In a blog post entitled Educating patients or blaming them? Public education campaigns on antibiotic resistance, Rebecca Glover, head of Economics, Social, and Political Sciences at the AMR Centre, LSHTM, Nicholas Mays, Professor of Health Policy at LSHTM, together with Margaret Dangoor, a patient representative, comment on the persistent mischaracterisation of the patient as a barrier to antibiotic stewardship in the UK.bmj 

Writing in BMJ Opinion, Glover, Dangoor, and Mays argue that the evidence for patient demand or pressure as a driver of inappropriate prescription is scant and unconvincing. The authors point to a range of other structural factors, incentives, and potential drivers in clinical settings that may be equally or more responsible for suboptimal antibiotic stewardship. Benchmarking against other European general practice environments, the authors note that capitation-style payment systems (such as in the UK NHS) ought to lead to lower rates of antibiotic prescription than fee-for-service systems.

Two drivers which may strain stewardship are broader policy pressures on clinical outcomes (system-wide targets on sepsis and meningitis are cited as potentially leading to precautionary prescriptive behaviour among GPs, as a wholly-understandable response to diagnostic uncertainty), and time pressures at practice level. In the latter case, the authors point to evidence of antibiotic prescription as a means of ensuring timely termination of a consultation. Thus, responsibility for managing the prescription of antibiotics needs to take account of systemic pressures, and recognise and build a shared purpose among clinicians and patients.

In the systemic examples cited, antibiotics would appear to fulfil an infrastructural role, enabling GPs to manage contending pressures which threaten to undermine quality of service. In other words, antibiotics make the rationing system work, make it possible to share out clinician time and health service money, independently of their role in preventing and managing infection. They can also underpin the trust between patient and clinician, even as antimicrobial resistance introduces tensions into this relation. It may be that the deep faith in antibiotics, which clearly transcends the specificity of their action and potency, can in itself be mobilised as a resource for building a powerful coalition for equity in health and resource management.