A Mixed Methods Study of Oral Antibacterial Prescribing in Primary Care Out-of-Hours Services in Wales

Abstract

The World Health Organization aims to combat antimicrobial resistance through strategies that include reducing unnecessary antimicrobial use. This global priority is reflected in the UK, including Wales, where national antimicrobial stewardship (AMS) plans guide efforts to optimise prescribing. Primary care accounts for approximately 80% of antibacterial prescriptions, with oral formulations representing the majority. Out-of-hours (OOH) services are an integral part of primary care that have gained momentum internationally; however, there is limited evidence on oral antibacterial prescribing practices within OOH services in Wales. Therefore, this thesis used mixed methods to explore oral antibacterial prescribing in OOH services through four studies. Study one conducted a scoping review to map current evidence on OOH antibacterial prescribing and identify knowledge gaps. Study two comprised two phases involving secondary analyses of prescribing and/or consultation data from primary care OOH services and the community pharmacy independent prescribing service (PIPS) during OOH periods to describe oral antibacterial prescribing over the available timeframe. Study three used interviews with key stakeholders to explore perspectives on oral antibacterial prescribing and factors influencing prescribing patterns. Study four also employed interviews to explore prescribers’ experiences and decision-making when prescribing antibacterials in NHS 111, an OOH service model. The findings showed decreasing prescribing trends across primary care and OOH services, alongside rising PIPS prescribing driven by increased service use. Factors, including healthcare incidents and their consequences, influenced prescribing. The results also suggested limited awareness and oversight of OOH services among stakeholders, with challenges such as data availability and quality hindering identification of issues requiring targeted actions. Prescribing was context-dependent, shaped by access barriers, patient acuity, remote care challenges, and communication strategies adopted to optimise prescribing. Understanding determinants of prescribing is essential to inform feasible and effective interventions. Investment in integrated, efficient data infrastructure is crucial for enhancing evaluation, surveillance, and AMS.