Contaminated Blood

Lord Goldsmith of Richmond Park Excerpts

Thursday 15th January 2015 Commons Chamber

[Alistair Burt]

I am grateful to the hon. Gentleman for his kind remarks and I appreciate them very much. Yes, one thing we were told in our meetings in April was that people are sick of coming to Parliament. They have been coming for many years and many of them will feel that even today, but this is the best we can do as Members of Parliament. We know that those on both Front Benches are listening.

[Zac Goldsmith (Richmond Park) (Con)]

I must admit that this issue was not on the radar for me until recently, when I had a discussion with a constituent who was one of three siblings all of whom were contaminated as a consequence of this blunder. I want to put on record my gratitude for the work that my right hon. Friend has done and my support for this campaign. I wish him all the best and all my support as it progresses.

[Alistair Burt]

I am deeply grateful to my hon. Friend, but the gratitude should actually be given to the sufferers and their beneficiaries who have made an attempt to approach MPs, sometimes for the first time. This year, we were able to bring it home to people that despite all the privacy and other reservations they might have had—some have not been able to tell family or close friends what they have been suffering—there is a need to approach MPs such as my hon. Friend to make them aware of the issue. That has been a new element of the campaign and is another reason for this debate.

Antibiotic Resistance

Lord Goldsmith of Richmond Park Excerpts

Wednesday 15th October 2014 Westminster Hall

[Zac Goldsmith (Richmond Park) (Con)]

I am thrilled that despite my breaking two rules in a short time when I walked into the Chamber you are still allowing me to speak in the debate, Mr Chope. It is a pleasure to follow all the speeches, which have covered virtually all the angles. I am grateful to my hon. Friend the Member for York Outer (Julian Sturdy) for securing the debate, and for the speech he made.

There is a depressing but nevertheless welcome consensus that we are losing our antibiotics to resistance, and effectively losing modern medicine as we know it. Notwithstanding the threat of Ebola it is hard to imagine a bigger health threat. The World Health Organisation has described antibiotic resistance as a bigger crisis than the AIDS crisis of the 1980s. If we lose antibiotics we risk the return of a time when basic operations will be deadly. I used to wonder what it would take to wake up the British establishment to that appalling threat. For years virtually nothing seemed to be done to combat the extraordinary phenomenon of antibiotic resistance. I thought, naively, perhaps, that once the health establishment blew the whistle, everyone else would fall into line and, fortunately, the health establishment has been blowing the whistle very loudly. We have heard various quotations today of the apocalyptic language of the chief medical officer, Dame Sally Davies. I think she has even used the term “apocalypse”. She has said that if we do not take action, deaths will go up and up, and modern medicine will be lost.

That is of course already beginning to happen. It is not a futuristic scenario. In 2006 there were just five cases in which patients failed to respond even to last-resort antibiotics in this country. Last year the number was 600. I know that there has been some action and I do not mean to disparage that. In March last year the Cabinet Office confirmed that it would examine the question of resistance as a national security issue. In September of that year it released an outline UK five-year antimicrobial resistance strategy. The Government have since set up a high-level steering group, chaired by Dr Felicity Harvey, the director general, public health, to implement the strategy once it is released, which I think will be later this year. All that is good news, and it is possible that the strategy will match the urgency of the situation. However, I am afraid that there are worrying signs that it will not.

Yes, there will be renewed efforts to develop new drugs, which is crucial. I was thrilled to hear the Prime Minister’s response to a question on the subject, during Prime Minister’s questions, when he briefly outlined the Government’s commitment to supporting the development of new drugs. That is obviously a prerequisite to solving the problem. There is nothing in the pipeline at all, and, as existing drugs become ineffective, we clearly must hope for new developments and do all that we can to facilitate them. There will also be renewed efforts to limit the inappropriate use of antibiotics in human medicine. That subject has been covered and I shall not dwell on it today. However, so far, successive Governments, including the present one, have resolutely avoided confronting a part of the problem that is not only huge but avoidable.

It is worth repeating that from day one, when Alexander Fleming accepted his part of the Nobel prize, he issued a dire warning. We have heard the quotation and I will not repeat it. The simple reality is that we have completely ignored that warning, more or less from the day he issued it. Instead of treasuring that miracle cure, we have squandered it—not just in hospitals but on intensive farms, and not just to treat sick animals but to keep animals alive in conditions where they otherwise would struggle simply to survive. That is not just a niche concern; 50% or thereabouts of the antibiotics that we use in this country are used on farms and it is even more in the United States and some other countries. Overall use per animal on UK farms is 18% higher today than it was a decade ago. That is disproportionately true of those antibiotics that are critical to human health.

[Graham Stringer (Blackley and Broughton) (Lab)]

The hon. Gentleman is making an important point: since tetracycline and penicillin-based antibiotics have been banned as growth promoters for farm animals, the use of tetracyclines has up gone tenfold and the use of penicillins has gone up fivefold. This is not a party political point: there is something that the Government can do immediately about that situation, which is to monitor and study it with a view to reducing the excessive use of antibiotics on farms.

[Zac Goldsmith]

I absolutely agree with the hon. Gentleman, and will come on to that briefly—I am going to try to keep my remarks short. That is exactly the point. Many people felt that the ban on the use of growth promoters back in—actually, I forget the year, but I think it was 15 years ago, although I may have got that wrong and am happy to be corrected—

[The Parliamentary Under-Secretary of State for Health (Jane Ellison)]

It was in 2006.

[Zac Goldsmith]

It was eight years ago, then. Many people felt that ban heralded the beginning of the phase out of the routine prophylactic use of antibiotics on farms, but, as the hon. Gentleman just pointed out, use has continued to increase across the board and disproportionately with regard to those antibiotics that are critically important. Given that the antibiotics used in veterinary and human medicine are closely related it is impossible to believe that that increase has not contributed to antibiotic resistance and the transfer of resistant bacteria from animals to humans.

The problem is that the industry has dug its heels in and contested the link. We have been told that there is no proof, but we know that resistant bacteria can be passed to humans on food, through the environment, directly via raw meat and so on. Some strains of resistant bacteria can mix with human strains and pass on resistant genes. For example, E. coli in animals is different from E. coli in humans, but we know that resistance can be and is transferred between animals and humans.

The industry also says that levels of resistance on intensive farms are no different from those on extensive farms, but two reports from the Department for Environment, Food and Rural Affairs have shown that resistance is 10 times lower on organic farms. The industry says there is no problem because antibiotics have to be prescribed by vets and everything is handled responsibly, but more often than not it is the feed mills that place orders for antibiotics rather than the farmers themselves. Finally, we are told that the use of antibiotics is necessary for the provision of cheap food. Perhaps that is the case, but that food will feel a hell of lot less cheap if the cost that society has to pay is the loss of modern medicine.

A briefing has been sent out to a number of MPs by the industry body RUMA—the Responsible Use of Medicines in Agriculture Alliance—saying:

“Fluoroquinolones are rarely used in poultry in the UK.”

RUMA has stated that as fact in response to the points that I and others have raised today. But on 8 September, a few days before that briefing was released, I met representatives of the Veterinary Medicines Directorate, who told me that the British Poultry Council has so far refused to provide any kind of data on antibiotic use at all. How the industry body RUMA can make such a bold and plain statement is beyond me—I suspect it is simply nonsense.

The experts take a different view from that of the industry. Sir Liam Donaldson, chief medical officer before Dame Sally Davies, went so far as to say that

“every inappropriate or unnecessary use on animals or agriculture is potentially signing a death warrant for a future patient.”

The European Food Safety Authority said last year that it is a

“high priority to decrease the total antimicrobial use in animal production in the EU.”

The Minister’s predecessor, my hon. Friend the Member for Broxtowe (Anna Soubry), told me after a debate on the same subject last year:

“Routine prophylactic use of antibiotics in both humans and animals is not acceptable practice”

and that she would be writing to DEFRA

“to ensure that existing veterinary guidance makes that very clear.”

I do not doubt the commitment of the chief medical officer—I am a wild fan of hers, as I know many hon. Members here are. I have not read her book yet, but I will do; I have read much of her writing. I have also met Dr Felicity Harvey and seen the seriousness with which she takes the issue. But so far, at least, DEFRA seems to be dragging its feet. There has been no sense of urgency in any of the meetings I have had, and any response I have had from DEFRA has been far more likely to mirror the industry line than anything the experts have said. The body language of DEFRA as a Department is almost completely defensive.

Thanks to the Netherlands and other countries we no longer have any excuse to stall. The Netherlands has seen a 50% reduction in livestock antibiotic use and expects a 70% reduction by 2015. It has phased out almost completely the use in agriculture of critically important antibiotics. There has been similar action in Denmark, Norway and Sweden. As I understand it, even the US, the land of agribusiness—it is where it was invented—has banned the use of fluoroquinolones in poultry.

The UK has no such targets or aspirations, and it is time that changed. We need to stop hearing excuses about lack of data that the industry has not provided and require those data to be collected. That is a prerequisite, as the hon. Member for Blackley and Broughton (Graham Stringer) said earlier. If the five-year strategy is to be taken seriously when it is eventually produced, it must provide a pathway to ending the routine prophylactic use of antibiotics on farms. That is now a black and white issue. In addition, the strategy must provide a pathway to an eventual ban—ideally, sooner rather than later—on the use on farms of antibiotics that are critically important to humans. Those two measures are the least we can expect from the five-year plan if we are to have any hope at all of combating a threat that the World Health Organisation has compared to the threat of AIDS.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (Jane Ellison)]

I thank all Members who have contributed to what has been an extremely good debate. I thank my hon. Friend the hon. Member for York Outer (Julian Sturdy), who led the debate and gave a thoughtful speech. I will try to respond to as many points as possible.

I will not spend much time on the scale of the threat, as many Members eloquently have outlined that. It was brought home to me clearly when, together with my noble Friend Lord De Mauley, on behalf of the Department for Environment, Food and Rural Affairs, and the chief medical officer, I represented the Government at a World Health Organisation conference in The Hague earlier this year. The conference started with a young woman talking to us. Essentially, she was dying: she had been through pretty much every stage of antibiotics available and all had failed. That brought home powerfully what we are talking about now and what Professor Dame Sally Davies has been writing about for some years. The case has been made by other Members and I will not dwell on it. This is an extremely serious global public health threat.

The Government have a “one-health” approach, working together across human and animal health with DEFRA. My hon. Friend the Member for Richmond Park (Zac Goldsmith) made some detailed points that I will probably ask DEFRA colleagues to respond to in more detail. We will be able to respond to some of them, and some will be encapsulated in the strategy, which will be published alongside an implementation plan. Virtually all the points made in today’s debate will be covered, as well as many additional points, in that publication; I will talk to Dr Felicity Harvey and the CMO to ensure that.

In the time available, I will try to outline what the Government have done to date and give Members reassurance that we are not complacent and that we recognise the scale of the threat. In response to questions raised by some Members, we are not waiting for a grand global strategy to try to take action ourselves; we already have many things in hand, because, as Members have said, time is running out.

In September 2013, we published the UK’s first five-year AMR strategy, taking the one-health approach that I have outlined to address the human, animal, food and environmental aspects of AMR, and set up the high-level steering group, to which some Members have referred, to oversee the delivery of that strategy and, importantly, to deliver metrics to assess progress and develop the implementation plan so that our progress can be judged. In June 2014, the steering group published the measures. Broadly speaking, they look at areas such as trends and resistance; antibiotic usage; the quality of antibiotic stewardship; public attitudes, knowledge and awareness; and changes in public and professional behaviour. All of those were touched on in the debate. I confirm to the shadow Minister that the Government published their response to the Health Committee’s report on 12 September.

The first annual progress report will be published later this year, alongside an associated implementation plan, which will pick up many of the points made in more detail. However, let me highlight some of the actions to date. I am delighted that the chief medical officer, Professor Dame Sally Davies, received so many plaudits from Members in the Chamber. I, too, have read her book, which is short but very alarming, and it brings home in graphic detail the scale of the problem we face—it certainly helped to focus my mind. She has led a global campaign of which the UK is right at the forefront.

The adoption in May 2014 of the World Health Assembly resolution on AMR, which was co-sponsored by the UK, was a major step forward. It provided a mandate for the World Health Organisation to develop a global action plan to tackle AMR by 2015. We are actively contributing to support the delivery of that global action plan.

The international nature of the problem was highlighted by many Members. India was mentioned by my hon. Friend the Member for York Outer and other Members, and I confirm that the recently produced Chennai declaration has begun to tighten up on over-the-counter use, so we are beginning to see significant action. India also supported a World Health Assembly resolution on this matter. However, sitting the table and hearing the different contributions at the conference at The Hague certainly brought home to me the fact that there are differing attitudes across the world. It will be a big task to get some countries to where they need to be and we certainly need to lead by example, which is a point that has been well made.

One of the things that we can do in supporting the work at a global level is building capacity and capability. As with so many problems of our developed world, we cannot afford to wait for everyone to go through the same cycle of development, discovery and identification of problems; we need to try to share our understanding. Public Health England is piloting a laboratory-twinning initiative, where high-income Commonwealth nations are working with low and middle-income countries to build up AMR education, training and surveillance capability, rather than waiting for them to develop their own.

The drugs pipeline is a huge issue, which was explained well and in some detail by my hon. Friend the Member for York Outer. That is an area in which we need rapid and concerted international action to stimulate the development of new antibiotics. The O’Neill review, which was commissioned by the Prime Minister in July, was mentioned. It is an independent review looking at the economic issues that cause this problem, and will make recommendations on what collective action can be taken by Governments globally. I confirm to my right hon. Friend the Member for North West Hampshire (Sir George Young) and others that that review will investigate solutions such as pricing and the introduction of incentives. The review is independent, so that team can think what they want—that is what they are tasked with—and we want them to come back with solutions to a problem that we know requires innovation. The interim report is due next summer, with the final report the year after that.

The faster adoption of new ideas was touched on, in particular those brought forward by small suppliers—Bioquell was mentioned. That is integral to the brief of the new Minister with responsibility for life sciences, my hon. Friend the Member for Mid Norfolk (George Freeman), who was recently given a joint appointment to the Department of Health and the Department for Business, Innovation and Skills to look at how we can accelerate the rate of innovation, because, as we know, we must not lose time on this.

Members were concerned to know whether, in the meantime, pending the O’Neill review, work was under way, and I can confirm that it is. Quite a lot of work is going on with the pharmaceutical industry. The industry is working with Chatham House and the Big Innovation Centre to explore issues about the pipeline and to look at possible options to stimulate antibiotic development. We expect the outputs of those initiatives to be published later this year, and they will feed into the independent O’Neill review. Other work is under way, some of which involves making public assistance available to smaller companies where they need it, but I can confirm that the pharmaceutical and biotech industries are fully engaged, as we need them to be, in exploring the issue and working together on the all-important research agenda.

Much of the focus for that research is diagnostics. We have commissioned work to improve our ability to diagnose infections quickly and increase the take-up and routine use of point-of-care diagnostics. That means being able to diagnose much more quickly—at the point of care—without the delay in having to send things away for study, and so on. The more quickly we can diagnose, the more quickly we can use appropriate medication. The Select Committee certainly pressed us on that when we gave evidence and we are aware that it wants us to take action on that issue. That is very closely linked to the work on improving prescribing, which is a key strand of efforts to reduce the overuse of broad spectrum antibiotics. Easy, cheap and accurate diagnoses will enable us to tailor patient treatment much more speedily and improve clinical outcomes, which is obviously a win-win.

Hon. Members have mentioned the award of the £10 million Longitude prize, which happened on the evening between the first and second days of the Hague conference, so it could not have been more appropriate and it was great news that came through while we were all there. It was fantastic on two counts: first, that money will go towards developing a new diagnostic for AMR, on which we expect further details to be announced shortly; and secondly, it felt like a great leap forward for public recognition and public engagement on the issue. That announcement was integral to a popular science programme on television—it was not just done by the scientific community; there was full public engagement, so I am really delighted about that and we have to build on it.

On research, hon. Members will be interested to know that the Medical Research Council is leading an AMR Funders’ Forum to improve the co-ordination of research relevant to all those different aspects of antibiotic resistance. In addition, there are two new National Institute for Health Research, or NIHR, health protection research units—I apologise for all the acronyms—with a focus on AMR and health care-associated infection. They were established in April at Imperial college London and at Oxford university, and they are in the process of agreeing their initial two-year work programmes, so more research is going on in those establishments.

In addition to important work to galvanise international action and stimulate drug development, we are trying to put in place the infrastructure and tools needed to improve infection prevention and control, and diagnosis and prescribing, in order to prevent the development and spread of AMR. That requires thinking about the problem in an entirely different way, because this problem is unique. The scale has been outlined by other people, but because of some unique aspects, we need to do things in a different way, and we are very aware of that.

Infection prevention is, of course, better than treatment, so we are refocusing attention on what more we can do to improve our ability to prevent infections and reduce reliance on antibiotics. To reduce the risk of importing very resistant infections from countries where the prevalence is higher—some of those countries have been mentioned—measures such as screening on admission to hospitals are now recommended and will be taken up.

Improving infection prevention includes work with NICE—the National Institute for Health and Care Excellence—and others to develop clinical guidance, best practice information and resources. We are also strengthening the code of practice on the prevention and control of infections to clarify for providers the measures they need to take to ensure effective infection prevention and, importantly, antimicrobial stewardship. That is being complemented by NHS England looking at the best ways to use levers on commissioning in the NHS and how it can establish local patient safety fellows to champion and help to embed best practice. On the animal side, DEFRA has provided guidance to assist with farm health planning. Work is under way to explore how we can make better use of vaccines and alternative treatments to reduce reliance on antibiotics and minimise the opportunity for resistant strains to develop.

I turn to the recent survey, the English Surveillance Programme for Antimicrobial Utilisation and Resistance —to which the shadow Minister nobly referred; it is quite a mouthful—or ESPAUR. That report from Public Health England was grim reading. It certainly made it clear that we have a long way to go in this regard, and it provided data that showed the enormous variability in the levels of prescribing across the health care system in England. It showed us some areas with extremely high prescribing rates, which often had the highest resistance rates. Although that report was tough reading, it was commissioned precisely because we did not really have a baseline report. We now have that, and it is a really important set of baseline information, from which we can go forward and help to improve practice.

[Zac Goldsmith]

Data are rigorously collected in relation to the resistance and use of antibiotics in human medicine, but they are hardly collected at all in relation to farm use. My understanding is that the whole system is entirely voluntary, and as a consequence, there are virtually no data at all. Is that an area where, at the very least, the Minister’s Department could pull rank on DEFRA and require the collection of data, so that we can have a meaningful discussion, because at the moment DEFRA does not seem inclined to pursue the matter with any great vigour?

[Jane Ellison]

I have already noted my hon. Friend’s concern about that, and I will bring it to the attention of my colleagues in DEFRA and ask them to give a detailed response. Although I had noted it as an area of concern, as I say, we work very closely together on this issue, which is why the UK, I think uniquely, sent two Ministers—one from agriculture and one from human health—to conference in The Hague.

To go back to GPs, we need to get to the bottom of why we have such variation around the country and why there is so much inappropriate use. That work is going on. There are some initiatives to support the optimisation of prescribing—essentially trying to give doctors more tools to enhance their professional skills. One of those is called TARGET—Treat Antibiotics Responsibly, Guidance, Education, Tools—and is being promoted by the Royal College of General Practitioners. Work is under way to develop this area and include it in health care training curricula. We have also developed new antibiotic prescribing measures for both primary and secondary care to try and help drive down that variability.

I think we can do more as MPs—all of us, in all our routine conversations with health and wellbeing boards, GPs and clinical commissioning groups, and with our local trust chief executives. This should be a standard question on our agenda for those meetings. That would really help, because I know, as a Government Minister, and I think we all know as MPs, that when we are aware that someone is going to ask us a tough question, we go away and start thinking about whether we have a good answer, so there is a lot more that we can all do to drive it at that routine level. There is only so much that the Government nationally can do to influence local GPs.

I want to reassure Members, however, that European antibiotic awareness day is on 18 November, and it would be a great moment for all of us to talk to our local health care professionals. I would be delighted if hon. Members here today, who are so interested in the subject, would work with me in putting together something in writing to all colleagues, with great questions to ask their local health care system. I would be delighted to do that and I can facilitate it. It would include posters for GPs’ surgeries as well as encouraging the public and professionals to become antibiotic guardians and to make pledges to undertake individual action in our effort to preserve antibiotics. Some members of the public are beginning to understand the scale of the challenge, but we are certainly not there yet, and I think Parliament has a role in trying to make that clear.

As a result of the work to date in the first year of the Government’s strategy, we have significantly better data and information, which we can use to inform the development of effective interventions. We have begun to define the scale of the problem much more, and I have outlined the action that we are trying to take in an international context to make sure that the spread of AMR is taken seriously across the world.

As I have mentioned, I will report all the points made in today’s debate both to the chief medical officer and to our cross-party high-level steering group to ensure that we have picked them up in the imminent publication. If there are any points that are not picked up, I will come back to hon. Members on them individually, but I want to reassure the House on the matter. I thank my hon. Friend the Member for York Outer for calling this debate and, indeed, the House for such a well-attended and thoughtful discussion. Everything we can do in this House to highlight the scale of the problem and the urgency of tackling it is very welcome, and I thank all hon. Members for their contribution today.

G8 Summit on Dementia

Lord Goldsmith of Richmond Park Excerpts

Thursday 28th November 2013 Commons Chamber

[Tracey Crouch]

I agree entirely with the hon. Gentleman, and I will hear more later of the initiatives his Committee is examining. The importance of research is very much the basis of my speech.

Hon. Members may talk about many aspects of dementia, but I shall address four, the first of which is investment. The statistics are gloomy, but there is a good-news story underlying the negative numbers: people are living longer and people can live well with dementia. We need to capitalise on best practice and ensure that we maximise people’s ability to maintain long-term well-being, despite their debilitating condition. Although we do not have a cure for dementia, we have come on leaps and bounds in recent years. A cure is hopefully no longer a lifetime away, but to ensure that we make that cure happen, we need to take action.

Dementia costs the UK economy £23 billion a year, which is more than cancer, stroke or heart disease, but the annual research spend on dementia is about £51 million. The research spend on cancer is £521 million —10 times more—yet dementia costs society much more than cancer annually. I therefore welcome the increase in investment in dementia research through the Government’s themed initiatives, which has resulted in Government investment more than doubling over four years. However, the investment comes from a low base and represents less than 1% of the overall science budget.

[Zac Goldsmith (Richmond Park) (Con)]

I congratulate my hon. Friend on securing this important debate. It is widely believed—it has recently been widely reported in scientific journals, including by scientists who will take part in the G8 meeting—that up to half of all Alzheimer’s cases can be attributed to modifiable and therefore preventable risk factors. If that is the case, and there seems to a general consensus along those lines, does she share my disappointment that, as far as I can see, none of the additional £22 million allocated for dementia research has been spent on prevention research?

[Tracey Crouch]

I am sure that the Minister will have heard the good point that my hon. Friend makes. I would like to concentrate on the fact that there has been an increase in investment for research. There are various reasons why we need research, and I am sure the Minister will address my hon. Friend’s comments in his response.

Oral Answers to Questions

Lord Goldsmith of Richmond Park Excerpts

Tuesday 11th June 2013 Commons Chamber

[Norman Lamb]

My hon. Friend has campaigned vigorously to ensure that as many people as possible get access to the drugs they need. The fund has been a great success. More than 30,000 have I think now benefited from it. We want to do all we can to ensure that the good lessons we have learned from it continue.

[Zac Goldsmith (Richmond Park) (Con)]

15. What progress has been made on implementation of the UK five-year antimicrobial resistance strategy.

[The Parliamentary Under-Secretary of State for Health (Anna Soubry)]

We will shortly be seeking cross-Government clearance to publish the UK strategy, which addresses the challenges raised in the chief medical officer’s annual report and sets out the priority areas for action, such as slowing down the spread of resistance, maintaining the efficacy of antimicrobials and supporting the development of new antimicrobials.

[Zac Goldsmith]

In January, the chief medical officer warned that the threat from antibiotic-resistant infections was so serious that it should be added to the Government’s national register of civil emergencies, the national risk register, alongside deadly flu outbreaks or catastrophic terrorist attacks. My hon. Friend is preparing a new cross-Government strategy on antibiotics. Given the growing evidence linking the routine use of antibiotics on intensive farms with antibiotic-resistant infections in humans, can she confirm that the strategy will tackle that reckless practice, regardless of pressure from industry?

[Anna Soubry]

I could give my hon. Friend a long answer, but in short, the matter will be raised at the next G8 meeting. Further to that, as a result of his excellent debate earlier this year, I undertook to write, and have done so, to my hon. Friend the Minister of State, Department for Environment, Food and Rural Affairs. He has replied that the Government recognise that we should look at the guidance issued to farmers. I am more than happy to share the Minister’s letter with my hon. Friend.

--- Later in debate ---

[Anna Soubry]

Absolutely yes on all those very important points. The hon. Gentleman makes an extremely important point to which I absolutely subscribe. I have regular meetings on this matter, and I hope that our sexual health strategy addressed exactly those points, but I am more than happy not only to write, but to meet him to discuss the matter further. If I might say, I think that all Members, whatever the party political divide, could do far more both here and locally to reduce the number of women who find themselves working on the streets as prostitutes. I have long taken the view that these are some of the most vulnerable people in our society, and without exception I have never met a prostitute—I used to represent many of them—who has not herself been abused, usually as a child. They are vulnerable people and we should recognise them for that.

[Zac Goldsmith (Richmond Park) (Con)]

T8. More than 5,000 schools across the UK now serve good-quality, sustainable meals with the Food for Life catering mark, but only three hospitals have achieved the same. It is often said that hospitals cannot do so because of the cost implications, but the three that have done so not only have incurred no extra costs, but, in the case of Nottingham hospital, have actually saved significant amounts. May I urge my hon. Friend actively to encourage take-up of the Food for Life catering mark as a model of best practice?

[The Parliamentary Under-Secretary of State for Health (Dr Daniel Poulter)]

We will certainly look into the issue that my hon. Friend raises, but he will be aware that there are campaigns throughout the NHS focused on supporting local food producers, which is important in many constituencies, particularly rural ones, and developing best practice and encouraging nutrition. Chefs such as James Martin have been involved in helping to drive up standards of care, particularly in Yorkshire and other parts of the country.

Oral Answers to Questions

Lord Goldsmith of Richmond Park Excerpts

Tuesday 15th January 2013 Commons Chamber

[Dr Poulter]

It is a decision for front-line medical professionals to outline when treatment should or should not be given. Treatment must always be given on the basis of clinical need, so I am sure the hon. Lady will be feeding that message back to local commissioners. There is an opportunity for people to appeal against decisions when they are not made on the basis of clinical need, as that is clearly not the right thing and not in the interests of patients.

[Zac Goldsmith (Richmond Park) (Con)]

Will my right hon. Friend’s Department make an assessment of the effects on local air quality and public health of a potential third runway at Heathrow, and will he submit those findings to the Davies commission on airport capacity?

[Mr Hunt]

I am very happy to look into whether that is an area where my Department should take responsibility.

Antibiotics (Intensive Farms)

Lord Goldsmith of Richmond Park Excerpts

Wednesday 9th January 2013 Westminster Hall

[Zac Goldsmith (Richmond Park) (Con)]

It is a pleasure, Mrs Main, to serve under your chairmanship. I will make a short speech, and allow as much time as possible for interventions.

Clearly, everyone is concerned about the rise in the number of cases of bacterial infection, whether campylobacter, MRSA or blood poisoning from E. coli, cases of which have increased by nearly 400% in the last 20 years. What makes the problem so much more alarming is the accompanying rise in resistance to those infections. As the Minister will know, antibiotic resistance is a growing worldwide problem. We cannot yet call it a crisis in the UK, but some indications are ominous, particularly as no new antibiotics are in the development pipeline to treat some important infections. It should be noted that, when resistance problems occur, the cost to the NHS of successfully treating a patient may increase between 10 and 100 times.

The Government’s assessment is that most of the resistance problems that affect UK patients can be blamed on the inappropriate use of antibiotics in human medicine. I am sure that is true, but the antibiotics used in veterinary and human medicine are closely related, and a growing body of evidence indicates that, for some serious infections, the inappropriate use of antibiotics on farms leads to the development of resistance among farm animals that can and does pass to humans. Sir Liam Donaldson, former chief medical officer, starkly acknowledged that in his annual report three years ago in 2009, when he said of antibiotics:

“every inappropriate or unnecessary use in animals or agriculture is potentially signing a death warrant for a future patient.”

For far too long, the link between the overuse and misuse of antibiotics in intensive farming and the serious threat from antibiotic resistance have been utterly ignored. For example, although I welcomed last year’s public warning from the current chief medical officer—

--- Later in debate ---

On resuming—

[Zac Goldsmith]

I had just quoted Sir Liam Donaldson, on

“a death warrant for a future patient”,

as a result of the overuse of antibiotics, and I had complained that the British Government have routinely ignored the link between antibiotics in intensive farming and the public health threat. I was about to cite the current chief medical officer, Professor Dame Sally Davies, on the growing problems of resistant strains of bugs, as well as the Health Protection Agency in November. It was striking that the message focused 100% on over-prescribing by doctors, with zero mention of the use of antibiotics in the livestock industry.

Similarly, when I tabled a parliamentary question to the Department of Health on what funding it provided for research into drug-resistant bacteria, the answer from the Under-Secretary of State for Health, my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter), explicitly mentioned hospital-acquired infections, but not the use of antibiotics in farming. I was encouraged, however, by a reply from the then Secretary of State for Health, my right hon. Friend the Member for South Cambridgeshire (Mr Lansley), when I asked him about the link between E. coli resistance to antibiotics and record antibiotic usage on farms. He said:

“Indeed, I was interested to see analysis some years ago of the extent of antibiotic resistance in hospitals in the Netherlands. Resistance was clearly much more prevalent in parts of Friesland where there was much greater antibiotic usage in farming. I therefore completely understand, and my colleagues in DEFRA understand this too. Just as we are looking for the responsible and appropriate prescribing of antibiotics in the health service, my colleagues feel strongly about the proper use of antibiotics in farming.”—[Official Report, 17 July 2012; Vol. 548, c. 842.]

However, since then, we have had a near complete clean sweep of Ministers at both Departments—the Department of Health and the Department for Environment, Food and Rural Affairs.

[Mr Andrew Smith (Oxford East) (Lab)]

I congratulate the hon. Gentleman on raising a very important subject. Is his argument, at least in part, that the collaboration cross-departmentally, which should take place through the chief scientific advisers committee, is not happening, or is what they are considering simply not being taken proper notice of?

[Zac Goldsmith]

I thank the right hon. Gentleman for his intervention. I suspect that that is part of the problem, but as I will come to later, I think it is also the case that the agribusiness sector in this country has had a disproportionate impact on policy. That is a point that I hope to impress during the debate.

As I was saying, there has been a near clean sweep of Ministers at both Departments, so this debate provides an opportunity to clarify Government policy. The Government are right to insist on better infection control in hospitals and changes in the way that antibiotics are prescribed by doctors. However, other than the brief answer that I quoted from the former Secretary of State, there has been virtually nothing from the Government that could in any way encourage vets and farmers to be similarly prudent. Not surprisingly, therefore, there has been little progress; on the contrary, analysis by the Soil Association of the Government’s statistics indicates that the overall use of antibiotics per animal on UK farms increased by 18% between 2000 and 2010, while the farm use of third and fourth-generation cephalosporins—drugs described by the Health Protection Agency as hospital workhorses—increased by over 500%.

Furthermore, recently published data from the Veterinary Medicines Directorate show that sales of fluoroquinolone antibiotics for use in veterinary medicine over the past two years have been 70% higher than they were in 2000. It is worth noting that when fluoroquinolones were first licensed for use in poultry in the UK in 1993, there was no registered antibiotic-resistant campylobacter in people who had not been treated with the antibiotics, but by 2007, almost half—46%—the campylobacter food poisoning cases caused by the most common strain were resistant. It is worth noting also that in 2008, the European Food Safety Authority said:

“A major source of human exposure to fluoroquinolone resistance via food appears to be poultry”.

Clearly, antimicrobials should be used to treat sick animals, and I do not think anyone would argue against that.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Gentleman on securing the debate. Does he feel that the use by the farming sectors—whether pig, poultry or beef—of antibiotics is unnecessary, because there is a blanket use, rather than reacting to disease? Does he feel that that has a direct impact on us as human beings? Many people come to me and say that the antibiotics are not working, and they are getting three doses from the doctor. Is that feeding off what is happening?

[Zac Goldsmith]

Again, I absolutely agree with the hon. Gentleman’s point, and I thank him for making it. I will come to that in more detail shortly.

There is no argument against treating sick animals with antimicrobials but, surely, not the most modern and medically important ones, especially when other antibiotics, which are not as critically important in human medicine, are available. I recognise that this topic does not lend itself easily to tabloid news, but there is a real, worrying chance that that could change. By overusing antibiotics, we risk ruining for future generations one of the great discoveries of our species. In short, we risk entering the post-antibiotics age.

My hon. Friend the Minister will know that some antibiotics have already been lost to resistance: for example, penicillin for staphylococcal wound infections, ampicillin for infections of the urinary tract and ciprofloxacin for treating gonorrhoea. Many more are under threat, and new antibiotics are increasingly hard to find and license. We are now using our reserve antibiotics, and worryingly, seeing the spread of resistance to them as well. For example, rises in resistance, such as those seen for E. coli, force doctors to use carbapenems, which were previously the reserve antibiotics for use when other treatments had completely failed. However, we are now using carbapenems much more and seeing the spread of resistance to them as well.

University of Cambridge researchers revealed the first cases in UK livestock of a new strain of the multi-resistant superbug MRSA. It is called ST398, and it has become endemic in European and north American pig populations and has spread to poultry and cattle. It is significant because, unlike most strains of staphylococcus aureus found in farm animals, it is readily able to transfer to humans. If not checked, that is likely to lead to rising community-acquired MRSA, just at the time that hospital-acquired MRSA is falling, due to sterling efforts by health professionals.

[Caroline Lucas (Brighton, Pavilion) (Green)]

I congratulate the hon. Gentleman on securing this important debate. In the light of the very real health risks and the strong words from a former chief medical officer, as the hon. Gentleman has said, about the unnecessary use of antibiotics being nothing less than

“a death warrant for a future patient”,

does he agree that we need a legally binding timetable for the phased ending of all routine, prophylactic, non-therapeutic use of antibiotics in animals?

[Zac Goldsmith]

I do, and I will be coming to that point as well, but I absolutely agree with the hon. Lady’s intervention.

Clearly, we need to continue with efforts to reduce the inappropriate use of antibiotics by doctors, but the European Food Safety Authority was spot-on—I do not often say that—last year when it warned that

“it is…of high priority to decrease the total antimicrobial use in animal production in the EU.”

To date, the UK Government’s antibiotic resistance strategy, as I have said, has focused exclusively on over-prescribing by doctors, with zero mention of antibiotics in the livestock industry. Although they have spent money trying to understand why we are seeing a rise in bacterial infections, they are spending nothing, as far as I know, to understand the rise in resistance, which is clearly the issue of importance.

The Department of Health is currently developing its new cross-Government, five-year antimicrobial resistance strategy and action plan for 2013 to 2018, so I ask the Minister these questions today. Will she promise that it will give significant consideration to the use of antibiotics on farms and to the link between farm use and resistance? Will the Government work with the veterinary profession and the agricultural industry, as they have done in recent years with the medical profession? Does she agree that we need better data on antibiotic use, published by antibiotic family and by animal species, as is already done in France? If we do not know the type and quantity of antibiotics used and how they are used, there is very little chance of our being able to understand the emergence of resistance.

Furthermore, will the Minister lobby vigorously her ministerial colleagues at DEFRA to take urgent action to restrict the prophylactic use of antibiotics, to limit the prescription and use of antimicrobials for the herd treatment of animals to cases in which a vet has assessed that there is a clear clinical justification and to limit the use of critically important antibiotics to cases in which no other type of antimicrobials will be effective?

Will the Minister call on DEFRA to ban the use of fluoroquinolone antibiotics in poultry production to reduce the risk of antibiotic resistance in E. coli, campylobacter and other infections in humans? Incidentally, it is worth pointing out that campylobacter is the most common cause of food poisoning in the UK, affecting some 350,000 people a year, and poultry is the source of between 50% and 80% of those cases. A ban of that sort would bring the UK into line with the US, where the Food and Drug Administration stopped the use of those antibiotics in poultry in 2005, because of increasing resistance in campylobacter. Denmark, Finland and Australia also do not use fluoroquinolones in poultry. All those countries have lower levels of resistance in humans.

I mentioned Denmark, and it is worth taking a moment to consider the Danish situation. The latest Danish disease surveillance report showed that, although the presence of antibiotic-resistant bacteria in the country’s pig population had decreased since the tighter restrictions came into effect, including the banning of cephalosporins, the level of antibiotic-resistant bacteria in meats being imported into the country is higher than in its domestic meat. Nearly half the tested samples of chicken meat imported into Denmark in 2011 contained resistant bacteria. The Danish Government, quite rightly, have taken their concerns to Brussels, complaining that their national approach has been undermined by other EU states’ continued overuse of antibiotics.

Almost certainly, excessive antibiotic use on farms is linked to the intensive manner in which animals are kept. Improving animal health and welfare by limiting overcrowding and the worst excesses of factory farming must therefore become key components of the Government’s antibiotic resistance strategy. Disease prevention should be achieved through good hygiene, husbandry and housing, without recourse to the regular prophylactic use of antimicrobials—a point that has been made by two hon. Members. I recognise that factory farming interests have wielded enormous influence on Government policy for many years and that any move to restrict the use of antibiotics today will be fiercely resisted by them.

[Simon Hart (Carmarthen West and South Pembrokeshire) (Con)]

Does my hon. Friend have any evidence to suggest that this problem is more prevalent in what he describes as factory farming than in what I would call farming more generally?

[Zac Goldsmith]

I thank my hon. Friend for his intervention. I will come to that point in about 20 seconds if he does not mind, because I want to demonstrate the vigour with which the industry has in the past resisted and will continue to resist any change such as I have described. Indeed, I had a briefing yesterday from the British Poultry Council that included some fascinating statements. In it, the BPC says:

“There is no scientific evidence that intensive farming systems contribute more to the overall risk of antibiotic resistance than extensive farming systems.”

On the contrary, two DEFRA-funded reports find that antibiotic resistance is roughly 10 times lower in organic chickens and pigs than in conventional equivalents. The BPC says in the same report:

“The industry is not aware of any recent evidence that ESBLs”—

extended-spectrum beta-lactamases—

“(E.COLI) are increasing in chicken farms across the UK.”

[Glyn Davies (Montgomeryshire) (Con)]

I would like to pursue this point a little further. The reference made then was to organic farming. I was an extensive farmer and I have always had the view that the sloppy use of antibiotics was every bit as bad in extensive farming as in intensive units. I can understand the point in relation to organic farming, but not to extensive farming.

[Zac Goldsmith]

The difficulty is that it is very hard to measure antibiotic use in extensive farming of the sort that my hon. Friend describes, whereas in organic farming there is quite clear regulation—self-regulation, in effect—which enables that comparison to be made. He is probably right, but I cannot authenticate what he says, because the data simply do not exist.

The second BPC quote that I read out cannot be true. The BPC must be aware of DEFRA’s statement last year that as many ESBLs were found in chickens in the first half of last year than in the entire previous year, so what it has said to me in its briefing simply is not true.

The BPC also says:

“Antibiotics may only be used on a farm if they have been prescribed by a veterinary surgeon”.

But it knows that producers often go straight to the feed mill, which will write out the prescription, send it to the vet’s at the eleventh hour and put pressure on them to sign it immediately. We know that because a number of vets have complained to the Veterinary Medicines Directorate about just that.

Finally, the BPC says:

“Scientific evidence increasingly recognises that the problem of antibiotic resistance in humans comes largely from the use of antibiotics in human medicine.”

That is true, as I have already acknowledged, but for certain bacteria—salmonella, campylobacter and E. coli—the farm use probably accounts for more than half the problem. It certainly accounts for a very significant chunk of the problem. With MRSA, it is probably accounting at the moment for only a few per cent. of cases, but if it is allowed to get established in UK livestock, that situation could very easily change, and dramatically.

The briefing adds, approvingly, that the use of growth-promoting antibiotics was banned 10 years ago in this country. It is probably worth pointing out that that ban came into force only in 2006 and was vigorously opposed by the BPC at the time. Perhaps for that reason, the British Government of the time, initially at least, was the only EU member state Government to oppose the ban. That is another example, I would suggest, of the industry calling the shots on this issue.

I must acknowledge that, 12 months ago, the BPC agreed to introduce a voluntary ban on the use of cephalosporins in poultry production and to stop giving fluoroquinolones to day-old chicks. That does not go nearly far enough, but it is an important step forward and demonstrates an acknowledgment by the BPC, albeit a reluctant one, of the problem.

There is no excuse to delay. The warning has been there since 1945, when, on accepting his part of the Nobel prize in medicine for the discovery and isolation of penicillin, Alexander Fleming said that

“there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant.”

If we continue to ignore this risk for fear of upsetting vested interests, we will be complicit in robbing future generations of one of the great discoveries of our species and propelling us—apologies for repeating myself—into a truly frightening, post-antibiotic age. It is surely time for the Government to act.

[Mrs Anne Main (in the Chair)]

For clarification to those participating in the debate, it will finish at 5.10 pm.

[The Parliamentary Under-Secretary of State for Health (Anna Soubry)]

It is a pleasure to serve under your chairmanship, Mrs Main. I congratulate my hon. Friend the Member for Richmond Park (Zac Goldsmith) on securing the debate, which is on an important subject. I shall say at the outset that, although I just about heard all the many questions that he asked me, I can say with complete confidence that I fear that I will be unable to answer any—well, a large number of them—in my speech this afternoon, but I undertake to ensure that he receives full written answers to them all. As you will understand, Mrs Main, and as I am sure he will too, it is impossible to answer them all in this short debate, especially because it is such a technical matter, with so many important questions that require technical, detailed responses.

I must begin by saying that of course we all recognise that antimicrobial resistance poses a threat to human and animal health. I can assure my hon. Friend and others that the Government take this resistance very seriously. DEFRA and its agencies have been collaborating for many years with the Department of Health, the Health Protection Agency and the Food Standards Agency on this issue. The Government’s collective objective is to ensure that antibiotic use in animals does not become a significant clinical problem for human health. I am told that there is little evidence on antimicrobial resistance transmission routes from animals to humans. The concern is that if bacteria in food-producing and companion animals develop resistance to drugs used in human medicine, those could be transferred to humans via food or through direct contact.

Controls in the veterinary sector need to be carefully balanced to minimise undesirable animal welfare issues and not hamper the efficiency of UK food production in a way that could disadvantage the industry in relation to other countries where controls may be implemented less well or less effectively enforced. Good farm management, biosecurity measures and animal husbandry systems underpin the health and welfare of food-producing animals. When applied appropriately, they enable the use of antibiotics to be minimised. We all want and welcome that.

We agree that the routine use of antibiotics in animals is unacceptable. I am assured that relevant guidance and regulation is given to the sector to make that absolutely clear. I will ask my hon. Friend the Minister of State, Department for Environment, Food and Rural Affairs, to consider whether current guidance on the responsible use of antibiotics can be strengthened to make it clear that the routine administration of antibiotics is not acceptable. I am also told that intensive farming systems do not necessarily use large amounts of antibiotics. Some have high health status livestock and so use very limited quantities of antibiotics.

The Government fully appreciate that effective controls are needed in the environmental, agricultural, food production, animal and human health sectors. Failure to act promptly and comprehensively could mean that we face impending problems with implications for animal health and welfare and knock-on effects for food supply and safety, as well as, ultimately, human health and patient safety.

Although the link between antimicrobial use in animals and the spread of resistance in humans is not well understood, there is scientific consensus that the use of antimicrobials in human medicine is the main driving force for antimicrobial-resistant human infections. The majority of resistant strains affecting humans are different from those affecting animals. Bearing that in mind, we have developed an integrated strategy to tackle the challenge of antibiotic resistance, and resistance to other antimicrobials, such as antifungals.

We have been working with DEFRA and other stakeholders to develop a new UK five-year antimicrobial resistance strategy and action plan, which we aim to publish shortly. The strategy will address all sectors, including veterinary use. To have maximum impact, the new integrated strategy will focus on a wide range of intervention measures to safeguard human and animal health, including: promoting responsible prescribing; improving infection prevention and control; raising awareness of the problem; improving the scientific evidence base; facilitating the development of new treatments; strengthening surveillance, and strengthening collaboration, data and technology.

There is general agreement that responsible prescribing is central to slowing down the development of antimicrobial resistance in humans and animals. Antibiotics, used responsibly, remain a vital part of the veterinary surgeons’ toolbox, without which animals suffering from a bacterial infection could not be treated effectively. The use of antibiotics in veterinary medicine is controlled by veterinary prescription and is equivalent to arrangements for humans. In that way, we are encouraging the responsible use of antibiotics and minimising their routine use.

In addition, the use of antibiotics as growth promoters has been banned in the EU since 2006, as my hon. Friend the Member for Richmond Park informed us. In the dairy industry, if a cow has been treated with antibiotics, the milk should be isolated, and there is regular routine testing of tanks to ensure that there are no traces of antibiotics. Those are some of the many checks in place to ensure that antibiotics do not get into the human food chain.

[Zac Goldsmith]

Antibiotic use on farms is increasing not decreasing, so despite the initiatives and efforts we have heard about, the trends are heading in the wrong direction. Will my hon. Friend commit on the record to reviewing and reading the references, with which I will provide her at the end of the debate, for all the points I made in my speech and checking the science behind them, so that she is certain that the brief she received from her Department is accurate?

[Anna Soubry]

I am more than happy to do all those things. As my hon. Friend will appreciate, I am no expert in this field and would not pretend to be for one moment. I shall make a very important point: my briefing does not come from the Department of Health only; we work in collaboration with the Department for Environment, Food and Rural Affairs.

One important thing about this debate is that my hon. Friend rightly asked for a Minister from the Department of Health to respond, so I am not, as others might have thought, someone from DEFRA. Many people are concerned about whether how an animal is treated has an impact on them if they consume some or part of it. Although we might not always make too many friends in the farming industry, we are all responsible for ensuring that we know what we are putting into our bodies and feeding our families. We bear that responsibility, so we need good, informed advice. Many people, but often those with the financial means to do so, will not buy fresh meat unless they know its antecedents—that it has come from a good butcher and a good beast.

Oral Answers to Questions

Lord Goldsmith of Richmond Park Excerpts

Tuesday 17th July 2012 Commons Chamber

[Mr Burns]

As ever. I do not share the hon. Gentleman’s analysis of the interpretation of what has happened with regard to the trust’s performance. There has been an historic problem with its performance, but I pay tribute to the staff, who have made tremendous efforts to improve performance, and have achieved some improvement. The trouble is that it is not sustainable not to put the trust on a sustainable financial footing. The hon. Gentleman said that he would like a meeting with me or my right hon. Friend the Secretary of State. [Interruption.] As he will know, if he keeps quiet for a minute, I have written to him offering a meeting with my right hon. Friend, on 24 July; I hope that the hon. Gentleman can attend.

[Zac Goldsmith (Richmond Park) (Con)]

Cases of blood poisoning from E. coli have increased by nearly 400% in the past 20 years, and E. coli resistance to antibiotics is almost certainly linked to record levels of antibiotic usage on factory farms. By over-using antibiotics we risk ruining for future generations one of the great discoveries of our species. Will the Department put pressure on the Department for Environment, Food and Rural Affairs finally to take that issue seriously?

[Mr Lansley]

I understand the issues. Indeed, I was interested to see analysis some years ago of the extent of antibiotic resistance in hospitals in the Netherlands. Resistance was clearly much more prevalent in parts of Friesland where there was much greater antibiotic usage in farming. I therefore completely understand, and my colleagues in DEFRA understand this too. Just as we are looking for the responsible and appropriate prescribing of antibiotics in the health service, my colleagues feel strongly about the proper use of antibiotics in farming.

Infant Mortality: Research

Lord Goldsmith of Richmond Park Excerpts

Wednesday 6th July 2011 Ministerial Corrections

[Zac Goldsmith]

To ask the Secretary of State for Health (1) what proportion of the funding allocated by his Department for health research was allocated to research on (a) maternal and (b) fetal health in each of the last five years;

Oral Answers to Questions

Lord Goldsmith of Richmond Park Excerpts

Tuesday 25th January 2011 Commons Chamber

[Mr Lansley]

No, they will not. We are making very clear our determination to ring-fence public health budgets so that prevention does not suffer, as it did under the hon. Gentleman’s Government. In 2005-06, the first things to disappear as a consequence of financial pressures were the public health budgets and public health staffing. We will not allow that to happen.

[Zac Goldsmith (Richmond Park) (Con)]

I welcome the Government’s commitment to ending mixed-sex wards, but does the Secretary of State agree that it is both unnecessary and extreme to extend that policy to children’s wards and to enforce it with the threat of fines?

[Mr Lansley]

I entirely understand my hon. Friend’s point, and the rules we have set out for the NHS are very clear. We are also clear that we will ensure, through the NHS, that people have access to the privacy and dignity they have a right to expect, contrary to what the hon. Member for Leicester West (Liz Kendall) has said. She said that as long as they get the treatment through the NHS, it does not matter whether they are in mixed-sex accommodation, but that is not our policy. It does matter, and we will enforce it.