Ninety-seven practices were invited and 15 expressed interest (15% response rate). Nine practices participated (Table 1). The study ran from November 2019 for 12 months. The COVID-19 pandemic from March 2020 onwards had an impact on UK general practice and study activities paused after this date. Results are focused on the period up to March 2020.
Champions and practice meetings
There were 11 champions across nine practices (Table 3). Seven champions answered the survey at 2 months. Six agreed that they were able to engage and encourage their colleagues to use the intervention resources; one was neutral. Champions were satisfied with how each AMS strategy was being implemented in their practice: communication strategies with leaflets (5/7); POC-CRPTs (7/7); and delayed prescriptions (7/7). Of the remaining 55 survey responders, 42/55 (76%) knew who their champion was; of those who did not, five were from practice H. Of those who knew their champion, over half agreed their champion encouraged colleagues to engage with intervention materials (29/55, 53%).
Interviews highlighted variation between practices in champion engagement with intervention materials. Five practices had clinicians who volunteered for the champion role. They were enthusiastic, often senior clinicians, with allocated time to dedicate to the role:
‘[She] has one session a week to do administrative work and she had the enthusiasm to do it, and she took it on, but it was on the proviso that she wasn’t having to do all the work, she passed over information to us but it was as long as we were all in on it. ’
(J2, GP, senior partner [the letter after each quote refers to the practice and the number, the participant]).
Four champions had been nominated for the role and appeared less engaged, with less time to give:
‘[The antibiotic champion] role came along with several other roles that were coming in, like children’s safeguarding, women’s health lead, opioid prescribing lead and we’re not a practice that has a lot of doctors. So, there’s a lot of roles that needed filling and there’s only so few hands, so somebody had to take something and it just fell to me. ’
(B1, GP)
Champions emphasised that they needed sufficient time to undertake the role of engaging others successfully, which was only possible for some individuals:
‘[You need] to select someone who willingly signs up, that shows motivation and if you can get the practice to commit to giving them some admin time every week, that way there’s structured time for them to engage. But if the [champion] is bogged down by admin and extra work, the motivation may be there but the energy isn’t and I think that may have been the same in my case. ’
(B1, GP)
‘I’m making sure that the [resources] are available to all the doctors. I’ve spoken to them and answered questions. Just trying to keep it in people’s minds really so they’re aware of it and they are thinking about the project and using the resources we’ve got … because it’s so busy here, it’s very easy for things to slip back into old routines … [the champion role] just means that the responsibility’s on one person to keep it current, else it will just get put in the back of people’s minds.’
(F1, non-prescriber)
Champion engagement influenced the content of practice meetings. Three champions (practices E, G, J) reported discussing all three AMS strategies with their teams. Other champions had not engaged with the website and only focused on physical materials (POC-CRPTs and leaflets, Table 3):
Interviewer:‘Can you tell me more what happened in that meeting? ’
Participant:‘[Doctor] did the front of house bit and I did the training bit. But all the team, both clinical and non-clinical were briefed on [the CRP machine]. ’
Interviewer:‘Did you focus on the CRP testing mainly in that meeting? Or were there other things? ’
Participant:‘It was a CRP meeting, also obviously about antibiotics — for looking at how they’re used generally within practice. I think [CRP] gives the doctors some evidence supporting their decisions really. ’ (F1, non-prescriber)
One champion (Practice J) focused on all three strategies and used the meeting slides provided on the website. The team decided how they would use delayed prescriptions and distributed patient leaflets and SureScreen tests to each consultation room:
‘Everyone who’s responsible for prescribing was at the meeting, we were all in agreement that we have to all be prescribing with the same ideals so that we could improve things.’
(J2, GP)
Website
Data showed that the website had 75 new users. Of all survey responders, 52% (32/62) had not visited the website at 2 months, 24% (15/62) had visited it once, and 21% (13/62) had visited it twice or more. Of 30 responders who had visited the website, most found the content helpful: communication strategies (19/30, 63%), delayed prescription (20/30, 67%), and POC-CRPTs (23/30, 77%).
In interviews, only one champion (Practice J) reported spending time on the website. Other interviewees were either not aware of the website or had only briefly looked at it, reporting that they already felt familiar with the content. Instead, champions had focused on the physical materials that had been posted to practices.
Some interviewees thought that the website was aimed at patients rather than themselves. Despite this, participants generally thought a website was an appropriate format for them to access information easily. Time was felt to be the main barrier to use:
‘[The website] will be a very useful thing, because all of us, even in our daily practice we use, I possibly use a dozen websites a day. So a website is good for quick referencing, so that you’re always one or two clicks away from things, so I would say it’s a very good idea. It’s a lot better than printed out information or email information.’
(B1, GP)
Interviewer:‘What, in your view, are the barriers to people going and looking at those resources online? ’
Participant:‘Time, to be honest, time. If you come in on a Monday morning and you’ve got four hundred prescriptions to do, and that’s, even before the day is out you’ll have got another two or three hundred. And to get through them is so fast and takes such a long period of time. I think the biggest obstacle in anything we have to achieve in primary care is time. ’ (H2, GP)
Communication strategies and patient leaflets
At the 2-month survey, most prescribers (28/35, 80%) responding to the survey were confident that they could effectively communicate a ‘no antibiotic’ decision without affecting patient satisfaction; this was up from baseline (19/39, 49%) (Supplementary Table S4). Prescribers reported that using patient leaflets interactively in consultations (29/35, 83%) had helped reduce antibiotic prescribing. At baseline 20/39 (51%) prescribers reported using patient leaflets in respiratory tract infection (RTI) consultations; at 2 months this had increased to 27/35 (77%) prescribers.
When commenting on discussing antibiotics with patients, interviewees referred to the need to ‘educate patients’. Interviewees from practices J and F had engaged with the communication strategies and discussed specific techniques that they found useful:
‘I’ve learned [about] using the resources to educate patients and explain to them that something lasting for four to seven days can be quite normal.’
(J2, GP)
‘The [handout] that gives points on how you can talk about antibiotics in a different way. I’ve been really advocating that, amongst the practice.’
(F2, GP)
Other prescribers felt they needed additional strategies (for example, POC-CRPTs) to back up explanations about no antibiotic decisions.
Interviewees were enthusiastic about leaflets and liked the evidence-based options provided, saying that they supported discussion although highlighted that leaflets were only used if close to hand:
‘If it’s not to hand it doesn’t really happen. A bit out of sight, out of mind, maybe we need to change that.’
(D1, GP)
‘We have them on the desk. We did that with all the clinical rooms. They are literally just in front of you. ’
(J1, GP)
Delayed prescriptions
At baseline most prescribers were confident that they could explain a delayed prescription to a patient and this did not change at 2 months (Supplementary Table S4). At 2 months, most prescribers reported using delayed prescriptions (29/35, 83%).
Most prescribers (25/31, 81%) agreed that increased use of delayed prescriptions had helped to reduce antibiotic use in their practice (of the six prescribers who did not use delayed prescriptions, two still answered the question about the effect of delayed prescriptions in their practice). Prescribers used various formats: gave to patient with advice to delay (19/29, 66%), post-dated prescription (12/29, 41%), asked to collect from agreed location (8/29, 28%), and contact practice again (6/29, 21%).
In contrast to the survey responses, interviewees reported that they did not think delayed prescriptions were useful and did not use them frequently or at all. Clinicians felt patients would take antibiotics immediately regardless of what they were told, and discussed delayed prescription formats as ways of preventing access:
‘I didn’t [use delayed prescriptions] very much because I suspect if I gave my patients prescriptions they’d go off and take them straight away. ’
(E1, GP)
‘I got the dispensary to show me how to do the delayed scripts by changing the date … by changing the script to the twenty-third, they can’t get it before the twenty-third.’
(C1, GP)
Three practices were dispensing practices; in one of these they did not use delayed prescriptions at all for this reason:
‘We’re a dispensing practice, patients pick medication up on their way out. I genuinely think we all feel it doesn’t work.’
(D1, GP)
In practice J, GPs discussed how they had changed their approach to delayed prescriptions because of the study:
‘We dispense to ninety-nine point five per cent of our patients [but] we came up with a plan. We give the Treating Your Infection leaflet and mark on there when and where to come and get the antibiotic and then the patient could come straight to the dispensary. ’
(J2, GP)
Interviewees from practice J also mentioned how they spoke about delayed prescriptions differently because of the study materials:
‘[Previously] I would have said, if it doesn’t get better in forty-eight hours come back. But I found it very helpful to say we don’t know what a natural course of a disease is and if things change, then it may be appropriate to use. ’
(J1, GP)
POC-CRPT
All practices were interested in using POC-CRPTs. Eight practices accepted Afinion equipment, which recorded all tests run (Table 4).
Table 4. The number of Afinion POC-CRP tests carried out per practice and results, as recorded on Afinion machines
Four practices (A, E, F, G) ran >50 Afinion POC-CRPTs. Most tests gave CRP values ≤20 (73%). No tests were run after March 2020. Practice J were provided with 60 SureScreen tests and had 20 remaining.
At the 2-month survey, most prescribers reported having used POC-CRPTs (26/35, 74%); most had used Afinion only (18/26, 69%). Most prescribers (22/35, 63%) agreed POC-CRPTs had helped reduce antibiotic prescribing.
Interviewees in four practices (A, E, F, G) reported that the Afinion machine was used by one person. Some practices had one GP referring patients to a nurse or ambulatory clinician to have a POC-CRPT and one had one GP doing tests on his own patients:
‘No one’s been trained to do it, none of the GPs really know how to do it, so I’m the only one that’s trained, so if I’m not here, they’re not able to do it, and if I’m here, then that’s when I’ll do the testing for them. ’
(A1, non-prescriber)
In all four practices only one GP’s prescribing was being influenced by the POC-CRPT; other prescribers did not participate in using, or referring patients to, the test. Practice B had also allocated the Afinion machine to a nurse but only recorded two tests being conducted. Other practices had POC-CRPT equipment available to all staff but reported infrequent use. In practice D, the Afinion machine was not used at all (except as part of training) because they could not find a suitable place to keep it.
Interviewees reported that they carried out POC-CRPTs mostly on patients presenting with cough, but some practices also included patients with other conditions, indicating mission creep. (Interview participants mentioned using POC-CRPTs for: polymyalgia rheumatica, chronic obstructive pulmonary disease, abdominal pain to check it was not diverticulitis, to rule out acute pancreatitis, and knee pain to rule out septic arthritis.) Participants most often discussed using POC-CRPTs to convince patients they did not need an antibiotic, although some did use it when uncertain:
‘Our patients will demand antibiotics and so we found the testing extremely, extremely useful for that because once you could give them the result and say, look, antibiotics really won’t be useful, they seem to accept that more than the explanation. I think we’re pretty confident that our prescribing did go down. ’
(E1, GP)
Two practices (C, F) mentioned that the SureScreen lateral flow POC-CRPT was more practical than Afinion during home visits or when they wanted to avoid leaving their consultation room.
In summary, results indicated that practice J had engaged with implementation as intended and had chosen to use all three AMS strategies in a way that worked for their practice (Box 1), practices A, E, F, and G had engaged partially with implementation (focusing on the physical resources of POC-CRPTs and leaflets), and the remaining practices had engaged very little.
Engagement
The antibiotic champion was a GP partner with time allocated to administrative tasks that could be spent on study activities. They were reported to be enthusiastic and effective at getting colleagues engaged with the study. They encouraged a team approach and set the precedent that everyone was expected to contribute. The champion looked at the antibiotic optimisation website closely and used the presentation slides provided to run the practice meeting. The practice meeting covered all three antimicrobial stewardship strategies and attendees discussed how each would work in their practice. Practice J was the only practice not to use the Affinion point-of-care C-reactive protein test (POC-CRPT) as they deemed it impractical to use one machine. The practice team made decisions to put SureScreen POC-CRPTs and leaflets in each consultation room so clinicians would have them to hand. The group also decided on how they would consistently issue delayed prescriptions. In interviews, both the champion and another member of staff displayed detailed knowledge of the antibiotic optimisation website. Practice J was the only practice where interview participants acknowledged the specific communication strategies (as detailed in the website) to discuss no antibiotic decisions and delayed prescriptions.
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Box 1. A summary of engagement reported by participants from practice J
