The growing threat of drug resistant bacteria

Alexander Pannett 12.15pm

Professor Dame Sally Davies, the Chief Medical Officer, has published an annual report that has made headlines by claiming that the rise in drug resistant infections is comparable to the threats of global warming and terrorism. She has called for the threat to be listed on the government’s National Register of Civil Emergencies.

The report highlights that, while a new infectious disease has been discovered nearly every year over the past 30 years, there have been very few new antibiotics developed to counter-act diseases that are evolving and becoming resistant to existing drugs.

This means that routine operations could soon cause infections that may prove fatal. Modern advances in health could be reversed as hospitals again resemble the mortality-stricken abattoirs of Victorian times.

We are already seeing this crisis unfolding throughout hospitals in the UK. The MRSA superbug made headlines with its prevalence amongst hospitals and resistance to antibiotics. MRSA has since been tackled by improved hygiene procedures at hospitals. But its presence heralds the threat of the worse that will come unless urgent action is taken now by world health authorities.

In evidence to the science select committee in late January, Professor Davies told MPs that the supply of new antibiotics had collapsed, and that the market model for delivering new antibiotics was broken.

New drugs are potentially a useful solution against resistance, but the drugs are often not available. Drug companies are not interested in developing a drug that, with widespread use, could be obsolete long before it has turned a profit; or a drug that is so effective that it is reserved as a final solution. New antibiotics that are developed are slight variations of existing drugs. Some classes of bacteria are not getting any new antibiotics at all.

An additional problem is that bacteria evolve at such a rate that any new antibiotic that is developed has only a short window in which it will work. In fact our very use of antibiotics encourages the development of resistant bacteria. Resistant bacteria may be rare, but rare mutations benefit the most when drugs kill off their competitors. Tests on mice with malaria have shown that the susceptible strains of bacteria win out over the resistant strains in the absence of antibiotics. However, after treatment the resistant strains re-develop at a faster rate and in greater numbers. The boost was biggest for mutant bacteria that were rare to begin with.

This, combined with the knowledge that governments are actively attempting to keep antibiotic prescriptions to a minimum, disincentivises pharmaceutical companies from investing in new drugs.

One answer is to develop new business models to encourage the development of new antibiotic drugs. Regulations can also be relaxed to allow pharmaceuticals to rush out antibiotics after targeted sample tests rather than the more lengthy current testing requirements.

However, for now the most immediate answer to alleviate the impending crisis is to restrict the use of antibiotics to only the most pressing of needs. The course of antibiotic treatment should be re-evaluated to limit the use of antibiotics to shorter durations where possible and eliminate antibiotic use where it is not necessary, such as viral infections and use in livestock. Better hygiene methods should also be used to prevent infections.

The growing resistance to antibiotics is a timely reminder that we must constantly review the tools we use to maintain a healthy society. Each of us has an obligation as members of a community to ensure that the advances we have made are bequeathed to future generations. The medical progress that has made life-saving operations a common feature of modern societies is a vital social imperative we must not surrender.

Follow Alexander on Twitter @alpannett

Mid Staffs: Whither 38 Degrees?

Nik Darlington 3.16pm

In September 2011, I cavilled about the “rise of the clickocracy”, that multi-headed hydra of modern political ‘engagement’. The internet has spawned several campaigning movements, 38 Degrees being pre-eminent, who exist to put the democratic process within reach of a mere click. Click, click, clickety click - and the job is done. Your voice is heard.

The well-funded 38 Degrees made its name by opposing the Coalition’s healthcare reforms. There were just “24 hours to save the NHS”, we were told. Millions of emails made their way to MPs’ inboxes. All, of course, to no avail, but the point was made, not least by that moronic Mirror headstone.

The Health & Social Care Act has of course not killed the NHS. Yet the revelations within the Francis Report threaten to kill public trust in an institution that Nigel Lawson called “the closest thing the English have to a religion”.

Paul Abbott, sometimes of this parish, has a good little piece over at ConHome today, asking what campaigners such as 38 Degrees think about the grotesque conditions at Mid Staffordshire and allegedly sundry other hospitals around the country.

“Now that the Mid Staffs report has been published and debated in Parliament, it makes difficult and upsetting reading - wherever you fall on the political spectrum. Thousands died. The truth was covered up. Problems were endemic and not just because of a few rogue individuals. But, where is the 38 Degrees campaign for NHS reform? Where is the e-petition on their website, saying, “24 hours to save the NHS”? In the past, they have moved quickly to jump on a topical news agenda. So why not now, on their central issue of defending the National Health Service?

38 Degrees will have no credibility on NHS reform in the future, if they don’t step up to the plate now. I’ve met the CEO of 38 Degrees - David Babbs - a few times, and like him. He’s a nice guy, and seems sincere in his intentions. He has told me more than once that he’s not a front for the Labour Party, and I believe him.

But why the silence on Mid Staffs, David? What’s going on?”

Now we shouldn’t expect the likes of 38 Degrees to take a stance on everything (heaven help us all if they did). Though it would be interesting to know what an organisation so vehemently against structural tinkering thinks about endemic cultural and managerial misanthropy.

As Paul suggests, where is the deluge of emails under the subject of “adopt the Francis Report recommendations in full”, or similar?

Typically, big and successful public campaigns rely on catchy, straightforward messages. The nuanced and complex truth cannot compete. Under such conditions do governments often flounder; and organisations like 38 Degrees, conversely, thrive.

Except the entire debate about Andrew Lansley’s NHS Bill was mired in nuance and complexity. 38 Degrees took on the Government with a simple (sometimes just absurd) message, but it still required people to grasp with elaborate change.

The Mid Staffs scandal is, in comparison, really rather straightforward (if frightfully hard to fix overnight). It is simply made for someone like 38 Degrees to take advantage of and put to the people and their clicking mice. Isn’t it?

Reshuffle round-up: inside gossip and double-edged swords

Nik Darlington 4.41pm

The dust has settled on David Cameron’s first Cabinet reshuffle. The press pack has largely plumped for Jeremy Hunt’s appointment as Health Secretary and Justine Greening’s ejection from Transport as the main stories. The former is deemed suitably rehabilitated since Leveson to restore public faith in the Government’s NHS policies; while the latter is off to DfID, ostensibly to clear the path for a third runway at Heathrow.

At least that is the view of the Mayor of London, Boris Johnson, and it is hard to disagree. Above all, it makes her appointment only a year ago look inept and extant policymaking ad hoc and desperate.

The junior ministerial changes look set to begin, with the Lib Dems’ Nick Harvey making way at the MoD, it seems as a trade ito get David Laws back into the Cabinet. As far as I am aware, Mr Harvey acquitted himself well as armed forces minister, but the return of Mr Laws is a long-awaited boost to the Coalition.

Meanwhile, Nick Herbert has apparently quit as police minister, which begs the question, which job wouldn’t he accept? It seems Damien Green will take his place, an appointment I thoroughly welcome. The changes among the lower ranks look set to continue into the evening.

So back to the Cabinet. I wrote about Ken Clarke this morning, and shall only reiterate that he remains a figure of vital importance to this Government and to the Prime Minister. A veritable, jolly ‘minister for the Today programme’, he is, as a friend suggested earlier, perhaps becoming something of a Willie Whitelaw to Mr Cameron.

Andrew Mitchell’s appointment as Chief Whip is a double edged sword in two ways. In itself, it feels like a good decision - until one considers how well Mr Mitchell ran DfID and how vulnerable that department (and its enviously coveted budget) might become in the hands of a disappointed Justine Greening.

Furthermore, Mr Mitchell is on no accounts universally loved. He has numerous friends and fans, of course, but the fears about his disciplinarian manner are already being well-aired. Matthew Parris said on the BBC this morning that the new Chief Whip will “either stop a rebellion or start a rebellion”.

Earlier today, one Tory backbencher mentioned Sir George Young - removed as Leader of the House in order to accommodate the demoted Andrew Lansley - as a superior candidate for 12 Downing Street. “Imagine having to go in to see Sir George and him calmly to tell you how ‘disappointed’ he was - you would feel awful.”

Elsewhere, the long-serving Oliver Heald is an apparently popular choice as Solicitor General, replacing the similarly popular Edward Garnier, who took his sacking with enough good grace to appear cheerfully on the telly immediately afterwards. With Ken moved, it is also awfully good to see that Dominic Grieve keeps his job as Attorney General.

Which brings me on to the Ministry of Justice, which now has a non-lawyer as Secretary of State (the Guardian has also picked up on this). Chris Grayling has done a very good job at DWP, not least in dismissing the claptrap spouted about the work experience programme, but his appointment is being lauded in several quarters for the wrong reasons. The likes of the Sun, the Daily Mail and ConservativeHome will surely be delighted. I hope Mr Grayling goes some way to disappointing them and continuing with the important reforms of the past couple of years.

The only other news of note is what hasn’t happened. Tim Montgomerie didn’t get his wish of Michael Gove as Conservative Party Chairman (that bauble goes to Grant Shapps), which thankfully means he can continue his exceptional work as Education Secretary. Iain Duncan Smith remains at DWP, overseeing the crucial implementation of his welfare reforms. And, of course, George Osborne is still Chancellor - but then only the truly cuckoo believe anything different.

I doubt there will be many promotions for the class of 2010, though I suspect we’ll see some worthy roles for their 2005 predecessors. The speculation shall, I’m sure, continue all the same.

Follow Nik on Twitter @NikDarlington

Ignorance about the Health Bill shows how few people read election manifestos these days

Nik Darlington 7.50am

Of course, none of this was in any of the parties’ general election manifestos.

I paraphrase, but is one of the most irritating claims in this berserk public debate about NHS reforms, right up there with “NHS privatisation” and “two weeks to save the NHS” (or, as Mr Burnham said way back in October 2011, “72 hours”).

The error, committed regularly by members of the public (egged on by sections of the media who should know better), can be corrected by doing something as simple as reading the relevant entries on health in the parties’ manifestos. The people in the photograph above clearly haven’t.

The Conservative party manifesto said:

“We have a reform plan to make the changes the NHS needs. We will decentralise power, so that patients have a real choice. We will make doctors and nurses accountable to patients, not to endless layers of bureaucracy and management…”

“…we will give every patient the power to choose any healthcare provider that meets NHS standards, within NHS prices. This includes independent, voluntary and community sector providers…”

“We will strengthen the power of GPs as patients’ expert guides through the health system by: (i) giving them the power to hold patients’ budgets and commission care on their behalf; (ii) linking their pay to the quality of their results; (iii) putting them in charge of commissioning local health services.”

And remembering the Health Bill is largely Conservative policy driven by a Conservative Health Secretary, read the Liberal Democrat manifesto, which contained pledges to “scrap Strategic Health Authorities”and “to make care flexible, designed to suit what patients need, not what managers want”. This should be achieved by “sharply reducing centralised targets and bureaucracy” and “putting front-line staff in charge of their ward or unit budgets”, as well as “empowering local communities to improve health services through elected local health boards, which will take over the role of Primary Care Trust boards in commissioning care for local people”.

Rather than the coalition parties’ manifestos not containing any inkling of the health reforms, it is almost surprising quite how much they actually did contain. And even more surprising is how similar the Lib Dems’ diagnoses and solutions were to the Conservatives’.

Even the Labour party’s manifesto contained the line: “We will support an active role for the independent sector working alongside the NHS in the provision of care, particularly where they bring innovation”.

One of the three main parties has reneged on election promises. It certainly isn’t the Conservative party, and for the most part (despite recent parliamentary amendments) it isn’t the Liberal Democrats.

Integrating health and social care: “The NHS was better in the old days”

Dr Dan Poulter MP 11.49am

My front-line NHS experience has shown me that under the previous government, there was an increasing and damaging emphasis placed upon nationally imposed, top-down, procedural bureaucracy, as opposed to improving the integration and delivery of key frontline healthcare services.

The result has been a failure to invest properly in healthcare and social services support for the elderly, and a failure to recognise that the healthcare challenges facing inner city areas in terms of disease profile are very different from those facing rural communities.

The single biggest challenge facing the NHS is how to meet both the human and the financial cost of looking after our growing elderly population.

We know that by 2033, it is predicted that a quarter of the UK’s population will be over 65, and on current projections, by 2035, the number of people aged 85 and over is projected to more than double to reach 3.6 million, and to account for nearly 7 per cent of the UK’s population. Most startling of all, the number of working age people for every state pensioner will fall from 3.2 (2008) to 2.8 (2033).

The priority must be to deliver a more integrated healthcare service that is tailored to individual patients’ needs.

In many parts of the NHS, there currently exist distinctly isolationist working practices - often referred to as ‘silo-working’.

There is the primary care silo, the hospital silo and the social services silo. Silo-working has failed patients, and has only served to drive up the cost of patient care. For example, hospitals are rewarded for treating patients for an acute episode of care - ‘payment by results’ - but hospitals are not incentivised to think together with primary care to promote better care in the community, which would avoid inappropriate and expensive hospital admissions.

Properly integrating NHS services means that we must recognise that different healthcare needs exist in different parts of the country, which requires a more tailored and locally-focused approach to the delivery of NHS and adult social services care. For example, the healthcare needs of those in metropolitan areas are often very different to those in rural areas. Lord Darzi’s super clinics may work in Islington but not in rural Suffolk.

In July 2011, the Dilnot Report was published. Among many compelling findings, it concluded that the current social care formula in the UK is simply unsustainable. Additionally, it recommended that a cap of around £35,000 should be placed on individuals paying for their care, that means tested support should continue, and, crucially, better integration of the health and social care sectors. We should welcome these findings as an objective, cross-party analysis of what is required for the future.

The previous Labour government was strong on the rhetoric of healthcare inequality but failed to address adequately the biggest healthcare inequality of all - meeting the care challenges of an ageing population.

The coalition’s NHS reforms are a step in the right direction. NHS budgets and health services will be mostly run from the community by local NHS commissioning boards, and this will help break down the funding divisions that currently exist between primary care and hospital services.

The result should be a greater emphasis on integrated, community based health services rather than acute response based medical services, or in other words healthcare that better supports people at home and prevents the inappropriate admissions that are so distressing to patients and expensive to the NHS.

The Dilnot Report makes clear that the greatest need for joined up healthcare exists in the better integration of NHS services with adult social care, but true harmonisation of healthcare service delivery in both financial and human terms will only be achieved by fully integrating the NHS and adult social care budgets in the way that they once used to be.

My consultants at medical school used to tell me that the NHS was better in the old days. As in so many other things, it looks like they were right.

Dr Dan Poulter is MP for Central Suffolk and North Ipswich and a former NHS hospital doctor specialising primarily in obstetrics, gynaecology and women’s health. He continues to practise medicine as a NHS hospital doctor part-time, and is a member of the Health Select Committee.

This is a shorter version of an article that originally appeared in the TRG’s autumn edition of Reformer, available to download here.

PMQs review: As a debate it was dreadful, but as a spectacle it was riotous

Jack Blackburn 1.39pm

There they were, their entourages in tow, ready for the latest bout in this series of fights organised by the NHS and Andrew Lansley. In the blue corner, the reigning champion, Dave “Flashman” Cameron. In the red corner, his spindly challenger, Edward “Not to be confused with David” Miliband.

Cameron entered the arena, flanked by his regular posse of Clegg and Hague, the latter offering vocal support, and the former performing an amusing mime act entitled, “Don’t do anything”.

Miliband, however, shook up his team, pushing Ed “Gesticulating” Balls to one side and replacing him with Andy “Eyebrows” Burnham. The scene was set. The atmosphere was expectant. The referee was impotent.

Edward tried to get an attack going with a few jabs, pointing at the ridiculous NHS summit from Monday. But Dave held his defence initially, deciding on a tactic of skipping round Edward, evading his questions.

So Edward tried again, and briefly there was some excitement in the ring as Dave fought back, challenging his opponent to ask a question about the substance of the bill. He said that Labour used to be in favour of choice, competition and GPs being in charge of budgets, but now they’re against it.

This should have been the start of a classic encounter, but a melee broke out around them and the chamber descended into utter chaos. Burnham began shouting with such verbosity that even Balls was impressed by, nay jealous of, such talents.

When Andrew Lansley tried to hand his pugilist some notes, Edward jumped on him like a cat: “The Prime Minister doesn’t want advice from you!” John “Squeaker” Bercow intervened for the 27th time in the session. He had been up and down like a jack-in-the-box, but nobody was paying any attention.

After which, Cameron stood up when it wasn’t even his question. There were howls, whoops, laughs and jeers. It was as like hearing the canned laughter tracks from the BBC’s radiophonic workshop on a diabolical loop.

Cameron called his Labour opponents “rank opportunists”, once again neatly avoiding answering any questions. Edward said that this was going to become Cameron’s “Poll Tax”, once again neatly avoiding making any statements of policy.

As a debate it was dreadful, but as spectacle it was joyous. Edward Miliband was actually quite funny. You’d have to have been there, but he was funny.

In fact, we’ve seen a real improvement from Edward this term. One wonders how he’ll fare on a topic other than the NHS. He can’t keep this up for three years.

Follow Jack on Twitter @BlackburnJA

Labour attacked from left and right for its morally corrupt blanket opposition to health reform

Nik Darlington 10.48am

Two important blogs appeared this morning. One is by a Conservative MP, one is by a former Labour party General Secretary. Both are about the NHS and, in their different ways, both identify the same problem: the Labour party’s stance on NHS reform.

Chris Skidmore is one of the most thoughtful of the 2010 Tory intake (he used to be an adviser to David Willetts, of course, where two brains are better than one). His blog for ConservativeHome is not exactly cerebral - it is more factional than phrenic - but it has a clarity of expression and fight that sadly has too often been lacking. Mr Skidmore is also an articulate historian. That he can write well clearly helps.

Burnham and Labour have set their face against an NHS that is centred around the needs of the patient, precisely what the Coalition’s reforms seek to achieve. They have become the party of anti-reform, anti-competition, anti-choice, and above all, anti-patient.

Peter Watt also happens to be one of the more thoughtful people in the Labour party. He regularly stands out as a voice of reason amid the silly squabbling, neither a fully-signed up Blairite nor a dyed-in-the-wool statist. In a blog for Labour Uncut, he attacks the Health & Social Care Bill in its current form - “a largely unnecessary piece of legislation” - which I cannot claim is an unreasonable position to take having questioned it myself.

But like Mr Skidmore, Peter Watt insists that the NHS must change. Reform is desirable and inevitable, which makes the Labour party’s opportunistic opposition to reform untenable.

…more reform is exactly what the NHS needs. The current legislation is clearly ill thought out and is rightly being resisted, but that does not mean that the NHS does not need to change. And if the Labour party really wants to save the NHS, it must aggressively embrace further change, not reject it. Because budgets will continue to be squeezed and efficiencies will still need to be found. At the same time patients will demand greater and greater choices, higher standards of care and service. This simply can’t be achieved without reform, even if money were no issue.

Labour’s shadow health secretary, Andrew Burnham, is censured from the left and from the right for hypocrisy and hysteria. Mr Skidmore writes:

…to listen to Andy Burnham, you would be forgiven for thinking that he was never a keen Blairite reformer of our public services. As Secretary of State for Health, he helped oversee an expansion of new providers in the NHS, particularly Independent Treatment Centres, the same expansion that this government backs, and that he now derides as privatisation. It was Andy Burnham who was happy to back an increase of £10 billion going to the private sector, between 2006-2010.  It was Andy Burnham who fought an election on a manifesto pledge to ”support an active role for the independent sector working alongside the NHS in the provision of care, particularly where they bring innovation.”

What a difference opposition makes. One of his first actions as shadow secretary was to fly in the face of expert consensus and declare that it was “irresponsible to increase NHS spending in real terms”, turning against the Coalition’s real-terms increases in NHS spending, despite knowing that the NHS is facing the toughest efficiency program in its history.

While Mr Watt, portraying Burnham more captive than co-opted, says:

Andy Burnham may be a supporter of competition and choice, but many of those rallying to the cause certainly aren’t. The Tories inept handling of a largely unnecessary piece of legislation has given them their chance. This is an opportunity to finally put a nail in the coffin of further reform and they are going for it. You can hear it in the rhetoric, the old cries of the NHS being “the best in the world”, of its great efficiency and how we need more cooperation and not more or any competition. All of which are highly debatable, no matter how much you love the NHS. So all in all, the prevailing mood within the Labour party is for less reform not more.

I have made no secret of my discomfort with the Bill, its presentation and its parliamentary management. But healthcare reform is essential.

The Labour party, lone sensible figures like Peter Watt aside, has behaved reprehensibly: a spiteful spasm of collective amnesia and nitwittedness.

Reforms begun under Tony Blair, by Alan Milburn and John Reid, were producing improvements in NHS outcomes. And the stubborn, statist and vested interests within the Labour party hated them for it. They hated them viscerally, for proving that the introduction of some choice, competition and independent provision could work.

The Labour party is, as Peter Watt writes, in its “comfort zone”, at the same time as the NHS, says Chris Skidmore, “faces a perfect storm of an ageing population and a boom in chronic illness and lifestyle-related diseases”. It is a thoroughly miserable, and morally corrupt, state of affairs.

If Simon Hughes says Andrew Lansley should go, his job must be secure

Nik Darlington 10.12am

One my desktop Twitter thing I have separate streams for Conservative, Labour and Liberal Democrat MPs. It can be quite revealing (you always know when the Labour party’s effective social media operation gets into action because its MPs start parroting the same tweets).

Last week, Labour MPs seemed happier than they’ve been for some time, perhaps even before it dawned on them that they’d been given a party leader who fires blanks. From the moment the shadow health secretary set upon Craig’s article on Wednesday morning, my Labour stream was awash with re-tweeting MPs and party hacks. I had a suspicion it might surface at PMQs. When I saw Mr Burnham sat at Edward’s right-hand side instead of the typical toad-in-arms, that suspicion was confirmed.

The Conservative stream was a curiosity. I checked often but over the course of Thursday and Friday I didn’t see a single tweet from a Tory MP in support of the health reforms or the besieged Andrew Lansley. And health minister Simon Burns cut a lonely figure as he did more telly appearances than Alexander the Meerkat.

Over the weekend, however, Cabinet colleagues took to air and screen to pledge their support for the Health Secretary - and rightly so.

Mr Lansley is not one of life’s natural communicators. But he is a brave and decent man. Moreover, having spent several years shadowing and then running the Department for Health, he knows the NHS inside out. I challenge anyone to identify an alternative candidate better qualified to take on such a complicated job at this desperate moment (and a realistic candidate: neither Alan Milburn nor Stephen Dorrell count).

Perhaps Simon Hughes has a better idea. The Lib Dem deputy leader roused himself to declare (£), with impeccable gravity, that the coalition had to “move on from this Bill”. And in consequence, said Mr Hughes, “my political judgement is that in the second half of parliament it would be better [for Mr Lansley] to move on.” How he must have agonised before bestowing us with this missive.

I said what I have to say about the Health Bill in Friday’s article. I shall not repeat it here, except to reiterate that worthwhile reforms have been mangled by poor communication, vested interests and indulgent opposition. What is worth salvaging must be salvaged, and unlike maritime convention, this is a moment when the sinking ship’s captain must survive to pick up the pieces.

The Prime Minister is doing the right, honourable and sensible thing in standing by Mr Lansley. It is one sort of humiliation to have one’s government run by hysterical newspaper headlines. To have it determined by the “political judgement” of the Member for Bermondsey & Old Southwark would be a farce.