Trade deals and aid cuts could undermine defence against antibiotic resistant pathogens, says PAC report
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Progress in tackling the global threat of antimicrobial resistance
(AMR) could be affected by trade deals and aid cuts. As well as
concerns around international diplomacy and aid, the Public
Accounts Committee's (PAC) inquiry into AMR found that, while the
UK has some resilience against the risk, there are questions around
its ability to scale up efforts to respond to an emergency such as
an AMR infection epidemic – just as in the COVID pandemic. The rise
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Progress in tackling the global threat of antimicrobial resistance (AMR) could be affected by trade deals and aid cuts. As well as concerns around international diplomacy and aid, the Public Accounts Committee's (PAC) inquiry into AMR found that, while the UK has some resilience against the risk, there are questions around its ability to scale up efforts to respond to an emergency such as an AMR infection epidemic – just as in the COVID pandemic. The rise of antibiotic-resistant pathogens already contributes to an estimated 35,200 deaths each year in the UK. If AMR were to grow out of control, antibiotics would stop working, making basic infections become increasingly difficult to treat. Despite the scale of this risk, Lord O'Neill of Gatley, who led the independent review on AMR, told the PAC's inquiry that he is concerned AMR has slipped down the international agenda. The PAC is calling on government to continue working to ensure it addresses AMR worldwide as well as within its own borders. Aid and trade policies are highlighted as potentially affecting global progress to shield populations from AMR's spread. The report notes recent cuts in aid spending in both the UK and the US. The UK Government told the inquiry that the recent cuts to UK Official Development Assistance spending is likely to put international development efforts on AMR under pressure. Cuts in other countries' aid budgets might have the same effect. AMR should also be prominently considered as part of trade negotiations with other countries, especially those with different practices and regulations on AMR or food safety. The inquiry heard that AMR should be a consideration when making trade deals with countries such as the US, particularly in relation to differing food standards. It is particularly important that trade agreements do not weaken the UK's resilience to AMR, and the PAC is calling for details on safeguards included in any trade deals relating to it. The mismanagement of wastewater and sewage by water companies, itself a serious public health concern with sewage entering waterways, also heightens the threat of AMR by increasing the prevalence and diversity of resistant pathogens in the environment. However, information on AMR in the environment is limited, and the PAC's report calls for government to set out public health goals relating to water, while monitoring the impact of increased investment by water companies. The report further finds strong indications that AMR is a health inequalities issue, with the most deprived fifth of the population being nearly 50% more likely to get a drug-resistant bloodstream infection than the least deprived fifth. Babies, the elderly, patients with compromised immune systems and certain ethnic groups are also more likely to be affected. Routine inequalities data in this area is currently limited, and government needs to address current shortcomings in data collection and sharing hindering efforts to tackle AMR. Sir Geoffrey Clifton-Brown MP, Chair of the Committee, said: “There is arguably no more haunting silhouette on the horizon for the entire world than AMR. If left unchecked, the loss of functional antibiotics has the potential to turn the clock back on modern medicine's capabilities to an unimaginable degree, to a time when infection was the most common cause of death, and life expectancy an average two decades lower. “The UK has much to be proud of in the global leadership already shown in building an international response to AMR. We implore the government to keep any potential domino effects created by its policymaking on aid and trade in particular uppermost in its thoughts, lest the nation's resilience to AMR be unwittingly harmed. The failed regulation of the water sector also creates public health risks in this space, and this is a topic our Committee will be reporting on in due course. “It was particularly unwelcome to hear in the course of our inquiry that, as with the COVID pandemic, the UK would be well-placed scientifically to understand an acute AMR emergency, but would face challenges in mustering efforts to respond to it. Our report calls for the NHS to put slowing the spread of AMR right at the core of its work, and for the government to place itself right at the cutting edge of scientific developments to shield the public from its harms. “Our report makes clear that all medical professionals – doctors, vets and pharmacists, need to be using the very best diagnostic tools to ensure antibiotics are only prescribed where necessary, and that the correct antibiotic is prescribed when required. In the longer run, we should be using all the tools available to overcome AMR such as vaccinations instead of prescribing antibiotics, gene sequencing and bacteriophages. “The government deserves credit for its innovative antibiotics subscription model, whereby it purchases a significant quantity of an antibiotic from a pharmaceutical company, and then controls the use of it. It should use this model to encourage companies to invest more into the research of new antibiotics. When it comes to AMR, the UK cannot afford to be behind the curve.” Notes to editors Antimicrobials are a category of therapeutic substances such as antibiotics which are used to treat infections and prevent them from spreading. Antimicrobial resistance (AMR) occurs when the pathogens which cause infections develop resistance to those treatments. While AMR is a natural process, it has accelerated partly due to misuse and overuse of antimicrobials in humans. PAC report conclusions and recommendations AMR is a global threat and the UK must continue working to ensure it addresses AMR worldwide as well as within its own borders. The UK cannot just protect itself domestically. Resistant pathogens can come to the UK via humans, animals and animal products from abroad, potentially undermining national attempts to mitigate the threat of AMR. The UK has done much to raise the profile of AMR on the global stage, using diplomacy to promote the global response and supporting low- and middle-income countries to address AMR. However, factors such as trade with countries with different AMR or food safety regulations and practices and reductions in the UK's and other countries' aid budgets might affect global progress on AMR. Recommendation 1. The government must retain focus on AMR as a global threat, including through international action and support. It is particularly important that trade agreements do not weaken our resilience to AMR. DHSC and Defra should provide advice on this matter before any trade agreement is finalised, including detail on any safeguards relating to AMR and with reference to the National Risk Register. Government has missed most of the targets in the 2019-24 National Action Plan (NAP) and the ambition of the new targets is much more modest. While the government previously set targets for reductions of 50% in Gram-negative* bloodstream infections and 10% in drug-resistant infections, the 2024-29 NAP targets are only to prevent an increase in the number of infections from a 2019-20 baseline. The government considers that its new targets are challenging due to demographic changes, such as an increasing and ageing population. However, they will not be enough to achieve a meaningful mitigation of the AMR threat in the UK. We were also told that there is an increasing threat from more resistant strains of pathogens which cause Gram-negative infections and are more likely to result in the death of the patient. There are currently no targets to further reduce antimicrobial usage in animals, and the Veterinary Medicines Directorate (VMD) is concerned that reductions have plateaued. Recommendation 2. DHSC and Defra should review progress against the AMR targets by late 2025 and at regular intervals after this to decide whether to increase the range and ambition of the targets to control AMR. Government has not been sufficiently transparent about what it is achieving against its AMR targets and commitments. Only one of the five domestic targets in the 2019-24 NAP was achieved, relating to reducing the use of antibiotics in food-producing animals. The other four, relating to reducing numbers of infections, reducing antimicrobial use in humans and using diagnostic tests were missed. The NAP also included 128 commitments, which were only tracked internally, with only seven of the 128 recorded as implemented. However, the government has not brought together and published information on this progress against its targets and commitments. In the AMR NAP 2024-29, the government acknowledged that progress had been slow in some areas, partly due to insufficient resources and focus. Government has also not published its chronic risk analysis of the AMR threat. Recommendation 3. DHSC and Defra should publish a regular update on their progress against the AMR targets and commitments. They should also coordinate with the Cabinet Office to include an assessment of the level of chronic risk that AMR presents. DHSC has made slow progress in implementing diagnostic tools that could help reduce AMR. Inappropriate prescribing of antibiotics in primary care is estimated to be around 20% of antibiotic prescriptions, which is too high and could drive AMR. 'Inappropriate' includes prescribing antibiotics or other antimicrobials when they are unnecessary (for example, using antibiotics to treat a viral infection), prescribing the wrong one (for example, not the most suitable antibiotic), or using them for longer than necessary. Diagnostic tools can be used to diagnose what infection a patient has, reducing inappropriate prescribing by enabling clinicians to determine with accuracy whether a patient needs antimicrobial treatment and, if so, which one. However, the 2019-24 NAP target to report on the percentage of antibiotic prescriptions supported by the use of diagnostic tools was not achieved and has not been included in the 2024-29 NAP, and there has been only limited progress in making better use of diagnostic tests. Recommendation 4. DHSC, NHS England and UKHSA should set out how they intend to make demonstrable progress in the use of diagnostic tools, including under the Pharmacy First Scheme, over the next two years. Addressing the threat of AMR should be a core part of all of the NHS's work, including the fundamentals that reduce the spread of infection. Infection prevention and control measures, such as good hygiene practices, aseptic techniques and high standards of cleanliness, are vital for reducing AMR infections in the NHS. By concentrating on these, MRSA infections were reduced but are now increasing again. Other factors include the poor condition of the NHS estate, which makes cleaning and infection control more difficult, shortfalls in the medical microbiologist workforce, and a lack of sustained impact from professional engagement campaigns. Recommendation 5.
It is vital that government keeps up to date with scientific developments that might help tackle the threat of AMR. Research can help identify better ways of mitigating AMR and treating those with AMR infections, including through the use of artificial intelligence, genomic sequencing, and vaccinations. DHSC and UKHSA fund research into these areas, for example through the National Institute for Health and Care Research - which reported that it spent £88 million as part of the 2019-24 NAP. Other organisations in the UK and abroad carry out much research and development, including developing new antibiotics or innovative treatments such as phage therapy, and the results could be very promising in the fight against AMR. Research has been included in the 2024-29 NAP through the top 10 research questions, however there needs to be sufficient resourcing, prioritisation and focus on implementation. Recommendation 6. NHS England, Defra and UKHSA must keep up to date with new scientific developments, continue to fund vital research and prioritise the consideration of how they can be applied in the fight against AMR. The government deserves credit for introducing an antibiotic subscription model, and it now needs to evaluate its impact on the usage of antibiotics and pharmaceutical companies' efforts to bring new antibiotics to the market. The UK was one of the first countries to develop a subscription model, under which pharmaceutical companies are paid a flat-rate subscription for recently-licensed antibiotics. The first round of contracts is expected to cost £1.9 billion over 16 years. This is intended to encourage investment in developing new antibiotics while also facilitating reductions in their use. However, the UK is only 3% of the global market for antibiotics and pharmaceutical companies will remain free to decide whether to invest more in research and development of new antibiotics. However, as part of Government funding of the subscription model, we would expect these companies to do so. Recommendation 7. The Government should encourage other countries to introduce an antibiotic subscription model, including by disseminating the results of its monitoring and evaluation of the UK model. The evaluation should include an assessment of the impact on pharmaceutical companies' focus on developing new antibiotics. Mismanagement of wastewater and sewage is a serious public health concern and heightens the threat of AMR. Storm overflows involve sewage getting into waterways such as rivers. They increase the prevalence and diversity of resistant pathogens in the environment and are a serious public health concern. In 2016, 862 storm overflow sites were monitored for spills, and they averaged 15 spill events in the year each. By 2023, the number of storm overflow sites monitored had increased to around 14,000, and they averaged 33 spill events each in the year. However, information on AMR in the environment and how it is affected by the UK's management of wastewater is limited. An independent evaluation of the 2019-24 NAP by the Policy Innovation and Research Unit criticised the relative lack of action taken to address the issue of wastewater in relation to AMR. DHSC stressed to us the importance of clean water and good sanitation as a public health issue, and the relevance of measuring the performance of water companies in public health rather than just environmental terms. VMD noted the importance to AMR of planned investment in wastewater treatment and told us that by the summer of 2025 Defra should have received recommendations from the Independent Water Commission on how to tackle systemic issues in the water sector. The Committee may be revisiting this in future as part of their inquiry into 'Water Sector Regulation'. Recommendation 8. To manage the public health risks from wastewater, Defra should:
There are shortcomings in data collection and sharing, hindering efforts to tackle AMR. The UK government operates a 'One Health' approach to AMR, encompassing human health, animal health, food safety and the environment, and intended to facilitate collaboration between these sectors. However, there are significant gaps in the collection of data on animal health relating to AMR, where routine data collection is focused on only pigs and poultry. Data sharing is also limited within the health and care sector, including between primary care and hospitals, or between hospitals and social care. This can make it harder for clinicians to make decisions on infection management and prescribing antimicrobials. DHSC also needs better data on AMR as a health inequalities issue, on which the 2024-29 NAP has a greater focus than before, to understand how groups are disproportionately affected, for example babies, the elderly, people with lower socio-economic status, and specific ethnic groups. Recommendation 9. DHSC and Defra should prioritise better data collection, sharing and analysis across human, animal and environmental health spheres. *Notes to editors Gram-negative refers to a group of bacteria which are named after the laboratory test used to identify them. They are the leading cause of healthcare-associated bloodstream infections and include a range of bacteria including E. coli. |