Development of a capability framework for antimicrobial stewardship specialist health professionals working in the NHS in England: utilizing Delphi methodology

Abstract

Background

Antimicrobial stewardship (AMS) programmes are led by multi-professional teams and are central to optimizing antimicrobial use and minimizing inappropriate use. Although frameworks exist that describe the knowledge and skills relating to antimicrobial resistance (AMR) and AMS for generalist healthcare professionals, there is a need to provide a framework for AMS specialists working in the NHS that supports the development of flexible capabilities rather than granular competencies.

Objectives

To develop a multi-professional capability framework to recognize and develop the specialist knowledge and skills of AMS staff across all sectors of healthcare, including adult and paediatric services, at all levels of post-foundation specialist practice.

Methods

A modified Delphi approach was adopted. Initial capability statements were derived from a literature review. An expert panel of UK-based AMS professionals participated in two Delphi survey rounds to assess the importance of each capability statement and map level of delivery against level of practice. Descriptors of practice and professional development resources were identified through follow-up workshops and consultation.

Results

From 922 source statements, 45 capability statements were agreed and structured into four domains: AMS Professional Practice, Leadership and Management, Education, and Research and Quality Improvement. Consensus was reached across all statements following two Delphi rounds. Descriptors of practice and development resources were identified to support benchmarking and professional development across all levels of specialist practice.

Conclusions

This multi-professional capability framework defines AMS specialist practice relevant to all NHS sectors, supporting professional development, career progression, and strategic workforce planning across all professional groups.

Introduction

Antimicrobial resistance (AMR) poses one of the greatest threats to human health, yet overuse and misuse of antimicrobials remains widespread across health systems. Overuse of antimicrobials is driven by diagnostic uncertainty, prescribing behaviours and cultures, clinician capability and confidence.^1–3 Misuse of antimicrobials encompasses unnecessarily prolonged therapy, inappropriately broad spectrum of coverage, and use of pharmacokinetically and pharmacodynamically inferior therapies. Patients and the public contribute to the overuse of antimicrobials by demanding prescriptions for antimicrobials or self-medicating, and can misuse antimicrobials through early discontinuation of therapy, sharing antibiotics, and unsafe disposal.^4–6

Antimicrobial stewardship (AMS) programmes are proven to reduce inappropriate antimicrobial prescribing and optimize the antimicrobial therapies that are prescribed.^7–9 AMS programmes are ideally delivered by multi-disciplinary teams traditionally formed of AMS specialist physicians and pharmacists, with AMS nurses and pharmacy technicians playing an increasing role in recent years. AMS specialists provide clinical expertise regarding the management of infectious syndromes and use of antimicrobials for patients at all stages of life across all sectors of care, including primary and tertiary care. Additionally, AMS specialists provide clinical and strategic leadership within their organizations and increasingly across healthcare systems and wider geographies.^10–13

The 2024 UK AMR National Action Plan (NAP) sets out several objectives and commitments to be achieved by 2029, including appropriate prescribing and disposal (commitment 4.2), use of behavioural interventions (commitment 4.3), health and social care training (commitment 5.1), and the health and social care workforce (commitment 5.2).¹⁴ The latter two commitments emphasize the need to develop career pathways for specialists in AMS and to consider the capabilities of the AMS specialist workforce on a system-wide basis.

Action has already been taken to underpin the development and capability of the generalist healthcare workforce in the NHS through the publication of competency frameworks for undergraduate and trainee health professionals, and an antimicrobial prescribing and stewardship competency framework for generalists, which are organized into the domains shown in Table 1.^15–19 More recently, NHS Education for Scotland published a knowledge and skills framework that is aimed at professionals who are not specializing in AMS, including supporting staff who do not prescribe antimicrobials, and is organized by the overarching processes of preventing, diagnosing and managing infections.²⁰ Infection prevention and control (IPC) education frameworks for generalist and specialist workforces in the NHS, published in 2023, include AMS and AMR statements that span foundation through to advanced practice.^21,22

Table 1.

Overview of the competency domains in existing AMS professional development frameworks

Undergraduate and trainee competency frameworks15–18	Antimicrobial prescribing and stewardship competency framework19
Infection prevention and control Antimicrobials and antimicrobial resistance Antimicrobial prescribing and stewardship Vaccine uptake Person-centred care Interprofessional collaborative practice	Person-centred care Infection prevention and control Antimicrobial resistance and antimicrobials Prescribing antimicrobials Antimicrobial stewardship principles Monitoring, learning and interprofessional collaborative practice

The ESCMID Study Group for Antimicrobial Stewardship established 88 core competencies across 15 domains for AMS team members that provide granular knowledge and skills statements. However, these are limited to secondary and adult care settings, and do not consider different levels of specialist practice.²³ Thus, there is an unmet need for a professional development framework for AMS specialists that is suitable for all professional groups working within AMS teams that is also applicable to all levels of post-foundation specialist practice regardless of sector of practice (e.g. primary, secondary and tertiary care).

The aforementioned frameworks all provide competence statements, but an important distinction should be made between competence and capability statements in relation to the education, assessment and overall development of specialist healthcare professionals—as these terms are used interchangeably, often inappropriately. Whereas competence statements describe completing a defined task, requiring the use of specific knowledge and skills, capabilities describe an individual’s ability to apply their broad knowledge, attitudes and skills to a range of situations, which are often complex in nature.^24–26 Capabilities more closely reflect the increasing complexities of caring for people with infections, often with multiple comorbidities, within complex organizations and health systems, that require flexible approaches.

Therefore, this study aimed to develop a capability framework for healthcare professionals working in AMS roles within the NHS, which will support professional development within AMS specialist practice regardless of professional group, sector of practice (including paediatric and adult services) and level of specialist practice. Given the lack of pre-existing frameworks that provide this, a consensus approach was required.

Methods

This project used a modified Delphi approach (for full method see Supplementary materials, available as Supplementary data at JAC Online) and followed the ‘Skills for Health 2022 guidelines and standards for the production and revision of capability and competency frameworks’ (see Supplementary materials).^27,28 A steering group was convened to lead the project, with oversight from NHS England (NHSE) (see Supplementary materials for membership and criteria). BSAC was commissioned by NHSE to undertake this work.

Step 1: desk exercise

First, the scope was agreed by the steering group to be a framework with capability statements, not competence statements. The steering group agreed that this framework should focus on enhanced, advanced and consultant level practice. Thus, foundation level practice was excluded as this was deemed to be sufficiently covered in other frameworks, and foundation practitioners would not at the point of specialism and therefore outside the aims of this capability framework.

A literature review was undertaken to identify available capability, competence and education frameworks relating to AMS, AMR, infectious diseases, infection prevention and control, clinical microbiology and general clinical practice. Guidance for AMS programmes published by the WHO, standards for the Global AMS Accreditation Programme, multinational consensus AMS recommendations for children managed in hospital settings, NICE guidelines and standards for AMS, and the UK 20-year vision and 5-year NAP were also included.^14,29–34 Relevant statements from these documents were extracted and analysed through content analysis.^35,36 Initial capability statements and overall framework structure were derived from the results of the literature review and content analysis. These were agreed by the steering group.

Step 2: Delphi round one

A self-administered online survey tool (Survey Monkey) was developed and refined by the steering group. The survey was then distributed via email to UK clinicians, including physicians, nurses, pharmacists and pharmacy technicians with expertise and experience in AMS. Participants were provided with detailed background information and a glossary of definitions, which was linked to throughout the survey. Data collection took place between 24 April and 19 May 2024.

Each capability statement was presented to the participant individually with the associated domain clearly indicated. A 6-point Likert scale of importance (where 1 = not at all important, and 6 = extremely important) was used. Participants scoring a capability statement as 4 or more were then presented with a mapping exercise regarding level-of-delivery against level-of-practice.

Optional open-ended questions were provided to give participants the opportunity to suggest changes to wording of the capabilities, suggest new/missing capabilities, and provide overall feedback. Participant demographic data were collected in the final step.

In keeping with the methods for developing other AMS frameworks, statements with a median score of 5 or more were deemed to be highly important, and an IQR of ±1.5 or less (equivalent to 25% variation, or less) was deemed to have met consensus.^16,23 Statements were accepted if they were scored as important, met consensus, and did not require amended wording. Statements were rejected if they were scored as not important, met consensus, and where no change in wording was required. Statements not meeting consensus were retained for re-presentation in the second Delphi survey. These criteria were set and agreed before the first Delphi round launched.

Responses to the open-ended questions were analysed through a content analysis approach. New statements and reworded statements were reviewed by the steering group and agreed through simple majority. All new and reworded statements were included in the second Delphi survey.

Mapping of level-of-delivery against level-of-practice was determined through simple majority of respondents completing the mapping for the relevant statement.

Step 3: Delphi round two

The same data collection and analysis approach was used as per round one. In addition, the median score for each re-presented capability statement from round one was provided to participants in round two. Similarly, if a statement had been reworded, the new and previous wording was presented to the survey participants.

Data collection took place between 4 July and 28 July 2024. After data analysis and review, a third Delphi round was not considered necessary by the steering group.

Step 4: descriptors of practice and scoping professional development resources

Participants were provided with a working document that provided guidance regarding descriptors of practice and presented each capability statement with the results of the mapping of level-of-practice against level-of-delivery. Participants proposed descriptors of practice for each level of practice on the working document, which were collated by the project team. Content analysis methods were used to remove duplicates and develop single overarching descriptors of practice for each level of practice for each capability statement. Participants were also invited to recommend resources that AMS practitioners can use to develop their knowledge, attitudes and skills. All responses were collated and duplicates removed. Online workshops were then held with participants to review the content analysis process and refine the descriptors of practice, and identify any omitted professional development resources.

Step 5: wider consultation and finalizing the framework

An official framework document was created following the NHSE publication guidelines and in line with recently published NHS professional development frameworks. The document was structured, and supporting narrative written, as per Skills for Health guidance (see Supplementary materials).²⁷ The official framework document was circulated to the steering group, all participants, the NHSE Antimicrobial Prescribing and Medicines Optimisation team, and the NHSE Publications Committee. Final comments were collated, and amendments made where necessary and within scope.

Ethics

Ethical approval was not required for this work according to the NHS Health Research Authority tool. Informed and explicit consent was obtained from all participants prior to commencing the surveys and online workshops. The aims of the data collection, analysis and publication were outlined in this process, and participants were given the opportunity to withhold their details from publications.

Results

Initial framework

Through the literature review, 922 statements were extracted from 29 resources (Table S1). These were distilled to create 44 capability statements, then the wording refined through three stages of review by the steering group.

Four domains were developed to provide overall structure for the capability framework (Table 2). These reflected the domains that are used across NHS and healthcare professional development frameworks, which were agreed by the steering group to underpin the areas of capability required of AMS specialists and be flexible enough for all professional groups, levels of specialist practice and care settings.^37–44 Other framework structures were identified, but the steering group determined these to be too granular or descriptive, risking the framework becoming overly large and competence based, rather than capability focused.

Table 2.

Final capability framework

Theme	Capability statements
Domain 1: Antimicrobial Stewardship Professional Practice AMS specialists provide specialist AMS knowledge, skills and practices to shape and deliver AMS in their organization and healthcare system, for the benefit of individual patients and services. They collaborate with other clinicians, managers, teams, patients and the public
Delivers and shapes antimicrobial stewardship programmes	a) Translates national guidance, policy and standards for the diagnosis, treatment and prevention of infection, including antimicrobial stewardship, into organizational and/or system policies and guidelines
	b) Develops guidelines and policies for the prevention, diagnosis and treatment of infection, including the optimal use and restriction of antimicrobials, across their organization and/or system; including where national guidance is absent
	c) Ensures local guidance and policies for the prevention, diagnosis and treatment of infections include advice on diagnostic testing, including how and when to obtain samples for testing, and interpretation of results; optimizing the diagnostic pathway and applying the principles of diagnostic stewardship
	d) Optimizes the communication of microbiology results and susceptibility testing results to clinicians across their organization and/or system
	e) Uses information technology, and collaborates with data and informatics teams, to design and deliver AMS activities and interventions including audit, monitoring, surveillance and quality improvement
Provides and supports person-centred care for those with infections, including resistant and challenging infections	f) Provides specialist advice regarding when and how to collect specimens for testing, to guide optimal diagnosis and treatment of infections and use of antimicrobials for individual patients; applying and promoting the principles of diagnostic stewardship
	g) Provides specialist, person-centred advice regarding the rational, safe and effective prescribing of antimicrobial therapies for individual patients across care settings; including patient risk assessment; the prescribing of restricted, specialist/off-label and unlicensed antimicrobials; and the use of source control and other non-antimicrobial management options
	h) Applies pharmacodynamic and pharmacokinetic principles to optimize the efficacy of antimicrobial therapies while maintaining patient safety; considering methods of drug-administration and monitoring, across care settings
	i) Interprets microbiology results and considers other diagnostic/radiology test results to provide person-centred recommendations regarding antimicrobial therapy and non-antimicrobial interventions
	j) Provides specialist advice in relation to contraindications, cautions, allergies, intolerances and adverse effects relating to antimicrobial therapies; making person-centred recommendations regarding alternative therapies and allergy de-labelling strategies
	k) Provides specialist advice in relation to the review of antimicrobial therapies for individual patients; including escalation and de-escalation, therapeutic drug monitoring, and use of outpatient parenteral antimicrobial therapy (OPAT)/virtual ward services
	l) Applies knowledge of health and social care inequalities and risk factors for poor outcomes to optimize the care of patients with infections and to reduce the risk of infection at the individual patient level
Works collaboratively with others on issues relating to AMR and AMS	m) Leads on AMS-related aspects of care and collaborates with the wider multidisciplinary team (including other infection specialists, non-infection specialist clinicians and laboratory staff) to optimize the care of patients with infections, including antimicrobial-resistant and/or complex infections, across care settings (including OPAT/virtual ward services)
	n) Collaborates with the Infection Prevention and Control (IPC) team to reduce transmission of infection and supports the investigation of, and response to, outbreaks; using AMR and antimicrobial usage data and expertise to underpin this
	o) Engages patients and the public in the understanding and development of AMS policies and guidelines
Domain 2: Leadership and Management AMS specialists provide leadership across organizations and health and social care systems to optimize the management of infections and use of antimicrobials. They lead on complex issues relating to AMR and behaviours driving antimicrobial use
Provides clinical and strategic leadership and accountability regarding antimicrobial stewardship	a) Implements the UK National Action Plan for AMR, including supportive national policies and strategies for AMS and AMR risk mitigation, within their organization and/or system
	b) Ensures AMR and AMS are identified, and sustained, as organizational and/or system priorities; working with, and reporting to, senior management/executive/board members
	c) Collaborates with senior management/executive/board to ensure key performance indicators and goals relating to AMR and AMS are included in the organization and/or system’s annual plan; contributes to the development and delivery of this annual plan to tackle AMR and improve AMS
	d) Provides specialist advice to the organization and/or system AMR and AMS lead(s); acting as this lead where appropriate
	e) Engages in multi-professional AMS committee(s) within their organization and/or system, to provide expertise and strategic leadership on AMR and AMS
	f) Advocates and creates plans for embedding and evaluating digital solutions to improve the delivery of the AMS programme; including data collection, analysis and reporting
Manages complex governance issues relating to AMR and antimicrobial usage to improve patient safety and outcomes	g) Ensures local formularies, guidelines, and policies meet the needs of the local population, focusing on local epidemiology of infectious diseases and AMR, upholding the principles of AMS (including cost-effectiveness) and addressing health inequalities
	h) Leads on issues relating to the antimicrobial supply chain within their organization and/or system, to ensure continuity of patient care while upholding the principles of AMS, including cost-effectiveness
	i) Uses local and national incidents and safety reports relating to infection, AMR and antimicrobials to review local guidance, policy and practice; applying the principles of clinical governance
	j) Ensures the accuracy of AMR surveillance and antimicrobial consumption data from an organization, system and/or national level so practice and care are changed in response to robust and reliable data
Acts as a role model and supports others to change their behaviours	k) Promotes the use of local, national and international guidelines and policies for the prevention, diagnosis and treatment of infectious diseases and optimal use of antimicrobials; ensuring these are easily accessible to clinicians across the organization and/or system
	l) Provides feedback and recommendations, as an individual or as part of a team, to other clinicians and teams within the organization and/or system regarding their management of infections and use of antimicrobials
	m) Applies behaviour change principles and methodologies to AMS programmes, strategies and interventions
Domain 3: Education AMS specialists develop and improve the knowledge, attitudes and practices of others regarding the optimal use of antimicrobials and use their own professional development to improve AMS programmes and patient care
Ensures own capability and competence remains at the forefront of practice and science	a) Undertakes horizon scanning of investigatory and newly approved antimicrobials, vaccines, drug-administration methods, diagnostic tests and biomarkers (including genomics)
	b) Is aware of emerging trends in infection and AMR epidemiology locally, nationally and internationally; identifying how and when this may impact on the health and care of the local population, including impact on AMS strategies
	c) Remains abreast of the literature and evidence regarding novel AMS initiatives, strategies and interventions, including their impact on infection management and AMR
Develops the AMS capabilities of health professionals and other staff	d) Develops and delivers AMR- and AMS-related training to all health professional groups at induction and regularly thereafter, across their organization and/or system; including to other infection and AMS specialists
	e) Develops and implements an education strategy and programme for all staff who prescribe, review, supply, administer and monitor antimicrobial therapy; including for other infection and AMS specialists
	f) Acts as a mentor and coach to other healthcare professionals developing their AMS practice and/or undertaking projects relating to AMS
	g) Supports training providers (e.g. universities, learned societies, clinical training locations, etc.) to embed and deliver AMR and AMS education and training within multi-disciplinary curricula and assessment strategies
Educates and engages patients and the public on issues relating to AMR and AMS	h) Delivers and/or supports the delivery of public awareness and engagement campaigns and patient and public education relating to AMR, optimal use of antimicrobials and infection prevention
	i) Develops and disseminates information relating to AMR and optimal use of antimicrobials for patients, family and carers; engaging patients and the public in this process
Domain 4: Research and Quality Improvement AMS specialists undertake surveillance and monitoring of antimicrobial use across services, organizations and systems. They develop and apply evidence to improve AMS programmes and interventions and optimize the use of antimicrobials
Applies data, evidence and research to improve AMS	a) Uses microbiology laboratory data to support the development of organization and/or system antibiograms; ensuring these influence guidance and policy, and the optimal management of infections and use of antimicrobials
	b) Uses data from local, regional and national surveillance of AMR and monitoring of antimicrobial prescribing and consumption to engage with clinicians and managers, to improve AMS within their organization and/or system
	c) Uses the latest research and evidence to review and inform guidelines, policy and services relating to the management of infections and use of antimicrobials
Undertakes and leads on audit, evaluation, quality improvement and research in relation to AMR and AMS	d) Undertakes and leads audits and quality improvement initiatives relating to antimicrobial prescribing and stewardship across their organization and/or system; facilitating and supporting others to engage in these projects
	e) Develops and delivers a programme of regular audits and point-prevalence surveys of antimicrobial prescribing and guideline adherence across their organization and/or system
	f) Collaborates on research relating to the management of infections and optimal use of antimicrobials
	g) Contributes to regional, national and international surveillance of AMR and monitoring of antimicrobial consumption
	h) Disseminates results and recommendations from AMR and AMS projects within own organization and/or system, and beyond where appropriate

Delphi round one

Of 72 individuals invited, 46 started the survey of whom 18 did not complete. Of the 28 (39% of those invited) who completed the survey 6 were physicians, 3 nurses, 16 pharmacists and 3 pharmacy technicians from across primary (n = 5) and secondary care (n = 16) and other sectors (n = 7) (see Supplementary material for full list). The mean time taken to complete the survey was 71 min (SD ± 48 min, range 17.5–118 min).

Consensus was reached for 42 of the 44 statements, with all 42 being agreed as important for AMS specialists (Table S2). Two statements did not reach consensus but trended towards being judged as important for AMS specialists. Analysis of open question responses (Table S3) resulted in the rewording of nine statements and the creation of one new statement, relating to health inequalities in person-centred care. As per the methods, reworded statements (n = 9), new statements (n = 1), and those not reaching consensus (n = 2) were presented in Delphi round two. Mapping of the capability statements by level-of-delivery against level-of-practice was completed for all the statements and is presented in Table S6.

Delphi round two

Of 28 individuals invited (who completed round one), 23 (82%) completed the second Delphi survey. Five were physicians, 3 nurses, 13 pharmacists and 3 pharmacy technicians from across primary (n = 3) and secondary care (n = 13), and other sectors (n = 7) (see Supplementary material for full list). The mean time taken to complete the survey was 20 min (SD ± 14.5, range 4–56.5 min). Two individuals started the survey but did not complete.

Consensus was reached for all the statements presented, with all accepted as important (Table S4). Mapping of new capability statements by level-of-delivery against level-of-practice was completed for all the statements and is presented in Table S6. Analysis of open question responses (Table S5) identified no new statements and suggested only minor rewording to five statements. These minor amendments were discussed and agreed by the steering group, who determined a third round of Delphi was not required as the ‘spirit/intention’ of the capabilities had not changed.

Descriptors of practice and scoping of development resources

Of 44 individuals invited, 28 (64%) contributed to developing descriptors of practice. Three were physicians, 7 nurses, 13 pharmacists and 5 pharmacy technicians.

A total of 1743 descriptors (703 for domain one, 451 for domain two, 326 for domain three, and 263 for domain four) were proposed, and after analysis 483 unique descriptors remained. These were further distilled into single overarching descriptors for each level of practice (n = 135) (Table S8). Fifty-six professional development resources were identified by participants (Table S9).

Feedback from the engagement workshops and wider consultation recommended minor changes to the capability statements (Table S7). This wording change was accepted by the steering group, who determined further Delphi was not required.

Final capability framework

The final capability framework contained 45 capability statements across the four domains of practice (Figure 1). Content analysis of these final statements, and the feedback obtained through the wider-engagement workshops, generated 11 capability themes, to provide an additional layer of structure within the framework and reduce the perception of duplication within Domain 1: AMS Professional Practice. The final capability framework, including domain structure, is provided in Table 2. The mapping of these statements by level-of-delivery against level-of-practice is available in Table S6.

Figure 1.

Diagrammatic representation of the framework domains and the levels of practice and delivery demonstrated by AMS specialists across these domains.

An official framework report was produced for NHSE, which includes guidance on how the framework should be used by individuals, managers, healthcare organizations and education providers. Relevant comments and feedback from the open questions in the Delphi surveys, and from the wider engagement workshops, were used to shape the narrative in the NHSE report. Final consultation and feedback were obtained from the steering group and all participants (see Supplementary materials, list of participants).

Discussion

Through a modified Delphi process a capability framework for health professionals working in AMS specialist roles in the NHS was developed, obtaining consensus from a multidisciplinary group of health professionals from medical, pharmacy and nursing backgrounds, working across all sectors of UK healthcare (e.g. primary, secondary and tertiary care) at all levels of specialist practice. The capability statements are organized in line with existing NHS multidisciplinary frameworks for enhanced, advanced and consultant level practice and will act as a framework by which AMS specialists can map their practice and identify areas for professional development.^37,38 Each statement describes what activities AMS specialists should be able to undertake to deliver effective AMS programmes in the NHS and provide specialist care and advice relating to the prevention, diagnosis and management of infections, including AMR infections. Moreover, the framework has been developed in line with the Skills for Health recommendations (Supplementary materials) and this report provides one of the only examples of this being used as a checklist to transparently report what is included, and what is not with justification—similar to ACCORD guidelines for reporting consensus studies.^27,45

In traditional Delphi-based studies, the first round usually involves the initial statements being developed from the ground up through cycles of workshops, feedback and preliminary surveys. This was deemed unnecessary due to the frameworks identified through the literature review, and the number of initial AMS capability statements derived from these.^28,46,47 This process was proven sufficient as the number of capability statements that Delphi survey participants recommended to be added or reworded were low, thus only two rounds of surveys were necessary to obtain consensus.

Broad, higher-level, outcomes-focused capability statements ensure they are flexible across NHS healthcare professions, sectors, and levels of practice.³⁹ This outcomes-focused approach also ensures duplication and encroachment with existing frameworks is minimized, and that their focus on competence, knowledge, skills and attitudes supports the development of overall capability as outlined by the statements developed in this project.

It was also important to future-proof the framework, to meet both the current and future needs and challenges of the NHS in relation to AMR, AMS and patient care. Healthcare at home, including virtual wards, and the emerging areas of pharmacogenomics, machine-learning and artificial intelligence, are likely to increasingly influence patient care and AMS in the future.^48–55 Thus, these were deemed important to include by the steering group and subsequently achieved agreement and consensus through Delphi, demonstrating their perceived importance for current and future AMS practice.

Research has shown that AMS programmes and interventions are more effective when they interlink with IPC and laboratory teams.^56–58 Although IPC and laboratory capabilities were not directly within scope of this framework, there are capabilities emphasizing that AMS specialists must be able to work with IPC and laboratory teams as part of the wider AMS programme, to embed diagnostic stewardship, to provide effective patient care, and respond to outbreaks.

The results of the mapping exercise were central to development of a core set of descriptors of practice. As with other professional development frameworks, descriptors are used to benchmark current level and scope of practice, provide examples of what an individual may do within the context of their own setting and practice, and provide ideas for professional development.^19,39,59 This will be particularly useful for individuals starting in AMS roles, especially in organizations and services where more experienced professionals are not available for in-organization coaching and support. By mapping every capability to all levels of practice it allows the framework to be aspirational and provide long-term career goals and development opportunities from enhanced practice through to expert and consultant level practice.^38,60 The cross-profession design of the framework is a key strength of this work and will enable and empower non-medical professionals, who have not traditionally assumed overall responsibility for AMS programmes or led on AMS research within the NHS, to develop and deliver these capabilities.^61,62

Relating to this, education and training resources were scoped during this project and are presented in the Supplementary materials and the formally published framework document, which can be used by all professional groups at all levels of practice to develop their knowledge and overall capabilities.

Limitations

There are several limitations to highlight. Firstly, there was notable attrition in responses during the Delphi surveys. In the first round, 39% (n = 18/46) of participants did not complete the survey and 6.5% (n = 3) did not complete the mapping of level-of-practice against level-of-delivery. The most likely reason for the dropout was the length of the first Delphi survey (mean time to complete of 70.96 min), which was exacerbated by the mapping exercise that presented an additional three questions for each capability statement that was scored as important by a participant, which would have presented up to 176 [44 × 4 (1 scoring, 3 mapping)] closed questions. This may have been deemed as onerous by participants, leading to in-survey dropout in the first round.⁶³ On reflection, the mapping exercise could have been undertaken as a separate survey once all the capability statements had been agreed and met consensus. However, attrition in numbers between Delphi rounds one and two is an expected, commonly reported phenomenon that can be exacerbated by including a large number of questions in the first round.⁶³

Secondly, although sufficient participants were included and stratified across professions, sectors and levels of practice, this stratification meant representation for each professional group was small. The required number of participants for Delphi studies is influenced by the aim and scope of the output from the surveys, with no formally agreed minimum number. Literature on the development of AMR and AMS competency frameworks for students, trainees and clinicians demonstrates wide variation in participant numbers (range 15–59).^15–17,19 The descriptor generation stage of this project and the final consultation included a larger number of individuals from each profession, and no significant feedback regarding the statements nor mapping was received, which mitigates this limitation.

Dentistry was not represented within the development of this framework. Although a dentist was invited to participate in the project, it was felt the framework would not be relevant to dentists and dental services. Dental prescribing in England is overseen by NHSE, which has a responsibility for AMR and AMS, and there will be heightened surveillance of dental antimicrobial prescribing within the UK AMR NAP.^14,64 The broad wording of the capability statements and descriptors means they will be relevant for dentists who develop a specialist interest in AMS or become responsible through evolving NHS structures.

Next steps and recommendations

AMS specialists can use the descriptors to map their level of practice against each of the capability statements, using this to identify areas for professional development that can be addressed using the resources identified through this project. AMS specialists can use this framework with their managers to set annual development goals, and map this to other professional development frameworks that underpin profession-specific career development and credentialing pathways.^{39,41–44,65–68} This will be particularly useful for individuals working in newer AMS roles, such as AMS nurses, and those working in primary care settings.

Senior management can use the framework to ensure there is adequate skill mix in AMS teams and provide additional support to develop the capabilities of AMS specialists, in line with the UK AMR NAP (commitment 5.3) and international standards for AMS programmes.^14,29,30 Management should also facilitate collaborative working with the individuals and teams mentioned in several capability statements, particularly for AMS specialists working across boundaries (e.g. those working in integrated care systems).

In line with UK AMR NAP commitments 5.1 and 5.2, training providers such as higher-education institutes, royal colleges, and learned societies should use this framework when developing resources for education, training, assessment and professional development relating to AMS practice.

Finally, the higher-level wording and flexibility of the framework gives scope for it to be used outside of the NHS by AMS specialists internationally, across all economic contexts. However, work will be needed to position this framework alongside existing competency-based frameworks and validate this with international stakeholders.²³

Funding

BSAC was commissioned to undertake this work by NHS England (PRN01247).

Transparency declarations

R.A.H. has received educational grants from Pfizer (2021) and attended an advisory board for A. Menarini (2022). F.G. has received honoraria from Menarini, Pfizer and Shionogi for participation in advisory boards and delivering educational presentations. R.A.S has received honoraria for speaking at symposia and/or for attending advisory boards for Menarini, Pfizer, Advanz, Mundipharma/NAPP and Shionogi. M.G. has received honoraria from Pfizer, Menarini, Eumedica, MundiPharma and Napp for participation in educational activities. J.M. received a Quality Improvement Grant from Pfizer (2023. Grant no. 88610815). None of these activities are related to content in this manuscript, and none of these organizations has been involved in this work or its reporting. D.C., S.P., N.M.B, N.F, G.D. and K.H. have no conflicts to declare.

Author contributions

Ryan Hamilton (Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Visualization, Writing—original draft, Writing—review & editing), Deborah Cockayne (Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Validation, Writing—review & editing), Frances Garraghan (Methodology, Writing—review & editing), Ronald Seaton (Methodology, Writing—review & editing), Mark Gilchrist (Methodology, Writing—review & editing), Sanjay Patel (Methodology, Writing—review & editing), Jo McEwen (Investigation, Methodology, Writing—review & editing), Nicholas Brown (Methodology, Writing—review & editing), Naomi Fleming (Conceptualization, Funding acquisition, Investigation, Methodology, Supervision, Writing—review & editing), Gillian Damant (Methodology, Supervision, Writing—review & editing), and Kieran Hand (Conceptualization, Funding acquisition, Methodology, Supervision, Writing—review & editing)

Supplementary data

Tables S1 to S9 are available as Supplementary data at JAC Online.