Reducing cultures of blame through behaviour change in General Practice


In this case study, we aim to present an example of how behavioural science methods can be used to help identify how to reduce antibiotic prescribing behaviour but crucially without creating a culture of blame which is often thought inevitable. In this context, culture of blame refers to an environment where individuals (such as general practitioners, or GP’s) are placed at fault for antibiotic prescribing (Locke, 2009). It is based on reviewing theories and methods of research in different social science disciplines and identifying an issue as potentially contentious and itself presenting a barrier for closer integrated and interdisciplinary work.  

The use of behavioural science to address what has become seen as unnecessary and potentially damaging prescribing of antibiotics, especially in a primary care setting, commonly involves the inevitable blaming of individuals for implied bad behaviour (Khatri, Brown and Hicks, 2009). Interventions are often directed at educating them about the dangers of AMR to scare them out of such practice or moulding their motivations to cultivate better habits. The aim of this case study is to show how carefully designed and interdisciplinary social interventions can address structural barriers to behaving in ways the prescribers already think is good practice, rather than pointing out problematic motivations of poor practice.

Behavioural science methods and interventions to reduce antibiotic prescribing

The focus of this case study is a GP in a local practice in London, United Kingdom. She prescribes antibiotics for a patient with a nasty chest infection when she is unsure of the cause of infection. In this case, a behavioural scientist is working to influence how GPs prescribe antibiotics, and she is charged with co-designing interventions to address different ‘barriers’ to behaviour deemed desirable to reduce antibiotic prescribing. She is using the COM-B framework for helping to understand that behaviour. 

Behavioural science methods

The COM-B framework (Figure 1) emphasises three factors in relation to behaviour. Capability refers to the physical or psychological ability to enact the behaviour. Motivation being the mechanisms that inhibit or activate behaviour. And opportunity being the physical and social environments that enable this behaviour. 

Figure 1: A visual representation of the COM-B framework as shown in (Michie, van Stralen and West, 2011). News media interest 1990-2019  (source: Davis et al., 2020b)

The behavioural scientist knows that information and motivation are components of the COM-B Framework and she has done a review of the existing literature which finds that educational and motivational interventions are most effective when accompanied with active interventions. Such interventions must also be multifaceted in nature to significantly influence long term changed behaviour (Roque et al., 2014). 

She also knows that GPs probably already have some expertise in antimicrobial resistance though their professional training, journal articles, and conferences, and are likely to think reducing use of antibiotics is generally a good idea, having seen or read about patients with antibiotic resistant infections. So, she looks at the remaining components of the COM-B framework, namely capacity and opportunity.  These will aid in addressing the structural/societal issues related to their prescribing behaviour. 

On reading the results of her semi-structured survey, the behavioural scientist sees that the GP in question knows that the patient is a single father of three boys and is self-employed needing to get back to work as soon as possible to pay the bills. She learns further that he is not sleeping because of the chest infection, and that his elderly mother is moving into residential care 300 miles away at the weekend. 

Any standard laboratory test results will currently take at least 72 hours. The GP understandably feels conflicted in her duties of care knowing that antimicrobial resistance is a growing problem. Yet, for the patient, as it stands, it looks like a course of antibiotics could help clear up a bacterial infection – if indeed there is one – and clear it up more quickly than leaving it to get better on its own. However, if the cause is viral, there is potential harm to the patient’s overall health and the antibiotic use could contribute to general resistance of microbes to it. The patient has tried over the counter remedies for his symptoms and is clearly struggling.     

During the co-design workshop based on her results, the behavioural scientist is reassured that there is no need to try to change the GPs’ knowledge, motivation, or strength of will. Indeed, in discussion of all the options, the GPs confirm that they should not be held accountable for some of the difficult situations in which they must be the gatekeepers and stewards of antibiotics. The GPs at times also feel pressured to meet the patients expectations and reduce risk of other adverse health outcomes (Lopez-Vazquez, Vazquez-Lago and Figueiras, 2012). Some interventions could, they acknowledge, be perceived as blaming certain individual GPs especially if surveillance projects of GP prescribing habits is presented in isolation of context and is not anonymised but picked up as a problem for social sanction at best, and professional reprimand at worst. 

Behavioural science intervention

The behavioural scientist persuades the GP practice to introduce one intervention which involves an extra service to increase the opportunities for GPs to reduce prescribing rates. This allows for a responsibility culture rather than a blame culture (Parker and Davies, 2020). These new services support patients when they are ill with extra and free childcare provision provided by local childminder services. She works with the local council to introduce a voucher system that allows for patients to receive vouchers from the GP that can be redeemed for the required number of free childminder days. This reinforces to the community the necessity of supporting one another. 

She is also campaigning for more councils to introduce this system to help compensate certain patients who are refused antibiotics for lost work while they recover. These are structural provisions to supporting those patients who are already socially and economically disadvantaged to contribute to a collective effort to address antimicrobial resistance. Patients are very pleased to see the new provisions, which are considered newsworthy in the local Gazette, and readily join the campaign to garner support for patients in financial difficulty during periods of illness. 

Given the administrative delays with sending samples to a centralised laboratory service and the difficulties GPs report in her survey about reconciling apparently conflicting duties, the behavioural scientist collaborates with health system academics to find a feasible way to decentralise laboratory services. They are able to introduce more efficient existing testing methods that reduce the delay in sample processing. GPs are keen to participate and find further efficiencies for the practice which result from these technologies with fewer patient visits and fewer laboratory tests.      


Far from thinking of individual prescribers as being irresponsible or even reckless over their supposed stewardship of antibiotics, attending to certain structural issues can further be seen to redress known social and health inequalities.  

Points of discussion

  • To what extent do you understand the potential consequences of antibiotic prescribing behaviour?
    Participants should be able to discuss both social/societal and biological consequences to long term negative antibiotic prescribing behaviour. 
  • Do you think the GP in this story is too focussed on the individual patient?
    Participants should discuss whether a more holistic or individualist approach to antibiotic prescribing behaviour should be considered. 
  • How does this example provide clues to the blame culture which may be underlying GP practice?
    Participants should be able to discuss what blame culture is and what behavioural indicators may suggest it in this context. 
  • How responsible should the GP feel for prescribing practices?
    Participants should discuss where responsibility lies in prescribing practices and how responsibility can shift across different contexts. 
  • What other options can you think of that the behavioural scientists could have explored? 
  • What skills should a behavioural scientist working in this setting need to have?
    Participants should discuss how these skills may be gained and what the long-term impact of applying these skills would be. 
  • What issues should the behavioural scientist have been trying to address in her semi-structured interview?
    Participants will discuss what the interview would look like, and which questions would be more structured in comparison to others. 
  • What are the practical barriers to enforcing the interventions suggested in this case study? How can they appear in different contexts?
    Participants should discuss the barriers, but also ways in which they can be overcome. They should also discuss whether barriers in this case study would be the same elsewhere and why/why not. 
  • What other interventions would be feasible in this context?
  • How would you monitor the impact of the intervention on GP behaviour?
    Participants should introduce and discuss structured methods of monitoring the impact of intervention and what outcomes they hope to observe. 
  • Discuss the impact of the ‘culture of blame’ on GPs working attitudes. 


Pedagogical notes

  • Students should role-play the semi-structured interview. This will include playing the behavioural scientist and the GP. This can aid in providing more context on the culture of blame, and what issues need to be addressed. 
  • Students can structure a timeline and discuss the best point of introducing an intervention in this context, and what the impact could mean for other patients. 
  • Students can design the semi-structured interview to determine the best way to effectively communicate and question in this setting. 
  • Students can model how discussions will take place to implement the change, including how they would present evidence to support the impact of their interventions. 
  • The larger underlying issue is the fear of blame, being reprimanded, and professionalism which is a barrier to AMR interventions in this context. Students can be motivated to explore similar situations in other settings.


  • Ramota Adelakun

PhD student and teaching assistant at University College London 

  • Sarah JL Edwards

Professor of bioethics at University College London 



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