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At the heart of general practice since 1960

GPs shouldn't face sanctions for trying to do the right thing

Researchers from the University of Bristol look at the recent suggestion from NICE on how to reduce antibiotic prescribing

The publication of new NICE guidelines on antimicrobial stewardship has provoked yet more finger pointing by the media at ‘soft-touch’ GPs, triggered by the suggestion that individual GP prescribing data should be reviewed during their annual appraisals and ‘persistent over-prescribers’ referred to the GMC.

The assumption that such severe sanctions are appropriate measures for ‘over-prescribing’ GPs ignores both the clinical uncertainty that GPs have to deal with and the wider cultural processes that contribute to high antibiotic prescribing.

We recently reported some of the research done under the TARGET Programme*, and we explained why parents of children with respiratory tract infections (RTI) seek care and why clinicians prescribe antibiotics at higher rates than may be necessary. A clear theme was that both parents and clinicians feel a need to ensure (and be seen to ensure) children’s safety. 

So sometimes parents bring their children to see the GP not because they are sure they are particularly sick or in need of antibiotics, but because they want confirmation that their child is not seriously unwell. This is both reassuring and allows parents to demonstrate they are acting responsibly. Similarly, once a child with RTI presents, the GP feels the need to rule out any risk of harm in order to justify not prescribing.  Antibiotics are sometimes prescribed ‘just in case’ because a clinician is concerned about missing potentially critical illness or that the child’s illness will deteriorate, primarily for the sake of the child but also because of possible medico-legal consequences.

The rising concern for child safety in our society leads to a greater focus on immediate risks than on more distant future ones (such as antimicrobial resistance).  In relation to antibiotic prescribing, parents and clinicians correctly judge that they would receive far greater social disapprobation – as well as direct adverse consequences - for a child suffering avoidable harm from an infection, than for an unnecessary consultation or prescription. Similar concerns may be felt by clinicians and carers treating elderly or other groups who are collectively seen as vulnerable.

The heavy sanctions proposed leave GPs between a rock and a hard place

Pronouncements on the causes of over prescription of antibiotics tend to focus on a supposed lack of understanding (by patients) or ‘incorrect’ behaviours (of patients and clinicians), yet other cultural processes are more relevant to understanding high rates of antibiotic prescribing.

Research has shown that GPs seek to adjust their prescribing rates to fit with the perceived social norm, implying that behaviour which is in line with one’s colleagues is seen as correct.  It has also been shown that junior clinicians adjust their prescribing practices to match those of more senior colleagues, which can mean prescribing more liberally than when they first qualified (given evidence that antibiotic prescribing rates are higher among GPs over 55 years of age).

Patient pressure is also frequently cited, although while clinicians commonly assume that patients expect antibiotics, there is substantial evidence to suggest that this is not the case. The interaction between patients and GPs, on the other hand, can create positive feedback reinforcing erroneous views about which symptoms and signs indicate a need for antibiotic treatment.

The heavy sanctions proposed leave GPs between a rock and a hard place. Where there is clinical uncertainty, if they don’t prescribe and the child becomes seriously unwell, or they do prescribe but this is deemed to be unnecessary, they may face serious consequences. This is not a sensible way to support clinicians to reduce antibiotic prescribing safely.

We need research that helps reduce clinical uncertainty, so that clinicians can feel more confident about whether or not antibiotics are needed. There are several research groups working in this area, including our own, and producing evidence and tools to support clinician prescribing practice.  We also need greater understanding of the cultural processes which influence prescribing and treatment seeking.  The problem of over-prescription of antibiotics need to be addressed through interventions across all social groups to change the underlying cultural and structural processes that have such a powerful influence on all of us.

By Dr Christie Cabral, Dr Helen Lambert and Dr Alastair Hay, Centre for Academic Primary Care Centre for Academic Primary Care, Department of Social and Community Medicine, University of Bristol

 

*The TARGET Programme is funded by the National Institute for Health Research’s Programme Grant for Applied Research Programme. This blog post summarises independent research funded by the National Institute for Health Research (NIHR) under its Programme Grant for Applied Research (Grant Reference Number RP-PG-0608-10018). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

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Readers' comments (10)

  • Vinci Ho

    While uncertainty remains at the point of prescribing in an individual circumstances , the word 'inappropriate' cannot stand as adverse outcomes cannot be categorically excluded.
    In common law , benefit of any doubt will go to the defendant .
    Please respect.

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  • Well done Alastair
    if only we could infect the press with common sense

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  • there is substantial evidence to suggest that this is not the case

    sorry i question that substantial evidence! it certainly is not the case for the people i see.
    If you do not reform regulation this problem will hound us

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  • Vincenzo Pascale

    Have your ever heard about civil disobedience? Against the barbarity of Nice's proposals. it's the time to rebel. Or Now or Never

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  • Avoid CQC, NICE, 10% cuts in pay! cuts in MPIG, seniority,pensions , indemnity, imposed Contracts, increasing workloads - just do not become a GP. I am amazed that 80% of training places are taken. Do they not know what they are going to meet.

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  • Good work and thank you to CAPC Bristol for this thoughtful, evidence-based contribution. Need more of these measured, informed insights rather than threats and blame.

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  • An increasing trend in our GP land is the prescribing of a 'pocket prescription' in those cases where we feel antibiotics are not required at the time of examination. This applies to all ages but seems more common in children. It would be relatively easy to set up some research to see how many of these scripts were actually activated, and if not why not.

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  • There has been research regarding delayed prescriptions. Was spoken about in the antibiotic stewardship PBSGL module. Can't remember exact numbers but a reasonable number were never used.

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  • " This is not a sensible way to support clinicians to reduce antibiotic prescribing safely. "
    Absolutely. None of us doubt it needs to be addressed but this will actually make that "antibiotics not needed here" conversation fraught with suspicion. It is counterproductive. This needs to be a shared decision and we need time to do it properly

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  • NICE supposed to be evidence based.
    The claim was not substantiated and furthermore failed to mention that antibiotic resistance is also a result of Hospital prescribing, especially in A &E, veterinary, nurse prescribers and I believe dairy herds get their fair share.
    Come on. Spread the load.

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