provide a co-ordinated global response, as underlined by last week’s G7 discussions. For that reason, we support low and middle-income countries through our £265 million Fleming fund to improve their surveillance capacity and capability. UK official development assistance will improve in-country laboratory capacity for AMR surveillance through a “one health” approach. It has already supported 31 countries worldwide to develop AMR national action plans that follow on closely from what we have done.

Many hon. Members have mentioned that a cross-Government approach is needed in Whitehall. That goes without saying. The officials advising me today are from the Department of Health and from the Department for Environment, Food and Rural Affairs. We work closely with officials and Ministers across Departments. AMR is a global problem that will not be addressed in the lifetime of any single strategy. Although the UK has led the way and made significant progress at home and overseas, this is a long-term, serious and urgent problem. I welcome initiatives such as World Antibiotics Awareness Week that enable us to continue to discuss the issue, give us a media hook to hang it on, keep it high on the agenda for professionals across all sectors and, vitally, keep it in the minds of members of the public.

I thank all hon. Members for their contributions and the Minister for his response. From speaking to him previously and from what he has said today, I know he understands the task ahead not only for us in the UK but globally. It is important to remember and to pay tribute to the work that has already been done, which was ably led by David Cameron and the O’Neill review—one of the most important reviews that was set out by the then Prime Minister.

We have a job to do in this House. I have attended packed Westminster Hall debates on issues such as cycling and bee health—I am not decrying those important issues; I do not want my inbox full of emails on that tonight—but if we are not getting hon. Members from all sides of the House in for a debate on something as important as antibiotic resistance that affects us all, all our constituents, our country and the globe, that is quite worrying. If all hon. Members take that away from this debate, that will be encouraging.

We are an immensely fortunate generation to have been born and to have grown up in the world of the antibiotic age. I look at this issue for the sake of future generations. I have an interest in that because I have young children, and I think the Minister has children of a similar age. When the next generation hit their 30s and 40s and begin to start families of their own, there is a real possibility that their children will be born into a world without antibiotics—a post-antibiotic age. That is quite terrifying. It is essential that the required steps are taken for that next generation.

If we get that right, no medals will be handed out. No statues will be erected in the streets. If the Minister becomes the Minister with responsibility for antibiotic resistance and succeeds in his pledges, he will not be immortalised in a statue in the centre of London. The world will continue as it is, and many will not even know the threat that faced them. If we stand by and do nothing, however, history will be extremely unkind to our generation. It is essential that we act. The UK is making great steps forward, but there is so much more to do and it has to be done on a global stage.

Question put and agreed to.


That this House has considered World Antibiotics Awareness Week.

Sitting suspended.