Popularity of GPs – do bugs have more resistance in OTC countries – or is farming the important issue?

Popularity is only one feature of a good doctor. Prescribing antibiotics for infections is only via GP access in the UK and some other northern European countries. Southern European countries like Spain and Portugal allow purchase of a limited number/choice overt the counter (OTC). This reduces demand on primary care, but the argument is that there are more “resistant” bugs in these countries. Perhaps there are, but more important is the use of antibiotics in farming. Allowing penicillin V, tetracycline and trimethoprim or cephalexin over the counter would be a small step to helping patients get treatment quickly.

Doctors in coffee rooms and a confidential safe environment sometimes say “doctors get the patients they deserve”..

So doctors who give out antibiotics too readily will collect patients who demand such a service. Large practices need to monitor the doctors to see who is most liberal and who is most stringent. Do the liberal ones have less admissions and less time off work? Do the stringent ones have more admission or time off work?

Chris Smyth reports in The Times 7th December 2015: GPs who refuse to give antibiotics are less popular

Patients are less satisfied with GPs who refuse to dole out antibiotics, the first study of its kind suggests.

Doctors who are the most conscientious about limiting needless prescriptions are marked down by patients, according to research that suggests that demand for the drugs is hampering the fight against superbugs.

GP leaders complained that doctors were “damned if we do and damned if we don’t”, urging patients to realise that doctors were not being “mean” if they refused to hand over antibiotics for coughs and colds.

The rise of infections that are resistant to common antibiotics terrifies doctors because procedures ranging from hip replacements to chemotherapy would be impossible if the drugs stop working.

Margaret Chan, the director-general of the World Health Organisation, warned recently that superbugs would mean “the end of modern medicine as we know it” if the world did not cut back drastically on the use of antibiotics to slow the rate at which bacteria develop resistance. A report ordered by David Cameron is expected tomorrow to urge cuts in the use of antibiotics in farm animals.

Doctors say that patients still badger them for antibiotics, and the study suggests that those who refuse are punished. Researchers at King’s College London compared satisfaction ratings for England’s 8,000 GP practices with satisfaction rates in an official survey.

Surgeries that cut antibiotic use by a quarter would expect to fall from an average rating to the bottom 45 per cent, even after adjusting for the local population, they report in the British Journal of General Practice.

Mark Ashworth, the GP who led the study, said: “Many patients come in asking for antibiotics when they have viral infections such as colds, coughs, sore throats or the flu, but antibiotics cannot treat viruses. GPs often feel pressured by patients to prescribe antibiotics and find it difficult to refuse.

He found that the same falls in satisfaction were not seen in surgeries that prescribed fewer painkillers or antidepressants, suggesting that the fall was not simply a measure of how keen doctors were to please patients.

“These findings suggest that practices that try to help prevent the spread of antibiotic-resistant bacteria by prescribing fewer antibiotics are likely to experience a drop in their satisfaction ratings. GPs who are frugal in their antibiotic prescribing may need support to maintain patient satisfaction,” Dr Ashworth said.

Tim Ballard, vice-chairman of the Royal College of GPs, said that the findings were frustrating for doctors who felt “damned if we do and damned if we don’t”.

“Patients want to feel as though they are taking something away from their GP appointment and family doctors are under pressure to prescribe accordingly,” he said.

“Patients need to know that if we do not prescribe antibiotics, we are not being mean, we are acting in the best interests of their health.

“Our patients need to understand that when diseases become resistant to antibiotics, it means that antibiotics will cease to work, and as it stands we don’t have an alternative.”

Doctors have been told to explain to patients why they are not getting antibiotics and there is some evidence that people accept this if they feel they have been listened to, but it remains to be seen how well this works on the front line.

Laura Piddock, the director of Antibiotic Action, said that an explanatory leaflet “should always be given to patients who do not receive an antibiotic as it contains advice as to how to treat their symptoms, but more importantly what to do if their symptoms do not improve”.

The Times, and particularly Kat Lay has been vocal on the issue:

Haroon Siddique in The Guardian reports 9th December 2015: Antibiotic use in food fuels resistance to vital drugs – report – Review on antimicrobial resistance warns that antibiotic use on animals outweighs that on humans in many countries, posing great health risk

Pushy patients are blamed for rise of drug-resistant bugs

Curb antibiotics to save millions from early death

One in seven antibiotics fail as fears grow over resistance

Britain faces an ‘antibiotic Armageddon’

‘Nuclear option’ needed to solve antibiotic crisis

Is this the end of modern medicine?

In The times letters 22nd November 2015: Farm antibiotics gives a sensible approach from many eminent people:

Why we need greater political action against the overuse of antibiotics in agriculture

Sir, The overuse of antibiotics in human medicine and the rise of antibiotic resistance are now firmly on the global agenda — but we also need greater political action against the overuse of antibiotics in farming. Farm animals account for almost two thirds of all antibiotics used in 26 European countries. Nearly 90 per cent of farm antibiotic use in the UK is for group treatments of pigs and poultry.

The current revision of the EU veterinary medicinal products legislation provides an opportunity for significant progress. We urge the government and the European Commission to support and implement an EU-wide ban on the purely preventative treatment of animals where no disease has been diagnosed. Routine medication of healthy animals is inconsistent with all responsible-use guidance.

Babulal Sethia, president, Royal Society of Medicine; Professor Neena Modi, president, Royal College of Paediatrics and Child Health; Professor John R Ashton, president, UK Faculty of Public Health; Professor Murat Akova, president, European Society of Clinical Microbiology and Infectious Diseases; Professor Alan Boyd, president, Faculty of Pharmaceutical Medicine; Dr Giles Maskell, president, the Royal College of Radiologists; Dr Suzy Lishman, president, the Royal College of Pathologists; Professor Michael Dixon LVO OBE FRCGP, chair, College of Medicine; Dr Ron Daniels, Chief Executive, UK Sepsis Trust;Vilma Gilis, president, Guild of Healthcare Pharmacists; Professor Chris Butler, Professor of primary care, University of Oxford. Cwm Taf University Health Board; Dr David McCoy, director, Medact; Nina Renshaw, secretary general, European Public Health Alliance; Derek Butler, chair, MRSA Action UK; Professor Reinhard Hoffmann, secretary general, German Trauma Society; Steve Nash, co-founder member, HUSH (Haemolytic Uraemic Syndrome Help) — the UK E.coli Support Group; Dr Evangelos J. Giamarellos-Bourboulis, Associate Professor of Medicine, Hellenic Sepsis Study Group; Emma Rose, coordinator, the Alliance to Save our Antibiotics; Gertrude Buttigieg, honorary secretary, Malta Health Network; Anja Leetz, executive director, Health Care Without Harm; Anna Zorzet, MSc, PhD, coordinator, ReAct Europe

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This entry was posted in A Personal View, Medical Education, Stories in the Media on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

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