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Revealed: Ministers consider using revalidation in crackdown on GP antibiotic prescribing

Exclusive Ministers have been encouraged to set national targets and use revalidation to hold individual GPs to account for their prescribing of antibiotics to combat fears of spiralling antimicrobial resistance, Pulse can reveal.

Documents published by the Department of Health this week reveal ministers are planning a wide-ranging crackdown on antibiotic prescribing by GPs, including setting national QIPP targets, new QOF points for delayed prescriptions and including  requirements in revalidation.

In an effort to encourage more prudent prescribing of antibiotics by GPs, Government advisers have recommended focusing heavily on the audits within revalidation and measuring ‘prescribing confidence', and specifically antibiotic prescribing,as part of the process.

The advisers also recommended developing national indicators of antibiotics prescribing and pushing for ‘an overall reduction of total antibiotic use in the community' to the 25th centile'.

The DH is acting on evidence, first reported in Pulse and later published in the BMJ in 2010, that increased antibiotic prescribing in general practice is associated with increased antimicrobial resistance.

Minutes from a meeting of the Advisory Committee on Antimicrobial Resistance and Healthcare-Associated Infections (ARHAI), a Department of Health advisory committee, show the paper was discussed in the meeting, and ‘prudent antibiotic prescribing in primary care was advocated'.

The minutes state: ‘It was acknowledged that changing behaviour was not easy and that there were a variety of incentives that could be used to increase the motivation to change.'

'A key indicator of overall reduction of total antibiotic use in the community was supported. Currently community prescribing is going up and as antibiotics are relatively cheap, cost is not an incentive to reduce prescribing. Reduction in prescribing could be achieved if it were to be made a priority for GPs and medicine managers.'

But the advisors noted that ‘with no contractual levers and only a small budget the methods of influencing GPs and bringing about change had to be innovative'.

The suggestions made during the meeting include assessing GP prescribing as part of revalidation, and developing a new indicator with the National Prescribing Centre, along similar lines as the existing QIPP Better Care Better Value indicators, to encourage ‘an overall reduction of total antibiotic use in the community' to the 25th centile.

The document states: ‘The GMC prescribing frameworks will apply to [new medical] graduates and all other medical practitioners will be assessed against these in re-licensing and revalidation. A similar approach is required for other prescribing professionals and the next stage is to re-engage with the bodies in charge of curricula. The need for audit and inclusion of prescribing confidence in revalidation processes was noted.'

With regards to new prescribing indicators, it reveals: 'It was suggested that a reduction in prescribing to the 25th percentile may be appropriate however this should be discussed with the National Prescribing Centre, and then agreed by ARHAI. Consideration would need to be given to practice age range, seasonality, local and national resistance patterns. If a reduction in prescribing is to be set as the 25th percentile this would need to be "set in stone"'.

The committee also suggested that reducing antimicrobial prescribing 'would be an ideal QOF indicator', and recommended encouraging GPs to offer patients delayed prescriptions for antibiotics, as 'it is cost effective to take more time to explain why an antibiotic has not been prescribed and reduces repeat consultation.'

Figures published this week by the NHS Information Centre show the number of antibacterial drugs prescribed in the community rose by 3.8% between 2009 and 2010, from 38.7 million to 40.2 million.

A Department of Health spokesperson said: ‘This work is still in its early stages and further discussion with other interested parties is required before firm recommendations can be made.'

But he added: ‘We are keen to take this forward and expect recommendations to be made in 2012. It is important to remember that many antibiotics are still being prescribed when they don't need to be. It is vital that GPs only prescribe antibiotics when appropriate and limit the use of broad-spectrum antibiotics to those who really need them.'

Dr Bill Beeby, a GP in Middlesborough and chair of the GPC clinical and prescribing subcommittee, said linking antibiotic prescribing to revalidation would be 'a very dangerous precedent.'

'It would become very complicated. You need to consider overall usage and patient mix. If you see a lot of people with acne, or chronic bronchitis, it's very possible your antibiotic prescribing will be higher. These things are never simple.'

Dr Andrew Green, a GP in Hull and member of the GPC sub-committee, said: 'I don't think revalidation is the most appropriate way. In order for audits to be meaningful they have to about things that GPs feel are important, after discussion with their appraiser. We don't want to see outside bodies, however well-meaning, trying to influence elements of revlidation.'

But Dr Alastair Hay, consultant senior lecturer in primary care at the University of Bristol and a GP in the city whose BMJ research prompted the recommendations, said: ‘GP prescribing does influence resistance and GPs need to take account of that in their prescribing decisions. Hitherto it's has been regarded as a theoretical link but it's very evidence-based now.'

‘I think this is a valid strategy to make GPs are aware of and monitor their antibiotics prescribing rates and also the types of antibiotics they prescribe. Appropriate prescribing means using the most narrow spectrum antibiotics possible, and avoiding broad spectrum antibiotics, and asking GPs to audit their own prescribing is an excellent way to do this.'

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