Improving the uptake and SusTainability of Effective interventions to promote Prudent antibiotic Use in Primary care (STEP-UP)

Bacteria are increasingly resistant to the antibiotics we use to kill them. This is a major problem for us all. The more we use antibiotics, the more resistant the bacteria become. In England, GPs prescribe about 3/4 of antibiotics used. Most of these prescriptions (about 80%) will not actually benefit the patient but all will help to increase antibiotic resistance.

Many ways to help GPs prescribe fewer antibiotics to patients who are unlikely to benefit have been tested. These have included training and strategies like 'back-up' prescriptions for patients to use if symptoms get worse. Many have worked well and GPs using them have prescribed fewer antibiotics. The problem is that GPs not taking part in the research have not started using them, so very little has changed overall.

Government policies have also been introduced to give general practices more money if doctors prescribe fewer antibiotics to patients who are unlikely to benefit. This cost millions of pounds, and reduced antibiotic use, but it is not clear how promising extra money actually makes changes happen.

When researchers test a new diagnostic tool or training package, they don't just ask whether it works, but how much it would cost the NHS to use widely. Working out 'value for money' balances costs now against benefits and risks in the future. Antibiotics are so cheap (usually under £1 for a course) that most analyses suggest everyone should always get antibiotics. The problem is that we don't have good ways to include the threat that resistance poses in the future in these cost-benefit calculations.

This means that we spend time and money looking for new 'magic bullets' to reduce antibiotic prescribing, without getting the most from what we already know can work, but is not used. We need to know why effective strategies aren't used and improve them so they are used regularly in every-day care.

This project aims first to understand in more detail how the strategies that previous studies have sown reduce antibiotic prescribing worked. We need to do this because 'common sense' ideas are often wrong: different people react in different ways to the same situation and what researchers think is going on is often not the case. This will help us come up with ways to make existing strategies more attractive and easier to use every day. These will increase their uptake across England, meaning we can continue to reduce unnecessary antibiotic use and the threat of antibiotic resistance.

We will investigate 4 different, carefully chosen, areas.
- Incentivising general practices: evaluating an England-wide policy to pay general practices to reduce unnecessary antibiotic use
- Changes to the system: exploring 'delayed prescribing' where GPs give a prescription that patients can 'cash-in' if their symptoms get worse
- Improving GPs communication skills: investigating ways to help GPs explain to patients when antibiotics are not needed
- Better-informing decision-makers: assessing how we balance the health and cost impact of antibiotic use now vs resistance in the future, and how we determine cost-effectiveness of changes in antibiotic use

In each area, we will run detailed studies to find out what the barriers are to using effective strategies, and work out ways to overcome them. These will include studies with clinical commissioning groups, with GPs, nurse prescribers, practice managers and patients. We will then develop ways to improve strategies, in partnership with different types of healthcare professionals and patients. We will test these enhancements in an implementation study. We will also develop and apply new economic evaluation research methods to assess value for money.

Our team covers expertise in health psychology, health economics, biostatistics, primary care, pharmacy and clinical epidemiology. It also provides the opportunity for younger researchers to take leadership roles whilst being supported by more experienced colleagues.

Who will benefit from this research?
This research will benefit the general public, patients, primary healthcare professionals, multiple policymakers in the UK and potentially abroad (see Academic Beneficiaries), and industry. It will directly benefit individuals involved in antimicrobial prescribing and resistance, but also has potential wider application by developing methods to bridge the 'implementation gap' and to improve assessments of cost-effectiveness.

How will they benefit from this research?
The major impact is continued year-on-year reductions in antimicrobial prescribing and consequently resistance.
- The general public will benefit from reduced antimicrobial resistance at a societal level, reducing their exposure to, and risks associated with infection with, antibiotic-resistant bacteria
- Patients will benefit from not receiving unnecessary antibiotics with associated side-effects, having increased understanding of why their GP might recommend this, greater ability to self-manage minor infections and with the 'safety net' of a delayed prescription if their symptoms worsen
- Primary healthcare professionals (GPs, nurse prescribers, practice managers, community pharmacists) will benefit from increased confidence in not prescribing immediate antibiotics, through use of delayed prescribing and improved consultation skills
- Improved consultation skills may also provide benefits beyond infections and antibiotics
- Resulting increased patient knowledge may also lead to reduced consultation for self-limiting illnesses, with increased appointment availability benefiting patients and professionals
- Clinical commissioning groups will benefit from identifying the most effective ways to implement financial incentives to improve clinical practice, which should be generalisable to other conditions beyond infections and antibiotics
- Public Health England and the Department of Health will benefit from evidence to indicate how interventions shown to be effective in research studies can be rolled out to actually change clinical practice
- National Institute for Clinical Excellence (and others including guideline developers, public health agencies, health technology assessors) will benefit from novel improved methods to assess the cost-effectiveness of interventions
- Industrial partners aiming to promote the uptake of point of care tests and improved diagnostics into primary care, and commissioners considering paying for such interventions, will benefit from in depth information about barriers and opportunities to uptake and sustained use

What will be done to ensure that they have the opportunity to benefit?
Our overarching objective to accelerate the uptake and maximise the sustainability of interventions to reduce prescribing in primary care is directed at ensuring that all groups above benefit from the research.

First, we will communicate and engage with patients and primary healthcare professionals through co-design workshops to ensure that research outputs accurately address the underpinning barriers and facilitators to intervention uptake, increasing their opportunity to benefit. This will be assisted by the inclusion of GPs and pharmacists at various career stages in the research team. We will communicate and engage with the clinical commissioning groups through the workshops and feedback activities within WS1.

At an institutional level, we will engage with policymakers through our advisory board which will include members representing DH (Mike Sharland, Chair of the Antimicrobial Resistance and Hospital Associated Infection (ARHAI) Advisory Committee), NHS England (e.g. leader in National Patient Safety) and NICE, as well as academics (as above). This will provide opportunities for them to shape the research before it starts, whilst it is ongoing, and throughout dissemination. Public representation on the advisory board will ensure that the research remains grounded in patient relevance