Simon has the vision: we have to deliver. Why saving the NHS is down to everyone of us.

Simon Stevens was on the @BBCR4 8.10am interview this morning, answering questions posted on twitter #AskNHSEngland about the new NHS Five Year Plan. It was a shame really as the tweets really skewed the discussion, and the important questions of where the money would come from (at least another £8Bn requested), the demographic challenge (the current labour intensive approach is unsustainable practically and financially), public redress where services don’t improve /are poor, and the role for each of us in ensuring a sustainable NHS were left unanswered.

There is a telling sentence at the end of summary of the NHS Five Year Plan published today. It reads “there are viable options for sustaining and improving the NHS over the next five years, provided that the NHS does its part, allied with the support of government, and of our other partners, both national and local.” It is a call to arms to all of us. The Five Year Forward View (FYFV) sets out aspirations and ideas for ensuring a sustainable NHS which will require action from everyone of us if it is to succeed.

2020health is delighted that so much of what we have published in the past few years is echoed in this Plan including:

  • In our ‘Going with the flow’ report we said there was a need to designate large, specialist hospitals, colour coded blue, as well as their being a role for small, local hospitals colour coded red. The Plan outlines the need to find viable models for smaller hospitals as well as strategic planning for specialist centres (FYFV pg 22).
  • In our same report we promoted much greater involvement of individuals and community organisations in health and social care – as we also did in our reflections on nursing – this is echoed throughout the FYFV.
  • In our ‘Careless eating costs lives’ report we detailed requirements to tackle obesity, many of which would help with other conditions too. The FYFV is determined or though not detailed on supporting action to deal with public health risks (FYFV pg 10).
  • The Plan recognises the vital part that technology has to play; our latest initiative, the ‘Health Tech and You’ Awards is at the forefront of showcasing to the public what is available to help us look after ourselves better, and our reports on the VHA’s use of technology, Electronic Patient records and Healthcare Without Walls have all detailed the art of the possible across healthcare.

The NHS FYFV particularly looks to employers and local authorities to play their part:

  • Getting serious about revolutionising prevention by incentivising healthier behaviours, giving local authorities more power on public health, targeted prevention strategies and employment support and workplace health.
  • Empowering patients through providing information, voluntary sector partnerships to help with condition management and expanding choice.
  • Engaging communities through supporting carers, promoting volunteering, voluntary sector partnerships and with the NHS as an exemplar local employer.

These are all noble aspirations, however much is required of local and national government to deliver the plan, and there are still some key components missing.

  1. Whilst the Plan talks about workforce training, we need to horizon scan for the impact of technology which is democratising health in a transformational way. The public will have far more information about themselves, their conditions and their management. The role of professionals will change radically and they need to be ready for that.
  2. Serious recognition that much of our health is determined by factors outside of the NHS: education, environment, housing, transport We know this is an NHS plan, but it doesn’t operate in isolation and can’t make improvements in the public’s health alone. Whilst it does reference the role of Local Authorities, this requires more of the coordinated approach that is already being talked about for health and social care.
  3. On the public’s health the Plan boldly states that: “So for all of these major health risks – including tobacco, alcohol, junk food and excess sugar – we will actively support comprehensive, hard-hitting and broad-based national action to include clear information and labelling, targeted personal support and wider changes to distribution, marketing, pricing, and product formulation. We will also use the substantial combined purchasing power of the NHS to reinforce these measures.” We know it is outside of their powers, but this FYFV should have been an urgent call to government to act now. Without immediate, determined action on problems such as obesity, much of this plan could fail to deliver a sustainable service.
  4. There is huge variation in the way the NHS adopts new technology and medicines and it often doesn’t provide the best, but just the best that can be afforded. If we allow patients to pay for the latest and best in class, then their cost will come down faster and they will be available to everyone more quickly. It is simply not fair to prevent people from choosing to spend some of their own money on a novel technology. The Plan does acknowledge the postcode lottery already in existence, but patients will increasingly look for themselves as to the best treatment available and what power will they have to ensure they receive it?

Elsewhere the report doesn’t pull its punches. It tells politicians to stop meddling:

“In particular, the tendency over many decades for government repeatedly to tinker with the number and functions of the health authority / primary care trust / clinical commissioning group tier of the NHS needs to stop.”

Whilst this is true for national NHS structures, this Plan does actually need local politicians to step up and intervene more to enable the prevention strategies of which this report gives exemplars. And the case still has to be made for intervention – Nigel Farage’s popularity is not independent of his propensity to drink and smoke in front of the cameras. Rebellious freedom appeals to us all in different ways. And that brings us back to the money. The NHS was not set up to prevent, but to treat. Local Authorities are in the early days of getting their heads around health and wellbeing with their Public Health colleagues. With more cuts to LA budgets on the horizon, improving public health could be pie-in-the-sky without at least transitional funding being found. We wait for the politicians to respond – but in the meantime we can begin to ask ourselves how we can Be The Change – for the good of our families, neighbour’s and country’s health.

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Extraordinary confessions, a rare strike and a plan

It’s busy in health news today. There’s the NHS strike over pay –  the BBC’s Norman Smith has just reported (at 7.40am) that “Health sec Jeremy Hunt says will sit down and negotiate with NHS unions if they agree to reform pay increments”. This reflects the fact that about half NHS have been getting pay rises through annual incremental increases, although those at the top of their pay bands have not had any increase, and a 1% pay rise for everyone can’t be agreed whilst the automatic pay increases for some remain in place.

What the government need to get across are the choices. On a fixed budget you can’t have pay rises and more staff and still-very-generous pensions, without tax rises. It would  be an interesting question to pose to the public: would you rather pay more tax so NHS staff have a pay rise, or so there are more nurses and doctors on the ward?

The other inconvenient truth for politicians is that we are living in a digital age which is disrupting old ways of working, massively changing the workforce we need and in which many will see their wages in real terms fall. A difficult political message to communicate.

The Tory Party’s admission that reorganising the NHS in the way they did was a big mistake – see exclusive from Chris Smyth, Alice Thompson and Rachel Sylvester in the Times – is not news to anyone who works in it, but quite EXTRAORDINARY to come out now. Tories have been saying it privately for a long time, but this confession is amazing. Maybe this admission wasn’t supposed to leak, maybe this is the start of a new ‘frankness’ with the public over political mistakes, maybe the powers at Tory Towers think they have time to win back support on the NHS between now and the election if they come clean… then again, maybe not. Whilst we welcome the apology (is it quite that yet?), it puts Jeremy Hunt in an incredibly difficult position. His bosses would do well to get their message clear and consistent from now on – is there a strategy?

The good news is that 2020health meanwhile has an action plan out to tackle Obesity: obesitythumbnailCareless eating costs lives was published yesterday and is available here. We hope all the Political Parties will take a look as, quite honestly, this is a far greater threat to our future and prosperity than ebola.

Recommendations from the report include:

* Introduce tax incentives for larger businesses to make wellbeing provision (such as access to occupational health, nutritionist, gym facilities) available to smaller local businesses.

* Introduce licensing for fast food outlets to control the location and numbers of

outlets in a local community.

* Recognising the positive response to the Responsibility Deal Government should

require all companies to follow the excellent example of participants. The

Responsibility Deal to turn into a legislative framework which is phased in over the

next 5-10 years.

* Practical cookery skills and clear food education to be a compulsory part of the

school curriculum for pupils up to the end of key stage 3 (age 14).

* Clear disclosure of calories per items on restaurant and cafe menus which adhere

to a defined standard for font size, formatting, contrast and layout of menus.

* The ban on advertising of unhealthy foods aimed at children should be extended to

day-time TV, from 7am to 9pm.

* A review needs to be undertaken of the economic and societal impacts of a

hypothecated tax on a range of food and drink contents at levels which are

deemed harmful to health.

* Increase awareness, coordination and reach of the Government’s ‘Healthy Start’ Voucher scheme. Extend voucher scheme to incentivise those who become active partners in their health by quitting smoking, reducing weight, walking a set number of steps etc.

* Establish a cross departmental permanent government task force on obesity. This

supports similar recommendations made by other health organisations.

* All new policies to be reviewed and assessed against an ‘obesity test’.

* Improved screening and normalisation of discussion about diet and weight at

medical appointments.

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‘Hot’ topic – Sexual Health Week

NatikaHHalil53Guest blog by Natika Halil,  FPA’s Director of Health and Wellbeing

Emergency contraception has been a hot topic since its inception over 40 years ago. Frequently the subject of sensationalist reports, it is the only method that can be used to prevent pregnancy after contraceptive failure or unprotected sex, and has benefited millions of women around the world by preventing pregnancies they know they would not want.

We have chosen emergency contraception for our Sexual Health Week theme this year because of the endless myths and misconceptions we hear about how it works and what the options are. The phrase that will spring to mind for many people is “the morning after pill”. It’s understandable that this has slipped into everyday use – but in truth it is really unhelpful and misleading, and we believe it helps propagate a couple of myths that could act as barriers to women getting the help they need when they need it.

For starterFPA-sexual-health-week-2014-poster-tightss there are three different methods of emergency contraception, and only two of them are pills. Further, none of the methods have to be used within 24 hours, or by the “morning after” to be effective. In fact one of the pills (ellaOne) and the emergency IUD (also known as the coil) can be used up to five days after unprotected sex, and the other pill Levonelle can be used up to three days after.

These are basic facts that – be it through lack of sex and relationships education or insufficient information from health professionals – unfortunately are not known by vast swathes of women, and indeed men, across the UK.

We surveyed more than 2,000 sexually active women* and found some glaring gaps in their knowledge and understanding. Across the UK almost two-thirds of women (62%) wrongly believed, or weren’t sure, that emergency contraception has to be used within 24 hours of unprotected sex to be effective.

More than one-third (36%) wrongly thought that you have to have a prescription to get any method of emergency contraception, or weren’t sure, and 63% thought repeat use of emergency hormonal contraception – the two pills available – can make you infertile, or didn’t know.

FPA-sexual-health-week-2014-poster-bagAnother stubborn myth is that emergency contraception is like having an abortion – in fact one prevents a pregnancy and one ends a pregnancy, and it is very clear in medical guidance and the law that they are different. Yet one half of women surveyed thought this was true, or weren’t sure.

While these results were shocking, in truth they probably weren’t surprising. Just 17% of the women had learnt about emergency contraception at school, and only one in six said they thought health professionals provide enough information about the different methods of emergency contraception that are available.

Where does that leave women to get their information from? The internet? Friends and family? Stubborn myths that seem to recycle for each new generation? We know there are many sources of less than trustworthy information out there, and unfortunately misinformation about emergency contraception can also be used as a tool by those with a less than pro-choice attitude.

During Sexual Health Week we are doing all we can to raise women’s awareness of what their options are, and give them evidence-based facts on which to base their decisions. We’re also talking directly to health professionals because the role is absolutely central to this. We’ve sent out more than 3,000 briefing packs to professionals who provide emergency contraception, and we want them to bear in mind the findings of our research as they go about their daily work, because it shows that there is more we can all do to tackle stigma and end ignorance.

For more information about Sexual Health Week, visit

*Survey of 2,509 UK women aged 16 to 54, of which 2,131 have ever been sexually active. All figures, unless otherwise stated, are from YouGov Plc. Fieldwork was undertaken between 22 and 25 July 2014. The survey was carried out online. The figures have been weighted and are representative of all UK adults (aged 18+).

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‘Counting the Cost’ – Meningitis Awareness Week (15 – 21 September)

Guest Blog by Chris Head, Chief Executive, Meningitis Research Foundation

Meningitis kills and seriously disables more young children in the UK and Ireland than any other disease. Young adults are the second highest at risk group but people of all age groups can be affected as 17,500 members of Meningitis Research Foundation can testify. Globally meningitis kills an estimated 1,000 people every single day.

We estimate 3,400 people are affected by meningitis and septicaemia in the UK and Ireland every year. One in ten dies and a quarter of all survivors are left with life altering disabilities ranging from deafness and brain damage to amputations.

And our Counting the Cost study concluded the lifetime financial cost to society of someone seriously disabled by just one form of the disease, MenB, is up to £4.5m – and that’s not including any litigation costs which may also be paid.

It’s our charity’s annual Meningitis Awareness Week (15 – 21 September) and 215 families have signed up to share their stories in the media.  You can also read many more personal stories in our Book of Experience online

Robbie's new legs 2014Robbie Jones, who celebrates his 8th birthday during Meningitis Awareness Week,  and his mum Jill are among those sharing their story. He was just 21 months old when he contracted meningitis – losing both his legs and all his fingertips.  Since then he has grown in and out of numerous legs. His latest pair features his favourite football club – Manchester United. He is also learning to swim, and the joy that the freedom water brings him is clear to see. Jill says: “ We had heard about meningitis but never thought it would happen to our family and had never seen the effects it could have on survivors.”

But awareness is not enough. We believe the first line of protection is vaccination and everyone should be immunised with all available meningitis vaccines. To this aim we have invested £17.5m in 140 international and UK based meningitis research projects to support finding solutions for this devastating disease.

We have been marking our 25th anniversary this year and in that time we have seen meningitis and septicaemia cases halve.  Improved protection has played a major role; vaccines for Hib, MenC and 13 strains of pneumococcal meningitis and septicaemia are all now freely available and an EU licensed vaccine for MenB is available privately and has been recommended for use in babies in the UK by the Joint Committee on Vaccination and Immunisation (JCVI).

However the question of whether adolescents will be included has yet to be decided. The UK Government has agreed to commission a very large study to show whether vaccinating teenagers could prevent the spread of the illness.  This indirect protection for the whole population has been key to the success of MenC and other meningitis vaccines which is why we are urging the Government to ensure this study happens without delay.

And research into the effectiveness of the MenC vaccine is why the UK Government is currently running a MenC booster campaign for those starting university this year. Vaccine protection was proved to wane over time and with MenC cases spreading rapidly through halls of residence, the Government decided to act with a catch-up campaign for students up to age 25 and all those who have never been vaccinated for MenC. The booster campaign augments the dose now given to teenage children at 14 years of age and will run yearly until 2017.

This charity has been supporting the MenC booster campaign by freely distributing posters and symptoms cards to universities, colleges and secondary schools.   It’s is just part of our year-round symptom awareness raising work.

We encourage everyone to recognise the symptoms and act fast to save lives. Other initiatives include a Meningitis Baby Watch card distributed to around one third of all new parents by local health authorities, officially endorsed guidelines for medical professionals, handy sized symptoms cards, informative leaflets and a symptoms video presented by our Patron, the popular TV GP, Dr Hilary Jones. Our symptoms information online receives over 1m visits a year.

But we cannot be complacent. Great strides have been made but that doesn’t mean meningitis has gone away.   We believe protection is the ultimate answer to meningitis.  We welcome the JCVI’s recommendation for a MenB vaccine at 2,4 and 12 months and we will play an active role in making parents and carers aware,  but we want to see an adolescent catch-up programmes for older children and Government commitment to prevent rarer forms of meningitis too.

It’s been a roller coaster ride for 25 years but there is still a lot more to do.

For symptoms information and much more, visit

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Scottish Independence – What’s Your Plan for Vaccination Alex?

Guest Blog by Stuart Carroll, Senior Health Economist and Epidemiologist

Screen Shot 2014-08-19 at 23.46.02In under a month’s time, the Scottish people will decide their fate: stay within the United Kingdom or go it alone as an independent country and carve up the Act of Union of 1707.  As we saw from the first TV debate (regrettably, only highlights due to STV prohibiting ITV and Sky from broadcasting across the rest of the UK), it is increasingly possible to distinguish between SNP stated policy (romantic fluff and guff) and the consequences of that policy (the real world perspective).  Apart from having no currency Plan A, no currency Plan B, no currency Plan C (yes, there is a trend emerging here around no currency plan full stop!), no “independent” monetary policy, no influence over Bank of England interest rates, no clue on financial regulation, no membership of the EU and no NATO, the case for Scottish independence is in a full flow (I obviously say this with some irony!).  Alistair Darling 1, Alex Salmond 0 at half time.  Indeed, Scottish independence makes about as much sense as Del Boy speaking French.  Bonnet de douche Alex!!

However, there is a long way still to go and the “Better Together” campaign should avoid hubris as this referendum is as much about emotion as it could ever be about the hard, cold and real world facts.  Moreover, Salmond is a strong communicator despite alleged briefings against him by his deputy, Nicola Sturgeon.  His Horlicks of a performance the other night, although fundamentally a consequence of bad and, quite literally, unbelievable policy, is likely to improve in coming weeks, and underestimating the SNP would be foolish.

To be fair to the Scottish First Minister, one area where there is no particular need for an “independence plan” per se is health policy.  Following devolution in 1999, Scotland has had its own fully politically independent NHS.  Holyrood is already responsible for legislative and operational matters with its own Cabinet Secretary for Health and Wellbeing, Alex Neil, and other organisational arrangements.  However, there is one area of health policy, or more to the point public health policy, that remains unclear and ill-considered should Scotland vote for independence.  That is, the business of vaccination policy.

In the case of other health technologies, namely drugs, medicines and medical devices, it is the Scottish Medicines Consortium (SMC) that handles decisions pertaining to their approval and recommendation for use on the Scottish NHS.  Following assessment criteria analogous, albeit not exactly the same, to that of the National Institute for Health and Care Excellence (NICE) in England, including assessments of cost-effectiveness and budget impact, the SMC has become a widely respected health technology assessment (HTA) body.

However, recommendation decisions for vaccinations still sits with the UK-wide Joint Committee on Vaccination and Immunisation (JCVI); an executive expert advisory body whose secretariat is Public Health England (PHE) and, despite nowhere near the same levels of transparency and process of NICE (more blogs on this topic to come), a committee that broadly speaking follows the same HTA criteria as that of the Institute. The JCVI makes it recommendations to the Secretary of State for Health (currently Jeremy Hunt) based on clinical review and cost-effectiveness, which are then subject to, in most cases, national tenders.  Some vaccines such as flu and pnuemo are procured locally by Clinical Commissioning Groups (CCGs) and follow slightly different arrangements in the devolved nations.  National tenders, however, are conducted on behalf of the whole UK and procured by the Department of Health with assistance from the Commercial Medicines Unit (CMU), which is considered favourable for “bulk purchasing” and negotiating better price and volume agreements with manufacturers versus higher official list prices.  The devolved nations then agree to payback the Exchequer in proportion to their populations and the numbers receiving vaccines.

Technically, the devolved nations of Scotland, Wales and Northern Ireland can do their own thing, reject JCVI advice, make their own recommendations and, in theory, run their own tenders.  However, this has so far never happened and can be considered most unlikely under current arrangements.  It would make little sense to duplicate the work of the JCVI and would add an extra unnecessary expense in terms of procurement.   Representatives of the SMC often appear on JCVI minutes as “observers” and have so far been happy to follow JCVI recommendation decisions in their entirety.   Moreover, given that vaccination is a population wide intervention designed to control infectious disease, cross nation coordination and a consistent vaccination policy are desirable, particularly in light of equity considerations and cross border movements.  In short, and arguably for very sensible reasons, Scotland does not have an “independent” vaccination policy.

Having read through “Scotland’s Future” – the SNP’s “plan” for an independent Scotland – there is no mention of vaccination and what Scotland would do in the event of a UK divorce.  As with everything else, the SNP would be wrong to assume that in the case of independence, JCVI advice would automatically be “handed over”, SMC representatives would still be invited in as “observers”, or the English taxpayer would happily go on paying for the administration of national tenders; the results from which go on to form vaccination policy and UK wide immunisation schedules.  After all, when you divorce you divorce.

So, would Scotland have its own JCVI?  Would responsibility for policy shift to the SMC?  Who would conduct the tendering process?  Would Health Protection Scotland undertake the very complicated and intricate infectious disease modelling to ascertain epidemiological trends and cost-effectiveness?  If so, what is the “human resource” plan to recruit people from what is already a very limited pool of experts?  All of this is on top of questions concerning how Scotland would handle the licensing of healthcare technologies given that the Medicines and Healthcare product Regulatory Agency (MHRA) is also a UK body.  Even the European Medicines Agency (EMA), which supersedes the MHRA, belongs to the EU and, regardless of SNP rhetoric, membership is not a “slam dunk” raising additional uncertainties regarding independence. There might be reasonably practical and straightforward answers to all these questions, but as with so many other things around Scottish independence nobody in the “Yes” campaign has properly thought it through.  Fluff and guff might be contagious, but it is also potently dangerous in the context of infectious disease and advancing a serious vaccination policy.

This might not be the foremost consideration, or immediate area of policy, that Scottish citizens may cogitate over, worry about or indeed lose sleep over when contemplating the merits of independence.  Also, against the backdrop of gargantuan questions such as the entire fate of the Scottish economy, its membership of the EU and future defence policy, there are obviously bigger political fish to fry.  Nonetheless, public health is important in its own right.  It is something the SNP has sought to emphasise in government and its blueprint for independence (Scotland’s Future) when considering obesity, alcoholism, drug addiction and smoking cessation (admittedly, only in six pages of largely rhetorical prose and pseudo English NHS bashing!).  More pertinently, it is another area of policy which the “Yes” campaign has completely neglected to consider.  Despite his bluster and guster and extraordinary “Braveheart” rhetoric, not even Mr. Salmond is “immune” from these small but important details.  #Better Together.

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World Humanitarian Day 2014 is today and there are many continuing risks Globally for humanitarian health workers.

Guest blog by Dr Iseult Roche

Global action is needed to help protect humanirtarian health workers attempting to deliver aid in areas of conflict and crises.

World Humanitarian Day 2014 is set among some of the most difficult and dangerous range of humanitarian crises and conflicts. Although many people will automatically reflect in the plight of those naturally caught up in the problems, not everyone will consider the dangerous circumstances Humanitarian Health workers place themselves in, to provide aid and attempt to help those in desperate need.

Screen Shot 2014-08-19 at 16.48.42Today, the World Health Organisation raised awareness of the dangers humanitarian health workers encounter,  by saying health workers had been “threatened , shunned and stigmatized ,” during aid work in Ebola areas.

In other areas, health workers, clinics and hospitals had been attacked.

The director-general of WHO, Dr Margaret Chan has said : “Doctors, nurses and other health workers must be allowed to carry out their life-saving humanitarian work free of threat of violence and insecurity.”

While Dr Richard Brennan, humanitarian response department director at WHO, said: “Assaults on health workers and facilities seriously affect access to health care, depriving patients of treatment and interrupting measures to prevent and control contagious diseases.

The World seems to be getting smaller and increasing global travel, can result in global transmission of disease. The vitally important work humanitarian health workers carry out is important to everyone, and, not only those in immediate direct need of aid.

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Threats to Mankind from Drug Resistant Bacteria and Viruses

The risk of an end to the human race may sound like science fiction. However, there are only a small number of threats that could theoretically lead to the extinction of mankind. The four main concerns that most experts share are:

1. Nuclear war.

2. Deadly plague that cannot be treated by drugs or prevented by vaccines.

3. A potent poison being widely disseminated.

4. Earth being struck by a large meteor.

Drug-resistant plague poses one of the most serious, potential challenges to mankind. The final responsibility for coordinating a response rests with governments. The dangers are being increasingly recognised by politicians with the British Prime Minister helping to lead the way and a far-reaching British enquiry planned. All Infections are caused by “pathogens”, which are usually bacteria, viruses, tiny fungi or other microscopic parasites. Bacteria are a specific type of one-cell living organism and can be seen with an optical microscope. Viruses are much smaller and comprise largely genetic material that enters human cells and tricks them into making more viruses. Fungal infections are relatively rare but do arise e.g. thrush. Malaria is an example of a microscopic parasite that does not fall into the other categories. All pathogens mutate so that their properties gradually change. As the reproductive cycle is short many generations can occur in a small period of time. Pathogens that have mutated in a way that makes them more able to resist the actions of drugs are more likely to survive in patients being treated with the products. Growing drug resistance in the community and hospitals results.

Resistant viruses are probably a greater threat to mankind than resistant bacteria, fungi or microscopic parasites. Viruses are necessarily harmful because they take over healthy human cells and use them to produce new viruses. They are often transmitted between people in specific ways e.g. by sneezing and absorbing viruses through the nose in the case of ‘flu or the common cold; through blood or sexual activity in the case of AIDS; through animal bites with rabies. Once viruses have entered the body they frequently target a particular organ or class of cell e.g. a type of white blood cell for AIDS; the liver for hepatitis. New viruses generally require the discovery of new drugs or vaccines to treat or prevent infections whereas a new strain of bacteria is generally treatable by existing antibiotics (antibacterials). Bacterial infections are normally curable whilst viral infections vary in this respect. Fortunately, viral infections that are easy to transmit and mutate rapidly tend to cause less serious infections (e.g. the common cold, ‘flu). However, there is no reason as to why this pattern will continue. The risk for mankind is the evolution of a virus that is as easy to transmit and that mutates as readily as the common cold or ‘flu but is also invariably deadly. There is no reason why such a virus will not emerge and why drug development might not turn out to be too slow to provide an effective response.

Resistance to existing drugs is growing in the case of all pathogens. The problem is arguably potentially more serious for antiviral drugs than for antibiotics because there are far fewer of the former from which to choose in practical clinical situations. Nevertheless, antibiotic resistance is a growing and serious problem that can lead to deaths when hygiene has proved inadequate and the right combination of antibiotics is not found in time for a specific patient’s infection.

What should governments, doctors and regulators do?

In my experience drug companies have not become more reluctant to research potential breakthrough antibiotics. The reasons why the pace of antibiotic drug discovery has slowed are partly the increased bureaucracy within drug companies affecting R&D productivity in all drug classes and partly a big reduction in the number of good ideas for new antibiotics for reasons relating to antibiotic science. Most antibiotics including all penicillins, cephalosporins, monobactams and carbapenems have what is known as a beta-lactam ring in their chemical structure. Such antibiotics are collectively known as beta-lactams. The commonest way in which bacteria become resistant to beta-lactams is by starting to make a substance belonging to a chemical family known as “beta-lactamases”, which destroy the beta-lactam ring in beta-lactam antibiotics and so render them useless. Antibiotic R&D since the 1950’s has been largely about testing many different beta-lactams with the object of finding chemical structures whose beta-lactam ring is more stable in the presence of beta-lactamases. Most possible structures have been considered so that discovering new antibiotics is now much harder. In addition, many beta-lactams have been subject to resistance from the beginning because they can be destroyed by beta-lactamases that are already encountered. Antibiotics that are not beta-lactams typically see just as much resistance develop in other ways, have higher side effects and work in a narrower range of bacteria.

Incentivising drug companies to develop new antibiotics would have limited effect since the industry is running out of good ideas for designing new antibiotics. Policies in the UK for rewarding drug companies cannot alone be of great importance on the world stage. It would certainly be fair and helpful to compensate companies for lost sales of any drugs that are held in reserve in case resistance to presently used products becomes unmanageable. However, this idea is not a solution in itself because of the limitations of current ideas for new antibiotics, although coordinated support from other countries would help.

The most constructive way in which governments can help in the discovery of antibiotics and antivirals is by funding academic research and courses relating to bacteria, viruses and microbiology in the hope of generating ideas that the industry can pursue and increasing the number of appropriately skilled scientists. In the meantime governments, doctors and managers should work to minimise resistance in the following ways:

1. Detailed, high-level, expert guidance is required on the best prescribing practice to provide the most appropriate treatment for patients with the least development of resistance.

Many doctors and scientists have opinions about what constitutes wise and responsible prescribing of antibiotics and antivirals. Nearly all experts agree that antibiotics should not normally be given to patients whose infection is obviously viral since antibiotics are not effective against viruses. The only exception arises when an antibiotic is needed as a preventative measure. Opinions vary considerably over more detailed matters where there is often little hard data and practice varies from country to country, region to region and doctor to doctor. Some of these differences reflect different types of infection and varying patterns of resistance. However, most differences reflect the impressions of doctors in the absence of conclusive evidence. For example, a standard course of most antibiotics in the UK lasts five days. In Spain the same drugs are usually taken for four days (i.e. a day less) but at double the daily dose. Which practice carries the lower risk of resistance developing and whether the position is the same for all antibiotics is simply not known reliably.

The assumption is often made that resistance will build up more slowly if antibiotics are used less. Certainly if they are never used resistance will be held in check. However, it is not true that the lowest dose will cause the least resistance. The dose must be high enough for relatively resistant bacteria to be unlikely to survive and patients should complete the course, once started.

The initial choice of drug given to a patient is important. If the original therapy works poorly the patient will benefit little from it and the scope for increasing resistance is high.

The consequences of using combinations of antibiotics or of antivirals require detailed modelling. Bacteria and viruses find it harder to become resistant to two drugs at the same time than one but if resistance does develop more than one drug stands to be compromised.

Certain combinations represent special cases. For example, in both AIDS and infections caused by a class of bacteria known as Pseudomonas a combination has always been needed to achieve high levels of effectiveness.

An interesting debate is ongoing about whether Augmentin should generally be prescribed in preference to amoxicillin. Augmentin is a mixture of amoxicillin, the most widely prescribed antibiotic in General Practice, and a substance known as a “beta-lactamase inhibitor”. The latter product has minimal antibiotic activity of its own but neutralises beta-lactamases and can therefore restore the lost potency of amoxicillin. Resistance to amoxicillin can only develop from the use of Augmentin if the beta-lactamase inhibitor fails to do its job. Use of Augmentin rather than amoxicillin alone should slow down the development of resistance to amoxicillin but risks introducing resistance to the beta-lactamase inhibitor.

Much work needs to be done, preferably at national level. New studies need to be carried out. The NHS needs to supply whatever data is reasonably required. A suitable agency to coordinate the necessary work might be NICE. This national responsibility could transform NICE from an organisation that carries out unnecessary studies relating to drug pricing with no effect on the NHS drug bill to a body at the forefront of helping mankind.

2. Development of quicker tests for identifying bacterial susceptibility to antibiotics

At present it usually takes at least 48 hours to test bacterial samples from a patient to determine what antibiotics will work against a patient’s infection. As a result the patient may initially be given ineffective medication with little benefit and a high risk of adding to resistance. Side effects may also result from combinations of antibiotics designed to increase the chance that an effective product may be included.

Whilst good ideas for promising new antibiotics are rare, the reasons for diagnostic companies not developing much quicker tests to determine the choice of antibiotic are commercial. Improved, very quick, accurate tests have the potential to have a significant impact on the development of resistance. A major drive to develop such tests and get them accepted is appropriate with either public funding or special arrangements to ensure an attractive financial return. The arrangements could be self-financing because of the reduced use of ineffective, expensive products and shorter stays in hospital.

3. Hospital Hygiene

Although viruses often enter the patient’s body in specific ways (e.g. through someone else sneezing) bacteria are often transferred through lapses in hygiene. Resistant bacteria are found most frequently in hospitals because vulnerable patients may be in close proximity, potent antibiotics are widely used and some facilities require to be sterile (e.g. operating theatres). Every case of suspected poor hospital hygiene should be independently investigated and recommendations made.

4. Isolation of sufferers from deadly new viruses

Robust plans are needed to put sufferers from new deadly viruses into isolation quickly and efficiently. Doctors must record details relevant to learning about the virus and send them to a national monitoring and coordinating centre. Scientists should start immediate work to see whether there is the potential to develop a useful vaccine rapidly.

ebolaThe new virus currently posing the greatest threat is Ebola, which was first identified in 1976 and was very rare until this year. From 1976 to 2013 fewer than 1,000 people per year have been infected. The World Health Organization (WHO) has now declared an International Public Health Emergency and ruled that it is ethical to make untested vaccines available to patients. Checking whether an antiviral or antibiotic is active against the intended pathogens can be tested relatively quickly in early-stage laboratory research before work is done to confirm that the product can be safely used in humans and reaches the required parts of the body.

Whilst few good ideas for new antibiotics exist, antiviral R&D is thriving. Since the emergence of AIDS in the 1980’s drugs have been found that in combination make life expectancy in HIV positive patients fairly normal. Strong progress has been made in the treatment of Hepatitis B and Hepatitis C. Gilead’s Sovaldi, also known as sofosbuvir,  for Hepatitis C was provisionally recommended for use in the UK by NICE last week at a cost of approximately £30,000 for a 12-week course. The drug is set to become the best-selling medicine ever.

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