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GP antibiotic prescribing under the microscope

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The panic surrounding increased levels of antimicrobial resistance has infected all levels of health policymaking, from Number 10 and Public Health England (PHE) to the CQC.

And, in the midst of the panic, there is one group of convenient scapegoats – GPs.

Public health chiefs have already announced plans to make GP practice-level data on antibiotic prescribing publicly available on the PHE website from next April.

But Pulse can reveal they are planning even more radical measures to put the spotlight on GP antibiotic prescribing, including possibly introducing targets into the GP contract and publishing individual GP prescribing rates.

However, this is only one element of a multipronged attack. The CQC also has plans to publish practice-level data on prescribing of antibiotics and benzodiazepines, as part of its ‘intelligent monitoring’ of practices, currently being rolled out.

But this obsessive focus on GPs’ prescribing habits begins to look dangerously misguided when PHE’s own data are brought into the equation.

Its new report on antimicrobial resistance shows antibiotic use rising overall, but a 3.5% drop in the total number of antibiotics prescribed by GPs between 2012 and 2013 – although this was offset by an increase in prescribing of some 3.5% in hospitals.

Catastrophic threat

Early last year, the chief medical officer described the problem of antimicrobial resistance as a ‘catastrophic threat’, and warned that within 20 years, without urgent action, even routine operations could become deadly because of the risk of infection.

The Government’s Five-Year Antimicrobial Resistance Strategy, launched shortly after the CMO’s comments, placed an emphasis on conserving existing antibiotics at the same time as promoting the development of new drugs. Although not a primary focus, the strategy hinted at work with NHS England to improve current guidance on antimicrobial stewardship in general practice.

Meanwhile, media reports have since repeatedly quoted shadowy ‘Downing Street spokesmen’ on the planned publication of individual GP prescribing data – something Number 10 has repeatedly denied to Pulse.

‘How many deaths can the country handle?’

‘The Government is asking clinicians and the public to reduce antibiotic use in a setting where we aren’t able to advance data that conclusively shows you get a reduction [in resistance].

‘There is no clear biomarker that clinicians would have faith in that can sufficiently rule out a bacterial infection. The rare events that lead to rapid death in a patient happen in people with none of these signs or biomarkers – so it’s a question of how many deaths the country can handle, from pneumococcal disease or other fatal diseases that evolve very rapidly.

‘We get two or three of them every year, and they are highlighted in the press, so the problem sticks in the mind of doctors and families.’

Professor Derrick Crook, professor of microbiology and head of the Oxford Public Health England collaborative NIHR Health Protection Research Unit, speaking at Public Health England’s 2014 conference

Yet this is an issue that has been ongoing for more than a decade. The Department of Health set out guidance to tighten up antibiotic prescribing in 1998, while in 2008, NICE brought out guidance recommending use of delayed prescriptions for self-limiting respiratory tract infections.

But a recent study found that, despite an initial drop in antibiotic prescribing, there had been a 40% increase in scripts for coughs and colds from 1999 to 2011, and surveys reveal that nine out of 10 GPs feel under pressure to prescribe the drugs.

And it seems policymakers have now decided that GP prescribing should be their main target for action.

Pulse revealed last month that PHE had been in discussions with NHS England about potentially putting antibiotic prescribing targets into the GP contract – and making data on individual prescribing available.

Professor Anthony Kessel, director of international public health at PHE, and a former GP, tells Pulse that cutting antibiotic use by GPs is a priority.

‘It makes sense to try to drive down the total amount of prescribing, especially in areas where it’s particularly high, because we will anticipate seeing a fall in resistance as a result,’ he says.

‘This is the start. Our intention is to make these data available more frequently than annually, and at practice level, but ultimately – although we can’t get there yet – individual practitioner, prescriber level.’

Peer support

Alongside this radical move to highlight individual prescribing rates are a series of more conventional measures, such as increasing education and peer support to change prescribers’ practice, refining the TARGET toolkit on the RCGP website, and new NICE antimicrobial stewardship guidelines coming out next year.

But a bigger change is being considered, Professor Kessel adds: ‘There will be new mechanisms, especially through work we’re doing with NHS England, to hold local health economies to account through contract arrangements and so forth.’

Asked if these mechanisms would include measures introduced into the GP contract, he concedes: ‘Potentially, yes.’

The CQC is also getting in on the act. Speaking to the RCGP conference in Liverpool last month, the chief inspector of primary care, Professor Steve Field, told delegates that the regulator would also be publishing data on practices’ antibiotic prescribing.

He said: ‘We’re… going to publish lots of data on every practice very, very soon, down into the prescribing of antibiotics and benzodiazepines.’

But GPs are already doing better at curbing antibiotic use than all other prescribers in the health system – and have most recently cut prescribing rates, according to PHE’s own figures.

Its report – the English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) 2014 – brings together community and hospital data on prescribing and antibiotic resistance for the first time.

It shows there was an overall 4.1% increase in total antibiotic prescribing by GPs over the four-year period between 2010 and 2013, but a drop of 3.5% from 2012 to 2013. By comparison, antibiotic prescriptions to hospital inpatients increased by 3.5% year on year, with a much bigger 12% rise over the same four years. Total prescriptions from other community services – including walk-in centres and dentists – rocketed by 32%.

Community prescribing

PHE is unclear why there has been such a big rise in ‘other community’ antibiotic prescribing of late, as these data cannot be broken down as yet. But it says the large proportion are from dentists, and are ‘likely to be a gross underestimation of dental prescribing, as up to 50% of dental treatments are performed privately and private prescriptions are not captured in these data’.

Dr Richard Vautrey, GPC deputy chair and a GP in Leeds, says the report shows GPs are already the most responsible prescribers in the health system.

He says: ‘These figures suggest GPs are working hard to address this issue and others have to catch up. It’s something we’re very aware of and GPs particularly have had a focus on prescribing for a generation – that’s probably why we are doing that bit better.’

But PHE points to variation across the country, with total antibiotic use in general practice 40% higher in the north-east of England than in London. PHE experts acknowledge this may be partly due to the way patients access healthcare – for example, they say more patients in London attend hospitals than GP practices. Hospital prescribing levels in London were highest nationally.

PHE, along with the DH and NHS England, has developed a set of antimicrobial prescribing performance indicators for primary and secondary care. The key targets for GPs are to reduce each CCG’s total antibiotic prescribing to 2009/10 levels, and to cut the proportion of cephalosporin, fluoroquinolones and co-amoxiclav classes used to less than 10% of total antibiotics prescribed, by 2018/19.

But it is the threat to expose individual GP prescribing rates and introduce contractual targets that is causing exasperation among GPs.

Dr Vautrey says targets are not the way to tackle inappropriate antibiotic use. He says: ‘I don’t think it would be a good idea [to put this in the GP contract]. I think we want to move away from those sorts of targets. We know what our professional and prescribing responsibilities are.’

He adds: ‘There’s always room for improvement, however well we’re doing and that’s the case not just for GPs but for everyone in the health service. The focus is on GPs because the data are there, whereas it isn’t readily available for other prescribing, such as in hospitals, veterinary surgeries, farming and dentistry – and also because there is a greater focus on the individual prescriber within general practice as opposed to hospitals, where it’s much more team-based.’

What does Public Health England plan to do?

• From April, data on GP practice-level antibiotic prescribing will be published by Public Health England, so people can ‘at the click of a button’ see how practices compare in the CCG area and nationally. Data on each individual GP’s level of antibiotic prescribing will also be added in future.

• This will be part of a ‘platform’ where ‘organisations can interrogate the key resistance and consumption measures’.

• Individual hospital pharmacy data will also be added ‘once validated’.

• The DH, PHE and NHS England have set out two key targets for primary care:

– Reduction in total annual antibiotic consumption to 2009/10 levels by 2018/19.

– Reduction in cephalosporin, fluoroquinolone and co-amoxiclav classes to <10% of total antibiotic items by 2018/19.

• PHE chiefs are also in talks with NHS England on contractual arrangements to hold CCGs and public health directors to account; this could ‘potentially’ involve performance-management of GP practices through the GP contract.

Source: PHE ESPAUR 2014 report


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