The Multi-Disciplinary Team

Has the whole practice approach adopted by Churchill medical centre supported your professional practice as a clinician? Well, as such, it’s enabled us to all speak with the same ethos. We all say the same thing. It means that I can happily and comfortably refuse an antibody if I don’t feel it’s appropriate. But I can also– I know the practice will back me if I recognise it is appropriate. But, you know, you will have the first line of checking whether it’s appropriate. And if it’s not appropriate, you then go to explain to a patient why it’s not appropriate. And you don’t prescribe. [door opens] And we all do the same thing.

So for my practice, knowing the doctors are doing the same as I’m doing, knowing my colleagues are doing the same as I am, it’s very supportive.

Rebecca is a deputy practice manager with Churchill medical practice and has been involved with the model of a whole practice approach from the very start. Can you tell me what that involves? So initially, it was a case of trying to gather together information about how things are coded on the notes. So that we could set a baseline audit search group for this. We contacted all the clinicians and said, if you– for example, if you see a patient with an ear infection, how do you code that on the notes? What code do you put on the notes? And we developed a whole group of searchers around that, broken down into different disease areas.

So we had, for example, acute exacerbation of COPD, acute exacerbation of asthma, sore throat, tonsillitis, ear infection. And we actually broke them down into specific diseases. We then looked at how many of the patients in each category were given antibiotics at the time of their visit, which meant that we could have a baseline for our starting point on how many patients have been seen with a respiratory infection who were given antibiotics. That was the starting point, which then allowed us to present that to clinicians and the entire practice staff, to be honest, to then develop that into the system that we used, which involved obviously the posters and information sheets for clinicians to use in their consultations to assist them.

So by asked the clinicians to submit their preferred recoding you didn’t impose a set of recodes on the clinicians– No. And clinicians continue to recode to suit themselves. Mhm. And each search contained multitudes of recodes, to be honest. You know, some of them had 10 or 12 different codes for sore throat. And it just depended on how people coded things. But you chose to capture the coding they used, rather than imposing a single coding approach. Mhm. And how did you then use the data you collected to say, this is what we’re doing at the moment, to then measure your change?

So Pete then collated all the information, and we presented it to the staff as, you know, this is where we are now, this is what we’d like to do. And we ran the programme for three months. And then searched again on exactly the same searches and noticed that there had been a significant reduction in the numbers of antibiotic prescriptions issued. And one of the real challenges with doing these sorts of quality improvement works is sustaining the change and the engagement. How do you manage that? So we re-audit it every year, just to monitor it. And presented that information to clinicians. Regular updates do help, little reminders. You know, an email here, or an email there.

Updating the posters, making sure that they’re in every room, making sure that they are available to people whenever they’re needed. You know, the information sheets for clinicians to show to patients and say, look, this is why I don’t think you need antibiotics at this point. And actually reminding people that they’re there helps. That’s really helpful. And as practice managers you’re involved with introducing new members of staff to the practice. [coughs] So how can you ensure that new members of staff are aware of this approach? This whole practice approach to antimicrobial stewardship? So it’s actually included as part of our induction programme for members of staff, particularly clinicians, including all of our registrars.

Everybody gets to sit down with one of the clinicians and has a discussion about prescribing in general, but also in particular the antibiotic prescribing forms part of their induction. That’s excellent. That’s really integrative. It’s a real whole practice approach. And in terms of patient complaints, when you started this approach how many patient complaints did you experience? Initially there were three or four. But it was quite simple to respond to them because it’s all evidence based medicine. The responses could include all the nice guidance and links to the relevant information. Because there was this cohesive practice approach it got away from the GP hopping aspect.

You know, where you go to see one GP who won’t give you antibiotics, so a patient thinks, oh, I’ll go an see someone else and they’ll get it. And that went, which is why we think we had a few complaints at the beginning. But it didn’t– was quite simple to respond to because of the evidence base that you could send out to them. And when was the last time you had a patient complain about not getting access to antibiotics? I don’t remember. In all honesty, it was– it was a long time ago. Great. Thanks very much, Rebecca, for sharing your experience with us. No problem.