Baroness Gardner of Parkes

Public Health England (PHE) has prioritised collecting the necessary data across the National Health Service to enable estimation and monitoring of the proportion of cases, deaths and costs attributable to carbapenemase-resistant Enterobacteriaceae.

In May 2015 PHE implemented an enhanced surveillance system of all carbapenemase-producing Gram negative bacteria, which was modified in 2019 to maximise efficiency. The health burden of cases, estimated from these data, will be published in the English Surveillance Programme for Antimicrobial Utilisation Report in November 2019.

The few published reports of outbreaks have estimated costs of at least £1 million, and up to £5 million, all indicating multi-model control measures are required, as outlined in the PHE toolkit for prevention and control of carbapenemase-producing Enterobacteriaceae which is currently being updated.

Using national surveillance and patient administration data to develop mathematical models, work is ongoing to estimate the reduction in levels of illness and death when specified detection and control measures are applied by 2020. Developed models will enable associated costs incurred to be estimated and the cost-effectiveness of control measures to be established by 2021.

Public Health England (PHE) has predicted future spread and the health and cost impact to the National Health Service of the Enterobacteriaceae Escherichia coli and a national outbreak of a highly-resistant organism, reflecting carbapenem-resistant Enterobacteriaceae. The models used in this assessment are published in the paper A Risk Assessment of Antibiotic Pan-Drug-Resistance in the UK: Bayesian Analysis of an Expert Elicitation Study. A copy of the paper is attached.

Such predictions are highly uncertain. There remain unknowns regarding transmission, efficacy of interventions and the additional hospital stay for infected patients (constituting a large part of the cost to the NHS).

PHE has worked with NHS colleagues, estimating the cost of controlling a carbapenemase-producing Enterobacteriaceae (CPE) outbreak in five London hospitals to be over £1 million. Monitoring costs alongside implementation of PHE’s upcoming update of the CPE toolkit for health and social care is an important component of enabling cost-effectiveness evaluation.

Staff interviewed about the challenges of implementing the existing CPE toolkit highlighted maintaining awareness and training as key challenges, alongside infection prevention resourcing. An analysis of the responses was published in the paper An evaluation of a toolkit for the early detection, management, and control of carbapenemase-producing Enterobacteriaceae: a survey of acute hospital trusts in England. A copy is attached.

The 2018 English surveillance programme for antimicrobial utilisation and resistance report contains information on carbapenem-resistant Escherichia coli (E. coli) causing bloodstream infections in England. In 2017 there were 18 cases. The number of people with other infections and carriage of E. coli resistant to carbapenems is harder to ascertain as surveillance is not as uniform.

Public Health England (PHE) publishes guidance on the prevention and control of carbapenemase-producing Enterobacteriaceae (including E. coli); guidance is available for both acute and non-acute settings, copies of the Toolkit for managing carbapenemase-producing Enterobacteriaceae in non-acute and community settings and Acute trust toolkit for the early detection, management and control of carbapenemase-producing Enterobacteriaceae are attached. PHE is supporting actions outlined in the United Kingdom’s Tackling Antimicrobial Resistance National Action Plan that aim to prevent and control the transmission of carbapenem-resistant bacteria, which includes reducing the number of specific drug-resistant infections in people by 10% by 2025; reducing UK antimicrobial use in humans by 15% by 2024; and adding carbapenem-resistant Gram-negative infections to the list of notifiable diseases in existing laboratory reporting systems.

While we can count many successes from our 2013-18 Antimicrobial Resistance (AMR) Strategy, resistance has continued to increase. In the United Kingdom we have seen a 35% increase in resistant blood stream infections in humans from 2013-17.

The number of bloodstream infections (BSIs) is increasing each year. Although the proportion of antibiotic resistant BSIs remain stable year to year, the burden on resistance increases. This is mostly due to increasing prevalence of E.coli bloodstream infections.

Estimates of the multi-resistant cases can be made, however not all the bacteria are tested against the same antibiotics, so a definitive number of cases cannot be given. The Public Health England Fingertips tool also has an indicator showing the rolling quarterly average proportion of E. coli blood specimens non-susceptible to at least three of the key antimicrobials (gentamicin, ciprofloxacin, piperacillin/tazobactam, 3rd-generation cephalosporins or carbapenems). For England this is 5.5% with little fluctuation over time.

This is exactly why the UK’s five-year national action plan for AMR, published alongside the UK 20-year vision for AMR on 24 January 2019, includes a strengthened focus on infection prevention and control, renewing our commitment to halve levels of healthcare associated Gram-negative blood stream infections (mostly E.coli) by 2023-24. The plan also sets a world-first target to reduce the actual numbers of resistant infections, with the aim to reduce them by 10% by 2025.

We are working with the devolved health administrations to develop consistent methodologies for reporting the incidence and mortality of key antibiotic resistant infections and antimicrobial use to allow us to report progress on the ambitions of the AMR national action plan.

As reductions in inappropriate prescribing also reduces the risk of promoting the growth of antibiotic-resistant bacteria, interventions to reduce antibiotic prescribing or transmission of the bacteria are complementary.

The Government provides online guidance on the steps employers and others must take to comply with the National Minimum Wage, which states that the hours of work that count for minimum wage purposes include any time when a worker is travelling from one work assignment to another.

The Government is clear that local authorities should have regard to the cost of care when setting prices. This is set out in the statutory guidance to the Care Act 2014.

In 2016 the Department worked with local government, the care sector and the Chartered Institute of Public Finance and Accountancy to produce a guide to understanding providers’ costs and fair fees – this was published in January 2017. A copy of Working with care providers to understand costs: A guide for adult social care commissioners is attached.

Information on numbers of patients with foetal alcohol spectrum disorders (FASD) receiving treatment on the National Health Service is not collected centrally.

The United Kingdom Chief Medical Officers’ low risk drinking guidelines advise women who are pregnant or think they could become pregnant that the safest approach is not to drink alcohol at all, to reduce risks to the baby to a minimum.

As part of the Maternity Transformation Programme, Public Health England (PHE) is leading work to provide prevention-focused leadership to support a reduction in the proportion of women drinking alcohol during pregnancy. Midwives and health visitors also have a role in providing clear, consistent advice and early identification and support. Additionally PHE’s Start4Life programme also provides online information on the impact of drinking alcohol during pregnancy, including the risk of FASD.

The Department for Education through the Adoption Support Fund has made funding available to local authorities to support adopted children with a range of specialist assessments and therapy to treat a variety of conditions. This includes FASD.

Information on numbers of patients with foetal alcohol spectrum disorders (FASD) receiving treatment on the National Health Service is not collected centrally.

The United Kingdom Chief Medical Officers’ low risk drinking guidelines advise women who are pregnant or think they could become pregnant that the safest approach is not to drink alcohol at all, to reduce risks to the baby to a minimum.

As part of the Maternity Transformation Programme, Public Health England (PHE) is leading work to provide prevention-focused leadership to support a reduction in the proportion of women drinking alcohol during pregnancy. Midwives and health visitors also have a role in providing clear, consistent advice and early identification and support. Additionally PHE’s Start4Life programme also provides online information on the impact of drinking alcohol during pregnancy, including the risk of FASD.

The Department for Education through the Adoption Support Fund has made funding available to local authorities to support adopted children with a range of specialist assessments and therapy to treat a variety of conditions. This includes FASD.

Information on numbers of patients with foetal alcohol spectrum disorders (FASD) receiving treatment on the National Health Service is not collected centrally.

The United Kingdom Chief Medical Officers’ low risk drinking guidelines advise women who are pregnant or think they could become pregnant that the safest approach is not to drink alcohol at all, to reduce risks to the baby to a minimum.

As part of the Maternity Transformation Programme, Public Health England (PHE) is leading work to provide prevention-focused leadership to support a reduction in the proportion of women drinking alcohol during pregnancy. Midwives and health visitors also have a role in providing clear, consistent advice and early identification and support. Additionally PHE’s Start4Life programme also provides online information on the impact of drinking alcohol during pregnancy, including the risk of FASD.

The Department for Education through the Adoption Support Fund has made funding available to local authorities to support adopted children with a range of specialist assessments and therapy to treat a variety of conditions. This includes FASD.

As independent contractors, it is for individual general practitioner (GP) practices to ensure their registered patients continue to have access to primary medical services where a GP is absent on jury service.

The Department has no plans to request an exemption from jury service for GPs.

At its public meeting on 30 November 2017 and following its review of and public consultation on Congenital Heart Disease (CHD) services in England, the NHS England Board agreed to note the outline proposal presented by the Royal Brompton and Harefield NHS Foundation Trust for how full compliance against the standards might be achieved; to confirm that NHS England should work with the Royal Brompton and other potential partners on the full range of options for delivering a solution that could deliver full compliance with the standards and ensure the sustainability of other connected services; and to continue to commission level 1 CHD services from the Trust, conditional on the Trust demonstrating sufficient progress within required timescales.

The commissioning of CHD services in England is a matter for NHS England. The Government will continue to hold NHS England to account as it takes forward the recommendations of its review.

The Royal Brompton Hospital conducted a total of 522 operations for congenital heart disease (CHD) conditions in 2015/16, comprising 390 operations for children and 132 operations for adults. In 2014/15, the Royal Brompton’s surgical activity comprised 512 operations for CHD conditions, which included 370 operations for children and 142 operations for adults. Surgical activity in 2013/14 at the Royal Brompton comprised 412 CHD operations for children and 125 CHD operations for adults, which gives a total of 537 CHD operations for that year.

The hospitals in England and Wales which conducted as many, or more, congenital heart disease operations for children and adults between 2013 and 2016 are Great Ormond Street Hospital, Birmingham Children’s Hospital, Evelina London Children’s Hospital, Leeds Children’s Hospital, Alder Hey Children’s Hospital, University College Hospital London, Queen Elizabeth Hospital Birmingham and St Bartholomew’s Hospital in London.

NHS England will make a decision on its proposals for changes to adult and children’s congenital heart services in England following a consultation which is now underway and which closes on 5 June 2017. It has worked, and will continue to work, with providers and other stakeholders to assess the impact of these proposals and will publish further information in due course.

The Government remains committed to introducing a cap on care costs and extension of means tested support, which will be implemented from April 2020.

The Spending Review 2015 set budgets for the next four years to 2019-20. The final year includes funding to cover the costs of local authorities preparing to implement the changes the following year. Decisions about the allocation of funding for these reforms will be confirmed nearer the time.

The Department will continue to develop the policy underpinning the cap on care costs in the run-up to a consultation on draft regulations and guidance in the summer of 2018. The Department will work closely with the sector to ensure that their views are taken into account as we plan for implementation.

In addition to the cap on care costs, the Dilnot commission recommended the introduction of national eligibility criteria and universal Deferred Payment Agreements, both of which have been implemented from April 2015.

The Government remains committed to introducing a cap on care costs and extension of means tested support, which will be implemented from April 2020.

The Spending Review 2015 set budgets for the next four years to 2019-20. The final year includes funding to cover the costs of local authorities preparing to implement the changes the following year. Decisions about the allocation of funding for these reforms will be confirmed nearer the time.

The Department will continue to develop the policy underpinning the cap on care costs in the run-up to a consultation on draft regulations and guidance in the summer of 2018. The Department will work closely with the sector to ensure that their views are taken into account as we plan for implementation.

In addition to the cap on care costs, the Dilnot commission recommended the introduction of national eligibility criteria and universal Deferred Payment Agreements, both of which have been implemented from April 2015.

The Government remains committed to introducing a cap on care costs and extension of means tested support, which will be implemented from April 2020.

The Spending Review 2015 set budgets for the next four years to 2019-20. The final year includes funding to cover the costs of local authorities preparing to implement the changes the following year. Decisions about the allocation of funding for these reforms will be confirmed nearer the time.

The Department will continue to develop the policy underpinning the cap on care costs in the run-up to a consultation on draft regulations and guidance in the summer of 2018. The Department will work closely with the sector to ensure that their views are taken into account as we plan for implementation.

In addition to the cap on care costs, the Dilnot commission recommended the introduction of national eligibility criteria and universal Deferred Payment Agreements, both of which have been implemented from April 2015.

The most recent comparable statistics are from the Public Health England Dental Public Health Intelligence Programme. The 2015 survey of five-year-old children showed an average of 0.8 decayed, missing or filled teeth among children in Birmingham and 1.3 teeth among those in Manchester. A copy of the National Dental Epidemiology Programme for England: oral health survey of five-year-old children 2015 A report on the prevalence and severity of dental decay is attached. There are no more recent figures for twelve-year-old children than those given by Earl Howe in his response of 22 April 2013 (WA 372), the 2009 survey showing an average of 0.65 decayed missing or filled teeth in Birmingham and 1.12 in Manchester.

Health profiles maintained by Public Health England (PHE) show that there are no significant differences in the general health of the populations of Manchester and Birmingham that might be attributable to water fluoridation. PHE’s Water fluoridation: Health monitoring report for England 2014 compared a range of dental and non-dental health indicators in fluoridated and non-fluoridated areas in England. The report concluded that water fluoridation is a safe and effective public health measure as there were reduced levels of tooth decay in fluoridated areas and no evidence of potential harm for the health indicators measured. A copy of this report is attached.

It has been the policy of successive governments that decisions on water fluoridation are best taken locally. The Health and Social Care Act 2012 gave powers to upper tier and unitary local authorities to make proposals in relation to fluoridation.

In 2014 Public Health England published a water fluoridation health monitoring report which showed lower levels of tooth decay in areas with water fluoridation.

Public Health England has also, in 2014, published an evidence informed toolkit for local authorities to support them in planning, reviewing and commissioning oral health improvement interventions for children and young people, including the potential role of water fluoridation.

Many extractions are already carried out on a day case basis; whether the extraction is carried out as a day case or requires an overnight admission is a matter for the clinicians involved.

NHS England has advised that NHS Lancashire and Greater Manchester have for a number of years commissioned day case surgery as well as overnight admission for children who require a full clearance of deciduous teeth under general anaesthetic.

Information on the number of patients on long-term Warfarin prescriptions who have access to self-monitoring technology is not collected centrally.

NHS England and clinical commissioning groups (CCGs) have responsibility for commissioned services for patients who receive anticoagulation treatments. It is for individual CCGs to commission treatment and services for patients on anticoagulation treatment or other medications which require monitoring, as they are best placed to identify what is needed in their local areas.

There is guidance in place to support CCGs in planning services for patients who receive anticoagulation treatments. Under its Diagnostics Assessment Programme, the National Institute for Health and Care Excellence (NICE) has published guidance on self-monitoring of anticoagulation treatments which is attached and also available at:

http://www.nice.org.uk/guidance/dg14

NICE has also published quality standards on the management and treatment of atrial fibrillation which set out that self-monitoring should be offered as an option to appropriate patients. The guidance is also attached and available at:

http://www.nice.org.uk/guidance/qs93/chapter/Quality-statement-6-developmental-Selfmonitoring-of-anticoagulation

The Government is seeking to address waiting times by reducing the number of children requiring admissions for clearance of their deciduous teeth and action is being taken by local commissioners and public health departments.

For instance, Greater Manchester advises that it is working with consultants in dental public health, public health commissioning, and oral health improvement teams in local authorities to develop oral health strategies. They intend to target delivery of care to areas of identified need according to the “National Dental Epidemiology Programme for England, oral health survey of five-year-old children 2012.” A copy of the survey is attached.

We understand there are no plans to reduce the specialised dental postgraduate training and research currently offered as a consequence of the proposed move from the current site.

In order to inform his recommendations, the independent chair of the Accelerated Access Review, Sir Hugh Taylor, will be seeking views from a variety of stakeholder groups, including patients and their carers, medical charities, academics and researchers, as well as industry, the National Health Service and key arm’s length bodies such as the National Institute for Health and Care Excellence and NHS England. We have agreed a systematic engagement approach for these groups to ensure they all have the opportunity to input. A workshop involving representation from all these stakeholder groups was held on 2 July, and the review team is asking umbrella organisations and trade bodies to support it in continuing to reach a wide audience by holding a series of engagement events throughout the summer; these events are currently being planned. The review’s website is also being developed to include a crowdsourcing platform to allow these groups, and the wider public, to participate.

We expect the report of the Accelerated Access review to be submitted by the end of the year.

The following table shows the estimated cost of tooth extractions for children aged 18 years and under for 2012-13. The data covers all tooth extractions, and does not distinguish between deciduous or adult teeth.

Source: Reference costs, Department of Health¹

Tooth extractions in children often involve general anaesthesia. Extractions involving general anaesthesia were restricted to the hospital setting following the recommendations of the 2000 report ‘A conscious decision’ that patients should have access to high quality critical care facilities when general anaesthesia is given. There are currently no plans to change this. Many extractions are carried out on a day case basis; whether the extraction is carried out as a day case or requires an overnight admission is a matter for the clinicians involved.

70% of five year olds now have no dental decay but we recognise that significant inequalities remain. Wider work is under way through dental contract reform and other prevention focussed initiatives to improve oral health.

Note:

¹www.gov.uk/government/publications/nhs-reference-costs-2012-to-2013

Cladribine is not licensed for the treatment of multiple sclerosis.

Prescribers can prescribe a medicine “off label” for unlicensed indications if they consider it to be of benefit to the patient and on condition that they retain full clinical responsibility for that patient.

The National Institute for Health Research Horizon Scanning Centre published a report on cladribine for multiple sclerosis in 2008 and this is available at:

www.hsc.nihr.ac.uk/topics/cladribine-movectro-for-multiple-sclerosis-relapsi

We have made no assessment of research undertaken in other countries.

Cladribine is not licensed for the treatment of multiple sclerosis.

Prescribers can prescribe a medicine “off label” for unlicensed indications if they consider it to be of benefit to the patient and on condition that they retain full clinical responsibility for that patient.

The National Institute for Health Research Horizon Scanning Centre published a report on cladribine for multiple sclerosis in 2008 and this is available at:

www.hsc.nihr.ac.uk/topics/cladribine-movectro-for-multiple-sclerosis-relapsi

We have made no assessment of research undertaken in other countries.