The RTI clinical iceberg

The paper ‘Expectations for consultations and antibiotics for respiratory tract infection in primary care; the RTI clinical iceberg’1 has striking workload implications for GPs given that 58% of the UK population surveyed reported an RTI in the preceding 6 months, for which one in five had contacted their GP surgery. It is an important finding that over half of those patients contacting the GP expected antibiotics (53.1%).

However, exactly how big the problem of over-prescribing is cannot be determined from this study as the survey did not ask responders if they had been prescribed antibiotics for an RTI. Presenting data on expectations for antibiotic prescription for an RTI next to data on antibiotic prescription for any condition, as the ‘clinical iceberg in RTI’ (Figure 2 in the article), is perhaps misleading. Furthermore, although we are told that ‘97% of participants were prescribed an antibiotic when they asked for one’, we are not told how many of the 74% who did not ask for antibiotics were prescribed them. Therefore it is not possible to attribute antibiotic prescription to patient demand.

Time pressures in primary care undoubtedly run counter to the need to minimise inappropriate antibiotic prescription as it takes longer to perform a full clinical and psychosocial evaluation of a patient, with education and safety-netting, than to issue an antibiotic. The paper overlooks the psychosocial drivers behind patients’ attendance with minor RTIs, presumably because they did not emerge as themes in the qualitative interviews; that those of lower socioeconomic status were more likely to have contacted their GP surgery than those of higher socioeconomic status hints at the possibility of life difficulties, coping skills, and educational attainment all influencing the need to consult in RTI.

On a more positive note, it is encouraging to learn that among the 14% of patients given a delayed prescription, a large minority (38%) did not collect them, confirming the usefulness of this strategy.

That 47% patients with RTIs consulted because their symptoms had not improved after several days confirms that patients often have unrealistic expectations about symptom or illness duration.2 Patient education on this topic needs to be delivered effectively by GPs in their consultations, and in any public health campaign to reduce demand.

• © British Journal of General Practice 2013