Oral antibacterial prescribing in NHS 111 clinical support hubs during out-of-hours periods: qualitative investigation of experiences and decision-making

Abstract Introduction Inappropriate oral antibacterial prescribing contributes to antimicrobial resistance. Antibacterial prescribing decisions are complex and may vary across care settings.[1] Out-of-hours (OOH) services (weekdays 18:30–08:00, weekends, and holidays) add further complexity, with perceived urgency and service pressures.[2] In Wales, OOH services are accessed through National Health Service (NHS) 111 telephone triage. Clinical support hubs (CSHs), an integral part of NHS 111, provide remote care delivered exclusively by general practitioners (GPs) and pharmacist independent prescribers (PIPs). Although OOH prescribing has been studied elsewhere, little is known about antibacterial prescribing decision-making in NHS 111 CSHs. Aim To explore GPs’ and PIPs’ experiences and decision-making processes when prescribing oral antibacterials in NHS 111 CSHs during OOH periods. Methods A qualitative methodology was employed using online semi-structured interviews and convenience sampling. The interview schedule was informed by literature, input from OOH experts, and a prior OOH prescribing study. It covered decision-making experiences, including factors affecting prescribing, strategies used, available resources, and perceived needs. GPs and PIPs who had completed their NHS 111 Wales training portfolios or at least 30 hours of training in CSHs were eligible. Gatekeepers shared study documentation with potential participants. Snowballing and social media advertisements were used to extend recruitment. Consenting participants were interviewed by one researcher. Interviews were audio- and video-recorded, transcribed verbatim, and thematically analysed independently by two researchers, with themes compared to ensure reliability and depth. Results Interviews were conducted with three PIPs (two females, one male), one of whom had completed the training portfolio. Four main themes were constructed: cognitive approach in practice, determinants of decision-making prescribing, strategies to improve prescribing, and strengthening antimicrobial stewardship (AMS) and professional development. Participants described adopting a patient-centred approach to decision-making that involved identifying patient concerns, gathering information, conducting examinations when possible, evaluating findings, making clinical judgments, and communicating decisions with appropriate follow-up guidance. They highlighted decision-making considerations, including accessibility and availability of other services, diagnostics, and recent laboratory results. The limitations posed by working remotely, such as the lack of physical examination and non-verbal cues were also noted. Prescribing decisions were made on a case-by-case basis, shaped by patient acuity and individual circumstances. Participants elaborated on strategies to support prescribing decisions, including peer consultations, referrals, evidence-based tools and resources, education and safety-netting, and engaging patients through communication and shared decision-making. They valued available training, ongoing education, and shared learning opportunities to strengthen AMS and professional growth, while noting insufficient audit and feedback on their prescribing. Conclusion This study provides the first exploration of PIPs’ experiences and oral antibacterial prescribing decision-making in NHS 111 CSHs. It highlights the complexity of prescribing, shaped by access constraints, patient acuity, and the challenges of remote consultation, alongside the critical role of effective communication. Context-specific understanding is essential to evaluate prescribing and design feasible and effective AMS interventions. Despite offering valuable insights to guide future research, recruitment challenges resulted in only a few PIPs and no GPs being interviewed, likely due to their workload, locum status, or lack of incentives, which limits transferability.