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.