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CMO's personal letters to ‘overprescribing’ practices cut prescriptions by 3%

The Chief Medical Officer sent letters to individual GPs warning them about their practice’s overuse of antibiotics, which public health chiefs claim resulted in 3.3% reduction in antibiotics dispensed by the highest-prescribing practices.

The letter – addressed to named individuals and signed off personally by Dame Sally Davies – was sent to half of practices that were among the top 20% of prescribers in their region (totalling 1,584 practices in all), with the other half receiving no such letter, as part of a randomised trial.

It warned the GPs that the majority of practices in their area prescribed fewer antibiotics than their own practice.

Researchers at Public Health England (PHE) said that six months after the letter was sent out, the rate of antibiotic prescribing had reduced by a statistically significant 3.3% at these practices when compared with the other high-prescribing practices where GPs did not receive it.

This would equate to more than 73,000 fewer antibiotic prescription items overall.

The letter said ‘reducing unnecessary prescriptions of antibiotics in primary care may help prevent a public health catastrophe’.

And in the second line, in bold, it tells the addressee that ‘80% of practices in your area prescribe fewer antibiotics per head than yours’.

It goes on to give information and instructions on cutting down antibiotics, including use of the TARGET toolkit, while a TARGET patient leaflet was also provided with the letter.

Lead researcher Dr Tim Chadborn, behavioural insights lead at PHE, said the letter helped bolster ‘GPs’ belief in the consequences of over-prescribing’, while emphasising ‘the link between their personal prescribing behaviour and the impact of antibiotic resistance’.

The findings come after a leading NICE expert said GPs who persistently overprescribe antibiotics should be referred to the GMC, while GPs are under pressure from their CCGs to meet targets on reductions in antibiotics prescribing.

The NHS Atlas of Variation in Healthcare, published today by PHE, highlights a 2.5-fold variation across CCGs in the percentage of key antibiotics prescribed in primary care, and calls on the highest-prescribing CCGs to cut prescribing.

Dr Andrew Green, chair of the GPC’s clinical and prescribing subcommittee, said the PHE initiative was ‘encouraging’ and that letters would be preferable to threats or sanctions, as this gave GPs support to change their prescribing rather than ‘naming and shaming’ them in public.

He said: ‘GPs in general are interested in how their work compares to that of their colleagues, and keen to improve if that is needed. The key thing here is not that they were informed that their prescribing was above average (and of course there may well be valid reasons for this) but they were also provided with tools that enabled change.’

Dr Green added: ‘I believe it is the combining of the provision of relevant data with the toolkits that has produced the change in prescribing, and that this approach is more productive than public naming and shaming, or threats of GMC referral.’

Dr John Cosgrove, RCGP Council member and a GP in Birmingham, said he ‘sympathised with colleagues who will have received such a letter’ as ‘GPs are now facing threats from all sides when what is sorely needed is collaboration and understanding’.

He said that some GPs ‘may have high antibiotic prescription rates through no fault of their own’, for example because of a more vulnerable or anxious local population, and that ‘as such, their workload may already be unusually high and sending such a letter therefore risks putting under further pressure those least able to bear it’.

Dr Cosgrove added that the approach could nonetheless be of ‘considerable benefit’ to GPs by cutting down future consultations, and countering ‘anxiety-provoking’ campaigns around sepsis, but that he ‘would want to see it backed up with adequately resourced support and efforts at a population level to allay health anxieties rather than stoke them in a non-evidence based quest for ever earlier diagnosis’.

Readers' comments (12)

  • Due to recruiting difficulties lots of Locums used, their antibiotic prescribing wil be attributed to a Principle, individually becomes a high prescriber, in reality not an outlier.

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  • I thought we'd already demolished this nonsense. We already know that vast amounts of antibiotics are used in farming but the CMO has chosen to attack doctors where there are likely to be strong demographic factors for higher antibiotic use.

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  • @11:02

    There's something in that, but surely the fact that GP antibiotic prescribing can be reduced by 3% simply as a result of a few minutes typing and a 60p stamp is cause for celebration, not defensiveness?

    Here is a simple, cheap intervention showing an impressive result. We should be welcoming the research.

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  • Has anybody looked to see if there was an increase in admissions from those practices.

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  • Has anyone looked to see if there was an increase in consultations at urgent care centres, out of hours services and walk-in centres for patients from the relevant GPs

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  • one of my partners is an anti-antibiotic zealot. I admit all his quinsies, septicaemias and pneumonias the day after he sees them (or more often telephone triages them). All this study shows is how terrified those docs were that more criticism and scrutiny was about to descend on them, so they neatly deflected off the patients to the walk-in clinic, simples!

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  • If these practices are outliers, regression to the mean would be another explanation.

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  • @11.35
    Surely this is an excellent point. Why are GPs so defensive? I find it hard to believe that every patient I hand antibiotics to when they frequently show no outward signs of illness is in desperate need. I frequently tell patients 'no you don't need antibiotics at this stage'. At the end of the day we are the professionals so why are GPs so scared to say no? Though I must had I think it's important other HCPs back GPs up and explain the importance of not using antibiotics unnecessarily.

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  • " surely the fact that GP antibiotic prescribing can be reduced by 3% simply as a result of a few minutes typing and a 60p stamp is cause for celebration, not defensiveness?"

    I'd have thought getting results by threatening people is the last thing we should be celebrating. All that you are doing is recalibrating doctors risk thresholds...for a while. It's cheap and crude.

    "At the end of the day we are the professionals so why are GPs so scared to say no?"
    I think you know the answer to that one. GPs now work in a world of fear where patients can refer you to the GMC by tapping on the screens of their iphones. Legal claims including so-called 'missed sepsis' have gone through the roof (you can even go to prison for this) and we receive little public support when things go wrong.

    The reality is that most GPs give antibiotics to people who are really ill or have underlying health problems that put them at risk. The education needs to be directed at changing the culture of expectation that some of the public have become indentured to.

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  • if cmo is sent a letter if he did not reduce 10% of his monthly expenses he will loose job. i think he will reduce his expense by 20% . such news does not prove any thing

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