Summary of the main findings
Antibiotic prescribing and, to a greater extent, patient consultation rates for acute respiratory infections varied widely between practices and over time. Practices with lower proportions of consultations resulting in an antibiotic prescription also had lower consultation rates for acute respiratory infections. Moreover, those practices that succeeded in reducing their antibiotic prescribing over time also experienced reductions in consultation rates. Although an observational study cannot prove that the relationship is causal, our results are consistent with the hypothesis that reduced antibiotic prescribing discourages GP re-attendance. The reverse explanation, that a falling consultation rate discourages antibiotic prescription, does not have a plausible underlying explanation. Indeed, it is possible that patients in practices with particularly low consultation rates for respiratory infection only attend with more severe symptoms and there may then be a stronger indication to prescribe, although our data showed no evidence of this trend.
These data were gathered over a period of 6 years, during which antibiotic prescribing and consultations for respiratory infections declined steadily. Since we analysed antibiotic prescription rates per consultation rather than the total volume of antibiotic prescriptions, observed reductions in prescribing did not occur simply because fewer people consulted with a respiratory infection. We consider the most likely explanation of our findings to be that patient expectations and illness behaviour have changed.8 Based on the concept of the ‘iceberg of illness’, which suggests that most patients do not consult with self-limiting illnesses, just small changes in help-seeking behaviour are likely to result in large changes in consultation behaviour. Others have suggested that a secular change in the incidence of a wide variety of acute respiratory infections might have occurred, accounting for the reductions in GP consultations for these illnesses.3 However, the true community incidence of respiratory infections remains unknown and cannot be estimated by extrapolating from the GP consultation rate.
Strengths and limitations of the study
Our dataset did not allow us to measure any confounding effects of consultation duration. It is possible, therefore, that reduced consultation rates might be more closely related to longer consultations than to reduced antibiotic prescribing.9 We had no first-hand qualitative data from patients, using methods such as symptom diaries, which could have demonstrated whether consultations for respiratory infections not resulting in an antibiotic prescription changed the consultation behaviour for similar illnesses on subsequent occasions. Such information would have strengthened the hypothesis that there was a causal relationship between these two factors.
The data were generally consistent across the grouped condition, ‘all respiratory infections’ and individual types of acute respiratory tract infections. Two individual categories of respiratory infection, laryngitis and sinusitis, did not reflect the more general pattern of lower antibiotic prescribing associated with lower consultation rates in the 1997 dataset. Similarly, reductions in antibiotics over 6 years were not associated with reductions in consultation rates for some individual categories of respiratory infection, although the correlation was significant for ‘all respiratory infections’.
Reductions in the recording of respiratory infections could have been an artefact, occurring because of changing recording patterns by GPs. We consider this unlikely since other possible consultation codes for respiratory diseases, symptoms, infective agents or non-specific infections showed no concomitant increases. Data that corroborates our findings have recently been published. Other researchers exploring the GPRD, but using a different methodology, have reported similar reductions in consultations for certain respiratory infections and in the proportion of consultations resulting in an antibiotic prescription.10
This study is the first to demonstrate a link between declining antibiotic prescribing and consultations for acute respiratory infections at practice level. The GPRD practices selected for this study covered just over 1% of the national population.
Implications for future research
Acute respiratory infections form a major component of GP workload.2 The GP's own behaviour, in terms of prescribing antibiotics, may have a bearing on long-term consultation rates for these infections. It has been suggested that increases in antibiotic prescribing by GPs in the early 1990s resulted in the medicalisation of self-limiting acute upper respiratory tract infections.11 Since 1995, the prescribing pattern has changed, antibiotic prescribing for upper respiratory tract infections has declined and our results suggest that the opposite process, de-medicalisation, might be taking place.
Medicalisation is defined as a process whereby aspects of everyday life come under medical dominion, influence and supervision.12 This phenomenon may occur at a broad conceptual level when there is a general perception within society that a condition is medical; or, it may occur at a more individual level, in the presence of the doctor, when a condition is diagnosed, awarded a medical label and treatment is administered.13
If we were observing the consequences of de-medicalisation, then this process would most likely be acting at an individual level, resulting in changes to the illness behaviour of patients with respiratory infections. Patients attending practices in which an antibiotic prescription for such infections was no longer an automatic outcome of their visit to the GP may consider alternatives to a GP consultation when suffering their next respiratory infection. Thus, the GP's action in prescribing fewer antibiotics may contribute to the process of de-medicalisation or may even initiate this process. Patient awareness about self-treatment options and the ineffectiveness of antibiotics in most acute respiratory infections would also contribute to the belief that these symptoms are not within the medical realm.
On the other hand, the twin processes of reduced antibiotic prescribing and reduced consultation for acute respiratory infection may not have been causally linked. For some years, GPs have come under pressure to curtail antibiotic prescribing. Similarly, patients have been advised through various health education campaigns to avoid bringing ‘coughs and colds’ to the doctor. Certain health authorities or primary care trusts may have been more vigorous in deterring patients from consulting with minor illnesses and discouraging GPs from antibiotic prescribing, possibly seeing both approaches as a means of achieving improved antibiotic prescribing indicators within the locality. Under these circumstances, patients might simply have transferred the object of their help-seeking behaviour away from GPs and towards other primary care professionals such as community pharmacists.
Further research, using a more qualitative approach, would be helpful to explore the processes involved in determining whether or not patients with respiratory infections choose to consult a GP. If unwell patients are choosing not to consult their GP, then we need to know about patients' experiences of, and satisfaction ratings for, subsequent self-care. There was no evidence from our data that low antibiotic prescribing resulted in more respiratory complications, such as pneumonia, but we need to know more about whether patients are aware of possible danger signs when they are ill but choose not to consult.
While the data presented reveal a continuing downward trend in GP consultations for respiratory infections, these reductions are much more evident in some GP practices than others. Our findings support the hypothesis that reduced antibiotic prescribing for acute respiratory infections reduces the likelihood of GP re-attendance. This consequence may be explained by the process of de-medicalisation, in which patients and doctors increasingly perceive some of these infections as being outside the domain of medical care. Whether these twin phenomena really are causally related can only be determined by qualitative, community-based studies that capture the views of patients deciding whether or not their respiratory symptoms merit an appointment with the GP and their attitudes based on the experience of previous antibiotic prescribing decisions.
