§ 7.10 p.m.
§ Lord Soulsby of Swaffham Prior rose to move, That this House take note of the Report of the Science and Technology Committee, Resistance to Antibiotics and other antimicrobial agents (7th Report, HL Paper 81).
§ The noble Lord said: My Lords, I express my appreciation for the honour it has been to chair this committee on a topic of wide public health and also professional interest. It is a global problem as we shall hear as we proceed with this debate. The international nature of this problem can be adduced from the fairly extensive evidence we have received from this country and from overseas.1044
§ At this point I pay tribute to people in the United States Government, the research institutes in Washington, the Centres for Disease Control in Atlanta and the School of Medicine, Tuft's University, Boston, which received a deputation from the sub-committee and were extraordinarily helpful to us. I thank them formally for their hospitality and their great assistance in our deliberations. To our specialist advisers, Professor Harold Lambert and Professor Richard Wise, I convey the grateful thanks of the sub-committee for their input, deliberations, guidance and their role in producing the draft report. Finally, I cannot praise too highly the committee Clerk, Andrew Makower, whose ability with words and concepts can be appreciated fully only when one serves as a chairman of a committee such as this.
At the press conference when we launched this report in March of this year we stated a conclusion reached in the report; namely, that,
our enquiry has been an alarming experience. Misuse and overuse of antibiotics are now threatening to undo all their early promises and success in curing disease. But the greatest threat is complacency, from Ministers, the medical profession, the veterinary service, the farming community, and the public at large. Our Report is a blueprint for action. It must start now, if we are not to return to the bad old days of incurable diseases before antibiotics were available".
§ Noble Lords will see that we identified an urgency for action. To some extent members of the committee are concerned that we have not yet received a response from Her Majesty's Government since the publication of the report in March. I hope that the complacency we identified in the report that has led to problems is not complacency on the part of the Government.
§ Those are strong words, but we meant them to be strong words to draw the attention of the House and the Government to the situation that faces us. Antibiotics have been used for 50 years or more. They are, of course, the wonder drugs. We hear about them every day. They have changed the practice of human and animal medicine across the world. The ravages of bacterial infection, which continued into the late 1950s, no longer occur. However, we are aware that there is an increasing worldwide alarming growth in the number of cases where humans do not respond as anticipated to the use of antibiotics to treat certain diseases. This may lead to severe ill health and indeed to the death of patients.
§ The situation in the animal field is not as serious as that in human medicine, but there is concern there too. In particular there is concern that antibiotic use in animals may in one way or another—I shall mention that in due course—lead to problems with treating humans because of the transfer of resistance to human pathogens.
§ The concept of eventual resistance to an antibiotic is, of course, not new. Even after the development of penicillin many years ago, penicillinase, an enzyme which destroys penicillin, was identified and it was predicted that resistance to antibiotics would be a problem. That has proved eventually to be the case with almost every antibiotic, although that has varied as regards the duration of use and the concentration of the antibiotic concerned. Now we have a global pool of bacteria, many commensal and not pathogenic in nature, with resistant genes in the pool that can transfer 1045 resistance to pathogens. The introduction of an antibiotic into that pool imposes selection pressure and encourages resistance to spread.
§ One may ask how serious is this resistance? The major concern, whatever the source of resistance, is the threat to human health. I believe that one should always keep that before one. In the absence of action to reduce the prevalence of resistance, there is the prospect of returning to the pre-antibiotic era. The reasons for resistance are several, but in the medical field unjustified prescriptions of antibiotics, especially the inappropriate use of antibiotics for mild to moderate viral infections such as a sore throat, the common cold or an earache, play a part in that resistance. It has been represented to us that depending on the part of the country one is in, between five to 50 per cent. of antibiotic prescriptions are unjustified.
§ We recognise in the report the dilemma faced by doctor and patient where the doctor must advise on the prudent use of antibiotics when faced with the consistent demands of the patient, especially if that patient also has a child. Indeed, in certain parts of the country, and certainly overseas, defensive prescribing of antibiotics is the rule as it is seen as a way of avoiding litigation should an apparently mild infirmity not treated with antibiotics eventually turn out to be something serious. If that were to occur, major litigation may arise. However, that problem is not only encountered by the general practitioner treating patients in his surgery; major problems also arise in hospitals with hospital facilities and procedures under severe pressure because of financial constraints, inadequate infection control teams, patient overcrowding, inadequate training, and so on.
§ Examples of the importance of antibiotic resistance include multi-drug-resistant salmonella. Some salmonella species are resistant to eight to 10 antibiotics. Staphylococcus aureus is a common commensal on the skin, but it can become resistant to methicillin and it is the "killer bug" about which we have heard so much in newspapers. In some hospitals, staphylococcus aureus will respond only to certain antibiotics such as vancomycin, and even then we have evidence that there are certain strains, in certain parts of the country, which have become vancomycin-resistant, and there is no fall-back position left.
§ Globally, we have other problems. Infections such as drug-resistant gonorrhoea and multi-drug-resistant tuberculosis, are extremely common overseas. One problem overseas, which we do not have in this country, relates to over-the-counter sales of antibiotics and the self-administration of antibiotics without prescription from a doctor.
§ One area where control is essential is the surveillance of antibiotic resistance. Surveillance is the intelligence system where policies are formulated, providing guidance for prescriptions and prescribing individuals, and assessing the success of control programmes. We found the support for surveillance—in, for example, the Public Health Laboratory Service—of concern as the Public Health Laboratory Service is suffering decreased 1046 subvention in this area. We believe that that must be revised urgently if we are to have adequate control of antibiotic resistance in this country.
§ Similarly, a major control programme of surveillance occurs in the World Health Organisation which takes on a global programme. It, too, is under-funded. The United Kingdom has been supportive of that particular initiative and we hope that Her Majesty's Government will convince other governments in the European Union to lend the same sort of support as the United Kingdom gives.
§ I turn now to antibiotic use in animals in relation to resistance in man. That is an area of great controversy and has been so for some considerable time. Some 30 years ago, the Swann Committee, chaired by the then Lord Swann, looked at the issue of antibiotic use in animals, especially as growth promoters. It recommended that there should be an over-arching committee to look into antibiotic use in all areas—medical, veterinary, livestock and horticultural—to provide guidance to people in those areas. Unfortunately, that was not acted upon, but one of our recommendations is that such an over-arching committee be set up.
§ In 1997, the World Health Organisation convened a meeting in Berlin and concluded that the low level use of certain antibiotics did, in fact, pose a threat to the human use of antibiotics in therapy and suspected that there may be cross-resistance. Most recently, the House of Commons Select Committee on Agriculture recommended the banning of antibiotics as growth promoters.
§ Your Lordships' Select Committee did not go that far. It recognised that antibiotics were of value in the animal field and did not wish to recommend their withdrawal when they were used prudently and for clinical use, but it identified certain antibiotics where low-level use for growth promotion, for example, rendered their use inappropriate and imprudent. With regard to animal feed and growth promotion, there have been comments that to discontinue the use of antibiotics in growth promotion may well lead to severe animal health and welfare problems. Supporters of animal use for growth promotion point out that there is no documented case where use of antibiotics has been proven to cause treatment failure. However, there is increasing epidemiological and circumstantial evidence that that is, indeed, the case. Where human lives are at stake and at risk it is imprudent to dismiss that evidence. Absolute proof would require, to my mind, the fulfilment of Koch's postulates; namely, the isolation of the suspected organisms, the deliberate infection of a person with those organisms and the recovery of those organisms thereafter. That is not an undertaking that anyone would recommend.
§ I conclude by asking about the effect of the report on antibiotic use in different areas. I am happy to report that the Department of Health produced a document entitled The Path of Least Resistance, which is applicable to doctors and patients alike and gives very good guidance. The British Veterinary Association produced a working document on antibiotics in animals 1047 and inter alia recommended that antimicrobial agents used as human therapeutics or known to select for cross-resistance to antimicrobials should be discontinued. Recently, a group known as the Responsible Use of Medicines in Animals has been set up, including the veterinary profession, the National Farmers Union and other groups from the pharmaceutical industry. That group has taken on a responsible attitude to the use of antibiotics in animals and livestock. Only last week the European Union proposed a ban on certain antibiotics lest they lead to resistance in humans for the treatment of certain infections.
§ Attention is being paid to the report. There is not the time to go over our 54 recommendations, but they include items for research. I feel that this report has stimulated action and that if action is continued it is less likely that antibiotic resistance will lead to serious human health problems and death; it is more likely that the complacency that we have identified will not continue and that adequate advice will be given to those who use and direct the use of antibiotics, both for humans and for animals.
§ Finally, we look forward to a positive response from Her Majesty's Government. I commend the report to the House.
§ Moved, That this House takes note of the Report of the Science and Technology Committee, Resistance to Antibiotics and other antimicrobial agents (7th Report, HL Paper 81).—(Lord Soulsby of Swaffham Prior.)
§ 7.28 p.m.
§ Lord Winston
My Lords, the hour is late and I shall be as brief as I can. This is a large and comprehensive report and it is not possible, or desirable, to go over every point in it. First, I thank our chairman, the noble Lord, Lord Soulsby of Swaffham Prior, for conducting our inquiry in such an excellent way. He made it a most stimulating committee on which to serve. It was, indeed, a privilege. At a time when the House of Lords is being discussed, dissected and held under a microscope, our Select Committees in general show this House in an excellent light.
It is also relevant that many of your Lordships who sat on this committee are not molecular biologists and yet your impressive speed of grasp of the scientific aspects of what is a very technical subject was remarkable. That also shows the House in a very good light indeed.
Two weeks ago my son, who is just 17, went to the funeral of a girl of his own age. She had had a two or three-hour rash and a slight headache. By the time she was admitted to the Royal Free Hospital, she was dead. She had meningitis, of course. Members of the school in which my son is educated and this young girl had been treated with some prophylactic antibiotics, with penicillin. But imagine if that penicillin were not available to us or if those bacteria were resistant to that drug.
When I approached this committee, because of my medical ignorance as a medical practitioner I had not fully appreciated the seriousness of the subject with 1048 which we were faced. There is a very real need for serious alarm and concern at the spread of antibiotic resistance.
In the time available, I do not intend to deal with bacterial and microbial infections overseas, but they are a particular point and one could go on at great length about them. I will simply say, out of self-interest, that there are some things happening overseas which are relevant to British practice in terms of the common infections in this country.
One has to understand the nature of the bacterium. In ideal conditions it reproduces itself in about 20 minutes, so in one hour it has gone through three generations. In human evolution we have about 30 generations in a thousand years; we have 300 generations in 10,000 years; and of course new genes mutate slightly and change all the time. The bacterium can do that in seven days or faster. The problem is an organism which is capable of adapting to the things which are threatening it. That is the major and very urgent problem.
It is true, of course, that if we withdraw antibiotics some of the resistance will fall. As one witness pointed out to us, this is an arms race, but disarmament—that is, the removal of the antibiotics—is not an option. We would then be going back to the commonest cause of death worldwide generally; that is to say, infection.
It is true that we as a medical profession have not been particularly distinguished in many aspects. I note, for example, my own Royal College of Obstetricians and Gynaecologists, which has a notable post-graduate function that deals with infection in common practice in obstetrics. There is remarkably little teaching about, or emphasis given to, the important common organisms which infect, for example, the vagina, such as streptococcus, and how they can become resistant. If it is true of my own college, believe me, it is also true of the other Royal Colleges that are responsible for post-graduate education in this country. It is something that we must, and can, do something about.
Medical education in general is poor. It is not particularly good even at undergraduate level. Too often microbiology is seen as a rather boring subject. Sadly, we heard evidence that there is a need to fill more places in microbiology at consultant level in hospitals.
We should not blame general practitioners. It is very easy to say that general practitioners over-prescribe. The general practitioner is in a difficult position. I have given your Lordships one anecdote; let me give another. When I was in training as a hospital registrar, like many people to earn a little extra money I became a locum as a general practitioner in Southend. On my second day in the practice a young woman came in with a child of about a year old. I think the child was in a buggy. She said, "He's not very well; he's a bit off-colour". I had been taught not to give antibiotics and I said, "Well, it's probably a viral infection", and I refused to give her antibiotics. But she wanted a prescription. Three hours later I was phoned for an emergency at that woman's house. I was told that the child was seriously ill. In fact the child was dead. I rushed over there and I remember 1049 seeing this child laid out on the bed; I remember the noise and distress and the general shock that that occasioned. That still lives with me.
The point is that the general practitioner is in a difficult position with the pressure to give antibiotics. It is true that an antibiotic almost certainly would not have helped—in fact, the post-mortem did not show any evidence of bacteriological infection—but that, for a young doctor, does not make any difference. You wonder whether you should have given that antibiotic. The GP is very much in the front-line.
There is great pressure from parents. In the United States, for example, increasing numbers of working mothers are putting their children into day-care centres. They are under increasing pressure to give their not-very-well children an antibiotic. It has been calculated that about 25 per cent. of antibiotics in the USA are prescribed to children. This may be rising, because there are more working mothers and more children in day-centres, which in turn is an ideal way of exchanging infection. It is not a simple problem. There is no doubt that there is a need to recognise when it might be a bacteriological infection which could be treated by antibiotics and when it is a viral infection, where they would make no difference.
The committee found that there was an astonishing gap in regard to information. This Government have said that they are going to invest in information technology. I hope they do. It is desperately needed in the health service. We need much better scope for NHS surveillance. There is remarkably little information collected across the country about specific organisms which infect people and very little information about the practice of prescribing particular antibiotics. It is a serious lack in our medical practice and something that we need to understand. We do not have full information on the patterns of antibiotic prescription.
There is also a definite link to the pattern of over-bedding and overcrowding in hospitals—pressures that we have heard about from King's College Hospital. King's College calculates that about 6 to 7 per cent. of patients have a hospital-based infection. It told us that most hospitals do not have or publish that information because they do not have the IT or are not carrying out the surveillance which is needed. That is partly because they are embarrassed and partly because we have not invested in what is essential in modern healthcare.
It is shocking to me that the Public Health Laboratory Service has been chronically under-funded in the way that it has. I hope that we can have some recognition from the Government, one hopes this evening, that this will stop. The PHLS is an important way of gathering information. It has in the past been important in research; it is an important resource. It has been under-funded because of inflation and this needs to be adjusted.
While the Science and Technology Committee shows the House of Lords in a good light, I am shocked that we have just had a debate on agriculture and virtually every farmer in the House left the Chamber as we were about to discuss the critical issue that animals are being given antibiotics, very often in an uncontrolled way, 1050 without proper information. It is a scandal that they are not listening to this debate. I urge them at least to read it in Hansard and understand that this is a crucial issue.
We have no evidence of how these growth promoters work. Why should we use an antibiotic? Let us look at other things. I believe it would be safer to use genetic engineering or to dose the animals with a cytokine. It is wrong to give animals these drugs unless they are really essential for their health and welfare. Of course, very often they are, but there must be much more careful regulation of this issue.
Finally, there is a need for more research. For example, we learnt that there is even need for research into rapid diagnosis. At present, in general the fastest we can get a diagnosis is within 48 hours—to find the bacterium and to find its specific resistance. There should be molecular ways, particularly through automation in the laboratory, to make this a much speedier process. Most pathological diagnosis has been automated, but automation has not yet happened much in microbiology. This could certainly be attained with modern molecular techniques. The R&D arm of the NHS can help a little, too, with carrying out more research in bacteriology, but there is need for basic research. Perhaps it would be a good idea for the research councils and the Wellcome Trust to consider some specific tranche of funding for this very important area of research.
This is a worldwide problem which needs to be addressed on a global scale. It is good to see the noble Baroness, Lady Warnock, in the Chamber because it was her report on embryology which was so influential in making this country and also other countries take action to start to regulate embryology. We could be a model for many examples of healthcare. Certainly, we should consider being that model in the case of bacteriology and the control of antibiotic resistance.
§ 7.41 p.m.
§ Lord Perry of Walton
My Lords, like the noble Lord, Lord Winston, I found it a privilege to be a member of the sub-committee chaired by the noble Lord, Lord Soulsby. He was a splendid chairman and the committee ran like clockwork.
I found the report particularly alarming because I was a doctor during the pre-antibiotic era. I graduated in medicine in 1943 and my first job was as a casualty officer at the Dundee Royal Infirmary. Every morning, one of my duties was to assist in the surgical outpatients department and there I would see and examine 10, 15 or 20 patients with infected fingers—not a very serious problem, noble Lords might say, but in those days it was.
When the staphylococcus got through the skin and infected the finger it was usually treated with hot fomentations at home until it swelled up, became very red and throbbed with pain. Then the patient came to the outpatients department, where it was necessary to incise the finger to let out the pus. That was only the beginning because the patient would come every day to have the finger dressed until it had healed. It might take days or a week or more to heal. That was not the end 1051 because the pain, the swelling and the bandages led to such loss of movement that the patient had then to attend the physiotherapy department for many weeks, and sometimes months, in order to regain movement. That was not always successful. One can imagine what could happen with those patients whose jobs required fine finger movements—for example, a pianist. It was a tragedy.
That was only one of the infections caused by the staphylococcus. I shall stick with the staphylococcus out of all the matters in the report because I should like to go through its history. Penicillin came into general use in the hospitals in about 1945 and transformed the situation. Someone with an infected finger was given the drug and in a day or two the infection was gone. It was magic. The antibiotic era had started but there were already, as noble Lords have heard, significant signs that antibiotics might not last for ever.
In the distant past mould and bacteria co-existed and the mould produced penicillin. Some of the bacteria, although not many, became resistant, probably by learning how to produce penicillinase. When the drug was given to patients the presence of the antibiotic selected out the resistant organisms because the susceptible ones were all killed off. That did not bother the patient, who got better anyway, but it did lead to passing the infection with the resistant organisms to other patients. That led to the spread of resistance. Now, more than 90 per cent. of staphylococci in the population have resistance to penicillin. That led the pharmaceutical chemists into making a host of different penicillins and trying to find one that would not show this resistance. In 1960, they finally managed with methicillin to find a penicillin variant which was not destroyed by penicillinase.
However, the bugs are very clever. They have more ways than one of developing resistance. This time it took rather longer. It was 1989 before a way was found to overcome the action of methicillin. By 1989 five per cent. of the isolates in this country were positive for what came to be known as methicillin-resistant staphylococcus aureus, or MRSA. The figure is now 32 per cent. of all infections in this country and in Japan it is 70 per cent.
Parallel to the search for variants of penicillin there was a continued search for new classes of antibiotics. There are about 160 antibiotics known today but only about 15 or 16 different classes. The others are variants of one class. It was as early as 1956 that the glycopeptides, of which the most important is vancomycin, were discovered. Vancomycin was expensive compared with penicillin—it was not used very much—and it was believed that it was impossible for organisms to become resistant to vancomycin. Now, VRSA—vancomycin-resistant staphylococcus aureus—has been discovered in the USA and Japan. Those countries can afford vancomycin and they use it widely and they have developed resistance to it.
This brings up the point made by the noble Lord, Lord Winston, about the need in this day and age of very rapid travel for some kind of international action if we are to prevent the resistant strains in other countries 1052 moving into this country. What about looking for a new antibiotic to replace vancomycin? There has not been a new class of antibiotic for the past 15 years. The pharmaceutical industry is presently developing two new classes and there may be valuable results. There is also a tremendous interest in genomics in the pharmaceutical industry; that is, examining the DNA structure of the bacteria. That may present a whole new set of targets against which new chemicals could be aimed. Even if one of those succeeds in producing a new antibiotic it will be at least 10 years before it becomes available for patient use. That means that we face at least a decade during which some patients will have no drug that will work on a staphylococcal infection. That is already the case in the USA and Japan. The age of post-antibiotics has arrived.
In The Path of Least Resistance, to which the noble Lord, Lord Soulsby, drew attention, the Department of Health stated:The loss of activity of vancomycin against MRSA would have disastrous effects in public health".It is no wonder that I and other members of the committee were alarmed.
What can we do? We can be prudent in the use of antibiotics. One thing we can do is not use vancomycin except for MRSA infections. We were upset when we discovered that it is widely used by practitioners in the United States to treat otitis media, a middle ear infection which is not usually caused by bacteria but by a virus. It will not respond to antibiotics; therefore using it in that way is just asking for resistant strains to develop.
What else can be done? More could be done in relation to infection control, as mentioned by the noble Lord, Lord Winston. We could follow the practice of Scandinavia and the Netherlands, where there are strict infection control policies, especially in hospitals. Those countries presently have no MRSA in their hospitals, whereas in this country the figure is 32 per cent. So the policy does work if it is strictly observed. It does not reverse the situation, but it slows down the development of more resistant organisms. It is no longer possible in many acute hospitals to isolate patients, which would be one way of preventing cross-infection. The infection control teams that should exist in all acute hospitals could keep a careful watch on standards of hygiene. Simple practices such as washing the hands after attending to each patient are often neglected. The cleaning of hospitals is now contracted out and is often not done carefully and well. There should be a limit on "bed-hopping"—patients moving from one bed to another in a hospital, sometimes for good medical reasons. This poses another risk of cross-infection. There ought also to be some training of staff.
I agree with the noble Lord, Lord Winston, that the matter is urgent. Not only do we face losing the advantages of antibiotics; we also face losing the practice of much modern surgery. Transplantation and joint replacement could not be carried out if there were not antibiotic cover. It would be too risky.
As the Government's report indicates, they are cognisant of the problem. I hope that they will take as much action as possible along the lines recommended in the report.
§ 7.54 p.m.
§ Lord Craig of Radley
My Lords, I wish to take this opportunity of congratulating the sub-committee on its excellent work. The opening of the Conclusions and Recommendations in Chapter 11 is eye-catching. It was intended to be so. It bears repeating:This enquiry has been an alarming experience, which leaves us convinced that resistance to antibiotics and anti-infective agents constitutes a major threat to public health, and ought to be recognised as such more widely than it is at present".Unlike many of the members of the sub-committee, I am, neither by training nor by strong inclination, readily able to assimilate and grasp totally many of the chemical and biological intricacies of this extremely complicated topic. But in spite of my lack of clinical and related expertise, I have little difficulty in grasping the import of many of the conclusions, particularly as they apply to hospitals.
Like many noble Lords, I have been, and no doubt may one day be again, a patient in hospital. I should declare an interest as the recently elected chairman of the council of Sister Agnes', the Edward VII Hospital.
In some detail the report draws attention to the special problems faced by hospitals and other care institutions. As the noble Lord, Lord Perry mentioned, infection control in hospitals is identified as particularly important in the fight against resistance to antibiotics. We find in this country as well as overseas numerous shortcomings in this field. The public learn of them from time to time from the media. I do not doubt that for every one story that reaches the national press, a dozen more do not. That is the nature of the media's approach.
But it is not reassuring to find so many witnesses who gave evidence of such problems. Is enough really being done to deal with the serious, indeed alarming, occurrence of MRSA, Methicillin-resistant staphylococcus aureus? The sub-committee's visit to the US disclosed that the proportion of MRSA among strains of Staph. aureus in large US teaching hospitals rose from 8 per cent. in 1986 to 40 per cent. in 1992, only six years later. And as MRSA increases, so does the use of vancomycin, the drug of last resort, bringing vancomycin resistance in its train.
In paragraph 4.35 of the report we learn thatMRSA poses one of the biggest challenges to infection control … it moves easily between hospital[s] … and in many United Kingdom hospitals it is now regarded as endemic".Yet in evidence the Minister for Public Health spoke confidently about MRSA, as rates of resistance were relatively low at 8 per cent. over the period from 1990 to 1995. If the Americans find that the rate can jump from 8 per cent. to 40 per cent. in only six years, I wonder whether we should be feeling so confident.
The overall impression that this excellent report gives is that of a juggler trying to keep many balls in the air. Each ball represents a specialism or an element of research within this vastly complex topic. Almost weekly, if not daily, new issues arise, new balls are added to the juggler's array, and he has to work faster and faster to keep them all in the air. Who is the ringmaster? Who takes a look at what the juggler is 1054 trying to do, and then tries to help him? It should be the Government, and in particular, the Department of Health. How do they respond?
This far-sighted and thorough report was published last March. Now, some eight months later, we have a chance to debate it. But where is the Government's response to help us in our deliberations? It is not for me to chide or berate anyone, but I believe that the serious and considered work of Select Committees should be responded to in a reasonable time, and well before we have a chance to debate the topic. I had thought that it was accepted convention, if not a more rigorous requirement, for a government response to Select Committees to be made within 60 days. I, for one, would be prepared to set a slightly lengthier time-scale, provided the Government gave a thorough and considered response to the report.
I am, I expect, not alone in finding it extraordinary that, when faced with the Select Committee's report on medicinal usage of cannabis, which we published last week, the Government chose to issue within a matter of hours a strong rejection of the key recommendation of those who undertook the inquiry. Their press release came out well before they could even have had time to read, let alone consider interdepartmentally, the excellent findings that the report contained. However, that is for another day. Meanwhile, it would be helpful if the Government could confirm that it is their intention to respect the value and thoroughness of this Select Committee's work by responding in a thorough and constructive way to the inquiry and other reports within a reasonable time-scale.
Let me finish where I began. The Select Committee concluded that this inquiry was an alarming experience. The Government have yet to reply. Do they share the committee's sense of alarm, or should we take it that their lack of urgency in responding reflects a lack of concern about the whole topic? If it does, I hope that the Minister will be able to reassure us with good reasons. I and many others need reassurance—for example, against the day that we may become in-patients in a major hospital.
§ 8.2 p.m.
§ Lord Jenkin of Roding
My Lords, other noble Lords began their speeches with personal anecdotes, and I should like to do the same. Some four years ago, when I was chairman of an NHS trust with a large district general hospital, the problems we faced with bed usage were being exacerbated by what our medical director called the problems of MRSA. I asked her what "MRSA" meant. She thought for a bit and said, "It is methicillin-resistant Staphylococcus aureus". I asked her what was so remarkable about that. She proceeded to describe to me the problems of spreading infection: that it comes in on the skin of patients from the community; that it spreads easily in the hospital; and that it is extremely hard to treat. She said that it was becoming a serious problem. I said that we all knew that hospitals were dangerous places and that one did not go there unless one had to, but what she told me was extremely worrying.
1055 I was comforted by the fact that the noble Lord, Lord Winston, said that he had found the learning experience on this Select Committee of enormous value to him. He is one of the country's greatest doctors in his field. As a layman, at that time when I was told about MRSA and thought that it was a serious problem, I did not know the half of it. Like everyone else, I have found this not only a fascinating study but also a very frightening one.
Under the admirable guidance of my noble friend Lord Soulsby of Swaffham Prior, we all learned a great deal, and some of it has been rehearsed in the debate this evening. This is an international problem, as the noble and gallant Lord, Lord Craig, said, which affects the whole world. We face a major threat to public health. Those are serious words.
My noble friend Lord Soulsby referred to the report of the Standing Medical Advisory Committee, The Path of Least Resistance. That committee headed an early chapter of its study, "Looking into the Abyss". The speech of the noble Lord, Lord Perry of Walton, describing what happened in the pre-antibiotic age and what we are therefore likely to go back to, should have put the "frighteners" on everybody. We are facing a return to the pre-antibiotic era, with untreatable infections, incurable diseases and major epidemics.
In our discussion of how to get the impact of the report across to the public, I suggested that we might call it, "How can we stop the bugs winning?" I was told that that was a rather undignified title for your Lordships' House. However, I was delighted to see, when the committee issued the press release, that it was entitled, "Lords lead fight against killer bugs". That is the right kind of approach. Every speech that we have heard so far this evening has underlined the gravity of the threat that we face.
In the light of this, I am sure that noble Lords will share the concern of the committee that the Department of Health's evidence was in some respects complacent. In the light of what we heard from witnesses, we were worried by that complacency.
Reference has been made to the fact that it is now seven or eight months since we issued the report and we have yet to hear the Government's full response. I am sure that tonight we shall hear from the noble Lord, Lord Hunt, who has had a long experience of health matters, of various pieces of work in hand to address the problems. What we need is a clear overall strategy that recognises the gravity of the problem we face and sets out a programme of action on the many fronts that we have indicated in the report.
What I learned about the use of antibiotics in husbandry was completely new to me. One knew in a general way, but I knew nothing about growth promoters and all the other things we heard about. To my mind, our recommendation as to what should be done about that is one of the most serious and controversial recommendations. My noble friend Lord Soulsby, who is perhaps the country's leading expert in this field, guided us through that with great skill. 1056 I wish to talk about three matters. The first is the prospect that antibiotics might become available over the counter, with no need for a doctor's prescription. Against the background of the threat which our report describes, the call for more prudent prescribing, and so on, it would be bizarre if, as a result of pressure from well-meaning people, consumerists, and so on, or, still worse, from European Union directives, we found ourselves dragooned into making antibiotics freely available as category "P" (pharmacy) as opposed to "POM" (prescription-only medicines).
I was not alone in being startled by the written evidence we received from the Royal College of Practitioners in paragraph 4.3:In principle, where the [Medicines Control Agency] considers it safe to do so, we would not object to the direct sale of certain antibiotics".I was startled by that. When the witnesses came before us I asked them to explain what they meant. They said that it was not really for GPs to weigh up the pros and cons of over-the-counter medicines. I pressed them further. Dr. Ross Taylor of the Royal College of General Practitioners took a rather firmer line. At Question 306 on Page 173 he finally said that if the MCA asked for advice on this matter the college would advise that it was not a good idea. That was not very strong but at least it pointed in the right direction. Noble Lords will observe that that is the phrase quoted in the report.
But if the Royal College of General Practitioners takes the view that in certain circumstances it may be safe to allow antibiotics to be freely dispensed by pharmacists over the counter we face a very serious problem. The Government must stand firm on this matter. I hope that we shall receive a categorical assurance from the Minister that the Government will resist all blandishments and pressures to allow antibiotics to become OTCs. I detected more than a whiff of political correctness in some of the evidence we heard in favour of OTC, and that must be firmly resisted.
Secondly, I underline what the report says about the need for much more effective control of infection. Other speakers have touched upon this. I wish that I had had this report before me when I was the chairman of an NHS trust. I have no doubt that we could have done a lot more in our hospital to tighten things up. The evidence from the front line given to the sub-committee by the Infection Control Nurses' Association was disturbing. The evidence of nurses who had to deal with infection in both the hospital and the community and their description of the lax procedures that had become widely accepted in the system, their difficulty in getting sufficient staff and the problems of training people properly were alarming. Behind it all was the unspoken assumption that perhaps it did not matter very much because if somebody got an infection from another patient an antibiotic would cure it. As we have heard this evening, antibiotics will not cure it.
The simplest procedures that have been mentioned by the noble and gallant Lord, Lord Craig of Radley, such as washing hands between patients, sterilising mops and other cleaning equipment every day and making sure that all the normal rules of hygiene are strictly observed 1057 should be absolutely standard practice in every hospital. In the old days one would have asked where matron was. I see the noble Baroness, Lady McFarlane, sitting opposite. Noble Lords look forward to hearing from the noble Baroness later. In the past it was the matron who kept up standards. That has been lost. I left the Department of Health at a time when I was arguing with the chief nursing officer that matrons should be brought back. She said that I could do it if I wished, but they were mostly men. I asked what was wrong with that and suggested that they be called chief nurses. Dame Phyllis Friend drew herself up to her full five feet and said, "I am the chief nurse". That was the end of the argument.
We must ensure that standards of hygiene are properly enforced. It is a question of giving the people concerned with this the clout to make sure that it happens. In my trust I was privileged to sit through an argument between the clinical microbiologist and pathologists, on the one hand, and the surgeons, on the other, because the trust wished to create a control of infection ward. That meant depriving one of the surgical specialties of some of their beds. On that occasion, happily, a very eloquent clinical microbiologist won the day and carried his medical colleagues with him. It could have gone the other way; we might have had a recalcitrant consultant force if the board had had to enforce that decision, but in the end the doctors agreed. I observe in parenthesis that another spin-off was that the particular surgical specialty increased its day-case rate by 50 per cent. in two months—something that we had been pressing it to do. Therefore, we won at both ends.
Noble Lords need to know this evening—I hope that I shall have the attention of the Minister—whether the Government accept in full the important recommendations of the Select Committee on infection control. The simple truth is that it is much better to avoid infection in the first place than rely on defeating increasingly resistant bacteria with antibiotics.
My third point concerns the need to modify public expectations. Jane Doe expects a prescription for her child's ear-ache; John Doe demands a prescription for his sore throat; and Joan Doe does not know that her cold is caused by a virus and that an antibiotic is entirely useless. Those three patients will almost certainly recover in a day or two but all expect prescriptions for antibiotics. Few members of the public appear to be aware of the risk of building up resistance. I do not know whether other lay members of the sub-committee have had the experience of trying to explain to other laymen the matter with which the report is concerned. There is a belief that it is all to do with patients' resistance to antibiotics; it is not. We are concerned with the bugs. It is quite difficult to get that point across.
I have sympathy with the point made by the noble Lord, Lord Winston, about the difficulty of GPs who face these demands. To anyone who wants to get a flavour of that I commend the evidence of the Osborne practice in Southsea which appears at page 440 of the evidence. That provides a graphic description of what it means for doctors who try to prescribe prudently and resist demands for inappropriate antibiotics.
1058 The Standing Medical Advisory Committee in its report calls for NAP (national advice to the public) in addition to a campaign on antibiotic treatment. The committee uses the following words that I believe to be extremely wise and entirely in line with the report:We see these as two sides of the same coin; modifying patients' expectations, through a process of public education. will make it easier for GPs to adhere to the recommendations".That must be right. General practitioners are given some valuable guidance by the Standing Medical Advisory Committee and patients need to understand it.
I shall end as I began, with another personal memory. I do not suppose that I was more than eight years old when, living in California where my father was working, I was given a marvellous picture book about germs. It showed little creatures in the form of cartoon characters rushing about. At that age I learnt what happened if germs got into a cut, how they were spread, for example by sneezing, and how if nasty germs got into food a person could become very ill. I have grown up with that pretty realistic understanding. They were called germs then because in America "bugs" was a rather improper word. I gained an understanding of some of the indications about bacteria. I remember to this day a cartoon picture of germs making their mischief in the human body. I was reminded of this when the other day I read a fascinating article in the British Medical Journal by an American author. Under the heading "Antimicrobial resistance: bacteria on the defence" the author considered the matter from the point of view of the bug. I end by quoting two passages from the article:To understand resistance, imagine being a bacterium in a world bombarded with antimicrobials. Living in a human, you would face antibiotics being taken for routine infections and for non-threatening conditions like acne. As a susceptible strain you have to acquire a survival mechanism. This is not too difficult, as your resistant counterparts, though less common, are very willing to share their antibiotic fighting strategies with you. Armed with their donated plasmids and transposons, you survive the continuous onslaught of antimicrobials. You may sustain a mutation, rendering the antibiotic target within you resistant. Your progeny bearing the mutation survive along with you, while your sensitive counterparts succumb and diminish or vanish. With any one or more of these new defence mechanisms, you are equipped to survive when introduced to new human [bodies]".It goes on in the same strain and concludes by saying,As such, you have helped create some of today's most resistant and feared pathogens".Just like my childhood book, I can conceive that the imagination of authors, television producers and cartoon artists could get this message across in that kind of way and get a large number of people, perhaps including children at school, to understand and become aware of the problem of resistance. I challenge them to use their imagination to do that. It is not a moment too soon to start.
§ 8.21 p.m.
§ Lord Rea
My Lords, I, too, should like to say what a privilege I felt it was to be co-opted onto this sub-committee and particularly to be one of the lucky ones who formed the subgroup of the committee that went to the United States. I share the acknowledgement of all the help that we had from our two advisers and from our excellent Clerk. I should like to add my thanks 1059 to the two assistant Clerks who helped our Clerk with the mass of paper work that was generated through collecting evidence and marshalling it into the report.
This inquiry is very timely. A number of other bodies from this country and throughout the world have recognised the importance of the subject. They have, or are, producing reports. The report which has been referred to already—namely, that of the Standing Medical Advisory Committee (SMAC) entitled The Path of Least Resistance, particularly in its synopsis form—is an excellent practical guide to the subject for all health workers and health administrators. I commend it.
Although I am not a micro-biologist, I thought originally that it might be useful to supplement the words of our excellent chairman and of the two other medical members of our team. But now I find that the noble Lord, Lord Jenkin, has covered very graphically the biological process that goes on to create resistance. I shall try to summarise it. The chance of one new mutation being advantageous occurs much more frequently, as my noble friend Lord Winston said, with micro-organisms than they do with multi-cellular organisms. As the noble Lord, Lord Jenkin, alluded, they sometimes have the added capacity to transfer genetic material through the cell walls by means of DNA-bearing particles called plasmids without the need for cell division. These can carry resistance genes from one species to another. (I hate to think what problems we would have if, as humans, we had developed that capacity). When micro-organisms encounter an antibiotic a few may already have the capacity to resist it. That was much more graphically described by the noble Lord, Lord Jenkin. In addition, if they undergo a mutation they will multiply and become the dominant variety, which is a form of "evolution in miniature". That was how it was described by Dr. Bruce Levin who was mentioned by my noble friend Lord Winston. We met him in Atlanta at Emory University. He believes that it is a "one-way street" and that even if the use of antibiotics is sharply cut back the proportion of resistant strains wanes slowly, if at all. Even moderate use of the antibiotic concerned still imposes heavy selective pressure. If use is resumed after being cut off, resistance rises again much more rapidly than before.
Even in Iceland and Finland where strict control of prescribing succeeded in reducing the resistance of pneumococci and other micro-organisms to penicillin and erythromycin, they were not eliminated completely. (These, incidentally are the only two known examples of success in actually reducing the frequency of resistance).
All methods of slowing down the march of resistance to antibiotics have to work within this framework of adaptive evolution. As soon as a new antimicrobial agent is used, micro-organisms are under selective pressure to develop resistance to it and usually do. It is in fact the exception to the rule that the spirochaete that causes syphilis and the B haemolytic streptococcus that causes sore throat and scarlet fever are still sensitive to penicillin after more than 50 years of use. Most other organisms which were originally sceptical to penicillin 1060 have developed resistance. I believe that penicillin could be referred to as the "First of the Mohicans"; but, sadly, it is now restricted in its frequency of use although it was a wonderful antibiotic to begin with.
The word "prudence" has been uttered by several noble Lords already. Prudence seems to have come back into fashion in a number of fields. We are told that our Government run their economics in a prudent fashion. I do not like the term myself. It reminds me of aunt Prudence or, possibly, even prudishness. Nevertheless, it implies being sensible about the use of antibiotics and restricting their unnecessary use. That is the upshot of all that has been said on how resistance develops.
Noble Lords may not have pointed out that in Britain doctors prescribe antibiotics considerably more frugally than in most other countries, the Scandinavian countries excepted. As a result, we have lower levels of resistance on the whole although the MRSA figures are not good. But there is plenty of room for improvement in our prescribing habits. Our report describes a number of initiatives which are under way, particularly in general practice, and as a GP I shall speak mainly about the measures which apply to primary care. Both the Royal College of General Practitioners and the BMA, despite the words of the noble Lord, Lord Jenkin, are fully aware of the need to rationalise and reduce prescribing antibiotics to the minimum necessary. Some patients, mainly the most highly educated, are aware that antibiotics are not a panacea and that they have dangers as well as benefits. However, there is a minority of GPs who over-prescribe antibiotics or prescribe them inappropriately; for example, expensive, new antibiotics. Most infections can and should still be treated with the older, cheaper antibiotics. The new antibiotics should be reserved for use where resistance has developed to the older equivalents. It is inappropriate to prescribe as a first line what are often known as second line antibiotics. They are also expensive to the NHS and encourage resistance so they should be held in reserve as a second-line treatment.
The pharmaceutical industry is far from blameless, since it naturally wishes to develop a market for its new products. Its representatives and advertising material have a habit too often of extolling the new drug for first line use but do not mention the drawbacks of so doing. There are, however, as we describe in the report, some very active moves afoot to involve general practitioners in improving their prescribing. It is interesting that economical prescribing is nearly always clinically better prescribing. That does not apply only to antibiotics but across the board. I should be grateful if my noble friend could spell out in outline the way in which the Government are supporting and encouraging the various initiatives that are under-way to assist general practitioners to improve their prescribing, although I realise that if one were to give a full account of those it would be a speech in itself.
Many practices have developed independently their own formulary and prescribing policy; and pharmaceutical advisers are employed in primary care in many health authorities. I went on a very useful course organised by Camden and Islington FHSA, when it existed. But often those courses and initiatives are 1061 preaching to the converted—to those GPs who are already interested and ready to improve their practice. Can my noble friend say how the Department of Health plans to reach those GPs who fall below the standards that are desirable? Incentives to good practice in which part of any savings are passed back to the practice have been on the agenda for some time. With the phasing out of fund-holding, which included an incentive element, can my noble friend say whether the new proposed primary care groups will be able to run or request incentive schemes to encourage good prescribing which, of course, would include rational antibiotic use?
We were rather disappointed that the Drug Utilisation Unit at Queen's University, Belfast, under the direction of Dr. Hugh McGavock has been closed under spending cuts decreed by the former government. I hope that my noble friend can reassure me that the promising COMPASS project started by that unit as well as its other work is being carried on. We have heard of other schemes, including the Grampian Formulary, the Scottish Intercollegiate Guideline Network (SIGN), and PRODIGY, the electronic guideline system for use in GPs' desk top computers—now becoming the norm. If my noble friend does not have time to give a progress report on all those projects, perhaps he will write to me or to the noble Lord, Lord Soulsby.
We heard about two promising schemes in the United States to improve the prescribing of doctors: one run by Dr. Jerry Avorn, of Harvard, which includes sending out pharmacists from the medical school to visit doctors in their offices. He found that for every dollar spent two dollars were saved on subsequent drug costs. Dr. Ben Schwartz of CDC Atlanta has produced a "non-prescription" form which doctors can give to patients, explaining why they are not getting a prescription.
My noble friend Lord Perry mentioned otitis media as one of the conditions in which penicillin is over prescribed. That has led in the United States to the development of penicillin resistant pneumococci. It has been shown that in some 90 per cent. of cases a virus is the cause. I was grateful to find that my own practice—which was to give a delayed action prescription to be made up in two days if there were no improvement—is the one recommended by the Royal College of GPs, and others, and is quoted in the report.
We were a little disappointed that more use is not being made of the very large bank of data that have been accumulated by the Prescription Pricing Authority and which are fed back to GPs in the form of PACT (prescription analysis and cost). That gives a complete breakdown of the prescriptions issued by every National Health Service GP. Although the prescriptions are not linked to individual patients, the pattern of prescribing could form a useful additional tool in the surveillance of community patterns of development of resistance. At Colindale we were told that this might well be usefully correlated with its surveillance plans. As well as having relevance to community infections, it might have relevance also to hospital infections.
There is no time to descend into the greater detail that many of these topics warrant, and it is getting late. However, before concluding, perhaps I may ask my 1062 noble friend two questions on rather separate issues. One concerns the international effort to reduce the development of resistance which the noble Lord, Lord Soulsby, stressed is of vital importance since infections with resistant strains now move with lightning speed—or at least aircraft speed—around the world. The World Health Organisation has a unit in Geneva, the Division of Emerging Diseases, which has a sub-unit, the Antimicrobial Resistance Monitoring Programme. It is important that that unit has secure funding. The United Kingdom has been highly supportive, as the noble Lord, Lord Soulsby, pointed out, through the Department for International Development. I hope that my noble friend can confirm that we shall continue to monitor that monitoring programme and ensure that it receives adequate funds from whatever quarter.
Finally, I refer to the question of vaccines, which if successful can prevent some diseases which are developing resistance to antibiotics. A worrying one is meningitis due to meningococcus B bacillus. I was recently on an Inter-parliamentary Union delegation to Cuba and was impressed by the development there of a vaccine for meningococcus B, which is apparently the only one in the world that shows any kind of success. It has been used in Cuba and Brazil, apparently with success. Of course it needs more trials, but I suggest that, if it is not already happening, it should be followed up because it might well be of use in preventing the sort of tragedy about which my noble friend Lord Winston spoke in his opening remarks.
§ 8.38 p.m.
§ Lord Fitt
My Lords, the noble Lord, Lord Winston, has made a remarkable contribution in respect of the terrible scourge of MRSA and other agents which affect our population. I make no apology for repeating what was said by the noble Lord, Lord Craig of Radley. At paragraph 12.1 the report states: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 more widely than it is at present".Yet we are all aware that tomorrow the press will dwell at great length on a debate which took place today as to what clothes should be worn by the Lord Chancellor.
My noble friend Lord Winston drew to the attention of the House—and it should be drawn to the attention of the country—the scourge brought about by resistance to antibiotics. When I saw the number of speakers on the list today, including those who were members of the committee, I was hesitant about taking part in the debate. However, I felt compelled to do so not because I have experience in the scientific field and of diseases but because of a personal reason for knowing what the debate is about.
Two years ago the noble Baroness, Lady Masham, introduced a debate on this killer bug in which I took part. I wonder how many people have since died from the effects of killer bugs in our hospitals. My personal experience and my justification for taking part in the debate is that two years ago my wife died from the results of MRSA.
1063 I had been married for 48 years. My wife suffered from asthma but had learnt to live with it and took the various treatments available. One of them was cortisone. On a particular Wednesday I accompanied her to her doctor. He said, "Ann, you have been taking cortisone for a number of years. I think we could change your medication to one which would have fewer side effects than cortisone." My wife looked over at me to see whether she could go into the hospital for a few days from the Wednesday to the Saturday. I shall feel guilty to my dying day for agreeing and saying "Yes". I bitterly regret having done so. I took her in a taxi to the Chelsea & Westminster Hospital. After some time she was admitted to a ward. She still had asthma but was not in the throes of an attack. She was going into hospital to be given a different regime of tablets.
On the Wednesday evening my wife was walking up and down the ward and was on the telephone talking to all our daughters. On Thursday it was the same. However, when I went to see her on Friday, she said, "There's something happening at the other end of the ward. They are very concerned. They have got the screens around that lady and I have heard them say something about a bug—something called MRSA". I had never heard of MRSA and did not know what it meant. I put my hands to my head when she told me that. I said, "Ann, if there's a bug in this hospital you're going to get it."
The next morning when I went to the hospital I was given rubber gloves and a rubber apron to wear. My wife had got MRSA. She had gone into hospital for a change of tablets and within 48 hours she had contracted MRSA. She was placed in a side ward in which there were two beds. My wife was the first to go in; another lady with MRSA joined her the next day. Does anyone realise the psychological effects on a patient who has contracted MRSA in hospital? It was necessary to wear aprons and gloves. The hospital staff who bought food into the ward—after such a devastating shock my wife did not feel like eating—pushed it on to the table and left the ward as quickly as possible. People who contract MRSA in hospital feel almost like lepers. When members of the family visit they are given aprons and gloves to wear in the ward. That had a devastating effect on my wife and on other patients.
My wife was treated with vancomycin. It was of no benefit at all; in fact it had side-effects which were very cruel. Not every patient suffering from MRSA can take vancomycin. After a few days she became so ill she had to be taken to the intensive care unit. She was on a life support machine for 19 days. Those 19 days were the longest of my life, the longest I will ever have. After she had partially recovered, I spoke to some of the doctors and tried to get them to tell me personally what they might not be able to tell me professionally. All the indications were that MRSA had entered into her respiratory system and there was no way of curing it. I decided to take her home from the hospital because there was nothing more that could be done.
My wife was transferred to the Royal Brompton Hospital, which is a chest hospital. As I have said previously in your Lordships' House, when I went there 1064 I was amazed. Many wards displayed a yellow notice, "Do not enter". There was almost a corridor full of people who had MRSA. Two of my daughters are nurses. I therefore have a good deal of sympathy for what nurses have to do. It was almost impossible for the nurses in that hospital to wash their hands every time they went in or out of a ward to see patients. You can wash your hands only so many times in a day. In fact, you can damage your hands with the red disinfectant they use. Those nurses were trying to do everything they could, but it was impossible to keep up with the ravages of MRSA.
My noble friend Lord Winston and other noble Lords speak with medical experience. I am very impressed. I wish only that the public could read Chapter 4 of the report which relates to what should be done to try to combat this awful scourge. The noble Lord, Lord Perry, says that it will probably be 10 years before we can perfect another drug which might begin to contain the ravages of MRSA. What do we do in the meantime? I believe that we should concentrate all our attacks on trying to bring about infection control in hospitals. That is only thing we can do.
I wish to quote from Chapter 4 of the report. Paragraph 4.12 states:Most of us…have lost isolation wards in the last five or six years…because they were no longer cost effective to run.The report also states that,adequate and appropriate handwashing is well recognised as the single most important measure in infection control…poor provision of readily accessible hand basins [accounts for] failures in this area…Advances in basic hygiene, both in hospitals and in the community, were reducing mortality steadily long before the discovery of antibiotics; but it is commonly believed that standards in this area are slipping, perhaps partly through over-reliance on anti-infective drugs. Poor hygiene has been definitely implicated in some outbreaks of hospital infection".The report shows that infection control can be gauged by its cost-effectiveness, but hospitals do not have the required finance. It is devoted to some other aspects. There are some hospitals—and I believe that this happened in the case of my wife—in this country and in this city where, when patients go in with a complaint, the staff look at their birth certificate. If they are over 70 years of age they are sent to the geriatric ward. Some people of 70 years of age are relatively mobile while others are more vulnerable. But all patients are put into the one ward because nurses can look after that particular ward. All the people in that ward are more vulnerable to a transfer of MRSA. Therefore, there must be some control over the way in which patients are admitted. They should be dealt with according to their complaint and not according to their age.
Again, I have a friend in Belfast at present, a man in his seventies, who went into hospital for a minor complaint two weeks ago. He contracted MRSA. He was released from the hospital. I saw him one day last week when his great granddaughter of a few months old was brought to see him. It broke his heart because he could not give that little great granddaughter a cuddle. All his friends and relatives must stand at the door because they are told, "Do not go near him". The disease has a devastating effect on the people who contract it.
1065 I have spoken to many nurses who are all of one opinion. Everyone knows that there is a shortage of nurses and that they are grossly underpaid. How are we to contain that dreadful MRSA, particularly in view of the fact that there is no known cure for it? We are unlikely to find a cure for 10 years. Therefore, I suggest that we must step up our attacks on infection control in our hospitals. That is the only way. I do not believe that a lack of finance should be a reason for preventing that.
I know that some hospitals will not be particularly happy when I say that my wife died from the effects of MRSA. However, that was not written on her death certificate. It is not put down as the main reason or a contributory factor which led to death. That is because if a patient goes into hospital with a minor complaint, contracts MRSA and then dies the relatives would be in a position to take up a claim against the hospital, the hospital having given the patient the disease from which the patient subsequently died. If MRSA is contracted because of the negligence or otherwise or because of non-infection control in hospitals, that should be on the death certificate if that is the reason for the death.
I believe that the members of the committee have performed a signal service not only to your Lordships' House but also to the country. I appeal to all those agencies, the media or otherwise, perhaps not to report this debate but to look at the report, as it has been printed, and the experience of the committee.
I conclude by saying that MRSA has had a devastating effect on my life. I was married for 48 years. My wife could still be with me had she not gone into hospital in order to change her tablets for asthma. I hope that that does not happen to anyone else. I urge that all necessary steps and all financial considerations are taken into account to make sure that infection control is available in all hospitals so that we can try to eradicate this terrible scourge.
§ 8.55 p.m.
§ Baroness Platt of Writtle
My Lords, as our first recommendation states clearly and forcefully,This enquiry has been an alarming experience".Other noble Lords have underlined that. First, I should like to say that that was not in any way due to our chairman, who led us through our meetings and recommendations in the most peaceful manner. We were fortunate also in the excellent drafting skills of our Clerk, Andrew Makower, and our advisers. I join whole-heartedly in the tributes made by other noble Lords to that assistance.
I must apologise to the House. This debate started so late that I may have to leave before the end to catch a train; but I hope not.
Our alarm was occasioned by the extremely frightening consequences which have been described so movingly by the noble Lord, Lord Fitt, which face the whole of humanity as those clever bacteria develop resistance quickly and skilfully to antibiotics, our principal weapon in preserving public health over 50 years.
1066 I remember, as a child, the quietness of the road where I lived when we all knew that a man was going through the crisis of pneumonia. In those days there was no antibiotic cure. It would be a global catastrophe to go back to those days. Our box 2 on page 13 illustrates the serious diseases like malaria, meningitis, and pneumonia which demand the use of effective antibiotics for their cure and to which we shall all be at serious risk if resistance continues to grow and accelerate.
The use of antimicrobials in medicine is well controlled in the UK, which is a comforting thought. However, with so much global human travel, resistant bugs can travel too. We cite an example of the explosive spread of penicillin-resistant pneumococci in Iceland in the early 1990s when rates rose from one per cent. in 1988 to 20-25 per cent. in 1993. The genetics of the strain showed that it almost certainly came from Spain, where it was common.
As in so many other fields, isolationism is no good. We must play a strong part, both in the European Union and the World Health Organisation, in encouraging the prudent use of antibiotics and also sharing with those organisations our own experience of successful practice.
As we show, countries with firmer controls have lower rates of resistant strains and:Holland and Denmark have amongst the lowest incidence of MRSA, due to their effective … control".In that context, it is extremely important that we should, as a nation in the European Union, continue our stand against over-the-counter sales of antibiotics, as my noble friend Lord Jenkin said earlier. The European Union proposal for an orphan drug regime, which is already encouraged in the USA, must also be supported strongly by the UK as it could lead the pharmaceutical industry to work on novel treatments for problem diseases of the world's poor, such as malaria, where the market is not lucrative but the cost in human suffering is large.
I do not intend to cover the question of the use of antibiotics in animal health. Other noble Lords, particularly our chairman, are far better qualified to do so than I am. Instead, I wish to concentrate on policies which affect humans directly while accepting that imprudent treatment on animals can have a serious effect on human beings.
As is so often the case, the need for better education is crucial to success. In the first instance, we suggest that undergraduate curricula should contain better advice to young future doctors on infectious diseases and antimicrobial therapy; and that that should continue just as strongly in postgraduate education and vocational training and in the continuing professional development of doctors in their prescribing policies.
We were much struck, as other noble Lords have stated this afternoon, by the dilemma of busy, inner-city doctors with short appointment time allocations when confronted by the worried mother with the crying child with a sore throat or earache demanding antibiotic treatment. We appreciated in those circumstances how much more difficult and time consuming it is to say "no". Good communication talents are clearly part of 1067 a good GP's essential skills. No one wants to put off prescribing antibiotics promptly against meningitis. What we are considering is the vital persuasion of the patient that antibiotics do not help runny noses, and may not be necessary for earache, and that over-prescription may destroy benign and friendly bacteria in our systems as well as encouraging the growth of antibiotic resistance in really dangerous bugs, to everybody's harm worldwide. This is not an easy matter, but it is vital to the continued successful use of antibiotics.
That means that the public as a whole need to be aware of the subject. It is most often mothers who take children to surgeries, and often their scientific education in school has been insufficient. One cannot blame them, therefore, if they try to achieve what they believe to be the most effective cure for their child while not being fully informed as to its harmful side effects. I hope that womens' magazines will take up our suggestion of user-friendly articles by experts capable of writing about the subject in an interesting, clear and persuasive way so that it is more easily understood and appreciated by worried mothers. That would be tremendously worthwhile over a period of years.
The Public Health Laboratory Service was most generous of its time to us and in explaining its vital work. Its funding must not be reduced at a time when it is important to invest in information technology to speed up the exchange of data locally, nationally and internationally and the return of information quickly to enable quicker and more accurate prescription by GPs. That investment in IT equipment must also be compatible with existing systems both among GPs and hospitals.
Money is short in all the public services. There will never be enough, especially as the medical profession discovers new and better ways of combating injury and disease. We are all grateful that today we do not have to stay in hospital for weeks after surgery and that day surgery has become common. However, a side effect is so called "hot bedding", which can mean inadequate cleaning between serial occupation of beds by patients. Infection-control nursing is a vital necessity in all hospitals and under-staffing was reported to us. Also, the use of cheap soap may lead to cracked hands and less handwashing, which is crucial to ward hygiene—a very simple but vital need. Infection-control nurses also need good IT provision and clerical staff. They must be listened to carefully in laying down infection control policies for hospitals. That must also include training of cleaners, both in-house or by contract.
Clearly all those things cost money. But the costs must be set against the enormous cost of an outbreak of MRSA. The Cooke Report calculates that the Kettering outbreak cost over £400,000, which of course cannot include the cost in human suffering, so vividly described earlier by the noble Lord, Lord Fitt. An outbreak, of course, also leads to bad publicity and loss of morale among the staff, as well as to the possibility of subsequent time-consuming and expensive litigation.
Already the health department is responding favourably to our report, as highlighted in its joint report with the Standing Medical Advisory Committee referred 1068 to by other noble Lords. I hope our report will be studied in considerable detail so that all our recommendations will be acted on and there will be no complacency—certainly on the part of the Government—and the alarming consequences that we highlight are at least delayed in this country and, if possible, worldwide.
§ 9.5 p.m.
§ Lord McNair
My Lords, I venture into these troubled waters as a non-medic and non-scientist who has a passionate interest in safer and more effective alternatives to modern drugs. I am not therefore in the least surprised that we are in the situation so graphically described in the report that we are discussing today. I should add that many products of the pharmaceutical companies have saved countless lives and will certainly continue to do so in the future.
During the debate on the Unstarred Question of the noble Baroness, Lady Masham, of 4th November 1996 (cols. 576 to 578) I spoke about the role that I know the oxygen therapies could play in solving this and related problems. On that occasion I described some of the technical aspects of oxygen therapies and will not repeat myself more than necessary on this occasion.
I apologise to the noble Lord, Lord Soulsby, for not mentioning to him that I would speak on this subject in this debate. In fact, I only decided to put my name down on Friday evening but would love to talk with him about it at some time in the future.
I will just say in summary that hydrogen peroxide is what the white blood cells produce to destroy viruses and bacteria. A body that is oxygenated is likely to be healthier than one that is not. In an earlier phase of the planet's evolution there was less oxygen in the atmosphere and that is when viruses and bacteria evolved.
Although it is licensed for 17 external applications, its increasing use orally and intravenously is outside the present stipulations of the Medicines Control Agency. I should add also that ozone gas is by far the best method of sterilising an enclosed space, such as a room, and also of sterilising stored water.
Section 11.2 of this excellent report makes clear that we were in a no-win situation. The hope is expressed that we may delay the rate at which bacteria become resistant to new drugs, but even that hope is dashed. It says:Improving control of the use of antimicrobials can be expected to slow down the spread of resistance; and in some situations the frequency of resistance may even decline. But this must not be expected to happen in every case; and, if control is once again relaxed, reversion to high rates of resistance may be swift".I believe it is true that such controls simply do not exist in many countries—and other noble Lords have spoken about this—particularly in the developing world. This makes the hope expressed in that section of the report seem rather forlorn.
I think it is likely that the picture will get worse. There are difficulties in the research and development of new drugs which I will discuss a little later in my remarks. The situation could be characterised as a war between anti-bug drugs and the anti-drug bugs. I believe 1069 that I have got that right. The report seems to suggest that the anti-drug bugs may be about to win the war. It is clear that we need a complete change to our operating basis. We need to bypass our normal habits and routines in the matter.
In this debate this impending tragedy has been discussed with no reference to the companies that create and produce the antibiotics, as though they just simply appear. It is almost as though the companies themselves were passive victims in the matter. It makes no sense to discuss this problem without looking also at the way the pharmaceutical companies conduct their activities in relation to the complementary medicine sector, the National Health Service and the Government. The subject matter of this report is not just a technical question of more knowledge, more research and more money; it reflects commercial policy choices made by the pharmaceutical companies in this and other aspects of their operations. They are running into considerable difficulties in their research and development programmes. As reported in last Thursday's edition of The Times, Dr. Arlington, who is head of pharmaceutical R&D consulting at Price Waterhouse Cooper, said:Costs must be slashed. It's not possible to maintain total shareholder returns at this level unless costs are driven back substantially … Failure of late stage trials and at launch must be stopped … These have to become a thing of the past".According to The Times report, it costs £420 million to bring each new drug to market and this includes the cost of the ones that do not make it.
The drug companies have been in the news quite a bit recently. The News of the World has stepped up its campaign to expose the sudden and dramatic price rises in advance of changes in legislation or regulations, which will mean a higher proportion of the NHS budget will go to drugs and less to operations and other vital services. This was clearly an exercise in protecting "total shareholder returns". The drug companies also featured in a powerful report in the Express, on the same day as The Times article, which ties in with information in a forthcoming book by Dr. Matthias Rath. Dr. Rath is a medical doctor and scientist who is the successor to Linus Pauling and was publicly endorsed by Dr. Pauling before the Nobel Prize winner's death. In fact, it was Linus Pauling's contention that vitamin C could have an antibiotic effect.
The report in the Express details the manoeuvres which the drug companies are engaging in to ensure that alternative solutions to health problems, such as vitamins and minerals, are reclassified as medicines, and also describes the efforts by parliamentarians to defeat them. The recent debate and victory against the drug companies by MPs and the people over Vitamin B6 was one round in this battle. Similar manoeuvres are used to keep the knowledge about oxygen therapies from practitioners and the public.
It is clear that the pharmaceutical companies have a very narrow understanding of social responsibility and their solely profit-driven philosophy has led us into the impasse that we are discussing today. The following 1070 quote from page 236 of Dr. Rath's book underlines this rather starkly. He had obviously been referring to the situation in the United States because he says:With the battle to make vitamins prescription items in the US lost, the pharmaceutical industry decided to regroup at the international level. In 1995 this industry founded an international Pharma-Cartel, under the auspices of the United Nation's World Trade Organisation and the German government. They camouflaged their efforts with the code name: "Codex Alimentarius". The goal of the "Codex" cartel is nothing else than to make up for the defeat suffered in the US and to make vitamins prescription items—this time for all member countries of the United Nations, that is world-wide".Another article in the Independent of Thursday 12th November tells of the Americans who are flocking to alternative therapists. It states,One study showed visits to alternative practitioners were up by 50 per cent. since 1990 and 4 out of every 10 Americans used some form of alternative medicine, spending 27 billion dollars on the services last year".It is no wonder that my discussions on this matter with the noble Baroness, Lady Cumberlege, went nowhere. If the Express article is anywhere near the mark, the influence which the drug companies have on the department is such that anything that threatens "total shareholder returns" will not appear in government policy.
I am throwing down a gauntlet to the Minister. I would like him to prove me—and the impeccably eminent medical opinion which understands the science and healthcare implications of this—right or wrong about hydrogen peroxide and in fact about the oxygen therapies in general. But I realise that he will not be able to pick up that gauntlet this evening. The only sure way out of this swamp is to adopt the suggestion I am making today. The drug companies have got themselves, Her Majesty's Government and us into this mess. I am offering HMG and the people of this country a way out.
One statement by a departmental official at our second meeting astounded me. She asked me at the end of the meeting, referring to hydrogen peroxide, "How come it is so good if there is no commercial benefit in it?" This official was clearly so steeped in the commercial philosophy of the pharmacologists who are entrenched as advisers to the department as to be unable to conceive of a substance that had, on the one hand, enormous potential benefit but, on the other, would never make any company the fortunes to be made from patentable drugs. The production of hydrogen peroxide is, after all, O-level chemistry.
The gauntlet I am throwing down for the Minister today is to risk no more than a quarter of a million pounds of his department's budget on a "free and fair", double blind clinical trial on any one of a number of groups of patients using conventional antibiotics for the control group and hydrogen peroxide for the experimental group. The trial would, of course, need a level playing field and that would mean joint monitoring by departmental doctors or officials and by doctors experienced with using hydrogen peroxide and ozone.
Then, and only then, is there some hope that we can overcome this seemingly intractable problem. I want to emphasise that hydrogen peroxide is not just another alternative health remedy but a fundamental 1071 physiological principle. In fact, it is so fundamental a part of our immune system that you could perhaps say that it is the only thing that stands between us and oblivion, that had there not been an increase in the percentage of oxygen in the atmosphere, complex life forms could not have evolved.
In fact, my reading suggests that the anti-cancer drug, Interferon, penicillin—which has been much discussed this evening—and Vitamin C all work by increasing the body's own production of hydrogen peroxide. It is such a fundamental feature of how our bodies work that once the knowledge is widespread it offers great possibilities for lay people to take responsibility for their own healthcare.
If there is anything I can do to help Her Majesty's Government with progressing this I should be happy to do so. There is a considerable amount of information about hydrogen peroxide on the Internet which officials can peruse at their leisure, not of course that they would have leisure working at the department! It goes without saying that the cost savings would be enormous, almost astronomical in fact, and these savings would, of course, open the way to spending more on other parts of the health service. The department would do more to help improve the nation's health by adopting my suggestion and promoting the health benefits of the oxygen therapies than by any other single action.
The discoveries about the healing power of oxygen were made in the second half of the 19th century but were never going to make any fortunes because the technology is so simple. The knowledge of the importance of hydrogen peroxide to internal medicine would have been relegated to a footnote of medical history had a dedicated band of enthusiasts not handed on the information to successive generations. The suggestion that one would have heard of it if it were valid is easily countered if one understands that this is a world based on public relations. The messages we hear and read are, by and large, the messages that someone has paid for. It is simply not worth anyone's while to pay to promote hydrogen peroxide.
So how should I communicate these ideas? I had a conversation with the noble Lord, Lord Winston, who I see has returned to his place. He made a helpful suggestion that I should contact the Wellcome Foundation. I did not in fact follow that up because I did not have much confidence in the separation between the Wellcome Foundation and Glaxo Wellcome.
My experience with the Department of Health has not been particularly productive. The noble Baroness, Lady Cumberlege, passed on to officials the small selection of papers I gave her. These were but a sample of the thousands of peer reviewed papers on oxygen therapies which have appeared in the medical press and other literature over the past 150 years, but they fell into the bottomless well for good ideas which must exist in all government departments.
I should like to see a much greater readiness in general by the department to consider new ideas that would, or could, lead to better healthcare and lower costs.
1072 If we are to continue the upward march of medical knowledge hand in hand with improvements in health we must reorientate ourselves in our view of what human and, indeed, animal health really is. I am attracted by the concept which I encountered recently of functional health. This approach to looking after our bodies mirrors best practice in driving and maintaining a car. It signals a new direction in our thinking.
Current thinking about exercise, food supplements and nutritional balance, in addition to the very basic science that underlies the use of oxygen to restore health, coupled with application of that knowledge in practice, combine to produce a state of health known as functional health. Regular servicing of the body will keep it in good condition. In fact, these new understandings should lead us to the point where we die when the body clock stops—and not of disease.
We will achieve, for the people of this country, this state of positive or functional health only if we are prepared to enlighten them about the simple facts of functional health, and, of course, about environmental threats to health which include toxins as well as antibiotic-resistant strains of bacteria.
Of course, we will not eliminate disability and disease. There will always be something for doctors and medical specialists to do, and there will always be a role for the pharmaceutical companies, albeit a reduced role. But, if we are prepared to base our medical technology and our philosophy of healthcare on the foundations I have outlined, and if we are prepared to arm people with the simple and basic knowledge of what functional health is so that they can take responsibility for ensuring they achieve it for themselves and their children, I can foresee a bright new dawn for the health of the nation in the 21st century.
§ 9.23 p.m.
§ Baroness McFarlane of Llandaff
My Lords, I too found it a great privilege to serve as a co-opted member of the sub-committee, the report of which is now before the House. The publication of our report received considerable publicity. I believe that it has already promoted a widescale discussion by both the public and professionals. Perhaps this debate is timely in that it serves to maintain the high profile of the subject with the general public. I believe that the well presented report of the Standing Medical Advisory Committee, The Path of Least Resistance, complements and underlines our report.
Before serving on the committee, I had been made aware of the problems of resistance in the administration of antibiotics to humans. I suppose that my further education started two years ago in the debate to which reference has been made, which was instigated by the noble Baroness, Lady Masham. I had been retired for 10 years then, so I referred to a former student of mine, an expert clinical nurse specialist. She turned the tables on me and supplied me with a reading list. She was even kinder than that and supplied me with photocopies on the subject which were several inches deep.
Since then, along with many other Members of your Lordships' House, I have felt alarm at the state we are in. At that point, like the noble Lord, Lord Jenkin, 1073 I was unaware of the extent of the applications in animal husbandry of growth promoters or the use of antimicrobial agents in fisheries, agriculture or plant culture. I suppose that it is only within the past few days that I have heard of apples being sprayed with streptomycin. I have deep concerns about our food chain. I shall certainly look forward to the Queen's Speech, to which reference was made at Question Time today, and to what may be said about the food standards agency. There is a real need to consider that.
Although I have great concerns about medical practice and the prescription of antibiotics, I think that it would be more fitting, in view of my professional experience in nursing, if I concentrated my remarks on the role of nurses in the health education of the public and in infection control, both in hospitals and in the community. I am, however, acutely aware that we all have to operate very much as a team, with the general public, patients and health professionals, including doctors and nurses, each having a vital role to play. In that team the infection control nurse, as well as the microbiologist, plays a pivotal role. As a result of Project 2000 and the revised system of nursing education, registered nurses are now very much better prepared in the principles of microbiology and their applications in their work.
Infection control nurses are a highly qualified group of nurse specialists: registered nurses who have taken a post-basic certificate or a diploma course in infection control. They have had a minimum of four years of post-registration experience and most have had some years of experience at ward sister or charge nurse level. So they are nurses with sound experience of clinical management in the nursing service. A significant number are now taking either first level or higher degree level subjects relevant to infection control. They have an understanding of the microbiology and public health issues that are entailed in their work and of the principles involved in health education.
My experience of working with infection control nurses in the past and of watching their professional expertise has given me a high respect for them and an appreciation of their value within the health service. I have seen them at work in hospitals where an outbreak of infection has posed a great threat. I am left with great respect for the contribution they make.
I believe that they are pre-eminently clinical nurse specialists of the calibre that the Secretary of State for Health has marked out as being deserving of recognition and reward. We as a sub-committee were certainly impressed by the calibre of written evidence presented by the Infection Control Nurses Association and the authoritative way in which witnesses presented their oral evidence and answered our questions.
Infection control nurses, by virtue of their knowledge and expertise, are well placed to contribute to the education of the public and professionals in respect of the appropriate use of antibiotics. The Infection Control Nurses Association has developed a number of educational packages for use with the education of healthcare staff—for example, residential and nursing home staff—and the development of national standards for the ambulance service.
1074 Infection control nurses contribute by working collaboratively with other agencies, including the Public Health Laboratory Service. One of their basic functions is monitoring clinical activity, which is an integral part of the role of the infection control nurse. They also have a function in the investigation of outbreaks of infection.
I want to dwell on some of the aspects of infection control to which infection control nurses make such a contribution—and to which noble Lords have already referred. In our report we say that in some respects hospitals achieve the level of infection control for which they are willing or able to pay. This shows that we need a will to devote resources and that resources need to be made available. It must be wearying for a government to hear about resourcing, resourcing, resourcing different services, but it is part of our role to draw attention to needs and to see that priorities are established against other demands in the health service.
I want to give just a few examples of where I feel we are making false economies. First, staffing levels in infection control have a direct bearing on the incidence of hospital-acquired infection. We were told by the Association of Medical Microbiologists that each infection control nurse in the UK covers 400 acute beds. The Infection Control Nurses Association put the number nearer to one nurse to 700 beds and said that a recent survey by the Public Health Laboratory Service identified a range of from 125 to 1,600 beds per infection control nurse. I ask noble Lords to visualise the function of one lonely infection control nurse trying to service 1,600 beds with all her skills. That study gave a medium of 460 beds per infection control nurse based on 19 district general hospitals.
Research in the United States has shown that hospital-acquired infection can be reduced by 30 per cent. if there is a ratio of one infection control nurse to 250 patients. Therefore, there is a strong recommendation that the staffing levels in infection control need to be increased if staff are to give an adequate service both in hospitals and in the community.
A corollary to the shortage of staff is the employment of so many agency staff who may be poorly versed in the infection control techniques of a particular hospital. Because of the great mobility of agency staff, they can carry infection from one area to another. But given adequate staffing ratios—if we were ever given adequate staffing ratios—there is a need to equip nurses to work effectively. We have already had reference to the lack of adequate provision of information technology and secretarial assistance for those nurses. The report states that the majority of infection control teams do not have formal contracting arrangements with their purchasers and that therefore there is a clear tendency for their needs to be neglected.
In their evidence the infection control nurses were particularly concerned about the bearing of hygiene practices on infection control. We have already had a number of references to that point. Ward cleaning is no longer under the control of the ward sister, so that the cleanliness of wards and other hospital departments is not as adequate as before. Obviously, trusts tend to award contracts to the cheapest tenderers. That means 1075 that wards are less frequently cleaned and less thoroughly cleaned. We were told of the lack of basic hygiene in cleaning practices, such as the cleaning of mops, dishcloths and so on. The role of the environment in the prevention and control of infection is important and warrants more research.
We have already heard about the isolation facilities being taken away. There are no longer facilities for placing patients in isolation wards. We have heard that one of the most important aspects of infection control is hand washing. This needs teaching but also monitoring. It seems, regrettably, that doctors are conforming less to standards in this area than other health staff. We were distressed to hear that, in the interests of economy, inferior quality soaps are bought by some trusts, which can result in the excoriation of nurses' hands.
If there are problems in infection control in hospitals, the situation is, if anything, worse in healthcare facilities in the community. The proportion of infection control nurses is smaller; some community trusts do not have an infection control nurse and rely on the services of a hospital infection control nurse. The standards of education in some nursing homes and residential homes is very poor. Staff may be unaware of how to deal with MRSA and other infections. At one point some residential and nursing homes were refusing to take patients from hospitals with MRSA. I understand that the department has now issued advice, which is being followed, so there are fewer refusals.
There is one other aspect of the report of the Infection Control Nurses Association which I found meaningful. I was reminded of it by the contribution of the noble Lord, Lord Fitt. I refer to the psychological trauma that it causes to patients and their relatives if they are diagnosed as having MRSA. We heard from some nurses who had been infected with MRSA and of the psychological trauma that that caused to them. They felt unclean and unable to sleep with their husbands; they isolated themselves from their family. I think that we can put ourselves in the position of nurses who have been so affected.
I trust that noble Lords will bear with my having rehearsed some of the items in the report that bear directly on the nursing service.
§ 9.37 p.m.
§ Lord Dixon-Smith
My Lords, by this stage of the debate it has all been said, and said rather well. I shall therefore attempt to be brief.
Tucked away among the interesting facts that we learnt in the evidence that we received was a statistic that has so far not been mentioned—that apparently we carry on and in us more bacteria than we have mammalian cells. That point inevitably stuck in my memory when it was thrust before us. Possibly there is a little bacterium in there that made sure I remembered.
It is a fact of life that bacteria are with us all the time—and not merely beneficial bacteria. We must live in some sort of symbiotic relationship. But we also carry with us most of the infective bacteria. We therefore have to assume that hygiene begins at home. Therefore what 1076 we are really talking about is those situations in which particular bacteria go on the rampage and out of control. In circumstances such as accidents, surgery and so on we become vulnerable, and the normal bodily resistance that keeps us in balance breaks down. It is necessary to bear that in mind in everything that we say and do. We are not going to be without bacteria at any stage. They are always with us. One of the strange results of the examination in which I was privileged to take part is that I have developed a very real respect for bacteria. We should keep that respect in mind.
I wish to touch on two matters: the first is information systems and the second is agriculture. It was surprising that, among all the information and the reams of evidence that we received, there was a great gap in factual information in terms of what was being prescribed, why it was being prescribed and what the outcome was. In general practice, where GPs have to a great extent adopted computers, this information is now instantly available, but there is no mechanism for collating it so that it can be used on a wider basis to find out what is happening and why resistance is a problem in the community, as we know it is.
More alarming than that is the fact that these systems are almost unheard of in hospitals. Hospitals prescribe antibiotics; they are recorded into their pharmacies and—to borrow and abuse a phrase that was used in the Falklands conflict—they are recorded out of the pharmacies; and that is where the information stops. Unless we know what antibiotic is used and why at the patient level, how can we hope to understand what is happening in the inevitable development of resistance? There will never be a situation in which we are bacteria-free or infection-free. These organisms are almost infinitely adaptable. As we put them under pressure as a result of one form of treatment, they will adapt and become immune; and so we develop another form of treatment.
This is a never-ending battle. But it would help enormously in treating this variable beast with which we are dealing if we knew what was being used and why and if that information could be collated. Infection patterns vary from place to place and treatment patterns vary from place to place. It is important to know what the local variations are so that one can know immediately what the possible variations in treatment are and not have to find out the hard way by experimentation, by giving a patient an antibiotic and four days later, when it has not worked, trying something else, with one's fingers crossed, which is not a satisfactory way of proceeding.
The information should all be pulled into the Public Health Laboratory Service and antibiotic-resistant bacteria treated as a notifiable matter so that we know exactly what has happened. PHLS could then transfer the information back to users in a readily understandable way and treatment could be more immediate.
The second aspect with which I deal is the use of antibiotics in agriculture, particularly prophylactic treatment in animal foods. This is a very emotive subject. If we accept, as we do, that generally in humans prophylactic medicines are not used, veterinary practice 1077 will also have to accept that as the norm. It is not just the vets who are responsible for this situation but commercial demand, for which there are very good reasons. But we must understand that use of antibiotics in that way is dramatically different from their use for medical purposes in man, not because they are growth promoters but because of what happens to the animals.
The two main uses of antibiotics are in pigs and poultry. The vast bulk of poultry meat that goes on to the shelves of supermarkets comes from chickens that are slaughtered at six weeks. It is very unusual for a chicken to go beyond 10 weeks. Even the versatility of bacteria has not overcome that particularly harsh fact. Pigs live a little longer, but not much. Mature animals do get on to the market, but the bulk of the food in the shops is grossly immature. These treatments have taken place and on the whole have not yet produced resistance, but they will. The difficulty is not so much what happens in the animal but it is most unlikely that the manufacturing process to which the carcass is subjected will remove all of the bacteria. That is the harsh reality.
Another aspect is that once a generation of stock leaves the farm the buildings can be thoroughly disinfected and the process started all over again. That is a harsh reality. That cannot happen in mankind. Hospitals are far too busy and pressured to close down wards, thoroughly disinfect absolutely everything, leave them empty for a week and then start all over again. That cannot become the general practice. The use of antibiotics in animals is very different from the use in man. Where one is dealing with growth promoters and the treatment of disease—no one has suggested for a whole host of very good reasons that antibiotics should not be used to treat diseases—one is dealing with wholly different circumstances. One is dealing usually with animals that have reached a level of maturity. There is a much greater chance in a dairy herd of a build-up of bacterial resistance because one has continual use over a long period in circumstances where disinfection is impossible.
This is an unending battle. We must hope that researchers come up with some further answers. But as they find answers to one problem so they create the next one. There is an unending task ahead. The report is a very good one and deserves the most serious attention. Dare I say (to echo the words of the noble and gallant Lord, Lord Craig of Radley) that it deserves rather more immediate attention than it appears to have received. However, very many beneficial events have occurred since the publication of the report. I join the chairman in commending it to the House.
§ 9.50 p.m.
§ Baroness Masham of Ilton
My Lords, the months that the committee spent looking into the resistance to antibiotics was without doubt a most interesting time in your Lordships' House. I thank the noble Lord, Lord Soulsby of Swaffham Prior, for his good humoured chairmanship of the committee. I also thank our two medical advisers and the Clerk, Andrew Makower, for their hard work and for the help given to me personally when we visited places outside your Lordships' House.
1078 I hope that the report will help to educate many people to a worldwide problem which needs global co-operation. The report asks the all-important question: can resistance be controlled? Professor Percival, professor of clinical bacteriology at Liverpool University, put it starkly. He said,The concept that antibiotic resistance is related somehow to the amount of use is critical, because, if it is not true, then we have no chance of controlling it".Although everybody believes that, the evidence to support and demonstrate it in a scientifically acceptable way is largely lacking. Countries with firmer controls on the supply and use of antibiotics and more rigorous infection control have lower rates of resistant strains. It is generally assumed that these things are connected. Holland and Denmark have among the lowest incidence of MRSA due to their effective antibiotic and infection control policies. Spain has the highest consumption of anti-infectives per capita in Europe and one of the worst records of antibiotic resistance. We heard how a drug-resistant infection had travelled from Spain to Iceland carried by one person but spreading the infection to many. Bugs have no boundaries.
We have heard many times that hygiene and proper isolation facilities in hospitals are of the utmost importance to avoid the spread of resistant strains of bacteria. I also read that many years ago in notes on nursing by Florence Nightingale. We heard many times during the evidence how important is the basic washing of hands for doctors and nurses before they touch a different patient. We heard at King's College Hospital that a doctor's tie touching different patients could spread infection. Perhaps they should wear bow ties if they need to wear ties at all. Stethoscopes and clothes can also spread infection from patient to patient.
We discussed the speeding up of testing for infections. Because testing takes so long sometimes patients are put on inappropriate antibiotics. Are the guidelines clear enough for junior doctors? It was felt that the process could be speeded up if results were reported electronically. The Royal College of General Practitioners told us that systems exist already. In the rural area where I live the system seems very slow and cumbersome. Perhaps the Minister can give a progress report.
As a paraplegic, I have had my life saved on several occasions by antibiotics. As president of the Spinal Injuries Association, I know the serious dangers to our members if new antibiotics do not materialise. The danger of the spread of methicillin-resistant staphylococci (MRSA) is a serious menace in spinal units where many patients have pressure sores when they are transferred from a general hospital where the nursing care is often inadequate for paralysed patients. Those using catheters or tracheostomies are also at risk. That demonstrates how patients, when they become paralysed, should go straight to the spinal unit.
The shortage of nurses, the large number of agency nurses and the pressure on beds make the controlling of MRSA more difficult, as does the shortage of side wards. MRSA has put many extra pressures and costs on hospitals, and patients have been made more ill. Recently I sat next to a couple at dinner while staying 1079 in an hotel. They told me that their daughter had had a baby by Caesarean section in a maternity unit of the hospital at Welwyn Garden City. She had been infected in her wound by MRSA and was ill. The couple had come for a break as they had had to look after her and the baby. They told me that half the patients in the ward had caught MRSA.
We found what the Department of Health had to say on the subject complacent. It is said that levels of MRSA in this country are low by international standards, but they are rising. They have risen, my Lords. The more MRSA circulates, the more Vancomycin must be used to treat it, bringing closer the prospects of VRSA which, in the words of the PHLS, would be "catastrophic".
We recommend that the NHS should set itself targets controlling MRSA in hospitals and publish its achievement. Dr. Edmonds, from King's College Hospital, showed horrific pictures of the effect of MRSA on leg ulcers in diabetic patients. I wonder whether the reporting systems are adequate. I should like to ask the Minister whether he thinks that MRSA should become a notifiable condition.
I have heard that MRSA does not like tea tree oil. I wonder how much research is being undertaken to combat resistance using alternatives to antibiotics. We agree that misuse and overuse of antibiotics are now threatening to undo all their early promises and success in curing disease. However, I agree with Tessa Jowell, the Minister for Public Health, when she says that parents should not be warned off antibiotics when their children may have meningitis. There have been too many tragedies of babies and young people dying from meningitis.
Our report states that the US has paid a heavy price in money and lives for letting down its guard against tuberculosis. The UK must not make the same mistake. As a member of the all-party HIV and AIDS Group, I was very concerned about the outbreak of MDR-TB among AIDS patients in some London hospitals. The serious problems in the US, which cost the city of New York 175 million dollars over four years, is a warning. The report stresses that TB services involve measures to ensure compliance along with port health controls, surveillance and facilities for isolation. We welcome the guidelines from the Department of Health that there will be more stringent infection control and more rapid diagnostic tests in cases of suspected MDR-TB.
Direct observed therapy (DOT) both in the hospital situation and within the community has improved cure rates and reduction in the rate of tuberculosis, drug resistance and relapses in a number of countries. Perhaps I may ask the Minister whether there are plans for such programmes here which depend on the skills of staff and resources. It was found to be a way forward in New York.
We were concerned, along with the Consumers in Europe Group, about the transfer of antibiotic resistance bacteria from animals to humans. Humans can acquire resistant bacteria from animals directly via food or through contact with the animal or animal foodstuffs or from living near the farm animals.
1080 At the Food Forum in the Houses of Parliament, we had a meeting some years ago when the then chief medical officer for health spoke. I remember asking the question.Is it not unethical to feed animal to animal?The answer I received was:Lady Masham, economics rule over ethics".The BSE problem appeared soon after that, and it has been an extremely expensive economic disaster.
I hope that all growth promoters will be banned. What is the point and why take the risk? Stock is not fetching much in the markets. Why make animals bigger?
Multiple resistance to antibiotics has been increasing for the most common salmonella infections in humans. Some years ago, there was an outbreak of salmonella typhimurium in your Lordships' House and both the noble Lord, Lord Carter, and myself had specimens sent for testing. The results came back the same. Therefore, the public health people were brought in and the infection was traced to raw eggs in mayonnaise. I believe that there are many cases of salmonella, campylobacter, enterococci and E.coli which go undetected because nobody bothers to find out and trace the outbreaks.
I hope that the Government will not shelve the food safety issue. How much research is being done on possible direct animal contact in food sources of E.coli 0157? Public health is of immense importance.
When taking evidence for the report, it became clear that the microbiologists and many people working in infection control needed their status raised. I hope that the whole field of infectious diseases and resistance to antibiotics will be put at the top of the health agenda. Education and public awareness are of vital importance both for professionals and the public but that is not enough. The resources must be there also. They have to be increased. As an example, when we visited King's College Hospital, Denmark Hill, there were infection control systems within the hospital but there is no infection control team in the community. We felt that to be a serious failing. The area around King's has the highest rate of gonorrhoea in the country. Education should go out into the communities within the community, which consists of many races and languages.
We have heard recently of the first new class of antibiotics for about 15 years called linezolid and the class of antibiotics is the oxazolidinones. The drug is active against multiple resistant Gram positive bacteria such as methicillin-resistant staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and penicillin-resistant streptococcus pneumoniae. That must be good news but how can linezolid be protected from also becoming resistant? Are the Government going to ensure that its use is carefully controlled? Is that a possibility?
Our visit to the US seemed to be well received. We met many enthusiastic and immensely interesting people. Looking at the list of research projects, it was good to see so many projects still trying to tackle the HIV/AIDS problem. The different laws concerning different states made for a complex network.
1081 One of the last people we met in Boston was Dr. Levy, a dedicated and enthusiastic campaigner. He expressed delight that the issue was receiving attention at Westminster. As our report says, he declared himself an optimist. We must not let the position get worse here. I hope that the Government's response tonight will be positive and hopeful and that we can look forward to better protection and higher morale in our infection control workforce.
§ 10.5 p.m.
The Earl of Clanwilliam
My Lords, I rise to speak briefly in the gap in order to draw your Lordships' attention to the evidence submitted to the committee by two bodies. The first is the Research Council for Complementary Medicine, on page 447; the second is the Soil Association, on page 499. That is a double whammy for my pet project, which I find hard to resist.
The RCCM demonstrated that herbal medicine has been shown positively to improve the immune system, while previous centuries have proved that there are no side effects, let alone induced resistance, to the effects of such treatments. Indeed, the findings of the committee and the speeches of all noble Lords reflect this as the reason for the public's interest in complementary medicine, as was mentioned by the noble Lord, Lord McNair.
I also draw your Lordships' attention to the evidence of the Soil Association on page 499 and at paragraph 3.8 of the recommendations. Organic farming reduces the use of chemicals of all descriptions and contributes to more healthy animals and more healthy food. The Soil Association has been operating for 50 years. Farmers who belong to that body do not and have not used growth promoters.
Neither complementary medicine nor organic farming provide complete answers to the problems of achieving good health or healthy food, but both are important contributors to those considerations. I submit to your Lordships that they deserve a place in this debate.
§ 10.7 p.m.
§ Lord Clement-Jones
My Lords, in winding up on behalf of these Benches, I pay tribute to your Lordships' committee. The report is extremely well written. As a layman, I found it most intelligible and readable. Tonight's speeches have clarified a number of issues arising out of the report.
I apologise to the House for being unable to hear all the speeches tonight. That was due to an unbreakable commitment. However, the speeches I have heard, particularly that of the noble Lord, Lord Soulsby of Swaffham Prior, were excellent in carrying the debate further.
The report has led to major coverage in the newspapers. It has led to coverage in specialist medical journals, scientific journals and even television programmes. But the real acid test is whether it will prompt government action. We are looking forward to hearing from the Minister tonight.
1082 The report highlights with frightening starkness the problems of microbiological resistance. I am afraid to say that it also highlights a certain complacency in the NHS, which may well be changing as a result of the report. Certainly, it was an aspect which came through to me quite strongly. As we have heard from many noble Lords tonight, as regards hospital infections, MRSA is a major problem when we have only vancomycin to protect us and when resistant strains have been discovered, notably in Japan. But it is also a problem in the area of disease where, both here and internationally, we are facing the real prospect of resistant strains of TB, meningitis, typhoid and pneumonia. All the diseases that killed our parents and our grandparents are potentially coming back to haunt us.
In the committee's conclusions and in its treatment of the evidence I found it particularly interesting that it was not absolutely convinced by the medical evidence that changing prescribing behaviour would necessarily alter whether or not specific bacteria became resistant. In my view it formed a perfectly valid working hypothesis that that is the case, working on the balance of probabilities. That seems to me to be a way forward that could commend itself to us.
The kind of problems identified by the committee on the primary care front struck a chord in my case. Doctors talked of parental expectations and the pressures from parents. The noble Lord, Lord Winston, was particularly moving in describing that kind of pressure. As the parent of an eight-month old child I recognise that one is not prepared to take the risk. When I come to discuss public education, I want to highlight that specific feature.
That kind of perfectly valid unwillingness to take any risk will have a knock-on effect. We have a major government childcare strategy and an expansion of childcare facilities. What effect will that have on GP prescribing behaviour? Likewise, people are living longer and there are more older people, often in homes. What effect will that have on prescribing behaviour? Will it lead to continued over-prescribing?
The report also highlights the whole area of hospital infection and emphasises that infection control is extremely important. But what impact will the increasing use of agency nurses have on infection control? By and large they will be unfamiliar with the infection control protocols and procedures of their hospitals, and inevitably that causes risk. Likewise, the use of contract cleaning services—a number of noble Lords referred to this—not directly under the control of the ward manager may lead to a lowering of standards.
So is infection control one of the casualties of the internal market? When an infection strikes the hospital, the cost is clearly massive. Short-term cost savings can therefore lead to huge costs in the long run. It is also extremely worrying, as the report indicated, that there are so many chairs of microbiology which are reported as being vacant. Even though the report came out in April, many of those London chairs are still vacant. It is staggering that major teaching hospitals have such vacancies. In the subheading of the report it indicates that there is a crisis in microbiology.
1083 Animals form part of the most controversial and difficult area in the report. The noble Earl, Lord Clanwilliam, referred to the evidence of the Soil Association. The second volume of evidence repays careful study. Some of the evidence received was excellent, particularly from organisations such as the Association of Medical Microbiologists. As someone whose family by preference eats organic food and looks for organic food in the supermarket, the evidence of the Soil Association had considerable attractions. But when we look at the situation, I am not wholly convinced. Let us face it, for 30 years farmers have used growth promoters for their animals. After all, that is why the Swann Committee was originally set up. It seems to me that there are conflicting views about the Swedish experience in terms of additional antibiotics that may be used for therapeutic use once we have banned growth promoters. I do not believe that the US evidence is conclusive; indeed, it appears that avoparcin was never licensed in the United States and yet it has major problems with vancomycin-resistant bacteria.
I believe that the prudent and proper course of action is to wait for the Advisory Committee on the Microbiological Safety of Food to report on the assessment of risks of drug resistance across the food chain, including the use of growth promoters. I think that that is a fair thing to do. Indeed, as we heard during the debate on the Statement about support for the farming industry, farmers are having a pretty hard time of it. We have to be sure of the scientific grounds for banning or extending bans on the contents of growth promoters.
Therefore, what conclusions should we be drawing, as policy makers and as politicians, from the Select Committee's report? First, the Government are clearly active in one respect. I welcome the recommendations issued in September by the Standing Medical Advisory Committee on the whole area of prescription of antibiotics and antimicrobials. However, I also believe that there are many further actions that the department needs to undertake to follow up the report. That is but a first step.
The strongest point in the report was the committee's conclusion that the major recommendation of the Swann Committee—namely, to have a single committee to regulate and oversee the use of antibiotics both in humans and in animals—was never followed. That seems to me to be a staggering fact. Here we are in 1998 talking about a committee which made what seemed to be an extremely sensible proposal in 1969, but we are still no further forward.
Moreover, we know that in the NHS a great deal of effort is currently being concentrated on information technology. We have seen the Information for Health information technology paper. That seems to be absolutely key in trying to regulate our use of antibiotics, our surveillance of how they are used and the way in which we test for infections. For example, we know that the development of Prodigy could have a great impact in terms of understanding what is being prescribed, where and how and, indeed, in what circumstances. Then we have the COMPASS system in 1084 Northern Ireland, which I hope will spread further in terms of audit. That will allow us to have a much greater and more detailed level of surveillance of resistant bacteria. We also hope that efforts will also concentrate on the whole question of speeding up testing for infections. However, if you actually look closely at Information for Health, I do not believe that the word "antibiotics" actually appears in the report. It should; indeed, it was published after the date of the Select Committee's report. I should very much like to hear from the Minister that the Government will be ensuring that that omission is rectified in the future.
We have heard about the whole issue of the crisis in academic microbiology, but we need basic medical education for the generality of doctors about the importance of microbiology. We need greater status for medical microbiologists. We need better staffed microbiology labs. We need not only more money for the PHLS—and this was something that came out strongly in the report—but we also need more money for basic microbiological research. Quite often the more glamorous things are funded by MRC, but there appears to be very little money available for this kind of absolutely essential research. Obviously we need to have more public education about antibiotics.
It seems to me that it is not purely antibiotics and antimicrobials that we are talking about. Noble Lords may have seen a recent television programme which dealt with the whole question of antibacterials as used in the kitchen. They seem to me to represent a very important area where bug resistance can build up because one is using these powerful agents in the home. Indeed, people are encouraged to use them when actually detergents and soap—which most microbiologists will tell you they use in hospitals—should be used, rather than using these antibacterials which will build up resistance in our own homes.
Aside from antibiotics and antimicrobial agents there are other potentially interesting areas of research. I confess to something of a hobby-horse in the area of what are called "bacteriophages". About 18 months ago there was a "Horizon" television programme on these, and yet there is a stunning silence from the academic community on this matter. These are viruses that attack individual bacteria and may be a fruitful area of research. What research is being done on them? All I have come across is a rather voluminous website which is interesting but does not give any indication that there is much happening among members of the research community in the UK.
The point that came across to me in the committee's report is that this is an international issue. We cannot isolate ourselves from the problem. I refer to the diseases I mentioned earlier and the way bacteria can spread and the way in which their resistant strains can cross boundaries. International co-operation is needed to research those matters. It is needed on the animal front and on the human front. A huge task lies ahead of us. When the noble Lord, Lord Soulsby of Swaffham Prior, introduced the debate he said that the report was a blueprint for action which must start now. He hit the nail absolutely on the head. I can think of no other agenda 1085 in medicine which will be of greater importance to our children and grandchildren than the one we are discussing.
§ 10.21 p.m.
My Lords, I, too, add my congratulations to my noble friend Lord Soulsby, to his committee and to its clerk for this superb report. I have never come across a report that is so well written and is so readable on such an important subject. It is a report which I am sure will be referred to for many years because of the wealth of well presented evidence that it contains, and yet it is a clarion call for action now. A loud call indeed is needed to wake up this Government!
The complacency of this Government has been remarked on by many speakers. I think it is exemplified most of all in paragraph 4.37 of this report which states,The Minister for Public Health spoke confidently about MRSA. Whereas many countries now accepted MRSA as a fact of hospital life, this need not be so here; rates of resistance were relatively low".Is the figure of 32 per cent. relatively low when zero per cent. is achieved in other countries? The report continues,the United Kingdom had 'excellent clinical guidelines' and surveillance which was the best in the world".How can they say that? They must know some of the facts that are in this report. Surveillance is awful. There is an enormous lack of facts. It is one of the great holes in what we are doing in this country in collecting data so that we can understand what is happening by way of resistance.
This is a quite breathtaking complacency on the part of this Government. An enormous amount needs to be done. It seems astonishing to me that neither the Minister for Public Health nor any of her civil servants have had the kind of experience—with regard to someone close to them or someone they know—that the noble Lord, Lord Fitt, described so graphically. I refer to the experience of sitting watching someone's pulse rate climb and his or her temperature climb while the doctors vainly try one antibiotic after another. In the end in most cases they find something, but it is a terrifying experience waiting to see if they will. That takes us right back to the days which the noble Lord, Lord Perry of Walton, described so graphically from his own memory when infection was commonplace and when people died in their tens of thousands from these infectious diseases. We got used to it then but it is a new thing to us now and it is frightening. I hope that some of that fear and some of that concern will manage to communicate itself to this Government.
There is a great deal that this report suggests should be done and most of it can be done with a great deal of ease, given government will. We have heard some extraordinary ideas this evening. My noble friend has suggested that we turn to organic farming as a recipe for dealing with this. Indeed there is much sense in that. Organic farmers have recognised that they cannot beat nature and have to control it by working with it. There is much we can do from that angle in dealing with bugs. Many of us—I am glad to say I do—consume Yakult 1086 every day. That is a horrible substance which is meant to improve our gut flora. That is at least one metaphor for organic farming on an internal basis. Perhaps on an external basis, one may do something about staphylococcus aureus by taking a bath in something similar every now and again.
We have heard from the Liberal Democrat Front Bench two versions of their policies. I shall leave to the Minister which of those two versions from his coalition partners he chooses to take as the official version, but at least there is a breadth of view there.
§ Lord McNair
My Lords, I am grateful to the noble Lord for giving way. At the beginning of my speech, I should have said that I was sitting on the Front Bench only incidentally because my noble friend could not be present then. My remarks were not Liberal Democrat policy in any sense; they were merely ideas which I felt may be useful to the debate.
My Lords, it is my experience that almost every policy is a Liberal Democrat policy at one time or another.
As has been said by many speakers, there is a great deal that needs to be done on the practice of microbiology in hospitals, ranging from the simplest matter of personal hygiene through to organisation and the raising of the status of clinical microbiology so that it becomes a profession that people seek to follow. An important part of that is making sure that research funds are available. Quality people follow money for research because they want to achieve something. If one cannot get money for a decent research programme, one will choose to do something else. There is little money for research in this area, but there is so much to be done, not only in basic research and in making sure that we have a continuing armoury of chemicals to deal with infection but also in diagnosis (to make sure that we have a quicker and better ability to understand what is happening to patients) and in practice, so that we know the best ways of dealing with infection control and can make use of all the data that we should like to see coming from better surveillance practices.
I share with at least one of the Liberal Democrat spokesmen a perception of what is the most important aspect of the report. I refer to the suggestion that the recommendation of the Swann Committee be taken up and that there should be an overarching government committee on antibiotics and infection generally.
I should like to look at that rather more deeply than considering just antibiotics. These questions are immensely complex. They cross not only departments, but run deep into the depths of individual departments. One example which has been quoted several times is the use of antibiotics as growth promoters in animals. The simple answer is to ban them, but we must consider also animal welfare. We must take decisions on which antibiotics we shall allow to be used on animals. We need curatives for animals. We need people who develop curatives for animals to know that they will not be taken away three years later because someone wants to use them for humans. Considering all the regulations these days, it still costs perhaps £100 million to produce 1087 a curative for animals. People involved in that need to know that they will have a continuing market and that there is some structure to ensure that if the curative has been "okayed" for animals, they will be able to keep it for animals. It is no good looking at virginiamycin and saying, "We have found something else; we have found a use for a similar chemical; we now want it for humans", because nobody will ever develop a substitute for virginiamycin because they always think that it will be used for human patients.
We must look at the costs to the industry of taking away such products. Under the World Trade Organisation regulations, we cannot prevent the import of a large quantity of, say, chicken from China or Thailand which has been produced using such substances. There is no way of detecting them by the time the chickens reach us. They will come in at a low cost. If we build a high-cost industry, as has Sweden, like Sweden we shall have to give it immense subsidies to survive. If we want to do something that allows us to make the change without incurring that cost, we have to plan for it long term. We have to consider tripling or quadrupling the amount of space allowed for chicken houses. That means that the Department of the Environment, Transport and the Regions will have to ensure that planning permission is granted. No one wants a chicken shed next to them. It is difficult to get planning permission for that.
Other questions relate to the alternatives. Sweden uses zinc compounds. That causes considerable problems with heavy metal wastes in the litter from chicken houses. Germany uses arsenic on pigs. I do not suppose that that is something that we want spread on our fields. All of the alternatives have consequences and require a great deal of thought and consistent and coherent planning.
One of the great lessons from the BSE disaster is that waiting until a problem hits you in the face is extremely expensive. We have spent something like £4 billion on taking out a disease which will kill seven people a year—a figure has been pretty consistent over the past four years—whereas we are here looking at a problem which could kill tens of thousands of times that number of people with the greatest of ease as soon as MRSA acquires a solid form of vancomycin resistance. All it takes is some daft scientist in a hospital to decide to see whether he can give MRSA vancomycin resistance because he wants to know if it can be done. Indeed, it has been done in a hospital not very far from here. The only good thing about it is that it was stopped before the scientist had time to drop the test tube. It will not be long before we have this animal with us. We must be prepared for it.
This Government have a considerable reputation for complacency. When faced with a difficult question they do not seem able to see further than a focus group can think. The astonishingly fatuous response of this Government to the report of this House on the medical uses of cannabis is but the most recent example. I expect nothing from the Minister but flannel and prevarication. Why else would the Government have taken seven months to reply to this report when it quite clearly 1088 demands urgent and multi-faceted action? I expect nothing, but the lesson of this report is that you should always prepare for the unexpected, and I shall be delighted if I am wrong.
§ 10.31 p.m.
§ Lord Hunt of Kings Heath
My Lords, today's debate has demonstrated once again the seriousness and complexity of the antimicrobial resistance problem. I am very grateful to noble Lords for their contributions which have been both constructive and helpful and are, as already stated, a demonstration of the valuable work of your Lordships' House.
The Government are well aware of the healthcare problems presented by antibiotic resistant strains of micro-organisms. The Government therefore welcome and commend the report of the Select Committee on Science and Technology. The report is comprehensive and far reaching and has found a wide and receptive audience. Indeed, the document has done much to stimulate the increased national and international attention this subject is now receiving. I pay particular tribute to members of the sub-committee and to the noble Lord, Lord Soulsby of Swaffham Prior, for the enormous amount of work they undertook.
The Government will be giving their formal response to the report shortly. The Government are not complacent. We did not reply earlier because we want to ensure that the response gives the full depth and breadth of consideration that this important issue rightfully merits. My right honourable friend Tessa Jowell wrote to the noble Lord, Lord Phillips of Ellesmere, at the beginning of July making that point. He responded saying that he was content with the reasons for preferring to delay the response until the autumn. The Government will of course take particular note of the points raised by noble Lords in today's debate, although I doubt that I shall be able to respond to all of them tonight.
This is an important issue. Microbial resistance is a major public health threat that the Government take most seriously. I shall briefly summarise some of the major issues and outline the Government's strategy in tackling them.
The first antibiotic—penicillin—was discovered 70 years ago. Since that remarkable discovery, a variety of other antimicrobial agents have been added to our armoury against the effects of infectious disease. The efficacy of these agents has inevitably resulted in their widespread use, frequently reducing suffering and death. The noble Lord, Lord Perry of Walton, provided some graphic descriptions. It is of great concern therefore that the increasing resistance of micro-organisms to antibiotics jeopardises many of the medical advances made in the treatment of infectious disease. Although the problem is not so widespread in the UK as in many other countries where antibiotics are more freely available and infection control procedures may be less effective, it is nonetheless a very serious problem, and we are treating it as such. My noble friend Lord Winston had some very important points to make in that respect.
The message from the Science and Technology Committee, behind which the Government stand four square, is that there is no room for complacency. Our 1089 past heritage will not itself protect the future. As the noble Baroness, Lady Masham, said, bugs have no boundaries. The world is becoming smaller and international travel more commonplace. The organisms which cause infection do not respect international boundaries and are able to move quickly and unseen among our communities with the ability to jeopardise healthcare. We must all be ever-vigilant in our fight against them and not relax our guard. If hard-to-cure infections are not to become more widespread and if treatment is not to become more difficult and expensive, action must now be taken to slow down or delay the emergence of antimicrobial resistance and limit its spread. But there is no quick or easy solution.
It is clear that resistance is to some extent an inevitable consequence of antimicrobial use, a point identified by the noble Lords, Lord McNair and Lord Dixon-Smith. However, apparent over-use and misuse of antibiotics is fuelling the proliferation of resistant micro-organisms. Some antibiotics are being prescribed when they might not be needed. Some patients are adding to the problem by expecting antibiotics for every infection, needed or not. Each unnecessary use of an antibiotic for a viral infection, like a cold or influenza, increases the chance that resistant strains might proliferate and spread among the body's naturally occurring bacteria.
Even when antibiotics are prescribed appropriately, many patients fail to use them as directed. Stopping antibiotics too early kills the weak micro-organisms, leaving the strong to develop resistance, flourish, and perhaps spread through the community.
By their very nature hospitals are significant sites for the development of antibiotic resistance. Noble Lords have referred to that point frequently during the debate. Hospital patients typically receive several, and often intensive courses, of antibiotics, creating ideal conditions for resistant strains to emerge and thrive. Resistance moves easily between hospital and community settings.
We cannot just rely on hopes of successful development of new antibiotics with appropriate efficacy to solve the problem, even though there may be new antibiotics or novel therapies on the horizon. Resistance problems have always existed and probably always will, no matter how many classes of antimicrobial agent or new mechanisms are developed.
What can be done? Slowing down or delaying the emergence of resistant micro-organisms and limiting their spread will not be a simple matter. But much can be done. In the UK the Government have already commenced a strategic plan of attack. An interdepartmental multidisciplinary steering group has already been set up with responsibility for co-ordinating and driving forward work on antimicrobial resistance. There is a need for continued outside advice from experts and we are actively considering how best to put this in place.
Our strategy is based on three key elements: better surveillance; prudent antimicrobial use; and effective infection control. This strategy continues to evolve as 1090 expert advice becomes available and an action plan for taking forward specific projects of work is being developed.
Across these areas a number of initiatives have already been undertaken or are under way. These include enhanced surveillance—a point made by my noble friend Lord Winston—a review of the clinical use of antimicrobial agents; a review of antimicrobial agents in the food chain; measures to improve infection control management and practice; and the promotion of research in the field and into the development of new antimicrobial agents and vaccines.
Last year the Chief Medical Officer asked the Standing Medical Advisory Committee to examine the issue of antimicrobial resistance in relation to clinical prescribing practice and make recommendations. The committee set up an interdisciplinary sub-group with cross-representation from the standing committees for nursing, midwifery, pharmacy and dentistry and it included veterinary and consumer representation. The final report entitled The Path of Least Resistance was produced and published in September. As my noble friend Lord Rea said, the main report is a comprehensive scientific source document, with summary and synopsis versions, that has been widely distributed in the UK and made available on the Internet. As an immediate step copies of the synopsis version were sent to all doctors. Alongside the Select Committee's report, the Standing Medical Advisory Committee's recommendations are key to the Government's future strategy and work programme.
Refinement of the use of antibiotics must be the key feature of the strategy to tackle the antimicrobial resistance challenge. The Government have an important role to play but they need support from, and action on the part of, healthcare professionals, expert groups and many others who have an interest in this important public health issue.
Reducing the unnecessary prescribing of antibiotics is likely to prove a significant factor in combating the development of resistant strains of bacteria. Patients, too, have a significant role to play by not pressurising their clinicians to prescribe them in circumstances where they are not effective, such as for colds and influenza. The noble Lord, Lord Soulsby, and my noble friend Lord Winston spoke clearly about the pressure on GPs.
Clearly, we have to get the balance right. When swiftly and appropriately prescribed, antibiotics can unquestionably be life-saving. We must scrupulously avoid discouraging people from visiting their GP when they feel unwell. Such a balance cannot be achieved overnight but is one which, in partnership with the profession, we can aim to achieve. The Department of Health is working on proposals for a public campaign. It is worth reporting that in 1997 GPs in England prescribed 6 per cent. fewer courses of antiobiotics than in 1995. Happily, that trend continued in the first half of 1998.
I turn to education, a point raised particularly by my noble friend Lord Winston. Educational initiatives for both health professionals and the general public are of major importance for improving the use of antimicrobial 1091 agents. The Government have brought the Select Committee's report to the attention of the professional bodies. These include the General Medical Council, the medical Royal Colleges, and the English national Board for Nursing, Midwifery and Health Visiting. It is clear that increased attention needs to be paid to antimicrobial therapy in their programmes of postgraduate education and vocational training.
The noble Baroness, Lady McFarlane, offered some valuable insight regarding the contribution of nurses, and specifically infection control nurses. Her comments will be studied with great interest.
A number of noble Lords raised the very serious issue of infection control in hospitals. The noble Lord, Lord Fitt, spoke movingly of his own experience in that regard. Improvements in hospital infection control arrangements are an important part of the action being taken by the Government. The responsibility for ensuring that effective arrangements are in place for the control of infection in trusts rests with the chief executive of the trust. Hospital infection control is an important part of an effective risk management programme to improve the quality of patient care. I wish to stress the chief executive's personal responsibility for the quality of care as part of the new clinical governance framework for which the chief executive is responsible to the NHS trust board.
All hospitals should have an infection control team which has primary responsibility for, and reports to the chief executive on, all aspects of surveillance, prevention and control of infection.
In 1997 the NHS Executive asked regional epidemiologists to survey communicable disease control arrangements at health authority level throughout England. The survey identified a number of shortcomings which have now either been addressed or are being addressed.
The NHS White Paper, A First Class Service, set out the detailed responsibilities of chief executives of NHS trusts for the quality of care to which I referred. That will include infection control services and will pick up many of the issues raised by noble Lords. For instance, as I said, as part of the clinical governance framework, infection control teams will be expected to produce regular reports to trust boards, but these could include hospital hygiene reports to bring deficiencies in cleaning standards to the attention of the trust board.
The noble Baroness, Lady Masham, asked whether MRSA targets could be established for each hospital. The Government agree that much work needs to be done to develop performance indicators and/or targets on hospital infection control, including MRSA, and are actively considering this recommendation alongside their proposals on clinical governance, to which I have just referred.
The noble Baroness also said that issues to do with infection control are as important in the community as in hospitals. The Government agree that there is a need for national standards and guidelines for community infection control management. The Department of 1092 Health is taking the lead in ensuring their development, working in partnership with many others who will be involved.
The noble Lord, Lord Soulsby, and my noble friend Lord Winston asked about funding for the PHLS. I can assure your Lordships that we shall be discussing the long-term funding of the PHLS with that body when it has completed the strategic review which it is currently undertaking. I am unable at this stage to say what the outcome of that review will be, but, in order to give the PHLS time to undertake the review, present its conclusions to Ministers and agree their implementation, £2.3 million in additional resources will be made available to the PHLS in the 1999–2000 financial year.
A number of noble Lords, including the noble Lord, Lord Lucas, referred to the recommendation of the committee that a single multi-disciplinary government committee should be set up to oversee all aspects of antibiotic use. The Government have established an interdepartmental multi-disciplinary steering group to develop the recommendations of your Lordships' Select Committee and the Standing Medical Advisory Committee to turn that into a wider government strategy and to steer and co-ordinate activity in this area. Consideration is currently being given to the need to set up an expert group to provide advice on scientific aspects of antimicrobial use.
My noble friend Lord Rea asked about vaccine research. The Government are involved in establishing a national framework for co-ordinating vaccine research. We intend that the UK population should have available at the earliest possible opportunity safe and effective vaccines. I should like to reassure noble Lords of the high priority which the Government give to this area.
The noble Lord, Lord Jenkin, asked about the Government's position in relation to over-the-counter antibiotics. I can reassure him that the Government will continue strongly to promote adherence to prescription-only status for all antimicrobials within the EC and elsewhere.
My noble friend Lord Rea asked about advice to general practitioners on prescribing. I can confirm that all health authorities continue to employ both pharmaceutical advisers and primary care medical advisers to provide advice on the use of medicines. As an important part of this role, they continue to visit GPs to discuss their prescribing. A number of studies have confirmed the effectiveness of their activities in this regard. My noble friend Lady Hayman announced last week that PRODIGY, a computerised prescribing-decision support system, is to be made available to all GPs without cost. Shared doctor-patient information screens and patient information leaflets can be printed to advise patients on management of their illnesses, which I think is a great advance.
My noble friend Lord Rea also raised the issue of the new primary care groups. With their establishment, subject to legislation, the Government will expect them to take an active role in professional development in this area. We also have examples of good prescribing practice in the use of antimicrobials in primary and secondary care. These will be identified and 1093 disseminated through health authorities, primary care groups, hospital trusts and post-graduate educational networks.
A number of noble Lords, including the noble Lord, Lord Dixon-Smith, referred to deficiencies in information in the health service. In September this year my right honourable friend the Secretary of State for Health launched the new information strategy for the NHS. This is part of a £1 billion investment to get the information systems right and to make information work for NHS patients and staff. Over a period of time it will ensure that we provide lifelong electronic health records for every person in the country, and instant access 24 hours a day in every hospital and GP surgery to patient records and best clinical practice. The whole emphasis is to bring together outcomes, activity and prescribing data. I believe that that will very much help the health service meet the very difficult problem that it faces.
There have been widespread concerns in the medical community and elsewhere that problems of resistance are being fuelled particularly in respect of foodborne pathogens such as species of salmonella by the use of antibiotics in animals. Much has been said about this by noble Lords today, particularly by the noble Lord, Lord Soulsby, in his introduction to the debate. I am not able to respond directly to that issue today. However, noble Lords will be aware that the Government have set up an investigation into microbial resistance in relation to the food chain which is being carried out by a working group of the Advisory Committee on the Microbiological Safety of Food. The noble Lord, Lord Clement-Jones, referred to the matter. As he suggested, the working group is expected to report to the committee before the end of the year. The committee will then offer advice to the Government on a range of issues concerning the responsible use of antimicrobial agents as veterinary medicines and growth promoters.
A number of noble Lords referred to the international dimension. The Government are determined to give constructive support to international initiatives and to take a leading role if required to ensure that effective systems for monitoring antimicrobial resistance can be set up without delay. We shall press for this to be given priority in the World Health Organisation's next global and regional biennial work programmes and in the future framework for European Union action in the field of public health.
With UK support the World Health Assembly adopted a resolution in May 1998 which urged member states to take measures broadly in line with the planned UK strategy and called on the director general to promote international co-operation. Within Europe, too, the European Commission in its communication of April 1998 on the development of pubic health policy in the European Community identified the growing problem of resistance to antibiotics as one of the new risks to health. The Commission's scientific steering committee has set up a working party to examine all aspects related to this question.
1094 I would be failing in my duty to your Lordships' House if I gave the impression that there was a quick solution in sight. Tackling antimicrobial resistance is a long-haul task that requires partnership between government and a wide range of organisations and individuals across many disciplines in both the UK and internationally. There is no doubt that antibiotic resistance presents one of the greatest challenges to us all. It is an unending battle, according to the noble Lord, Lord Dixon-Smith. The UK Government are rising to the challenge and taking action to help tackle the problem. They are playing a leading role both nationally and internationally but alone they cannot do all the things that need to be done. If they are to succeed they need a strong spirit of partnership, co-operation and determination among healthcare professionals, expert groups, communities and every individual citizen.
Today's debate and the reports of your Lordships' committee and the Standing Medical Advisory Committee present a very clear message to us all. The Government will be resolute in their response.
§ 10.53 p.m.
§ Lord Soulsby of Swaffham Prior
My Lords, the hour is late and I shall not detain the House much longer. I thank all noble Lords who have contributed to the debate. They have supplemented one another's contributions to an extent and provided important information both from their experience and the report. They have expanded on areas that I have failed to deal with adequately.
I do not think that anyone who has heard the noble Lord, Fitt, describe the tragic end to his wife's life can now doubt that antibiotic resistance is a very important entity to which we must attend. We should thank him for so bravely bringing the information to us. It must put an indelible mark on our minds that he is a person who has experienced at first hand the tragedy of antibiotic resistance.
The noble Baroness, Lady Masham, identified the problem of pressure sores to individuals like her who have to sit in a wheelchair. All these are very important matters which may well miss the attention of those of us who consider ourselves to be reasonably normal, although at times that is under challenge by various people.
Perhaps I may briefly identify some of what I believe to be the headlines of this debate. Surveillance has been identified by a number of noble Lords. To my mind that is particularly important. I was pleased to hear from the Minister that the Government are going to attend to some of deficiencies in the public health laboratory service, which have been identified with the input of several million pounds. I did not deal with research in my opening comments, but it is particularly important. If we had more research so that we could identify antibiotic resistant organisms in a clinical environment such as in a doctor's surgery it would be a major step forward.
The education of the doctor at the undergraduate and postgraduate level has been identified. The noble Baroness, Lady Platt, who, unfortunately, is not in her 1095 place, identified the education of young mothers and children as regards the use of antibiotics. In committee she was very keen to identify the fact that women's magazines would be an excellent medium for getting over that message. Indeed, that has happened.
The use of alternative medicine has been identified by the noble Lord, Lord McNair, and my noble friend Lord Clanwilliam. That area was touched on only briefly in the report. Some evidence was given to us about alternative medicine. I am delighted that my noble friend Lord Lucas takes probiotics every morning in order to repopulate his intestines with beneficial bacteria instead of antibiotic resistant bacteria. I do the same occasionally, but not every morning. That is an area for future development. The noble Lord is a little ahead of the game in that respect.
He mentioned the Swedish system for the control of the use of antibiotics in animals. Initially, that was not viewed very favourably; but after 10 years, and due to the fact that the Swedes depended very much on the use of antibiotics in animal husbandry for the control of disease, that has now been improved and the benefit of the withdrawal of antibiotics in animal husbandry has been shown to take place. The amount of antibiotics used is now very much reduced, but, as mentioned by several noble Lords and the Minister, that cannot happen overnight. It takes quite a long time.
We had a very good input from the noble Baroness, Lady McFarlane, on antibiotic and infection control in hospitals. In committee her experience and knowledge of the matter was very valuable and put into perspective the problems that we have and which we identified.
I am delighted to hear the Minister say that there is no place for complacency. We were aware that the response was to be delayed but, with due respect to the Government, we did not expect it to be this delayed. The response may well be the better for that delay; I do not know. However, the publication, The Path of Least Resistance, is welcomed. It details effectively how to handle the situation.
Education is welcome too. I have mentioned the £2.3 million additional funding to the Public Health Laboratory Service—that is also welcome—and its strategic review. It is good news that there is to be, I hope, an overarching committee, and progress is being made on that. We find that important in dealing with the problem of antibiotic use and resistance.
Finally, we are delighted to hear—as I am sure is my noble friend Lord Jenkin—that the Government will abide firmly by the principle of no over-the-counter antibiotics.
We have had a good debate. It has been a prolonged debate, but much of importance has been said. I commend the Motion.
§ On Question, Motion agreed to.