Antimicrobial Prescribing Report. Medicines Optimisation 2012/13

Antimicrobial Prescribing Report Medicines Optimisation 2012/13

Executive Summary Antimicrobial resistance and antibiotic prescribing, especially in relation to healthcare associated infections are key issues for CCGs. The DH report 3 published in March 2013 placed the issue of antibiotic resistance and antimicrobial stewardship centre stage and warns of a major increase in the number of bugs resistant to antibiotics. Of particular concern are MRSA and Clostridium difficile infections which remain serious threats, especially to hospital inpatients. The UK Five Year Antimicrobial Resistance Strategy 2013 2018 sets out key challenges and areas for action in slowing the development and spread of antimicrobial resistance. The Medicines Optimisation team have already done considerable work in this area, including development of antimicrobial prescribing guidance based on HPA recommendations and audits of the appropriateness of antibiotic prescribing, however despite a positive impact, especially upon broad spectrum antibiotic prescribing, antimicrobial resistance is still on the rise. The Medicines optimisation team continues to work with GPs, local hospital trusts and infection control teams to build on this work to address antimicrobial resistance and to ensure antimicrobial stewardship remain high on the local prescribing agenda. This winter patients will be supported by an antibiotic awareness campaign as part of the Choose Well Cumbria winter programme. Other work includes the development of educational materials, the provision of comprehensive prescribing reports and working with local infection control teams. In 2012-13 antibacterial items increased by 3.57% (2nd lowest increase of the 13 North East CCGs) Cumbria CCG prescribing frequency compares favourably with other NE CCGs (5 th lowest) but Cumbria CCG prescribing average of 130.7items per 100 QIPP antibacterial STAR-PU is slightly higher than the England value of 128.2.. 13 of the 81 practices in Cumbria (16%) participated in the antibiotic audit for QOF MM, 8 of these improved QIPP score. 13-14 workplan includes an improved audit, promotion of the RCGP Target Toolkit, 26 Practices (32%) have chosen to work on Antibiotic prescribing in 2013-14 The CCG Communications Team have developed resources to support the Cumbria winter antibiotic campaign. The aim of the material is to raise awareness among patients that antibiotics are not always the answer and to encourage patients to self care when they have a common winter illness. Recommendations - All practices should audit any Red or Amber QIPP antibacterial indicators and aim to achieve green. - All Practices should participate in a group reflective learning session &/or e-learning on antibiotic prescribing - All Practices should promote the Winter Antibiotic campaign - All Prescribers should ensure patients understand their responsibilities around compliance once an antibiotic is prescribed - Prescribers should use No prescription or delayed prescription strategies and patient information as appropriate. 2

Introduction Primary care is responsible for the majority of antibiotic use (80%). 40% of people consult their Doctor with an infection each year 1 and about one-quarter will present with an acute respiratory tract infection (RTI) which in turn accounts for 60% of antibiotics prescribed 2. This prescribing pattern encourages people to consult again when they have similar symptoms. The DH report 3 published in March 2013 from The Chief Medical Officer placed the issue of antibiotic resistance and antimicrobial stewardship centre stage and warns of a major increase in the number of bugs resistant to antibiotics. The UK Five Year Antimicrobial Resistance Strategy 2013 2018 sets out key challenges and areas for action in slowing the development and spread of antimicrobial resistance, based around 3 strategic aims: 1. Improve the knowledge and understanding of antimicrobial resistance 2. Conserve and steward the effectiveness of existing treatments 3. Stimulate the development of new antibiotics, diagnostics and novel therapies Key actions for primary care highlighted by this strategy continue to involve: Only prescribing antibiotics in situations where they are clearly indicated Appropriate choice of antibiotic if an agent is actually required Ensuring patients understand their responsibilities around compliance once an antibiotic is prescribed Of particular concern are MRSA and Clostridium difficile infections which remain serious threats, especially to hospital inpatients.nhs organisations have been mandated to implement national guidance that includes restriction of broad spectrum antibiotics, and in particular second and thirdgeneration cephalosporins, quinolones, co-amoxiclav and clindamycin, often referred to as the 4Cs. The prescribing of quinolones (e.g. ciprofloxacin) is a particular cause for concern. Resistance to quinolones is increasing at a considerable rate. Extended Spectrum Beta-Lactamases (ESBL s) producing Escherichia coli (E.coli) and Klebsiella are also becoming problematic especially in UTI s. Most ESBLproducing E. coli are resistant to cephalosporins, penicillins, quinolones, trimethoprim, tetracycline and some other antibiotics, leaving very limited options for oral treatment in the community. The Medicines Optimisation team continue to raise awareness among prescribers of the high volume antibiotic prescribing in Cumbria and support good prescribing practice with audit tools, quarterly antibacterial prescribing reports, QIPP comparators and the annual winter antibiotic campaigns. In 2008/9 Cumbria was the 3 rd highest prescriber of antibiotics (by volume) in the North West with few practices comparing favourably against the national and North of England averages, by 2011/ 12 Cumbria had improved to the 8 th highest and was below the North West and England averages. In 2011/12 Antibacterial items reduced by 2.43% compared to previous year In 2012-13 antibacterial items increased by 3.57% ( 2 nd lowest of the 13 North East CCGs) 3

The Regional RDTC Antibacterial report now compares Cumbria with North East CCG s (13) North East & Cumbria CCG antibacterial prescribing frequency 2012-13 Cumbria CCG prescribing frequency compares favourably with other NE CCGs (5 th lowest), but slightly above the England prescribing frequency. North East & Cumbria CCG antibacterial prescribing frequency 2010-13 North East & Cumbria CCGs: Weighted prescribing frequency of antibacterial drugs - April 2010 to March 2013 45 Items per 100 QIPP antibacterial STAR-PU 40 35 30 25 Cumbria Darlington Durham Dales, Easington & Sedgefield Gateshead Hartlepool & Stockton Newcastle North and East Newcastle West North Durham North Tyneside Northumberland South Tees South Tyneside Sunderland Teaching North of England England Cumbria 20 1011Q1 1011Q2 1011Q3 1011 1112Q1 1112Q2 1112Q3 1112 1213Q1 1213Q2 1213Q3 1213 This shows seasonal variations as well as prescribing trends. Cumbria mirrors other Northern CCGs. copyright RDTC 2013 4

Cumbria Antibiotic Prescribing 2011-13 trend 45,000 42,500 Antibiotic Prescribing 2011-2013 40,000 2011 2012 Number of Prescriptions 37,500 35,000 32,500 32,928 2013 30,000 30,639 27,500 25,000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec This graph shows the increasing number of antibacterial prescriptions prescribed. In April 2013 32,928 items were prescribed compared to 30,639 in April 2012, an increase of 2,289 items (7.47%) 14.00 Broad Spectrum Antibiotic Prescribing 2005-2013 12.00 10.00 8.00 6.00 4.00 2.00 0.00 3.98 3.72 4.02 3.56 1.70 1.61 2005/6 Q1 2006/7 Q2 2006/7 Q3 2006/7 2006/7 Q1 2007/8 Q2 2007/8 Q3 2007/8 2007/8 Q1 2008/9 Q2 2008/9 Q3 2008/9 2008/9 Q1 2009/10 Q2 2009/10 Q3 2009/10 2009/10 Q1 2010/1 Q2 2010/1 Q3 2010/1 2010/1 Q1 2011/2 Q2 2011/2 Q3 2011/2 2011/2 Q1 2012/3 Q2 2012/3 Q3 2012/3 2012/3 Q1 2013/4 Month % of all antibiotics prescribed ------- Cephalospori ------- Co-amoxiclav ------- Quinolones This graph Illustrates the fall in prescribing of the 3 Cs-broad spectrum antibiotics Cephalosporins has decreased significantly. - During 2012-13 there was a further drop of 0.42% 3.98% 3.56% Co-amoxiclav has shown no recent decrease but a small increase - During 2012-13 an increase of 0.30% 3.72% 4.02% Quinolones have shown a smaller decrease. - During 2012-13 a further drop of 0.09% 1.70% 1.61% However,Q1 2013-14 is showing an increase in prescribing of all 3 high risk broad spectrum antibiotics. 5

The RDTC report April 2013-March 2013 - compares Cumbria CCG with the other 12 North East CCGs Cumbria ranking ( 13 CCGs) Macrolides 2 nd highest Quinolones 3 rd highest Cephalosporins 5 th highest Co-amoxiclav 8 th highest Minocycline 5 th highest Topical antibiotics 6 th highest Clindamycin 3 rd lowest Tetracyclines 2 nd lowest Y:\Docs\antibiotics\ 2013\Annual Report\C The report shows there is further improvement to be made in the prescribing of all broad spectrum antibiotics including macrolides as well as volume of all antibiotics prescribed. Please refer to RDTC report 2012-13 for further detail on prescribing of broad spectrum antibiotics. A recent Guardian newspaper article 4, includes an interactive digital map and shows the areas where GPs are most, or least, likely to give a patient a prescription for antibiotics. http://www.theguardian.com/society/datablog/2013/jun/11/antibiotic-prescription-by-gp-practicemapped The area which prescribed antibiotics the most was Newcastle West clinical commissioning group (CCG). The incidence rate of prescribing by GP surgeries there was 8.4%. Cumbria CCG rate was 7.2% By contrast, GP practices in Camden, north London, prescribed antibiotics the least. incidence rate was just 4% for 2012. There is a pronounced North/South divide, with Northern GPs much more likely to prescribe antibiotics than their Southern counterparts. Ambler's research 4 shows that 69% of northern CCG areas prescribe more than the national average, compared with 39% of southern ones. QOF Audits 2012-13 The Practices used the QIPP indicators as a measure for the QOF MM audits. 1. Antibacterial items STAR-PU (lower the better) 2. Cephalosporin & Quinolones % items (lower the better) 3. 3 days Trimethoprim ADQ/item (lower the better) 13 of the 82 Cumbria GP practices (16%) chose to audit antibiotic prescribing.highest participating locality was Allerdale, the lowest was Furness. Copeland locality Catherine St & Lowther Allerdale locality Oxford St, Bank St, Maryport & Dalston Carlisle Locality Longtown, Stanwix & Fusehill Eden locality Glenidding & Court Thorn South Lakes Lunesdale & Sedbergh Furness no practices 6

Antibiotic QIPP comparators Locality Performance % Cephalosporins & Quinolones 3 days trimethoprim ADQ/item 2011/12 2012/13 change 2011/12 2012/13 change Baseline Q1 2012/13 2012/13 change LOCALITY ALLERDALE 0.320 0.330 +0.010 5.74 4.32-1.42 5.81 5.23-0.58 CARLISLE 0.389 0.344-0.045 4.64 4.14-0.50 5.64 5.63-0.01 COPELAND 0.384 0.390 +0.006 6.74 5.21 -.1.53 6.13 5.38-0.75 EDEN 0.289 0.289 0.00 5.33 5.16-0.17 6.12 5.87-0.25 FURNESS 0.379 0.371-0.008 6.10 7.17 +1.07 6.53 5.95-0.58 SOUTH LAKES 0.290 0.301 +0.011 5.49 5.97 +0.48 5.86 5.99 +0.13 CUMBRIA average 0.37 0.35-0.02 5.79 5.76-0.03 5.91 5.91 0 % Cephalosporins & Quinolones 3 days trimethoprim QDA/item baseline baseline baseline 2011/12 2012/13 2013/14 2011/12 2012/13 2013/14 2011/12 2012/13 2013/14 England / PCT 75thcentile 0.37 0.36 0.36 6.84 6.41 6.41 n/a 6.47 6.44 England / PCT - 25th centile 0.33 0.32 0.31 4.35 4.18 4.18 n/a 5.78 5.76 England average 0.35 0.34 0.33 5.79 5.79 5.27 n/a 6.15 6.08 the QIPP comparators for 2012-13 show Carlisle, Copeland & Furness are the highest prescribers of antibiotics by volume. Eden is the lowest. Furness, South Lakes & Copeland are the highest prescribers of Cephalosporin and Quinolones %. Carlisle is the lowest. Furness % Cephalosporin and Quinolones have increased from Amber Red Furness is also the highest prescriber of longer courses of Trimethoprim but has decreased from Red Amber. Allerdale is the lowest. Locality Performance-charts England average England / PCT - 25th centile England / PCT 75thcentile CUMBRIA average SOUTH LAKES FURNESS EDEN COPELAND CARLISLE ALLERDALE Antibacterial items STAR PU -0.1-0.05 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 change 2012/13 2011/12 7

% Cephalosporins & Quinolones England average England / PCT - 25th centile England / PCT 75thcentile CUMBRIA average SOUTH LAKES FURNESS EDEN COPELAND CARLISLE ALLERDALE -2-1 0 1 2 3 4 5 6 7 8 change 2012/13 2011/12 3 days trimethoprim ADQ/item England average England / PCT - 25th centile England / PCT 75thcentile CUMBRIA average SOUTH LAKES FURNESS EDEN COPELAND CARLISLE ALLERDALE -2-1 0 1 2 3 4 5 6 7 change 2012/13 2011/12 Practice Results (See table on next page for more detail) Antibacterial items/star PU Longtown achieved a significant reduction from 0.68 0.36 STAR PU, a 47% decrease and has moved from being the highest antibiotic prescribing practice in Cumbria Red Amber Stanwix Medical Practice has improved Red Amber Oxford St improved 0.39 0.37 still Red Catherine St & Lowther Medical Practice figures increased from 0.45 0.50 and still Red Fusehill Medical improved from0.42 0.39 still Red Dalston Surgery small reduction from 0.41 0.40 still Red % Cephalosporin and quinolones Glenridding, Bank St and Maryport achieved Green indicators Fusehill Medical improved from Red Amber Bank st improved from Red Amber Dalston Surgery improved from 8.62% 6.00% Red Amber 3 days trimethoprim ADQ/items Court Thorn moved from Red Green Sedbergh moved from Amber Red Lunesdale surgery is still Red 8

Indicator Lower the Better Oxford ST Stanwix Longtown Lowther Catherine St Dalston Fusehill Practice Results QIPP Practice Dashboard January to March 2013 Baseline Current Quarter Previous Quarter Upper Quartile Target Lower Quartile Target Locality PCT England Change Previous Quarter 0.39 0.37 0.39 0.36 0.32 0.33 0.35 0.34 0.42 0.36 0.44 0.36 0.32 0.35 0.35 0.34 0.68 0.36 0.42 0.36 0.32 0.35 0.35 0.34 0.48 0.50 0.47 0.36 0.32 0.39 0.35 0.34 0.44 0.50 0.45 0.36 0.32 0.39 0.35 0.34 0.41 0.40 0.41 0.36 0.32 0.33 0.35 0.34 0.42 0.39 0.40 0.36 0.32 0.35 0.35 0.34 Cephalosporins & Quinolones % items Bank St Cephalosporins & Quinolones % items Glenridding Cephalosporins & Quinolones % items Maryport Cephalosporins & Quinolones % items Fusehill Cephalosporins & Quinolones % items Dalston 3 days Trimethoprim ADQ/item Court Thorn Surgery 3 days Trimethoprim ADQ/item Sedbergh 3 days Trimethoprim ADQ/item Lunesdale 6.85 3.71 6.25 6.84 4.35 4.32 5.76 5.79 5.68 1.79 1.96 6.84 4.35 5.16 5.76 5.79 6.91 2.83 3.68 6.84 4.35 4.32 5.76 5.79 4.08 4.40 4.28 6.84 4.35 4.14 5.76 5.79 8.62 6.00 9.11 6.84 4.35 4.32 5.76 5.79 7.74 4.99 6.81 6.47 5.78 5.87 5.91 6.15 7.18 6.69 5.95 6.47 5.78 5.99 5.91 6.15 6.66 9.33 8.06 6.47 5.78 5.99 5.91 6.15

Locality & GP Practice Results Cephalosporins & Quinolones % items ALLERDALE QIPP INDICATORS 2012/13 2011/12 % change 2012/13 2011/12 A82014-CALDBECK SURGERY 4.70 5.39-0.69 A82014-CALDBECK SURGERY 0.26 0.28-0.02 A82028-CASTLEHEAD MEDICAL CENTRE 4.15 3.51 0.64 A82028-CASTLEHEAD MEDICAL CENTRE 0.26 0.30-0.04 A82029-THE CROFT SURGERY 5.78 4.78 1.00 A82029-THE CROFT SURGERY 0.39 0.33 0.06 A82063-BANK STREET SURGERY 3.71 6.85-3.14 A82063-BANK STREET SURGERY 0.32 0.27 0.05 A82022-DALSTON MEDICAL GROUP 6.00 8.62-2.62 A82022-DALSTON MEDICAL GROUP 0.40 0.41-0.01 A82045-WIGTON GROUP MEDICAL PRACTICE 3.43 6.17-2.74 A82045-WIGTON GROUP MEDICAL PRACTICE 0.32 0.27 0.05 A82623-SOLWAY HEALTH SERVICES 3.58 2.58 1.00 A82623-SOLWAY HEALTH SERVICES 0.40 0.36 0.04 A82021-CASTLEGATE SURGERY 4.12 4.30-0.18 A82021-CASTLEGATE SURGERY 0.31 0.29 0.02 A82037-SILLOTH GROUP MEDICAL PRACTICE 3.16 3.11 0.05 A82037-SILLOTH GROUP MEDICAL PRACTICE 0.35 0.33 0.02 A82047-JAMES STREET GROUP PRACTICE 3.07 3.07 0.00 A82047-JAMES STREET GROUP PRACTICE 0.32 0.33-0.01 A82032-MARYPORT HEALTH SERVICES 2.83 6.91-4.08 A82032-MARYPORT HEALTH SERVICES 0.38 0.36 0.02 A82057-DERWENT HOUSE SURGERY 4.63 5.07-0.44 A82057-DERWENT HOUSE SURGERY 0.23 0.25-0.02 A82049-ORCHARD HOUSE SURGERY 4.72 8.47-3.75 A82049-ORCHARD HOUSE SURGERY 0.30 0.31-0.01 A82055-ASPATRIA MEDICAL PRACTICE 4.70 4.55 0.15 A82055-ASPATRIA MEDICAL PRACTICE 0.34 0.35 0.00 A82050-OXFORD STREET SURGERY 6.02 6.90-0.88 A82050-OXFORD STREET SURGERY 0.37 0.39-0.02 A82048-BEECHWOOD GROUP PRACTICE 7.40 11.20-3.80 A82048-BEECHWOOD GROUP PRACTICE 0.28 0.31-0.03 AVERAGE 4.32 5.74-1.22 AVERAGE 0.33 0.32 0.01 % change

Cephalosporins & Quinolones % items CARLISLE QIPP INDICATORS % % 2012/13 2011/12 change 2012/13 2011/12 change A82015-WARWICK ROAD SURGERY 3.54 4.99-1.45 A82015-WARWICK ROAD SURGERY 0.260 0.284-0.024 A82012-BRAMPTON MEDICAL A82012-BRAMPTON MEDICAL PRACTICE 3.85 4.56-0.71 PRACTICE 0.340 0.366-0.026 A82019-FUSEHILL MEDICAL PRACTICE 4.40 4.08 0.32 A82019-FUSEHILL MEDICAL PRACTICE 0.390 0.417-0.027 A82635-GROSVENOR HOUSE A82635-GROSVENOR HOUSE SURGERY SURGERY (W) 3.15 2.90 0.25 (W) 0.340 0.304 0.036 A82020-EDEN MEDICAL GROUP 2.77 3.16-0.39 A82020-EDEN MEDICAL GROUP 0.370 0.378-0.008 A82052-STANWIX MEDICAL GROUP 4.95 5.60-0.65 A82052-STANWIX MEDICAL GROUP 0.360 0.416-0.056 A82017-BRUNSWICK HOUSE A82017-BRUNSWICK HOUSE MEDICAL MEDICAL GROUP 4.39 4.30 0.09 GROUP 0.430 0.418 0.012 A82654-GROSVENOR HOUSE A82654-GROSVENOR HOUSE SURGERY SURGERY (A) 4.13 3.51 0.62 (A) 0.290 0.375-0.085 A82641-GROSVENOR HOUSE A82641-GROSVENOR HOUSE SURGERY SURGERY (F) 4.74 4.79-0.05 (F) 0.340 0.331 0.009 A82016-ST PAULS PRACTICE 4.72 5.59-0.87 A82016-ST PAULS PRACTICE 0.360 0.382-0.022 A82018-SPENCER ST SURGERY 4.32 4.98-0.66 A82018-SPENCER ST SURGERY 0.290 0.314-0.024 A82646-LONGTOWN MEDICAL CENTRE 5.45 6.70-1.25 A82646-LONGTOWN MEDICAL CENTRE 0.360 0.685-0.325 AVERAGE 4.14 4.64-0.50 AVERAGE 0.344 0.389-0.045 11

Cephalosporins & Quinolones % items COPELAND QIPP INDICATORS % % 2012/13 2011/12 change 2012/13 2011/12 change A82023-DISTINGTON SURGERY 5.81 9.03-3.22 A82023-DISTINGTON SURGERY 0.360 0.327 0.033 A82075-MANSION HOUSE A82075-MANSION HOUSE SURGERY 4.64 5.01-0.37 SURGERY 0.350 0.330 0.020 A82024-SEASCALE HEALTH A82024-SEASCALE HEALTH CENTRE 5.89 5.05 0.84 CENTRE 0.360 0.382-0.022 A82064-WESTCROFT HOUSE A82064-WESTCROFT HOUSE SURGERY 3.29 5.17-1.88 SURGERY 0.320 0.464-0.144 A82060-TRINITY HOUSE A82060-TRINITY HOUSE SURGERY 2.24 5.32-3.08 SURGERY 0.330 0.347-0.017 A82040-CATHERINE STREET A82040-CATHERINE STREET SURGERY 7.34 8.40-1.06 SURGERY 0.500 0.439 0.061 A82044-FELLVIEW HEALTHCARE A82044-FELLVIEW HEALTHCARE LTD 5.19 8.50-3.31 LTD 0.370 0.318 0.052 A82058-QUEEN STREET MEDICAL A82058-QUEEN STREET MEDICAL PRACTICE 7.21 7.35-0.14 A82041-LOWTHER MEDICAL CENTRE 4.77 6.72-1.95 PRACTICE 0.420 0.368 0.052 A82041-LOWTHER MEDICAL CENTRE 0.500 0.483 0.017 AVERAGE 5.21 6.74-1.53 AVERAGE 0.390 0.384 0.006 12

EDEN QIPP INDICATORS Cephalosporins & Quinolones % items 2012/13 2011/12 % change 2012/13 2011/12 A82620-GLENRIDDING HEALTH CENTRE 1.79 5.68-3.89 A82620-GLENRIDDING HEALTH CENTRE 0.280 0.216 0.064 A82031-SHAP MEDICAL PRACTICE 3.22 4.22-1.00 A82031-SHAP MEDICAL PRACTICE 0.260 0.277-0.017 A82617-KIRKOSWALD SURGERY 7.88 3.69 4.19 A82617-KIRKOSWALD SURGERY 0.260 0.301-0.041 A82036-THE LAKES MEDICAL PRACTICE 3.85 5.08-1.23 A82036-THE LAKES MEDICAL PRACTICE 0.260 0.250 0.010 A82038-TEMPLE SOWERBY MEDICAL PRACTICE 2.74 4.76-2.02 % change A82038-TEMPLE SOWERBY MEDICAL PRACTICE 0.260 0.225 0.035 A82004-ALSTON MEDICAL PRACTICE 4.65 4.31 0.34 A82004-ALSTON MEDICAL PRACTICE 0.340 0.294 0.046 A82035-BIRBECK MEDICAL GROUP 5.25 5.71-0.46 A82035-BIRBECK MEDICAL GROUP 0.290 0.308-0.018 A82006-APPLEBY MEDICAL PRACTICE 4.25 3.98 0.27 A82006-APPLEBY MEDICAL PRACTICE 0.300 0.352-0.052 A82013-UPPER EDEN MEDICAL PRACTICE 6.53 5.80 0.73 A82013-UPPER EDEN MEDICAL PRACTICE 0.290 0.312-0.022 A82631-COURT THORN SURGERY 10.40 10.13 0.27 A82631-COURT THORN SURGERY 0.350 0.353-0.003 AVERAGE 5.16 5.33-0.27 AVERAGE 0.289 0.289 0.000 13

SOUTH LAKES QIPP INDICATORS Cephalosporins & Quinolones % items 2012/13 2011/12 % change A82026-THE JAMES COCHRANE PRACT. 4.20 4.50-0.30 A82026-THE JAMES COCHRANE PRACT. 0.250 0.232 0.018 A82642-HAWKSHEAD MEDICAL PRACTICE 7.80 5.85 1.95 A82642-HAWKSHEAD MEDICAL PRACTICE 0.300 0.315-0.015 A82613-WRAYSDALE HOUSE SURGERY 13.01 5.06 7.95 A82613-WRAYSDALE HOUSE SURGERY 0.220 0.283-0.063 A82608-SEDBERGH HEALTH CENTRE (LUMB) 7.80 6.28 1.52 A82608-SEDBERGH HEALTH CENTRE (LUMB) 0.300 0.337-0.037 A82647-CARTMEL SURGERY 6.69 7.16-0.47 A82647-CARTMEL SURGERY 0.260 0.292-0.032 A82046-WINDERMERE HEALTH CENTRE 3.82 4.59-0.77 A82046-WINDERMERE HEALTH CENTRE 0.290 0.228 0.062 P81113-PARK VIEW SURGERY 3.83 3.50 0.33 P81113-PARK VIEW SURGERY 0.290 0.286 0.004 A82027-STATION HOUSE SURGERY 5.97 5.24 0.73 A82027-STATION HOUSE SURGERY 0.300 0.297 0.003 A82053-NUTWOOD SURGERY 8.04 5.39 2.65 A82053-NUTWOOD SURGERY 0.360 0.396-0.036 A82065-FAIRFIELD SURGERY/PENINSULA 10.11 4.29 5.82 A82065-FAIRFIELD SURGERY/PENINSULA 0.310 0.385-0.075 A82003-ULVERSTON HEALTH CENTRE (MURRAY) 7.99 5.66 2.33 A82003-ULVERSTON HEALTH CENTRE (MURRAY) 0.330 0.293 0.037 A82025-CAPTAIN FRENCH SURGERY 5.35 6.15-0.80 A82025-CAPTAIN FRENCH SURGERY 0.280 0.242 0.038 A82068-ULVERSTON HEALTH CENTRE (GRAHAM) 5.14 6.71-1.57 A82068-ULVERSTON HEALTH CENTRE (GRAHAM) 0.300 0.303-0.003 A82650-HAVERTHWAITE SURGERY 2.27 3.61-1.34 A82650-HAVERTHWAITE SURGERY 0.310 0.300 0.010 A82074-ARNSIDE SURGERY 3.49 5.16-1.67 A82074-ARNSIDE SURGERY 0.290 0.293-0.003 A82005-AMBLESIDE HEALTH CENTRE 5.47 7.99-2.52 A82005-AMBLESIDE HEALTH CENTRE 0.350 0.348 0.002 A82034-STONELEIGH SURGERY 5.14 5.16-0.02 A82034-STONELEIGH SURGERY 0.400 0.360 0.040 A82070-ST.MARY'S SURGERY 4.19 6.00-1.81 A82070-ST.MARY'S SURGERY 0.270 0.279-0.009 A82030-LUNESDALE SURGERY 6.37 6.95-0.58 A82030-LUNESDALE SURGERY 0.300 0.326-0.026 AVERAGE 5.97 5.49 0.48 AVERAGE 0.301 0.305-0.004 2012/13 2011/12 % change 14

FURNESS QIPP INDICATORS Cephalosporins & Quinolones % items 2012/13 2011/12 % change % chang 2012/13 2011/12 e A82071-BURNETT EDGAR MEDICAL CTR 3.31 3.27 0.04 A82071-BURNETT EDGAR MEDICAL CTR 0.310 0.325-0.015 A82009-BRIDGEGATE MEDICAL CENTRE 4.72 3.95 0.77 A82009-BRIDGEGATE MEDICAL CENTRE 0.410 0.426-0.016 A82619-NELSON STREET SURGERY 2.81 0.80 2.01 A82619-NELSON STREET SURGERY 0.270 0.275-0.005 A82062-ATKINSON HEALTH CENTRE (WIEJAK) 4.53 8.03-3.50 A82062-ATKINSON HEALTH CENTRE (WIEJAK) 0.280 0.302-0.022 A82039-DALTON SURGERY 6.98 6.34 0.64 A82039-DALTON SURGERY 0.330 0.298 0.032 A82651-DUDDON VALLEY MEDICAL PRACTICE 3.84 5.04-1.20 A82651-DUDDON VALLEY MEDICAL PRACTICE 0.280 0.239 0.041 A82007-DUKE STREET SURGERY 5.40 6.91-1.51 A82007-DUKE STREET SURGERY 0.340 0.349-0.009 A82629-THE FAMILY SURGERY 1.75 3.43-1.68 A82629-THE FAMILY SURGERY 0.340 0.384-0.044 A82008-NORWOOD MEDICAL CENTRE 5.86 4.36 1.50 A82008-NORWOOD MEDICAL CENTRE 0.310 0.339-0.029 A82621-ASKAM SURGERY 1.74 7.71-5.97 A82621-ASKAM SURGERY 0.380 0.383-0.003 A82072-RISEDALE SURGERY 7.02 7.45-0.43 A82072-RISEDALE SURGERY 0.420 0.516-0.096 A82011-HARTINGTON STREET MEDICAL PRACTICE 9.87 10.53-0.66 A82011-HARTINGTON STREET MEDICAL PRACTICE 0.460 0.387 0.073 A82010-ABBEY ROAD SURGERY 7.83 9.30-1.47 A82010-ABBEY ROAD SURGERY 0.360 0.407-0.047 A82033-WATERLOO HOUSE SURGERY 12.05 7.15 4.90 A82033-WATERLOO HOUSE SURGERY 0.420 0.410 0.010 A82077-LIVERPOOL HOUSE SURGERY 7.85 8.00-0.15 A82077-LIVERPOOL HOUSE SURGERY 0.650 0.650 0.000 AVERAGE 7.71 6.10 1.61 AVERAGE 0.371 0.379-0.008 15

GP Practice Antibiotic Prescribing Chart Jan-March 2013 Cumbria Antibiotic Prescribing 2013 Jan-March WRAYSDALE HOUSE SURGERY DERWENT HOUSE SURGERY THE JAMES COCHRANE PRACT. THE LAKES MEDICAL PRACTICE KIRKOSWALD SURGERY CARTMEL SURGERY SHAP MEDICAL PRACTICE WARWICK ROAD SURGERY CALDBECK SURGERY CASTLEHEAD MEDICAL CENTRE NELSON STREET SURGERY ST.MARY'S SURGERY CAPTAIN FRENCH SURGERY ATKINSON HEALTH CENTRE (WIEJAK) DUDDON VALLEY MEDICAL PRACTICE GLENRIDDING HEALTH CENTRE SPENCER ST SURGERY BEECHWOOD GROUP PRACTICE PARK VIEW SURGERY TEMPLE SOWERBY MEDICAL PRACTICE WINDERMERE HEALTH CENTRE GROSVENOR HOUSE SURGERY (A) BIRBECK MEDICAL GROUP ARNSIDE SURGERY UPPER EDEN MEDICAL PRACTICE APPLEBY MEDICAL PRACTICE STATION HOUSE SURGERY ORCHARD HOUSE SURGERY HAWKSHEAD MEDICAL PRACTICE LUNESDALE SURGERY BURNETT EDGAR MEDICAL CTR ULVERSTON HEALTH CENTRE (HAMBLY) PENINSULA MEDICAL PRACTICE CASTLEGATE SURGERY HAVERTHWAITE SURGERY BENTHAM MEDICAL PRACTICE NORWOOD MEDICAL CENTRE WIGTON GROUP MEDICAL PRACTICE JAMES STREET GROUP PRACT WESTCROFT HOUSE SURGERY ULVERSTON HEALTH CENTRE DALTON SURGERY BANK STREET SURGERY TRINITY HOUSE SURGERY SEDBERGH HEALTH CENTRE (LUMB) ALSTON MEDICAL PRACTICE GROSVENOR HOUSE SURGERY (W) GROSVENOR HOUSE SURGERY (F) BRAMPTON MEDICAL PRACTICE DUKE STREET SURGERY THE FAMILY PRACTICE MANSION HOUSE SURGERY SILLOTH GROUP MEDICAL PRACTICE COURT THORN SURGERY AMBLESIDE HEALTH CENTRE DISTINGTON SURGERY LONGTOWN MEDICAL CENTRE STANWIX MEDICAL GROUP ST PAUL'S MEDICAL PRACTICE SEASCALE HEALTH CENTRE NUTWOOD SURGERY ABBEY ROAD SURGERY EDEN MEDICAL GROUP OXFORD STREET SURGERY MARYPORT HEALTH SERVICES FELLVIEW HEALTHCARE LTD ASKAM SURGERY FUSEHILL MEDICAL PRACTICE ASPATRIA MEDICAL GROUP THE CROFT SURGERY STONELEIGH SURGERY SOLWAY HEALTH SERVICES DALSTON MEDICAL GROUP BRIDGEGATE MEDICAL CENTRE WATERLOO HOUSE SURGERY IRONSIDE'S FAMILY PRACTITIONERS RISEDALE SURGERY BRUNSWICK HOUSE MEDICAL GROUP HARTINGTON STREET MEDICAL CATHERINE STREET SURGERY LOWTHER MEDICAL CENTRE LIVERPOOL HOUSE SURGERY GREEN RED 0.000 0.100 0.200 0.300 0.400 0.500 0.600 0.700 Items per SUB THER STAR-PU Penicillins Cephalosporins Tetracyclines Aminoglycosides Macrolides Clindamycin Other AB's Sulphonamides/TMP Antituberculars Metronidazole etc Quinolones UTI's

Medicines Optimisation work plan for 2013-14 Prescribers across Cumbria have made significant reductions in the amount of broad spectrum antibiotics prescribed; however, the 2013/14 work plan aims to support Prescribers to continue to reduce the volume of antibiotics prescribed including the broad spectrum antibiotics. Taking feedback from the 2012/13 audit into account, a user friendly antibiotic audit toolkit has been produced to support prescribers audit their own antibiotic prescribing and group reflective sessions and e-learning are being facilitated by the Medicines Optimisation Pharmacists and the Practice Medicines Managers The Medicines Optimisation audit toolkit offers 3 options: 1 Antibiotic prescribing (all) 2 Cephalosporins & quinolones 3 Urinary tract infections This audit toolkit is intended to be used by all Prescribers including Non Medical Prescribers (NMP) and will measure individual prescribing, adherence to antibiotic guidelines and practice prescribing patterns. The RCGP Target Toolkit is being promoted Cumbria wide especially to GP practices choosing to audit antibiotic prescribing http://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit/trainingresources.aspx Consultant Microbiologists from NCUHT and MBUHT have also offered to continue educational visits to GP practices. Recommendations - All practices should audit their antibiotic prescribing specifically any Red or Amber QIPP antibacterial indicators aiming to achieve green indicators. - All Practices should participate in a group reflective learning session &/or e- learning on antibiotic prescribing - All Practices should promote the Winter Antibiotic campaign with materials provided - All Prescribers should ensure patients understand their responsibilities around compliance once an antibiotic is prescribed - Prescribers should use No prescription or delayed prescription strategies and patient information as appropriate 17

26 GP Practices have chosen to work on Antibiotic prescribing in 2013-14 topic x Interpretation-the lower the better Baseline QIPP indicators January-March 2013/14 GP Practice Locality Antibacterial Items/STAR PU Cephalosporins & Quinolones % items 3 days Trimethoprim ADQ/Item A82028-CASTLEHEAD MEDICAL CENTRE ALLERDALE 0.26 4.15 5.26 A82037-SILLOTH GROUP MEDICAL PRACTICE ALLERDALE 0.35 3.16 3.71 A82014-CALDBECK SURGERY ALLERDALE 0.26 4.70 4.29 A82032-MARYPORT HEALTH SERVICES ALLERDALE 0.38 2.83 4.75 A82029-THE CROFT SURGERY ALLERDALE 0.39 5.78 6.80 A82623-SOLWAY HEALTH SERVICES ALLERDALE 0.40 3.58 5.89 A82045-WIGTON GROUP MEDICAL PRACTICE ALLERDALE 0.32 3.43 4.82 A82021-CASTLEGATE SURGERY ALLERDALE 0.31 4.12 5.31 A82055-ASPATRIA MEDICAL PRACTICE ALLERDALE 0.34 4.70 5.50 A82047-JAMES STREET GROUP PRACTICE ALLERDALE 0.32 3.07 5.59 A82063-BANK STREET SURGERY ALLERDALE 0.33 3.71 7.49 A82057-DERWENT HOUSE SURGERY ALLERDALE 0.23 4.63 5.53 A82049-ORCHARD HOUSE SURGERY ALLERDALE 0.30 4.72 5.76 A82022-DALSTON MEDICAL GROUP ALLERDALE 0.40 6.00 4.00 A82050-OXFORD STREET SURGERY ALLERDALE 0.37 6.02 5.24 A82048-BEECHWOOD GROUP PRACTICE ALLERDALE 0.28 7.40 6.21 A82012-BRAMPTON MEDICAL PRACTICE CARLISLE 0.34 3.85 5.30 A82015-WARWICK ROAD SURGERY CARLISLE 0.26 3.54 5.37 A82635-GROSVENOR HOUSE SURGERY (DR WARD) CARLISLE 0.34 3.15 4.50 A82019-FUSEHILL MEDICAL PRACTICE CARLISLE 0.39 4.40 4.79 A82654-GROSVENOR HOUSE SURGERY (DR WIGMORE) CARLISLE 0.29 4.13 6.20 A82020-EDEN MEDICAL GROUP CARLISLE 0.37 2.77 6.04 A82018-SPENCER ST SURGERY CARLISLE 0.29 4.32 5.51 A82052-STANWIX MEDICAL GROUP CARLISLE 0.36 4.95 6.12 A82641-GROSVENOR HOUSE SURGERY (DR FROST) CARLISLE 0.34 4.74 8.78 A82646-LONGTOWN SURGERY CARLISLE 0.36 5.45 6.24 A82016-ST PAULS PRACTICE CARLISLE 0.36 4.72 6.14 A82017-BRUNSWICK HOUSE MEDICAL GROUP CARLISLE 0.43 4.39 5.10 A82023-DISTINGTON SURGERY COPELAND 0.36 5.81 3.73 A82024-SEASCALE HEALTH CENTRE COPELAND 0.36 5.89 5.24 A82075-MANSION HOUSE SURGERY COPELAND 0.35 4.64 5.58 A82064-WESTCROFT HOUSE SURGERY COPELAND 0.32 3.29 4.88 A82060-TRINITY HOUSE SURGERY COPELAND 0.33 2.24 4.77 A82040-CATHERINE STREET SURGERY COPELAND 0.50 7.34 5.44 A82041-LOWTHER MEDICAL CENTRE COPELAND 0.50 4.77 5.30 A82044-FELLVIEW HEALTHCARE LTD COPELAND 0.37 5.19 5.69 A82058-QUEEN STREET MEDICAL PRACTICE COPELAND 0.42 7.21 6.91 A82620-GLENRIDDING HEALTH CENTRE EDEN 0.28 1.79 3.00 A82036-THE LAKES MEDICAL PRACTICE EDEN 0.26 3.85 4.77 A82031-SHAP MEDICAL PRACTICE EDEN 0.26 3.22 5.96 A82038-TEMPLE SOWERBY MEDICAL PRACTICE EDEN 0.26 2.74 5.22 18

Baseline QIPP indicators January-March 2013/14 GP Practice Locality Antibacterial Items/STAR PU Cephalosporins & Quinolones % items 3 days Trimethoprim ADQ/Item A82004-ALSTON MEDICAL PRACTICE EDEN 0.34 4.65 3.35 A82617-KIRKOSWALD SURGERY EDEN 0.26 7.88 4.96 A82035-BIRBECK MEDICAL GROUP EDEN 0.29 5.25 5.99 A82631-COURT THORN SURGERY EDEN 0.35 10.40 4.99 A82013-UPPER EDEN MEDICAL PRACTICE EDEN 0.29 6.53 7.79 A82006-APPLEBY MEDICAL PRACTICE EDEN 0.30 4.25 8.90 A82071-BURNETT EDGAR MEDICAL CTR FURNESS 0.31 3.31 5.27 A82062-ATKINSON HEALTH CENTRE (WIEJAK) FURNESS 0.28 4.53 4.59 A82619-NELSON STREET SURGERY FURNESS 0.27 2.81 7.00 A82651-DUDDON VALLEY MEDICAL PRACTICE FURNESS 0.28 3.84 8.10 A82007-DUKE STREET SURGERY FURNESS 0.34 5.40 5.16 A82039-DALTON SURGERY FURNESS 0.33 6.98 7.85 A82072-RISEDALE SURGERY FURNESS 0.42 7.02 6.34 A82629-THE FAMILY SURGERY FURNESS 0.34 1.75 5.44 A82009-BRIDGEGATE MEDICAL CENTRE FURNESS 0.41 4.72 5.84 A82621-ASKAM SURGERY FURNESS 0.38 1.74 7.00 A82011-HARTINGTON STREET MEDICAL PRACTICE FURNESS 0.46 9.87 7.63 A82008-NORWOOD MEDICAL CENTRE FURNESS 0.31 5.86 6.33 A82033-WATERLOO HOUSE SURGERY FURNESS 0.42 12.28 5.57 A82010-ABBEY ROAD SURGERY FURNESS 0.36 7.83 4.72 A82077-LIVERPOOL HOUSE SURGERY FURNESS 0.65 7.85 5.87 A82026-THE JAMES COCHRANE PRACT. SOUTH LAKES 0.25 4.20 5.32 P81113-PARK VIEW SURGERY SOUTH LAKES 0.29 3.83 5.04 A82647-CARTMEL SURGERY SOUTH LAKES 0.26 6.69 5.61 A82642-HAWKSHEAD MEDICAL PRACTICE SOUTH LAKES 0.30 7.80 4.92 A82046-WINDERMERE HEALTH CENTRE SOUTH LAKES 0.29 3.82 5.62 A82065-PENINSULA MEDICAL PRACTICE SOUTH LAKES 0.31 10.11 3.64 A82053-NUTWOOD SURGERY SOUTH LAKES 0.36 8.04 5.97 A82613-WRAYSDALE HOUSE SURGERY SOUTH LAKES 0.22 14.52 3.67 A82027-STATION HOUSE SURGERY SOUTH LAKES 0.30 5.97 7.05 A82650-HAVERTHWAITE SURGERY SOUTH LAKES 0.31 2.27 6.16 A82025-CAPTAIN FRENCH SURGERY SOUTH LAKES 0.28 5.35 6.42 A82074-ARNSIDE SURGERY SOUTH LAKES 0.29 3.49 5.48 A82608-SEDBERGH MEDICAL PRACTICE SOUTH LAKES 0.33 7.16 6.69 A82003-ULVERSTON HEALTH CENTRE (MURRAY) SOUTH LAKES 0.33 7.99 5.74 A82068-ULVERSTON HEALTH CENTRE (GRAHAM) SOUTH LAKES 0.30 5.14 6.30 A82005-AMBLESIDE HEALTH CENTRE SOUTH LAKES 0.35 5.47 5.60 A82030-LUNESDALE SURGERY SOUTH LAKES 0.30 6.37 9.33 A82034-STONELEIGH SURGERY SOUTH LAKES 0.40 5.14 6.16 B82061-BENTHAM MEDICAL PRACTICE SOUTH LAKES 0.31 8.54 5.69 A82070-ST.MARY'S SURGERY SOUTH LAKES 0.27 4.19 7.89 CCG average 0.35 5.25 5.60 England / CCG - 75th centile * 0.36 6.41 6.44 England / CCG- 25th centile * 0.31 4.18 5.76 England average 0.33 5.27 6.08 19

CCG Communications Team Winter Antibiotic Awareness Campaign Following discussions with GPs, Practice Nurses and Pharmacists, the Communications team have produced patient materials to support the winter antibiotic campaign. Initially Stanwix Surgery in Carlisle and practices in the Furness area will pilot the draft materials and if successful the materials will be available to all practices in 2014. The aim of the campaign is to raise awareness among patients that antibiotics are not always the answer and to encourage patients to self care when they have a common winter illness. Posters and Non-prescription pads are being produced with a Keep Calm theme and distributed to all GP practices in Cumbria. Community pharmacies will receive posters and door stickers. In addition, a wider campaign to support patients this winter Choose well Cumbria is underway www.choosewellcumbria.co.uk which encourages patients to choose the most appropriate care setting this winter. References 1. Chief Medical Officer. Getting Ahead Of the Curve. DH 2002 2. NICE guidance 2008 3. https://www.gov.uk/government/publications/chief-medical-officer-annualreport-volume-2 4. http://www.theguardian.com/society/datablog/2013/jun/11/antibioticprescription-by-gp-practice-mapped 20

Contact details: Melanie Graham Medicines Optimisation Pharmacist for NHS Cumbria CCG, Eden locality, North of England Commissioning Support (NECS), 4 Wavell Drive Rosehill Industrial Estate, Carlisle Cumbria.CA2 2SE Mobile: 07909 890754 Email:melanie.graham@cumbriapct.nhs.uk. 21