improvement and assurance schemes
Reducing antibiotic consumption by NHS Trust providers of acute care
During the financial years 2017 to 2018 and 2018 to 2019, NHS hospital Trusts providing acute care services participated in the NHS Commissioning for Quality and Innovation (CQUIN) scheme to reduce their antibiotic consumption, and this requirement moved into the NHS Standard Contract 2019 to 2020. Within this contract, all NHS Trusts providing acute care were required to reduce their antibiotic consumption by 1% from their own 2018 calendar year
baseline value. Performance was measured as the total number of antibiotics as Defined Daily Dose (DDD) per 1,000 hospital admissions and reported in the ESPAUR Report 2019 to 2020.
However, since that publication, we refreshed the data due to updates made to admissions data, DDDs on RxInfo and acute Trust mergers, and the 2019 to 2020 NHS Standard Contract performance has been re-published in the Chapter 7 data tables that accompany this report. As a result total consumption of antibiotics for 2019 to 2020 reduced from 4,669 DDD per 1,000 admissions as reported in the 2019 to 2020 ESPAUR Report (187) to 4,612 DDD per 1,000 admissions. However, the number of Trusts meeting the requirement to reduce total
consumption by 1% did not change.
The NHS Standard Contract 2020 to 2021 (188) continued this focus to reduce antibiotic consumption with a requirement for all NHS Trusts providing acute care to reduce antibiotic consumption by 2% from the same 2018 calendar year baseline value. However, this contract, which included the requirement to reduce antibiotic consumption, was suspended in March 2020 (189) in response to the COVID-19 pandemic. Consequently, the NHS Standard Contract 2021 to 2022 (190) now includes the requirement to reduce antibiotic consumption by 2% from the 2018 calendar year baseline by 31 March 2022. The effect of the COVID-19 pandemic on antibiotic consumption in NHS acute Trust has been reported in Chapter 5.
NHS Commissioning for Quality and Innovation (CQUIN) scheme 2020 to 2021
The NHS standard contract 2020 to 2021 (191) included an AMR CQUIN scheme ‘CCG1:
Appropriate antibiotic prescribing for urinary tract infections (UTI) in adults aged 16 years and over’ (192). Improving the diagnosis, antibiotic prescribing and management of UTI, including review of urinary catheter use, will reduce treatment failure, risk of healthcare associated bacteraemia, and reduce associated length of stay. This CQUIN scheme also supports
continued improvement delivered in the NHS England 2019 to 2020 CQUIN scheme ‘CCG1a:
Improving the management of lower urinary tract infections in older people’. However, the 2020 to 2021 CQUIN scheme was suspended in March 2020 in response to the COVID-19 pandemic,
Improving the management of lower urinary tract infection in older people in primary care
NHS England and NHS Improvement released the RightCare UTI data packs to enable local health systems to identify opportunities for further improvement in the safe and effective management of UTI in primary care, in particular in older people, and builds on the
improvement delivered by the NHS 2019 to 2020 CQUIN scheme ‘Improving the management of lower urinary tract infections in older people’ (193). The packs are available from the Urology site in the Outpatient Transformation Platform Empowering Patients (194) site on the
FutureNHS (195) collaborative platform. In addition the antibiotic prescribing metrics used in the data packs are reported by the NHS Business Services Authority in a new ePACT2 (196)
Antimicrobial Stewardship RightCare UTI dashboard, and the 9 antibiotic prescribing metrics are published by NHS BSA (197).
These metrics report at a variety of NHS organisational levels, and are updated monthly, supporting local health care system improvement of appropriate antibiotic prescribing for lower UTI in adults aged 70 years and over.
NICE guidance Urinary tract infection (lower): antimicrobial prescribing (198) advises that a lower risk of resistance may be more likely if trimethoprim has not been used in the past 3 months. The ePACT2 Antimicrobial Stewardship RightCare UTI dashboard reports 153,097 people had been prescribed trimethoprim more than once in any 3 consecutive months in the last 12 months to March 2021. The dashboard facilitates NHS primary care clinician review of this patient group.
In 2021 to 2022 the RightCare UTI data will be also be published in the NHS Model Health System supporting system level assurance activity.
Reducing antibiotic prescribing in primary care
The NHS Oversight Framework (200) is intended as a focal point for joint work, support and dialogue between NHS England and NHS Improvement, clinical commissioners, providers and sustainability and transformation partnerships and integrated care systems. The NHS Oversight Framework contains the 2 antimicrobial resistance (AMR) related indicators with set targets that have been used in NHS improvement and assurance schemes for CCGs since 2015. The indicators are:
• 107a: reduction in the number of antibiotics prescribed in primary care to be equal to or below value of 0.965 antibacterial items per Specific Therapeutic Group Age-sex Weightings-Related Prescribing Units (STAR-PU) (12 months)
• 107b: number of co-amoxiclav, cephalosporins and quinolones as a percentage of the total number of selected antibacterials prescribed in primary care to be 10% or below
NHS Oversight Framework data sources
NHS England and NHS Improvement, in collaboration with the NHS Business Services Authority, report CCG performance for these 2 AMR indicators in order to monitor antibiotic prescribing in primary care and report CCG progress towards the national targets within the NHS Oversight Framework. The NHS Business Services Authority report CCG performance monthly in the NHS England and NHS Improvement Antimicrobial Resistance NHS Oversight Framework 2020 to 2021 dashboard.
Antimicrobial prescribing in primary care and NHS clinical commissioning group performance
NHS CCGs have participated in NHS England improvement and assurance schemes since 2015 and have delivered sustained reductions in primary care antibiotic prescribing during this time frame. In financial year (FY) 2020 to 2021 133 out of 135 (99%) CCGs met or exceeded the national target to reduce antibacterial items per STAR-PU to the national target of 'at or below 0.965'. This is an improvement on FY 2019 to 2020 when 96 out of 191 (50%) CCGs met or exceeded this target. However this is a far larger reduction than expected, due to reduced primary care antibiotic use during the COVID-19 pandemic, and delivered an England value of 0.744 antibacterial items per STAR-PU. This is a lower value than that reported in the previous FY 2019 to 2020, and is a 36% reduction compared to the 2013 to 2014 baseline.
At the same time, 59 out of 135 (44%) CCGs met or exceeded the national targets to reduce the proportion of co-amoxiclav, cephalosporins and quinolones to less than or equal to 10%; a reduction on the financial year 2019 to 2020 where 171 out of 191 (90%) CCGs met or
exceeded this target. However, this prescribing metric has been impacted by the large reduction in the denominator value, resulting in an increase in England value to 10.2%, despite a small reduction in the number of prescription items for broad spectrum antibiotics in primary care from 2,552,634 in financial year 2019 to 2020 to 2,510,802 prescription items in financial year 2020 to 2021. The NHS Business Services Authority report CCG performance monthly in the NHS England and NHS Improvement Antimicrobial Resistance NHS Oversight Framework 2020 to 2021 dashboard.
NHS System Oversight Framework 2021 to 2022
The 2 AMR indicators remain in use to monitor primary care antibiotic prescribing in the new NHS System Oversight Framework (201) in 2021 to 2022, but now with the introduction of a new lower target: Antibacterial Items per STAR-PU 'at or below 0.871'. The NHS Business Services Authority continue to report CCG and STP performance monthly in the NHS England and NHS Improvement Antimicrobial Resistance NHS System Oversight Framework 2021 to 2022 dashboard.
NHS Pharmacy Quality Scheme 2020 to 2021
Contractual Framework (CPCF). It supports delivery of the NHS Long Term Plan and rewards community pharmacy contractors that deliver quality criteria in 3 quality
dimensions: clinical effectiveness, patient safety and patient experience. Details of the PQS for 2020 to 2021 have been provided in Part VIIA (203) of the Drug Tariff and include an Infection Prevention and Control and Antimicrobial Stewardship Domain. This aims to reduce the
potential harm caused by antimicrobial resistance (AMR) through the promotion of Antimicrobial Stewardship (AMS) activity in community pharmacy, and specifies quality criteria aligned to this aim.
Quality criteria
On the day of the declaration, all patient-facing pharmacy staff that provide advice on medicines or health care must have satisfactorily completed the PHE Antimicrobial Stewardship for
Community Pharmacy learning and assessment (204) on the Health Education England e-Learning for Healthcare website.
In addition, contractors must have available, at premises level, an antimicrobial stewardship action plan for the pharmacy, which details how they will promote AMS. The action plan must demonstrably include details of how all pharmacy staff involved in the provision of self-care advice will incorporate the principles of AMS into self-care advice, including reinforcing the messages around appropriate use of antibiotics, and the uptake of vaccinations, including the influenza vaccination. All patient-facing staff that provide health advice, should also become antibiotic guardians, if they have not already done so, and have an awareness of the local antibiotic formulary.
Details of the Pharmacy Quality Scheme 2021 to 2022 (205) have been published. The scheme includes a requirement to enhance antimicrobial stewardship using the PHE TARGET Antibiotic Checklist (206).