on NICE and antibiotics

Call to Punish GPs over antibiotic use” was the headline on BBC News  that greeted me yesterday morning. The article attributes this title to an interview with Prof. Mark Baker of NICE, talking about the new NICE Guidance on Antimicrobial Prescribing.

Cue my indignant anger, reflected in a quote from the Royal College of GPs noting  “Any suggestion that hard-pressed GPs – who are already trying to do their jobs in increasingly difficult circumstances – will be reported to the regulator is counter-productive and unhelpful.”

However,  if you actually listen to the interview, it’s 1min 44sec of really rather sensible stuff (importance of antibiotics, most doctors prescribe sensibly, need to measure, understand, use education etc to improve things) and 20 seconds at the end about ‘coming into line’ using ‘performance processes’ via the GMC etc.

But I suspect most people aren’t actually going to click and sit through, they’re going to read the headline and believe that it represents what Prof. Baker said, not entirely unreasonably. Indeed, I’ve since had 5 or 6 colleagues come up to me and ask me about all the GP-bashing in the news.  It’s an odd one – I still can’t work out why it is GPs that seem to have come under fire this time,  and why we hospital docs seem to have ducked under the firing line of this particular media salvo.  The NICE Guidance reflects all prescribers, and I honestly can’t find anything in Prof Baker’s interview or the text which makes it GP specific except for the fact it’s GPs who have provided the comments in reply.

Which leaves me with the question…. why?? Why churn up this subject with accusatory statements? Why totally deflect attention away from a very sensible, reasonable set of guidelines by making it about GP-punishing?

I’m sure everyone will have their own views. Do I personally find it frustrating that Prof. Baker talked about disciplinary measures in an interview, when surely it could have been anticipated that this would be jumped on by the press? Yes. Some of my colleagues have highlighted what seems to be the current political agenda to find any possible negative portrayal of Doctors, and create ruckus and friction. But usually I’d expect to see that sort of stuff in the Daily Mail, not BBC News quoting a NICE representative (in my mind: hey, these are the good guys! Or at least, better guys).

Most of all I find it frustrating on behalf of everyone who has worked incredibly hard at the Guidelines, only to have them reduced to a single line which utterly fails to represent their sentiment, aim, and their progressive, practical, collaborative nature.

I’ll finish by noting that it seems totally counterproductive to, one one hand, threaten to name and shame Doctors for missing cancer diagnoses, or introduce financial penalties for missing treating sepsis,  and then on the other hand say that by over-using antibiotics (to avoid ‘missing’ treating infections or possible sepsis) we should also be disciplined. And also that it risks unfairly targeting Doctors who deal with a high number of ‘grey cases’ such as in highly-dependent elderly patients, where the definite diagnosis of infection requires invasive, distressing investigations and otherwise unnecessary stays in the alien hospital environment. I could write a long piece about the challenges of striking the right balance whilst respecting your patient in a severely time-limited over-worked setting, but this piece by a hard-thinking, hard-pressed GP, does it far, far better than me. Well worth a read for anyone who feels in the mood to give GPs stick about antibiotics.

And it’s certainly made me think harder before starting/joining in an irate twitter tirade against the wrong people based on a misrepresentative headline.

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P.S. For the evidence-based colleagues around, there was also a question about whether there was any evidence that disciplinary-based measures actually addressed antibiotic overuse. Well… sort of

For anyone who hasn’t seen it, there is a quite remarkable paper from a few months ago in PLosOne about a dramatic antibiotic reduction in multiple healthcare centres in China .  A multilevel approach appeared to reduce antibiotic use by around 50% over about a 1 year period.  An article which includes the illuminating phrase “disciplinary actions caused by infringement on the antibiotic guidelines lead to the cessation of the prescribers’ medical career.”

redb

Antibiotic reporting in DDD/100 bed days from 2010-2014, reproduced from article above.

To be noted:  this is reported antibiotic use (bear in mind the severe results of reporting over-use).   It also doesn’t tell us whether it was all achieved by reducing inappropriate use, or whether it might have resulted in patients not getting the antibiotics they needed. It’s in a totally different setting, different bugs, different resistance patterns, different economics of healthcare, with different culture around both antibiotic use and state-control/enforcement.

Ultimately, does threatening medical disciplinary action for antibiotic use improve the care of patients with possible infection?  That’s the question I’d want answered, I think, if I were a patient. And really, if someone can enlighten me with a proper reason behind all this I’d love to hear. Was this genuinely an important message that NICE wanted to put out? I don’t believe in knee-jerk reactions blaming it all on government agendas/sensationalistic attention-grabbing journalism without looking for other alternatives first….

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