There are many issues to consider in a GP consultation – prevention, discussion, examination, ruling out serious illness. So why do patients assume that dealing with infection is a simple business?
The rise of antimicrobial resistance and acquired infections, such as C. difficile, has increased the importance of prescribing antibiotics appropriately.
The need for careful prescribing was debated recently, as the chief medical officer again highlighted the issue of antibiotic resistance to mark Antibiotic Awareness Day on 18 November. And yet, as Pulse reported last week, the National Pharmacy Association (NPA) is planning the national roll-out of a scheme giving patients access to some 16 medicines – including antibiotics – without a GP consultation, via a patient group direction.
GPs everywhere notice an increase in consultations when winter approaches, as infections increase and hospitals report increased admissions. And allowing pharmacists to offer certain antibiotics without a prescription would indeed reduce workload during this busy period.
Increased resistance and perhaps the failure to identify other conditions is often not an immediate ‘adverse event’. Delayed diagnosis may not become apparent for some time, particularly if information is not shared to ensure appropriate follow-up. Coughs persisting for three weeks may be a chest infection, but chest X-rays are recommended to exclude lung cancer. How do we identify patients with recurrent urinary infections who may require investigations if they attend multiple pharmacies? Patients with chlamydia may benefit from easy access to azithromycin, but is contact tracing likely to occur?
The list of antibiotics available in the scheme is interesting. Most local antibiotic guidelines recommend amoxicillin as first line for chest infections, based on evidence, cost and reducing resistance, and yet it is not on the NPA’s list. Should patients presenting to a pharmacist not expect to be treated in the same way?
In Bassetlaw, where I work, we identified the need to reduce prescriptions for certain antibiotics due to a high local rate and concerns about the number of C. difficile infections. There is evidence of an association between cephalosporins and quinolones (such as ciprofloxacin) and the risk of C. difficile, as well as resistance. We reduced the percentage of these antibiotics from 14% of all antibiotics to 4%. This was a sustained change, and has led to a significant reduction in local C. difficile infections. Yet ciprofloxacin is included in the NPA’s list.
I wouldn’t support the introduction of the NPA scheme in my area.
We already know how difficult it can be to persuade patients that antibiotics may not be needed. They often use walk-in centres for a ‘second opinion’ when their GP refuses a request for antibiotics. Just think how easy it could be for a patient to get what they want if they had half a dozen pharmacists to harangue. An NPA spokesman describes the proposals as ‘all about improving access to self-care’, but buying antibiotics without obtaining a GP prescription isn’t necessarily self-care; it’s just using a different route to get them.
Reviewing medication, reducing polypharmacy and improving prescribing in nursing homes are excellent initiatives that allow pharmacists to improve quality and reduce morbidity and admissions. But pharmacists are experts at medication, not diagnosing, safety netting or consulting.
We need a consistent message on antibiotics: they are essential, but it is important to use the right one at the right time. It is difficult to understand the rationale of reducing antibiotic prescribing and encouraging patients to self-care, but then making antibiotics available without an individual prescription. The World Health Organisation has repeatedly identified antibiotics being accessed without a prescription as a factor contributing to resistance in many countries. The UK should not join that list.
Dr Steve Kell is chair of NHS Bassetlaw CCG and a GP in Doncaster
