CHAPTER 11 CONCLUSIONS AND
11.1 This enquiry
has been an alarming experience, which leaves us convinced that
resistance to antibiotics and other anti-infective agents constitutes
a major threat to public health, and ought to be recognised as
such more widely than it is at present. Antimicrobial resistance
is a fact of life, and the recommendations which follow will not
solve the problem; but they should put the United Kingdom in a
better position to face it and live with it.
Can resistance be controlled?
11.2 The evidence set
out above in paragraphs 1.31-41 leads us to conclude that any
antimicrobial agent must be expected to encounter resistance sooner
or later. The emergence of resistance may be slow; but sometimes
it is rapid, and either way it is inexorable. Resistance will
take longer to emerge and spread if antimicrobial use is controlled
and prudent from the start. Improving control of the use of antimicrobials
can be expected to slow down the spread of resistance; and in
some situations the frequency of resistance may even decline.
But this must not be expected to happen in every case; and, if
control is once again relaxed, reversion to high rates of resistance
may be swift.
Prudent use in human medicine
11.3 The present use
of antimicrobials in medicine in the United Kingdom is controlled
and conservative by international standards, but on the evidence
we have received (paragraphs 2.3-9) there is still plenty
of room for improvement. In general practice, where most antimicrobials
in human medicine are prescribed, there are wide variations in
practice; many such prescriptions (witnesses offered figures ranging
from 5 to 50 per cent in different settings) are unjustified
on strictly clinical grounds, and where a prescription is justified
the drug used is often inappropriate (and more expensive than
necessary). In hospital the volume of drugs is less, and control
is tighter; but even in hospital many prescriptions are made by
junior doctors without proper review, and there are doubts about
some aspects of present practice in relation to both treatment
and prophylaxis, in particular the duration of courses.
11.4 We acknowledge
the dilemma facing doctors and patients alike (paragraph 2.9),
that what is prudent from the point of view of public health may
be highly imprudent from the point of view of the individual patient,
and vice versa. To use the stark example offered by the
Minister for Public Health, if a child shows possible signs of
meningitis, antibiotics are needed fast, and nothing must be said
or done to deter the parent from seeking help or the doctor from
giving it. This dilemma cannot be wished away; but we have learned
that much can be done to reduce the area of uncertainty.
11.5 We commend the
current trend towards local antibiotic formularies and evidence-based
clinical guidelines (paragraphs 2.10-14), giving professionals
agreed definitions of prudent practice in particular situations.
But the issuing of documents is not enough to turn policy into
practice; it must be followed through in professional education,
and continuing professional development.
11.6 We recommend
that the Education Committee of the General Medical Council and
the medical Royal Colleges should review the evidence presented
to us (paragraph 2.31) that undergraduate curricula
give insufficient emphasis to infectious diseases and antimicrobial
therapy. Given the consequences of poor practice for the development
of resistance and therefore for public health, the Royal Colleges
should increase the attention paid to antimicrobial therapy in
their programmes of postgraduate education and vocational training.
11.7 We commend those
health authorities which are devoting resources to continuing
professional development of doctors in the area of prescribing.
On the evidence presented to us, this is best achieved by prescribing
audit and feedback (paragraph 2.34), and by educational outreach
(paragraph 2.35); we recommend that health authorities
should step up their efforts in these areas, since they are
not only effective but cost-effective.
11.8 We do not recommend
that GPs should be required to establish antimicrobial susceptibility
before prescribing (paragraph 2.22). This, we believe, would
at present be impracticable, and would overload diagnostic services
which are already stretched. But improved access to microbiological
testing clearly reduces uncertainty in prescribing. We recommend
that industry and the grant-giving bodies should give priority
to work on rapid affordable systems for diagnosis and susceptibility
testing (paragraphs 2.16-18); where promising developments
emerge, they should be quick to move them towards the market.
11.9 It has been put
to us (paragraph 2.23) that the systems for licensing new
anti-infectives could be recruited to the fight against resistance.
We recommend that the Medicines Control Agency should consider
whether the drug licensing system could be used more effectively
to encourage prudent use in the interest of public health.
Any change might of course involve amendment of the Medicines
11.10 We do not recommend
further controls on the promotional activities of the pharmaceutical
industry in the United Kingdom; we accept the evidence (paragraphs 2.24-25)
that a system of self-regulation is in place through the ABPI.
There is clear evidence that some doctors are induced to prescribe
new drugs where older drugs would do; but this is a matter for
the continuing professional development referred to above. We
commend the work of the WHO, through its Division of Emerging
and other Communicable Diseases Surveillance and Control, to equip
professionals and regulators in the developing world to respond
appropriately to pharmaceutical promotions (paragraph 9.3).
11.11 The evidence
is clear (paragraphs 2.26-30) that prudent use is much harder
to achieve if antimicrobials for internal use are available over
the counter. We commend the Government and the ABPI for their
firm stand against over-the-counter antibiotics, and urge them
not to give way. Since this is an area of EU responsibility,
and the position in several other Member States appears to be
different, we recommend that the Government should engage in
active diplomacy to ensure that, should the issue be raised in
the Council of Ministers, their position is understood and their
allies are in place; and, in the long term, to induce those Member
States which are currently more relaxed about over-the-counter
antibiotics to introduce more controls.
11.12 On the evidence
presented to us (paragraphs 2.3-7), it appears that the greatest
bulk of imprudent use of antimicrobials in human medicine in the
United Kingdom is the prescription of antibacterials by GPs for
self-limiting or viral infections and in other inappropriate situations.
This encourages resistance, for example, in the pneumococcus,
and might give rise to resistance in the meningococcus, which
would be a disaster for public health. The increased education
for doctors which we recommend above should include education
in communication skills (i.e. how to explain the reasons for refusing
a prescription) and other ways to avoid prescribing on demand
(e.g. delayed-action prescriptions) (see above, paragraph 2.37).
11.13 We are disturbed
by the evidence (paragraphs 2.36-39) that in many cases doctors
prescribe unnecessarily under pressure from their patients, and
under pressure of time. There is an urgent need for public health
education in this area. We commend what is already being done;
but we urge the Government and health authorities to do more.
In particular, we recommend a campaign targeted at mothers of
young children. One appropriate vehicle for such a campaign
would be the popular women's magazines, with their enthusiasm
for articles on health and parenting.
11.14 The message for
any such campaign requires careful consideration. It would be
overstating the case dangerously to say that antibiotics are bad
for you; nothing must be done to deter people from visiting
their GP promptly, or from taking their medicine when necessary.
But there is evidence (paragraphs 2.40-45) that unnecessary
antibiotics not only have public health consequences, but also
increase the risk to the individual patient that any subsequent
infection will involve a more resistant strain (to say nothing
of the possibility of an adverse reaction to the drug itself).
The Government and the health authorities should present this
evidence to the public.
11.15 The problems
of inappropriate prescribing are compounded by the failure of
many patients to comply with therapy by taking their medicines
as instructed (paragraphs 2.46-47); but "complete the
course" is good advice only if the antibiotic is appropriate
in the first place, and if the course is properly defined. The
NHS should work with the relevant professional bodies to see that
courses of antibiotics are defined according to the best available
current information; wide variations in practice among different
countries, as in the case of otitis media, suggest strongly that
something may be wrong.
11.16 Compliance is
particularly important, and particularly difficult to achieve,
in cases of tuberculosis. TB services in the United Kingdom are
something of which the Health Services can feel justly proud;
but the recent outbreaks of MDR-TB among AIDS patients in London
hospitals, and the serious problems in the USA (which cost the
City of New York, for example, $175m over four years), must serve
as warnings. TB services involve measures to ensure compliance,
along with port health controls (DH p 371), surveillance
and facilities for isolation; cuts in these services to save pennies
today would cost this country millions of pounds tomorrow, to
say nothing of the cost in human suffering. We welcome the
news that new TB guidelines from the Department of Health are
to recommend more rapid diagnostic tests, and more stringent infection
control, in cases of suspected MDR-TB; the Department must
find the necessary resources.
11.17 It is notoriously
difficult to manage what cannot be measured; and we have heard
much about the contrast between the excellent data on GP prescribing,
captured by both the Prescription Pricing Authorities and GPs
themselves, and the lack of data on antimicrobial use in hospitals
(paragraphs 10.4-7). We draw this to the attention of
those responsible for the NHS Information Technology Strategy.
Information from the pharmacy stock-control system is not
enough for these purposes; all hospitals should install computer
systems for patient-specific prescribing information at ward level.
Prudent use in animals
11.18 Even though we
made it clear from the start that use of antibiotics in animals,
fish and plants was not the primary focus of this enquiry, since
the Working Group of the Advisory Committee on the Microbiological
Safety of Food is looking at the issue in depth, few of our medical
witnesses have forborne to express concern in this area. Concern
focuses on the role of the growth promoter avoparcin (which the
EU has recently prohibited) in inducing resistance to vancomycin
and other glycopeptides; the role of fluoroquinolones used in
veterinary medicine and prophylaxis in inducing resistance to
this important class of drugs in Salmonella, Campylobacter and
E. coli; and the possibility that the growth promoter
virginiamycin has already induced resistance to the new streptogramin
Synercid. The evidence that we have heard (paragraphs 3.7-13)
strongly suggests that there is a continuing threat to human
health from imprudent use of antibiotics in animals.
11.19 The United Kingdom
led the world in addressing the threat to human health posed by
antibiotic use in farming practices with the Swann Report in 1969.
Unfortunately, some of the recommendations of Swann were not acted
upon and many believe that, had action been taken then, our present
concerns would be much less than they are now, at least as regards
the situation in the United Kingdom.
are highly efficacious in animals as they are in man. The aim
must be to maintain this potency. We do not go so far as some
of our witnesses, who call for a ban on all growth promotion and
long-term mass prophylaxis. However, on the evidence before us
(paragraphs 3.20-24), we recommend that antibiotic growth
promoters such as virginiamycin, which belong to classes of antimicrobial
agent used (or proposed to be used) in man and are therefore most
likely to contribute to resistance in human medicine, should be
phased out, preferably by voluntary agreement between the professions
and industries concerned, but by legislation if necessary.
11.21 Potent agents
important to human medicine, such as the fluoroquinolones, deserve
extreme economy of use in veterinary practice (paragraphs 3.15-19,
25-26). It is right for large animals and companion animals to
receive such agents on an individual basis for short-term therapy;
but mass-treatment of herds of pigs and flocks of poultry with
such agents cannot be best practice from the point of view of
human public health. The veterinary profession must address
by introducing rapidly a Code of Practice on when such compounds
should be prescribed (e.g. when other agents have failed)
and how (e.g. for no longer than necessary); we recommend
self-regulation in preference to legislation.
11.22 Many people have
pointed out that, even by comparison with the human scene, surveillance
of resistance patterns in animals is very limited, making analysis
of the problem along the whole food chain very difficult (paragraph 3.12).
We draw this to the attention of MAFF, and of the new Food
Standards Agency, since the Minister told us that it will
have surveillance as an "important function" (Q 755).
11.23 The role of farming
and veterinary practice in contributing to resistance in human
pathogens goes beyond the question of food, since pathogens and
resistance genes originating on the farm can reach people by routes
other than the food chain - for instance, via contact with companion
animals. Departmental and Agency boundaries must not be allowed
to prevent the Government from getting a grip on the whole of
this issue, in the interests of public health. A single multi-disciplinary
Government committee to oversee all aspects of antibiotic use
should now be set up, as originally recommended by the Swann Report
11.24 We draw to
MAFF's attention the evidence of Dr Coles (paragraphs 3.36-41),
which suggests that resistance in worms and scab pose a serious
and imminent threat to the British sheep farming industry.
There is no threat to human health; but, if Dr Coles is right
and if nothing is done about it, the economic consequences for
farmers in the present state of the industry, and the animal welfare
consequences, could be serious.
11.25 Besides being
desirable in itself, infection control is particularly important
to the fight against resistance in two ways. It reduces the need
for treatment and therefore the selective pressure which induces
resistance in the first place; and, when resistance arises, it
limits the damage by keeping the resistant organism within bounds.
In respect of hospitals, the NHS is well equipped with policies
for infection control; but we are not convinced that they correspond
with the reality of life on the wards. We have had disturbing
evidence (paragraphs 4.3-19) of infection control teams under-staffed
and under-resourced; of poor standards of basic hygiene (e.g.
hand-washing), exacerbated by the contracting-out of cleaning
services; of inadequate facilities for isolation; of over-crowding
of patients, and of "hot-bedding" with inadequate provision
for infection control; and of inadequate control of agency staff,
and inadequate training for all staff (including doctors, nurses
and ancillary staff, and agency staff) in even the basics of hygiene.
11.26 The rise of MRSA
and other hospital infections has taken place at a time when the
Health Services have placed emphasis on patient throughput and
economy; this may have led some managers and clinicians to see
infection control as a cost and an impediment, rather than a basic
component of patient care. The present Government express determination
to change the ethos of the Health Services in this respect. As
one practical way to do so, purchasers and commissioning agencies
should put infection control and basic hygiene where they belong,
at the heart of good hospital management and practice, and should
redirect resources accordingly. The evidence of the cost of
hospital-acquired infection (paragraphs 4.30-34) suggests
that such a policy will pay for itself quite quickly. In
particular, the NHS Executive should assure themselves that
every NHS hospital is covered by a properly trained infection
control team, as recommended in the Cooke Report.
11.27 While we do not
go so far as to recommend a national task force against MRSA,
we found what the Department of Health had to say on this subject
complacent (paragraphs 4.35-37). Levels of MRSA in this country
are low by international standards, but they are rising. The more
MRSA circulates, the more vancomycin must be used to treat it,
bringing closer the prospect of VRSA which in the words of the
PHLS would be "catastrophic" (p 44, Q 95).
We recommend that the NHS should set itself targets for controlling
MRSA in hospitals, and publish its achievements.
11.28 As Dr Winyard
himself acknowledged (Q 811), infection control beyond the
hospital is an area of particular weakness (paragraphs 4.20-25).
This is especially true of nursing and residential homes, which
can act as reservoirs of MRSA and other resistant organisms which
are carried back into hospitals again and again. As a step towards
improving the situation, we recommend that, once the current review
of the Public Health (Control of Disease) Act 1984 is concluded,
the NHS should draw up national standards and guidelines for
community infection control management, along the lines of
the Cooke Report for hospitals. These should include a requirement
that every district health authority should have at least one
community infection control nurse. Such an exercise might
also usefully include the special factors affecting prisons (paragraph 4.29).
11.29 We draw to
the attention of those responsible for the review of the Public
Health (Control of Disease) Act 1984 Dr Mayon-White's evidence
(paragraph 4.26) as to shortcomings of the provisions
for compulsory medical examination and detention in hospital,
and the case for a more humane regime, and for extending the legislation
to provide also for supervised treatment at home.
collection of microbiological data for comparison, analysis and
feedbackis vital to the fight against resistance. It supports
prudent prescribing, by tracking the rise of resistance, and informing
local formularies and policies accordingly; and it supports infection
control, by giving warning of areas of weakness. In both areas,
it allows practice to be evaluated by revealing its effects on
local rates of resistance and infection.
11.31 The PHLS were
admirably frank with us about the shortcomings of their surveillance,
especially in the area of denominator information (paragraphs 10.9-10).
We recommend that the NHS R&D Directorate should support
microbiological surveillance among the population at large, with
a view to improving denominator information, as a legitimate call
on the NHS R&D Budget. This is just the sort of public
health research which we had in mind in 1988 when we first recommended
that there should be a NHS R&D Budget.
The MRC and the medical charities should also be prepared to
support such work.
11.32 It is astonishing
that the Departmental subvention for the PHLS is falling (paragraph 5.14),
at a time when surveillance of infectious disease and particularly
resistant disease has become so important. The Department of Health
must reconsider these cuts.
11.33 We draw to
the attention of those responsible for the review of the notification
provisions of the Public Health (Control of Disease) Act 1984
the proposals of our witnesses (paragraphs 5.2-6) for
reporting of diseases by causative organism, and for mandatory
reporting of certain resistances. Any increase in the burden of
reporting placed on hospital laboratories will have resource implications
which the NHS must face; and it must be matched by an improvement
in the level of feedback from the PHLS.
11.34 We recommend
that Health Ministers assure themselves that liaison between the
PHLS and its analogues in Scotland (especially in the context
of impending Devolution) and Northern Ireland is as close as possible
(paragraphs 5.7-9). In particular, Ministers should set
a deadline for full compatibility of definitions and data-collection.
11.35 We draw to
the attention of those responsible for the NHS Information Technology
Strategy the scope for IT to facilitate surveillance of disease
and resistance (paragraph 5.10), particularly by speeding
up exchange of compatible data locally, nationally and internationally,
and by permitting links to be made between microbiological data
and clinical data of prescribing and outcomes, subject to the
necessary safeguards for confidentiality of patient-specific information.
11.36 We congratulate
the PHLS and the NHS on the establishment of the Nosocomial Infection
National Surveillance System (NINSS) (paragraphs 5.11-13).
The usefulness of NINSS will be much enhanced if it can be linked
with data on the use of antimicrobials. We recommend that the
NHS should examine the ICARE Project run by the US Centers for
Communicable Disease Control and Prevention (CDC), and consider
the possibility of setting up something similar, possibly in partnership
11.37 We commend the
efforts of the BSAC and the PHLS to put resistance surveillance
on a more strategic and comprehensive footing (paragraphs 5.18-22).
The Government must engage constructively with those involved,
and find additional resources. Surveillance depends on many
microbiological laboratories in the NHS and the medical schools,
as well as those which are part of the PHLS, and we have received
evidence that these are generally under-staffed; we recommend
that NHS Trusts and universities should examine their priorities
in this area.
11.38 We are concerned
at evidence (paragraphs 5.15-17) that clinical academic microbiology,
which provides much of the expertise for surveillance, and for
infectious disease medicine generally, is currently failing to
attract recruits and fill senior posts. The problem is widely
acknowledged; it must be addressed by the NHS, the Higher Education
Funding Councils, and the heads of medical schools. This may
be a special case of a more general problem concerning the pressures
placed on clinical academic medicine by the conflicting demands
of the Research Assessment Exercise and the ever-growing burdens
of teaching, service provision and administration; we have
expressed concern about this before, and we do so again.
New drug development
11.39 We congratulate
the British pharmaceutical industry for renewing their efforts
to find novel antimicrobials (paragraphs 6.2-4). We wish
them success; but results cannot be expected in the short term.
Pharmaceutical development is a very lengthy process; drugs at
the R&D stage today may not be on the market for several years,
during which time resistance to existing drugs could get dramatically
worse. The sequencing of complete genomes, such as that of Mycobacterium
tuberculosis which was achieved at Hinxton Hall as our enquiry
drew to a close, is a great achievement, but only a first step;
there are numerous other steps between a gene sequence and a new
drug product, including characterisation of the gene products
and the trial of many possible drug targets.
11.40 We commend the
EU proposal for an "orphan drug" regime (paragraph 6.6).
The Government should respond positively, and should seek to
ensure that the scheme gives the pharmaceutical industry a real
incentive to work on novel treatments for problem diseases, particularly
diseases of the world's poor such as malaria where the market
is at present worth relatively little but the cost in human suffering
11.41 As more antimicrobials
lose their effectiveness, the importance of vaccines grows (see
Chapter 7). What is more, like other forms of infection control,
vaccines act against resistance at source, by reducing the amount
of antimicrobial chemotherapy required and therefore reducing
the selective pressure on bacterial populations. We commend
the establishment of the Edward Jenner Institute. The numerous
agencies committed to research into effective vaccines must keep
up the good work. Vaccines effective against malaria, group B
meningococcus and HIV, and more effective vaccines against the
pneumococcus and TB, would be particularly valuable.
11.42 As new antivirals
reach the market (see Chapter 8), the NHS must ensure
that they are used prudently from the start, and that changes
in susceptibility are monitored. The lessons learned from
50 years of use and abuse of antibacterials must be fully applied.
11.43 We congratulate
the PHLS on establishing the world's first reference laboratory
for antiviral resistance, under Dr Deenan Pillay in Birmingham.
The PHLS must adequately resource the development of this important
11.44 Resistant bacteria
do not respect frontiers. The international trade in food of all
kinds exposes British shoppers to the consequences of the misuse
of antibiotics in farming practice around the world. In the era
of mass travel by air, a resistant bacterium of gonorrhoea (for
example) may evolve in Bangkok one day and be in Birmingham the
next. Public health in the United Kingdom is therefore affected
directly, for better or worse, by action or inaction in other
parts of the world.
11.45 We commend the
Government, and particularly the Department for International
Development, for their exemplary support over recent years for
the WHO Division of Emerging Diseases (paragraph 9.4). This
support should be maintained, and the United Kingdom Government's
example should encourage other nations and agencies to contribute
to this vital work. We endorse the resolution on this subject
which is to be considered by the World Health Assembly in May;
we urge the Assembly to pass it.
11.46 The United Kingdom
has had a good record of support for malaria research, and for
the efforts of the WHO to help poor countries to combat this disease
(paragraphs 9.6-15). The Government and the grant-awarding
bodies must maintain this record.
Resources for research and data-collection
11.47 There is still
much that needs to be done to increase understanding of the mechanisms
of resistance and the action of antimicrobials and, in the clinical
sphere, methods of using agents to best advantage (paragraphs 10.2-14).
There are data to be collected on resistance and use (in animals
and man), and how to prevent the emergence and spread of resistant
pathogens (bacterial, viral, fungal and parasitic); and many educational
ventures are required in order to find the most suitable approaches
to control the problem.
11.48 Research in this
area evidently falls between a number of stools (paragraphs 10.15-20),
receiving inadequate support from the major grant-giving bodies
and the NHS R&D Strategy. The grant-awarding bodies and
the NHS Executive should reconsider the important public health
issues surrounding antimicrobial research, and should give such
research an enhanced priority. As in the case of surveillance,
we particularly commend this as a suitable area of activity
for the NHS R&D Strategy.
11.49 We note that
both the MRC and the Wellcome Trust report a shortage of high-quality
research proposals in this area. We challenge the research
community to come forward with proposals which, given the increased
interest in the field which is already apparent, will fully justify
support from the grant-awarding bodies.
11.50 Although research
including surveillance is imperative, it should not take the place
of immediate action to improve antibiotic use and prevent the
spread of infections.
11.51 Information technology
can play a major role in the fight against antimicrobial resistance,
in three main areas: audit of antibiotic usage (see above, paragraphs
11.7 and 17), collection and analysis of disease surveillance
data (paragraph 11.35), and linkage of the one with the other.
The full benefits of IT in this area, as in others, will only
be realised when every GP, every hospital ward and infection control
team, and every clinical microbiology laboratory, has compatible
and interconnected IT. The NHS Executive must work towards
this goal, accepting that it will involve considerable cost, and
giving a strong lead from the centre to ensure compatibility.
An epidemic in its own right
11.52 It will be apparent
from the above that we take the issue of resistance to antibiotics
extremely seriously. The evidence we have received is alarming
enough as to the present situation, and even more so as to the
prospect for the future. In the long term, science may come to
the rescue, with novel antimicrobials and additional vaccines;
but in the short term the world is facing what may be described
as an epidemic in its own right, and the dire prospect of revisiting
the pre-antibiotic era.
11.53 As things stand,
the United Kingdom has much to be grateful for, and a certain
amount to be proud of. Rates of resistance here are lower than
in most countries, and the health care professions are doing their
best to keep them so; and our contribution to the fight against
resistant disease in other parts of the world is considerable.
But the trend of resistance is upward, and we are not convinced
that either Ministers,
the public or the veterinary and agricultural community have fully
grasped the importance of action in the short term. The health
care professions may have a better grasp of the problem, but lack
the resources to address it vigorously. To the extent that the
problem is understood, the fact that it crosses several departmental
and disciplinary boundaries is impeding action; hence our recommendation
for a multidisciplinary interdepartmental committee as recommended
11.54 We do not wish
to overstate the problem, at least as it affects the United Kingdom.
This country is facing nothing like the continuing tragedy of
malaria in Africa. But food poisoning and hospital-acquired infection
are already at levels which cause concern, and, if action is not
taken now, it is quite conceivable that VRSA, or further outbreaks
of MDR-TB, may arise here, with all the consequences of suffering
and expense. The Government clearly desire to develop a strategy
to safeguard the effectiveness of antimicrobials; we conclude
by urging them to follow this project through along the lines
recommended in this report, to back it with resources, and to
set themselves and the Health Services challenging targets for
real improvement. Antimicrobial resistance is here to stay; but
action or inaction now, not only by the Government but by everyone
with a stake in public health, will have a real impact on the
public health legacy which we pass on to the next generation.
Including directly-observed therapy-BMA p 381. Back
The evidence of the British Veterinary Association (p 393)
suggests that they are already doing so. Back
Priorities in Medical Research,
3rd Report 1987-88, HL Paper 54. Back
The Chief Medical Officer has made it clear in his annual reports
for 1995 and 1996, and in his evidence to us (QQ 756, 765)
that he is seized of the problem. Ministers will shortly receive
advice on prudent use in human medicine from a sub-committee of
the Standing Medical Advisory Committee (Q 759), and on prudent
use in animals from the Advisory Committee on Microbiological
Safety of Food (see above, Chapter 3). Back