Understanding the delayed prescribingof antibiotics for respiratory tractinfection in primary care: a qualitativeanalysis

R Ryves,1 C Eyles,1 M Moore,1 L McDermott,2 P Little,1 G M Leydon1

To cite: Ryves R, Eyles C,Moore M, et al.Understanding the delayedprescribing of antibiotics forrespiratory tract infection inprimary care: a qualitativeanalysis. BMJ Open 2016;6:e011882. doi:10.1136/bmjopen-2016-011882

▸ Prepublication history andadditional material isavailable. To view please visitthe journal (http://dx.doi.org/10.1136/bmjopen-2016-011882).

Received 11 March 2016Revised 10 August 2016Accepted 16 August 2016

1Department of Primary Care& Population Sciences,University of Southampton,Southampton, UK2Department of Primary Care& Population HealthSciences, King’s CollegeLondon, London, UK

Correspondence toDr GM Leydon;gerry@soton.ac.uk

ABSTRACTObjective: To identify general practitioner (GP) viewsand understanding on the use of delayed prescribing inprimary care.Design: Qualitative semistructured telephone interviewstudy.Setting: Primary care general practices in England.Participants: 32 GPs from identified high-prescribingand low-prescribing general practices in England.Method: Semistructured telephone interviews wereconducted with GPs identified from practices withinclinical commissioning groups with the highest andlowest prescribing rates in England. A thematicanalysis of the data was conducted to generate themes.Results: All GPs had a good understanding ofrespiratory tract infection (RTI) management and howthe delayed prescribing approach could be used inprimary care. However, GPs highlighted factors thatwere influential as to whether delayed prescribing wassuccessfully carried out during the consultation. Theseincluded the increase in evidence of antimicrobialresistance, and GPs’ prior experiences of using delayedprescribing during the consultation. The patient–practitioner relationship could also influence treatmentoutcomes for RTI, and a lack of an agreed prescribingstrategy within and between practices was consideredto be of significance to GPs. Participants expressedthat a lack of feedback on prescribing data at anindividual and practice level made it difficult to know ifdelayed prescribing strategies were successful inreducing unnecessary consumption. GPs agreed thatcoherent and uniform training and guidelines would beof some benefit to ensure consistent prescribingthroughout the UK.Conclusions: Delayed prescribing is encouraged inprimary care, but is not always implementedsuccessfully. Greater uniformity within and betweenpractices in the UK is needed to operationalise delayedprescribing, as well as providing feedback on theuptake of antibiotics. Finally, GPs may need furtherguidance on how to answer the concerns of patientswithout interpreting these questions as a demand forantibiotics, as well as educating the patient aboutantimicrobial resistance and supporting a goodpatient–practitioner relationship.

BACKGROUNDRespiratory tract infections (RTIs) are usuallybrief and self-limiting conditions, with antibio-tics having little or no clinical benefit, unlessthere is a serious underlying comorbidity.1

However, UK figures have revealed that recentfalls in prescribing have stalled,2 with RTIaccounting for ∼60% of all prescriptions inprimary care.3 4 Prescribing unnecessary anti-biotics can be a drain on the National HealthService (NHS) resources, and can haveserious consequences to patient health,including the risk of side effects and the anti-microbial resistance (AMR).5 6 AMR has beendescribed by the WHO as a serious issue thatmust be addressed with some urgency,7 aswell as being cited as a ‘catastrophic threat’ bythe UK’s Chief Medical Officer.8

The delayed prescribing of antibiotics forRTI is a technique that can be used byhealth professionals to reduce unnecessaryprescribing in primary care.9 Delayed pre-scribing is a method whereby a prescriptionis issued by a health professional for use bythe patient at a later date, if their symptomsdo not improve. The National Institute forHealth and Care Excellence (NICE)

Strengths and limitations of this study

▪ Using a purposive sample of high-prescribingand low-prescribing practices in England cap-tured a broad view of delayed prescribing strat-egies in primary care.

▪ Individual prescribing data were not availableand this may have been beneficial to ensuremaximum variance of the sample interviewed.

▪ Recruitment to the study was difficult, but thesample collected was varied according to keyparameters and the findings resonate with otherpublished research, which increases confidencein face validity and transferability of the findings.

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guidelines have recommended this strategy as a manage-ment option for most patients presenting with RTI,unless they meet a specific criteria of risk factors thatsignal potential complications.The use of delayed prescribing can limit the collection

of prescriptions by patients to just 40%.9–11 Researchshows that delayed antibiotic prescriptions are as effect-ive as immediate prescriptions in reducing complicationsfrom RTI, as well as reducing the need for patient recon-sultation;12 which suggests that delay offers a reasonablealternative to an immediate prescription. In addition,delayed prescribing has the potential to be more effect-ive in reducing antibiotic use for RTI, so long as healthprofessionals provide clear treatment advice topatients.9 13 A Cochrane review of the use of delayedantibiotic prescribing compared with immediate or noprescribing found there were no differences betweenthe strategies for clinical outcome; with delayed prescrib-ing resulting in a significant reduction in antibiotic usecompared with immediate prescribing.11 However, thereis some evidence to suggest that patient satisfaction con-cerning the outcome of consultations appears to belower in those receiving a delayed prescription com-pared with those being issued one immediately.9

Reports on antibiotic prescribing suggest that thedelayed prescribing technique may not be widely or consist-ently used by general practitioners (GPs).2 Data have illu-strated large differences in antibiotic use across thecountry; however, these rates have only been observed andnot explained.2 4 Moreover, some GPs have been reportedto be critical of the delayed prescribing approach whenfaced with uncertainty about prognosis and handing overdecision-making to patients.14 Perceived patient expecta-tions for antibiotics may also influence GP prescribingbehaviours.15 16 Given these complex contextual factors,delayed prescribing can potentially be an effective prescrib-ing strategy in providing reassurance for the GP and thepatient, by making antibiotics available should symptomsworsen, and in terms of validating patient concerns.17

The aim of this study was to identify GP views on theuse of delayed prescribing, their use of the techniqueand factors that can enhance or inhibit its use in routinegeneral practice. In addition, the study aimed to elicitGPs’ views on current prescribing guidelines, and whatinformation would be beneficial if training were to beprovided. It was anticipated that the information gath-ered from the study could be used to inform the futuredevelopment of an intervention to aid effective delayedantibiotic prescribing.

METHODSA qualitative research design using semistructured tele-phone interviews was conducted with GPs from high-prescribing and low-prescribing primary care practicesin England. Research Ethics Committee (REC) approvalwas obtained from the host research site (Hampshireand Isle of Wight) in November 2013.

Practices were identified using National PrescribingData available through the NHS Business ServicesAuthority Portal.18 Eight clinical commissioning groups(CCGs) with the highest and lowest prescribing datawere selected according to specific therapeutic groupage–sex related prescribing units data.19 The 10 prac-tices with the highest prescribing data within each of thehigh-prescribing CCGs, and the 10 practices with thelowest data within each of the low-prescribing CCGswere selected. Walk-in centres were excluded from thestudy as the research was aimed to understand prescrib-ing behaviours in general practice. It was anticipatedthat this primary sampling approach of identifying high-prescribing and low-prescribing practices would facilitatemaximum variation sampling to get a range of differingGP views about the use of antibiotics for RTI anddelayed approaches to prescribing. A target of 30–50GPs was estimated (15–25 GPs from each group), oruntil saturation was indicated through data analysis.Practices were telephoned by RR to elicit interest in

taking part in the study. Interested GPs were sent anelectronic participant information leaflet (PIL) with areply slip and consent form. Initial recruitment to thestudy was slow; therefore, an invitation letter from theRoyal College of General Practitioners (RCGP) NationalClinical Champion for Antimicrobial Stewardship(co-author MM) was sent together with the PIL andconsent form to all GPs within identified practices, usingthe Docmail mailing service. Clinical research networksalso contacted practices on behalf of the research teamto help with recruitment. Once written informedconsent was received RR made contact with GPs toschedule a time for a telephone interview. GPs wereoffered £50 as payment for taking part.A semistructured interview topic guide was developed

(see online supplementary 1) building on questionsfrom a topic guide for a study exploring GP views in rela-tion to antibiotic prescribing in infection.17 The guideaimed to elicit GP views and experiences of usingdelayed prescribing in practice for RTI, as well as per-ceived barriers and facilitators of implementing thistechnique. GPs were invited to discuss their opinions ofhaving training in using delayed antibiotic prescribingstrategies. The guide was piloted with a practising GP toensure the acceptability of the questions asked and thefeasibility of completing interviews within a 30 min time-frame. The topic guide changed as new ideas emergedfrom early data collection, but the general focus of theinterviews remained the same. RR conducted all inter-views. Interviews were recorded, anonymised and tran-scribed verbatim.Interview data were analysed using thematic analysis.20

An inductive approach was adopted because this was arelatively unexplored area that required researchers tobe open to new insights. RR led the analysis and devel-oped the initial codes. The reviewing and agreement ofthemes were discussed and confirmed through repeateddata sessions with GML and CE, who are both experts in

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qualitative research. The stages of the analytic processare shown in figure 1. Thematic saturation was achievedwhen no new themes were emerging from new data.

FINDINGSParticipantsFigure 2 illustrates the process of recruiting GPs to thestudy.Table 1 provides demographics of the CCGs and prac-

tices from which GPs were recruited. The prescribinglevel was relevant to the analysis as accounts from GPs ofhigh-prescribing and low-prescribing practices were com-pared to identify any similarities or differences betweenthe groups. Interviews with the 32 GPs lasted between 12and 34 min (M=25.08).

ThemesFour major themes and nine subthemes were identified(table 2). The themes and subthemes are discussed withillustrative quotations. The GP identification numberand whether they are from a high-prescribing or low-prescribing practice are included at the end of eachquotation.

Management of RTI in a GP consultationGPs were invited to discuss their understanding of RTIand how symptoms could be self-managed by patients.In addition, GPs described their views on the use andefficacy of prescribing for RTI.

Understanding of RTIAll GPs understood that most upper RTIs were viral andself-limiting, with most symptoms clearing without theneed for antibiotics.

The vast majority are viral and it’s best to avoid antibio-tics, except in extreme cases. Most antibiotics don’tbenefit most conditions. (GP5, high prescribing)

The majority of GPs would try to discuss the naturalhistory of RTI with their patients in order to help buildthe evidential basis for no antibiotic disposal. All GPsdescribed suitable alternative treatments for the self-management of RTI symptoms, and described routinelytrying to inform their patients of these.

Three things that I use is if they drink a lot of water, takea lot of rest and take paracetamol on and off with a fever,most of the time it’s a supporting measure as the bodyfights very well. (GP12, high prescribing)

However, a few GPs explained that they did not offeralternative advice or treatment strategies to their patientsdue to the pressure of time constraints:

I don’t have time really. Most GP consultations are tenminutes long and there’s not actually that much time totake a history, examine a patient properly, to go throughthe findings, what the plan will be and then to then gothrough the ways of managing. (GP22, high prescribing)

Figure 1 Stages of data

analysis.

Figure 2 Recruitment flow chart.

CLRN, Comprehensive Local

Research Network; GP, general

practitioner.

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Patient assessment during consultationTreatment decisions were primarily determined throughexamination and history of the patient. If a patient hada serious underlying condition, GPs would be morelikely to prescribe antibiotics if they felt the patient wasat higher risk of developing an infection. As well ascomorbidities, some GPs explained that the age ofpatients would guide their decision:

There are other patients who are more vulnerable likethe elderly, people with concomitant conditions as wellthat might make them more vulnerable. So those are thegroup of patients that I think NICE was talking aboutexcluding in terms of either prescribing antibiotics orthis concept of delayed antibiotics. (GP24, highprescribing)

GPs described a heightened sense of obligation toissue antibiotics to children compared with adults due togreater levels of uncertainty about the severity of theirsymptoms. Others reported that they felt a greater

pressure to prescribe antibiotics when confronted with aconcerned parent:

With parents the impression you get is ‘You need to givesomething to make my child better’. If you’re not givingthem something to make them better then you’remaking them worse or you’re not helping.(GP22, lowprescribing)

Some GPs acknowledged that the risk of issuing anti-biotics for an RTI outweighed the potential benefits,and they would explain this to their patients in the con-sultation to try to avoid unnecessary prescribing.

Then going through the discussion that there’s lots ofevidence nowadays to say that antibiotic prescriptionsdon’t reduce complications, they barely reduce the dur-ation of the illness, and if it is it’s only by a few hours.Then you’ve got to weigh that up against the possibleside effects of taking the medication. (GP20, highprescribing)

Understanding and uses of delayed antibiotic prescribingAll GPs conveyed understanding of delayed antibioticprescribing, different methods of issue and its appropri-ate use for patients presenting with an RTI. Two sub-themes encompass the views expressed: the use ofdelayed antibiotic prescribing in the consultation andGP attitudes towards delayed antibiotic prescribing.

Delayed antibiotic prescribing in the consultationGPs were invited to provide their own definition andmethod of delayed prescribing. All GPs perceiveddelayed antibiotic prescribing as a strategy that could beused when they believed that antibiotics might not beneeded by the patient at the time, but a prescriptionshould be issued as a precaution:

This is trying to explain to patients that this is what isgoing on, and this is the progression that we wouldexpect for the illness, and that there’s no indication forgiving antibiotics at this stage, but if x, y, and z happensthen it may be worth cashing the prescription and start-ing the antibiotics. (GP9, high prescribing).

Table 1 CCG and practice demographics

CCG

Prescribing

level

Practices

recruited

Average practice

list size

Average practice

deprivation score*

GP

total

Brighton and Hove Low 2 8992 4 2

County Durham and Tees Valley High 9 9104 5 7

Derbyshire High 3 10 220 8 1

London Low 6 9896 6 3

Newcastle West Low 6 9097 4 5

South of Tyne and Wear High 1 9963 2 1

Trent Low 2 9212 3 2

Data sourced from DCLG.*Index of Multiple Deprivation Scores, where lower scores=higher deprivation.CCG, clinical commissioning group; DCLG, Department of Communities and Local Government; GP, general practitioner.

Table 2 Themes and subthemes derived from thematic

analysis of the data

Theme Subtheme

1. Management of RTI in a

GP consultation

1.1 Understanding RTI

1.2 Patient assessment

during consultation

2. Understanding and uses

of delayed antibiotic

prescribing

2.1 Delayed antibiotic

prescribing in the

consultation

2.2 GP attitude towards

delayed prescribing

3. Factors that influence the

use of delayed antibiotic

prescribing

3.1 Influences on GP

decision-making

3.2 Protecting the patient–

practitioner relationship

3.3 Guidelines and policies

4. Views on the need for

training

4.1 What training should be

given

4.2 Training delivery

GP, general practitioner; RTI, respiratory tract infection.

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All GPs were able to identify at least one method ofhow to delay an antibiotic prescription (table 3), and allGPs reported that they had used delayed prescribing ona regular basis when needed.The majority of GPs would issue a prescription during

the consultation, and advise patients to only cash it in iftheir symptoms were to worsen. Commonly short delayswere used—shorter than the likely natural history of theinfections, or than strategies used in previous trials:

Delayed antibiotic prescribing, from my point of view, iswhere I provide the prescription for an antibiotic with adate at some point in the future, normally 24 or 48 hoursthereafter. With instructions to the patient, or the family,as to the indicators for cashing the prescription andusing it. (GP10, high prescribing)

As well as postdating prescriptions, another strategydescribed was leaving the prescription at reception forpatients to collect:

I put a nice big D on the right hand side and just drop itin the box. The staff then know that that’s a delayed pre-scription and I can say to a patient ‘I’ll leave it out foryou at reception’, […] if it’s not been prescribed within acouple of days, an appropriate length of time, then it willbe taken out. (GP17, low prescribing)

Alternatively, a few GPs would not provide a prescrip-tion during the consultation, but would advise reconsul-tation if symptoms did not self-limit:

For me, it would be not to prescribe in the morning ofthe consultation, and to prescribe three or four days laterbecause there have been some changes in the symptomsof the patient that shows me that there is some evidencenow that it could be beneficial to use some antibiotics.(GP11, high prescribing)

GPs from high-prescribing and low-prescribing prac-tices expressed uncertainty as to whether they wereadopting the correct approach, which technique was themost effective, or were ‘not quite sure’ (GP7, high pre-scribing) of other methods. One GP suggested thatdelayed prescribing strategies were ‘just too complicated’(GP22, low prescribing).

When asked about their prescribing rate, GPs wereuncertain about how many delayed antibiotic prescrip-tions were cashed in. Some GPs felt that it would be auseful figure to know to see whether their delayed pre-scribing method was effective, which in turn wouldjustify their use of the strategy:

I have no idea how many of these delayed prescriptionsare cashed in, which is a great shame because it wouldbe very nice […] it would be very interesting, wouldn’tit? (GP1, high prescribing)

GP attitude towards delayed prescribingDespite some reservations (as above), GPs generally hada positive attitude towards delayed prescribing. Theydescribed it as a practical, convenient tool for the GPand the patient and that it was primarily used to ‘avoidunnecessary antibiotic prescription’ (GP12, high pre-scribing). It was hoped that by using a delayed approach,patients would not cash in the prescription.GPs explained that issuing a delayed prescription was

practical for patients as it would enable them to accessantibiotics if their symptoms were to worsen or notimprove, without the need for reconsultation. This maybe down to issues of travel, or time constraints from thepatient and practice. Some GPs reported a greater per-ceived demand to prescribe during consultations at theend of the week, thus delayed prescribing was a usefultool to relieve this pressure:

[On a] Friday afternoon it’s a useful thing to givebecause of the difficulty sometimes in accessing medicalout-of-hours services, which can be a bit complex andgeographically can be quite awkward if people who usedto be seen locally now have to travel 15 miles to be seen.(GP26, low prescribing)

One GP explained that delayed prescribing offered acompromise when the GP was of the opinion that anti-biotics were not appropriate but the patient desired anantibiotic prescription. If GPs were encountering diffi-culties in ending a consultation then a delayed prescrip-tion was described as a closing strategy.

I think it’s often used in a situation where the cliniciandoesn’t think antibiotics are justified, but the patient is

Table 3 GPs’ preferred delayed prescribing strategy

Delayed antibiotic prescribing strategy

High

prescribing

Low

prescribing Total

Issue prescription in consultation and advise when to collect 10 13 23

Issue postdated prescription in consultation 3 1 4

Offer recontact with clinician to agree release of prescription if symptoms worsen 3 0 3

Collect prescription from reception if symptoms worsen 0 1 1

Issue prescription for patients to take antibiotics then consult over telephone to

stop or continue course

1 0 1

GP, general practitioner.

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adamant that they would like them and it’s seen as acompromise. So it’s basically a way to end the consult-ation where both parties can feel happy that they’ve gotwhat they wanted. (GP31, high prescribing)

Some GPs described how delayed prescribing as acompromise elicited positive outcomes for the GP andthe patient. One GP explained that patients felt theyhad been listened to. It also provided the GP with asafety net, in case they had missed signs of a moreserious infection, as well as alleviating the fear ofmaking the wrong diagnosis:

…they like to have a bit of paper when they leave us. Ithink there’s a little bit in my mind as well…like I saywhere I’ve had one or two where people have usuallythree or four weeks down the line actually deterioratedbut still blame me for the fact that I didn’t give some-thing at that time. (GP25, low prescribing)

However, some GPs found particular methods ofdelayed prescribing to be ‘mutually inconvenient’(GP13, low prescriber) for the GP and the patient. OneGP thought that if the method of telephone reconsulta-tions was used, this created more work for the patientand the GP. Delayed prescribing could also potentiallybe confusing for the patient, as the instructions riskedbeing viewed as vague or unclear. As a result, one GPsuggested that delaying a prescription might neither besafe nor sensible:

I think sometimes it actually muddies the water and that’swhy I’ve sometimes thought it’s actually better not to doit […] unless you give them a really specific guideline itcan be quite vague. (GP31, low prescribing)

Moreover, a couple of GPs thought that delayed pre-scribing conveyed a contradictory message to patients:

I feel that to be saying, ‘There’s no indication for antibio-tics at this stage, but if you’re no better in 48 hours thenby all means take them’ is a mixed message for me.(GP9, high prescribing)

Factors that influence the use of delayed antibioticprescribingGPs were invited to reflect on factors that acted as facili-tators or barriers to using delayed antibiotic prescribing.Factors included influences on GP decision-making, pro-tecting the patient–practitioner relationship, and the useof guidelines and policies.

Influences on GP decision-makingOne factor that influenced GPs’ treatment decisions forRTI was a culmination of the increase in evidence ofAMR and the experience they had gained in practice. Inparticular, GPs from practices with low-prescribing ratesfelt that this had helped reduce their prescribing:

Experience, training in the past and also over the last15 years there’s been a lot of discussion and debate aboutantibiotics in the medical journals on courses, and Ithink over the years, […] certainly my antibiotic prescrib-ing has changed and we have antibiotic prescribingaudits within the practice. Our prescribing is reducing.(GP23, low prescribing)

Those GPs with higher levels of experience expressedhigher perceptions of self-efficacy in using delayed pre-scribing strategies:

As time goes by I think you develop better explanationsfor patients that mean when you are explaining to themwhy they don’t need an antibiotic you are more convin-cing. (GP31, low prescribing)

However, some GPs from high-prescribing practicesfound delayed prescribing strategies were complex andthe uncertainty in administering them led to difficultiesin successfully delaying a prescription. These difficultiesincluded being able to fully understand the method ofdelayed prescribing and the confidence in using thestrategy during the consultation, particularly when metwith perceived patient pressure for an antibiotic pre-scription. In contrast, GPs from low-prescribing practicesexplained that using a delayed antibiotic prescriptionwas useful as a precautionary measure and using somecaution when treating a patient helped manage thisuncertainty:

If you’ve clinically got somebody with you who you dothink’s unwell, but you’re still not really getting clearsymptoms of a bacterial infection, then yes, to manageyour uncertainty. (GP21, low prescribing)

Another influential GP factor was the variation in pre-scribing rates and management of RTI among GPswithin and between practices in the country.Consequently, GPs explained patients may be providedwith conflicting treatment strategies from different GPs.GPs described the negative impact this could have onthem educating their patients about the natural historyof RTI and when antibiotics would be appropriate. GPsfrom high-prescribing and low-prescribing practices feltthat it was important to spend time discussing antibioticprescribing issues within the professional community toensure that patients receive consistent treatment andadvice:

When patients do return to come and see you often it’sbecause they aren’t clear on what’s going on, or they’vegot mixed messages from different doctors, from thatpoint of view, and I think certainly to present a commonground, sort of like a united front, in terms of policy, Ithink can be useful. (GP10, high prescribing)

Another challenge GPs faced was by their patientsaccessing out-of-hours care, where GPs felt that antibio-tics for RTI were more readily available. The doctors at

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the walk-in centres would have no history of the patientand would therefore be more likely to give out antibio-tics rather than educating the patient.

They [patients] often go to the out-of-hours centre andthe out-of-hours centre does tend to give out antibioticsand I think that’s entirely understandable because theydon’t know these people. (GP 1, high prescribing).

Overall, GPs described prescribing as a strategy tonegotiate patient pressure due to social arrangements,comorbidities and age, as well as reducing the need toreconsult with patients.

Protecting the patient–practitioner relationshipGP accounts suggested that the relationship with theirpatients was a major influence on whether a delayed anti-biotic prescription would be issued during a consultation.The majority of GPs described how perceived patientdemand played a large role during the consultation andfelt pressured into issuing a prescription if patientsattended the consultation with an expectation for an anti-biotic. Interviewees defined patients with a previous (suc-cessful) experience with an antibiotic for RTI as most likelyto expect an immediate prescription for a new episode.

When you see them for the next time they have sinusitisor sinus pain, expect to be given antibiotics and thenyour consultation goes badly from the word go becausethat patient’s expecting antibiotics and suddenly they’recoming up against a barrier and somebody who’s suggest-ing we don’t use antibiotics. (GP21, low prescribing)

GPs would appease or mitigate this patient demand byspending time during the consultation explaining thenatural history of RTI, ineffectiveness of antibiotics intreating the majority of upper RTIs and that the risks oftaking antibiotics outweighed the benefits. Most GPs feltthat spending time educating and reassuring patientsthat RTI symptoms should clear over time, and to usealternative treatments (such as analgesics and rest) facili-tated their consultation.A couple of GPs also expressed concern over receiving

complaints from patients for not prescribing antibiotics.This in turn would make GPs more likely to prescribe.These concerns were preponderantly expressed by GPsfrom practices with high-prescribing rates:

I’ve had a complaint because I didn’t prescribe an anti-biotic once and that changes the way you prescribebecause you don’t want to have a complaint against youeven if you are right. (GP8, high prescribing)

Overall, GPs described the use of delayed prescribingas a useful tool to help maintain a strong patient–practi-tioner relationship.

If the explanation that’s gone with the delayed prescrip-tion is adequate and reasonable and there’s been adecent consultation where everyone’s felt involved and

understands the reasons why the outcome is theoutcome, generally it’s a positive thing. (GP 10, highprescribing)

Some GPs explained that the initial consultationwould allow for a form of shared decision-making,through negotiation and educating the patient aboutRTI in order to come up with an appropriate treatmentplan. GPs described how spending time in the consult-ation to devise a treatment strategy and in some casesissue a delayed antibiotic prescription provided thepatient with sufficient leverage to make an informed,(semi)-autonomous decision about the next steps intheir treatment for RTI.

…sometimes they’re much more receptive to the delayedprescription of it, and giving them back the autonomy: ifthey are the more self-caring, if you like, set of patients,who have given it a significant amount of time. (GP10,high prescribing)

Strategies GPs used to ensure patients were alignedwith their treatment disposal included offering paper-based or web-based information leaflets, as well as pro-viding reassurance to the patient by doing a clinicalexamination and clearly explaining their findings.However, GPs emphasised that giving patient complete

autonomy on the management of their RTI was relianton how ‘trustworthy’ the patient was, which in turnwould influence their decision as to whether to issue adelayed prescription. A minority of GPs describeddelayed prescribing as a poor strategy because it gavetoo much power to the patient by ‘leaving decisions inthe patient’s own hands’ (GP5, high prescribing). TheseGPs conveyed a paternalistic practice style as appropriatewhen treating RTI:

That’s why you’re a doctor and what you’re paid for, soit’s better for you to make the decision. (GP5, highprescribing)

Guidelines and policiesThe majority of GPs were aware of guidelines (eg, NICEguidelines, Centor Criteria) that had been created toassist them with the management of RTI and advise theuse of delayed antibiotic prescribing where appropriate.However, no GPs mentioned any current initiatives thatwere in place to encourage antimicrobial stewardship(such as the RCGP TARGET Toolkit21).Some GPs suggested that there were so many different

guidelines and policies; the amount of information wasalmost overwhelming:

We’re bombarded with so many different guidelines forso many different things. Trying to keep up with all thatis really tricky. (GP13, low prescribing)

GPs tended to rely on guidance and policies providedby their local CCG. However, GPs did not always findthese guidelines useful and hard to implement in

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practice, because of perceived patient expectation anddemand for antibiotics. Moreover, some GPs highlightedthat local policies were inconsistent between CCGs overthe country and stressed the importance of having somesimple, standardised guidelines that could be easilyimplemented to ensure consistent prescribing at anational level. A few GPs highlighted that this issue asprescribing differences between and within practicesequated to a national variation of prescribing rates. OneGP from a low-prescribing practice suggested that CCGsshould be responsible for auditing prescribing rates andthat reducing antibiotic prescribing become a nationalpriority:

I think the CCGs need to have an assessment in theirarea and see what the volume of prescribing is, where it’scoming from and I think it does need to be right acrossthe board including the out of hours teams, the respira-tory nurse specialists, the urgent care nurses. (GP16, lowprescribing)

The findings suggest that GPs with greater belief intheir experience and knowledge of how to implementdelayed prescribing strategies were more confident indelaying an antibiotic prescription. Protecting thepatient–practitioner relationship by educating thepatient as well as discussing treatment options was bene-ficial. Finally, the consensus among GPs was that theguidelines and policies were inconsistent and sometimesoverwhelming, with differences between and within prac-tices and CCGs.

Views on the need for trainingParticipants were invited to share their opinions ofwhether training in how best to use delayed antibioticprescribing would be useful for them, and if so, whattraining should be provided and how.

GP attitude towards trainingThere were mixed opinions with regard to tools or train-ing to be provided to GPs to assist them with delayedprescribing in practice. Some were open to the idea oftraining with the caveat that it would have to be relativelyeasy and not time intensive. Some expressed reservationsabout the perceived utility of such training for all GPs.

It’s difficult. I mean, I haven’t had any training fordelayed prescribing of antibiotics, it’s just a kind ofcommon sense scenario. If I had a proper training, yes, itwould be helpful for me. Some GPs might feel it’s totallyinappropriate. (GP19, high prescribing)

Most GPs felt that training in a conventionalclassroom-based sense was not necessary, but describedthe potential benefit of policy and research updates orstandardised policies:

Would I go if there was a training session on delayed pre-scribing? I have to say probably not. I’d rather have the

written information, the protocols in place. (GP16, lowprescribing)

What training should be givenThere was no consensus as to what training should begiven; however, GPs felt more standardised, simplerwritten information should be provided to give morestructured guidance for antibiotic prescribing. In add-ition, a high proportion of GPs discussed the utility ofhaving prescribing rates specific to their practice toclarify whether the practice and their own personal prac-tice needed to be changed in any way. GPs demonstratedwillingness to share such individual prescribing informa-tion with their colleagues.GPs also suggested that training in antibiotic prescrib-

ing should be given to GP registrars:

I think training needs to be given to GPs, and particularlyGP registrars and trainees, about where to prescribe anti-biotics, because particular GP registrars learn their pre-scribing habits from the practices that they’re in, and Ithink there is a tendency not to question what goes on.So if you go, as a GP trainee, to a practice where there’shigher antibiotic prescribing you’ll learn habits fromthem, rather than any sort of scientific approach. (GP5,high prescribing)

Some GPs suggested that training in communicationwas essential in order to improve their prescribing rates.Learning how to have an effective consultation withpatients would facilitate the delayed antibiotic prescrib-ing process:

[It is] about communication skills, working out what thepatients actually want, and what their ideas and concernsand expectations are. (GP3, high prescribing)

Training deliveryGPs that were supportive towards training were uncer-tain as to how best to deliver it. Time pressure appearedto be the biggest concern but most GPs felt they wouldget best value out of having a face-to-face meeting withother health professionals within their CCG.

I think the best choice would be at CCG time-out meet-ings, or if somebody could come and give a talk, so therewere loads of GPs there rather than going to individualpractices. If there is a possibility of some hand-outs orleaflets about it, just for us to go through and find out,or maybe some information from the practice pharma-cists who can then pass it on to the GPs. (GP18, highprescribing)

GPs described a need for such information and guid-ance to be provided by a credible source, such as micro-biologists, or fellow GPs who have experience of treatingpatients on a day-to-day basis.Although there were mixed opinions as to whether

training would be beneficial, GPs felt that having someguidance of implementing these strategies into practice

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may be useful. Training should have a wider focus oncommunication with the patient. The delivery of train-ing would need to be time-efficient, and delivered by acredible source.

DISCUSSIONThis study explored GPs’ views and understanding ofdelayed antibiotic prescribing in primary care. The find-ings illustrate that all GPs have a good understanding ofRTI, and how to assess and treat the illness. All GPs wereaware of and were generally positive about delayed pre-scribing, but felt that certain factors would sometimesmake it hard to implement this strategy.

Strengths and limitationsThe findings offer a novel insight into GPs’ prescribingpractice for RTI in a primary care setting. However, onenotable limitation was that individual prescribing beha-viours of GPs were unknown. Therefore, the prescribingrates of the practices obtained from the NationalPrescribing Data may not reflect the prescribing rates ofthe GPs interviewed for the study. Having data illustrat-ing individual prescribing rates of GPs would have beenbeneficial to recruit a more representative sample.Practices were approached and recruited according totheir global prescribing rates (not isolated to RTI) so itmay be possible that GPs had ‘good’ prescribing habitsrelating to RTI, but not to other infections, which couldexplain the practices’ high-prescribing rate.The recruitment of GPs to the study was low, despite a

three-pronged approach to elicit expressions of interest(see figure 2). Low recruitment may have influenced thefindings as respondents with greater familiarity or a morepositive attitude towards delayed prescribing may havebeen more willing to take part in the study. However,more practitioners from high-prescribing practices wererecruited, which may minimise this risk. Moreover, ana-lytic saturation was reached and the findings reflect thoseof another qualitative study investigating delayed pre-scribing strategies in primary care.14 This increases thetrustworthiness and transferability of the findings.

Main findingsThe findings suggest that despite GPs knowing thenatural history of RTI, they may use this knowledge toprovide a more nuanced approach to delayed antibioticprescribing. Antibiotic prescriptions would be postdatedwith a considerably short delay compared with researchsuggesting delays of up to 14 days for some RTIs.22

While all GPs were able to provide a definition and atleast one example of delayed antibiotic prescribing, themajority were unaware of alternative delaying methods.However, evidence suggests that the choice of method isnot critical.9 GPs would find benefit in knowing howmany delayed prescriptions were cashed in comparedwith immediate use prescriptions at an individual andpractice level, to see whether particular delayed prescrib-ing strategies are effective.

Despite generally positive attitudes towards delayedprescribing, there was a preference for no prescribing atall, which is the preferred strategy for management ofinfection.11 Delayed prescribing was seen as a comprom-ise or a negotiation, either to meet a presumed patientexpectation for antibiotics or to provide reassurance tothe patient. GPs with greater experience or knowledgein using delayed antibiotic prescribing found theapproach easier to use and manage uncertainty. SomeGPs felt that the delayed approach maintained thepatient–practitioner relationship by providing thepatient with some form of autonomy in the manage-ment of their illness.The findings further emphasise that patient expect-

ation and clinician perception for antibiotics when pre-senting with an RTI could be influential, whichcorroborates with other research.23 Where an antibioticprescription is not indicated, doctors will still issue a pre-scription during the consultation ‘just in case’ a patient’ssymptoms worsen.24 However, effective communicationwith and education of the patient about the naturalhistory of RTI may be more beneficial in reducing thenumber of unnecessary antibiotic prescriptions. There issome empirical evidence to support the role ofimproved communication skills in reducing prescrib-ing.23 25 This could provide reassurance for the patient,as well as validating their illness, which in turn willenhance opportunities for maintaining a strong patient–practitioner relationship for future consultations.15 17

The favoured delayed prescribing strategy was issuinga prescription during the consultation, advising patientsto cash it in if symptoms worsen, which may be due toperceived patient demand and expectation for antibio-tics.26 Despite a mixed response from GPs with regard totraining in how to use delayed prescribing strategieseffectively, there was some consensus of the need of astandardised policy between and within practices andCCGs to ensure that strategies are consistent throughoutthe country. GPs were uncertain as to how trainingshould be delivered and it is likely that it would need tobe flexible to suit local needs, using a variety of teachingmodalities. One interesting finding was that GPs wereunaware of existing tools that have been developed toassist with antibiotic prescribing in primary care, such asthe RCGP TARGET Antibiotics Toolkit,21 an onlineresource to encourage responsible antibiotic prescribingin primary care.There appears to be a lack of transparency regarding

antibiotic prescribing within and between primary carepractices in England. Clear, shared goals are requiredand can be aided by some form of training informed bynational and local guidance. Prescribing practice is theresult of interaction between two parties: the patient andthe GP, with effective communication at the heart of theprescribing relationship. Negotiation is an importanttool for achieving a successful outcome, but there isinsufficient knowledge as to how best GPs can achievean optimal negotiation with individual patients and for

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the wider population. The lack of feedback of the resultsof delayed prescribing were highlighted as one problemeroding motivation, this could be addressed throughimproved information technology.

Comparison with existing literatureFew qualitative studies have explored the use of delayedprescribing in UK primary care; however, the main find-ings of this study resonate with some of the findings ofone study exploring the usefulness of the delayed pre-scribing strategy.14 Both studies highlight that perceivedpatient expectation makes consultations more challen-ging, as well as the use of delayed prescribing to manageuncertainty during a consultation, as a safety net, and tomaintain the patient–practitioner relationship. Our find-ings further suggest that GPs with a greater understand-ing of delayed prescribing strategies and experience ofusing it are more positive towards the approach.Moreover, the current study suggested that GPs may notbe taking into account the variation in the natural historyof RTI and would issue a delayed prescription with ashort delay regardless of the anticipated duration of theillness. Lower RTI lasts on average 12 days following theindex consultation and there is unlikely to be a substan-tial improvement with 24–48 hours, which in turn mayresult in collection of unnecessary antibiotics.22

Qualitative research conducted in other countries hasdemonstrated similar findings to the current study.27–30

Evidence suggests that GP prescribing decisions dependon the interaction with the patient and other influen-cing factors, such as GP characteristics and continuity ofcare, mutual trust, and flexibility with the patient.30 GPsinterviewed for the current study also saw prescribing asa negotiation tool; however, some did not agree with thedelayed prescribing approach as they found it to becontradictory and felt patients ought to have lessautonomy.In addition, the setting of the encounter was of

importance to GPs.30 GPs found that having consisten-cies in prescribing behaviours throughout the primarycare centre, as well as the use of local professional dis-cussions and exchange of experience that facilitatestheir prescribing practice. This emphasises the call forwider policy implementation and open discussion withinand between practices within CCGs, to enable a moreconsistent rate of prescribing around the UK.However, we confirmed the concerns of some prescri-

bers who perceive delayed prescribing to be an unhelp-ful management strategy for patients with self-limitingRTIs.14 Suitable training could potentially address theseconcerns to enable prescribers to use delayed prescrip-tion appropriately and manage consultations moreeffectively. Other research has suggested that to reduceantibiotic prescribing, interventions need to includeseveral factors such as education about appropriate RTImanagement, making strategies more acceptable to GPs,which in turn may improve the effectiveness of theirimplementation.31 32

Implications for policy, research and practiceThe findings from the study highlight the importance ofdeveloping, revising, and implementing consistent,coherent guidelines and policies both across and withinCCGs. GPs would benefit from having accessible infor-mation of the natural history and duration of RTI thatthey should discuss with patients during the consult-ation. Suitable training for less experienced GPs couldbe provided with emphasis on communication andnegotiation of the management of RTI at a patient andpractice level.More feedback for practices may reinforce the use of

the delayed strategy. Improved national data on theprevalence of this technique could generate more inter-est in the approach and start to normalise the tech-nique. The implementation of improved surveillanceand tracking of prescribing is of paramount importanceto reduce the number of antibiotic prescriptions inprimary care. GPs may want to consider experimentingwith different approaches to delayed prescribing toascertain how best to obtain feedback on how often pre-scriptions are collected.Further research could be conducted to examine the

views and understanding of delayed prescribing strat-egies with other prescribing practitioners. Given thatGPs in a primary care setting explained that theirpatients may access out-of-hour care services whenshowing RTI symptoms, it would be beneficial to knowwhat prescribing strategies are used by out-of-hours prac-titioners, as well as other prescribing professionals.Moreover, investigating how GPs communicate with theirpatients about RTI and AMR and the influence differentcommunication approaches have on prescribing out-comes in a consultation would be useful.

CONCLUSIONWhile delayed antibiotic prescribing strategies are recom-mended in primary care when doctors feel it is safe notto prescribe immediately,11 it is not always successfullyimplemented in practice, and the use of short delays incontrast both to the evidence of natural history and thestrategies used in trials. This study identifies a need forgreater clarity over which method is best to delay a pre-scription during a consultation, and how best to oper-ationalise delayed prescribing to create uniformity withinteams and localities. Providing feedback on the uptake ofantibiotics at individual and practice level may facilitatethis, as well as responding to patient concern appropri-ately without misinterpreting the patients’ agenda.Finally, the way in which GPs communicate with

patients to provide greater clarity on delayed prescribingmay be beneficial. While a good rapport developsthrough experience, it is important to acknowledge theseverity of the illness while addressing the needs of thepatient. This study suggests that GPs may need guidancein how to answer the concerns of patients without inter-preting these questions as a demand for antibiotics.

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Twitter Follow Rachel Ryves at @rachelryves

Contributors GML conceived the idea of the study and was responsible for allaspects of the study including design, data interpretation and manuscriptpreparation. RR was responsible for leading the data collection and analysis,and preparation of the manuscript. CE was involved in the preparation of thestudy design and ethics submission, data analysis and interpretation ofresults and manuscript preparation and revisions. LM, PL and MM wereinvolved in the generation of the study idea, design, interpretation andmanuscript comments and revisions.

Funding This work was supported by the National Institute for HealthResearch School for Primary Care Research (NIHR SPCR) grant 197.

Competing interests None declared.

Ethics approval University of Southampton Faculty of Medicine Ethics on 7October 2013.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

Open Access This is an Open Access article distributed in accordance withthe terms of the Creative Commons Attribution (CC BY 4.0) license, whichpermits others to distribute, remix, adapt and build upon this work, forcommercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

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