5 Questions with…Dr Nandini Shetty

1. Can you tell us about your journey into global health – why did you decide to specialise in clinical microbiology and infection prevention control? 

After a brief spell working as a junior doctor in India, I decided to specialize in clinical microbiology for two reasons: I had a very inspiring undergraduate teacher – who impressed upon us the value of understanding the science of microbes and to remember always that we were clinicians, and that the patient was central to all our considerations. And secondly, I had the opportunity in the UK to witness in practice what we had learned in theory. So, I’ve always found it fascinating to have one foot in scientific arena in laboratories and the other in the clinical arena consulting with my clinical colleagues who dealt with patients on a daily basis. In the UK I also witnesses how clinical microbiology is inextricably linked with Infection Prevention and Control (IPC). I saw that IPC is not just the simple dos and don’ts of good hygiene on a ward or in theatre, it starts with education and awareness, and with having appropriate policy and engagement of clinicians and other health care staff who are at the patient interface. From the practice of clinical microbiology, it was a very natural transition to go into public health because the management of communicable diseases is not limited to healthcare facilities – it needs to go into the community and to community practice. Later, I was approached by the global health department at UKHSA to lead on health systems development and laboratory capacity and capability building in several of the UK overseas territories. Working with WHO, I advised on antimicrobial resistance (AMR) policy, management, and training in low- and middle-income countries (LMICs). AMR and the clinical and scientific basis of the use of antimicrobials were very much part of my day-to-day work as part of a NHS Clinical microbiologist, and when I joined the UKHSA I worked very closely with the AMR reference centre and was one of the co-directors of the WHO Collaborating Centre for Reference and Research in AMR. So, AMR has been part of my microbiology DNA right from the beginning of my journey in clinical microbiology.  

2. What is the AMR priority for the Fleming Fund and how does CwPAMS programme contribute to these? 

I am one of the champions of the work that CwPAMS does in empowering pharmacists. The main priority for Fleming Fund is to get robust AMR data and to use that data at health care facility level to influence prescribing guidelines, and at political level, to garner political support for AMR. The current priorities for the Fleming Fund are:   

• To have robust governance structures in place so there is country ownership of AMR data and the problems related to AMR/AMU/AMC in country  
• To push for a sustainable programme; that through development of facilities to manage AMR, we are also contributing to general health systems strengthening. When we work on capacity and capability building for communicable diseases (including AMR) at facility and community level, we believe that we are strengthening the system in the country to deal with AMR and flex it to deal with any communicable disease. Through the principles of good laboratory and clinical practice, we support countries to deal with any communicable disease. This is the general health systems strengthening approach that will speak to sustainability in the future. 
• One of the biggest strategic shifts and priorities for the Fleming Funds is to engage clinicians. We have mostly focused on lab capacity/capability and surveillance, but now need to engage with clinicians to use the lab before they treat patients empirically with a broad-spectrum antibiotic. This is where CwPAMS contributes. The work of CwPAMS is to empower pharmacists so they can lead the whole concept of rational use of antimicrobial agents, speaking directly to clinicians, about patient care. 

I have worked with amazing pharmacists in the NHS – they have played a huge role in supporting us to create evidence-based guidelines for antibiotic management for a variety of conditions, they have helped in the management of complicated patients, and in how to provide the safest therapeutics for these patients. They are partners with us in management of patients. What CwPAMS does, is trains pharmacists to be that liaison between laboratory and clinician and to spread those very valuable messages on rational antimicrobial prescribing. 

That particular role of bridging the science of the pharmacology of antimicrobials and the microbiology of the infection and taking that information to the clinician to develop a treatment strategy for the patient at hand, is an amazing role that CwPAMS does in training these pharmacists. We want to emulate the model that we benefit from in the UK through working in partnership with pharmacy colleagues in different countries in the CwPAMS 2 programme. This is the major contribution that CwPAMS in the Fleming Fund programme – it engages with clinicians, contributes to rational antimicrobial prescribing, monitors, and influences antimicrobial consumption – all which contributes to the health system strengthening. It promotes an important Fleming Fund priority of country ownership and therefore sustainability. The more people you train in country, the more sustainable the programme is. We train people and then we train trainers, and I’m hoping CwPAMS will continue to do that.  

3. Why do you think Health Partnerships are an effective model for addressing AMR and strengthening pharmacy capacity? 

Health Partnerships are absolutely vital. It is ripple effect, you start with one health partnership, where one pharmacist goes to a LMIC and then performs the training and has exposure to the clinical arena in which pharmacists work. Many pharmacists are not empowered in LMICs to participate in clinical management and antimicrobial stewardship. CwPAMS helps this empowerment and confidence – by sending NHS envoys to LMICs, NHS volunteers are helping to empower local pharmacists, as they can see what the UK pharmacists can do [in the UK setting]. It is absolutely essential to strengthen pharmacy capacity to be able to engage with clinicians and to be able to link the microbiology diagnosis with the choice of antibiotic. Furthermore, training in point prevalence surveys (PPS) helps with analysis of consumption data and the economic impact. I think what these Health Partnerships do, take a model that works in the UK and explore if it can be modified so that it is country specific in the LMIC. When you train a local individual to be a trainer, or you train them in basic leadership principles and encourage them to train others, what you’re creating is a ripple effect. Every single trained person that comes under the influence of such a partnership, will then spread that message in the contacts that they have created, and this contributes to creation of a community of practice and this impacts on sustainability. Supporting capability of healthcare professionals locally is important and Health Partnerships are an essential model. Furthermore, it is an immense opportunity for individuals to go to LIMICs from the UK, and what a tremendous learning experience for them to understand firsthand the constraints that health workers face in some contexts. These partnerships enrich and develop not only those who receive the training in the LMIC but develops leadership and training skills in the those from the UK who volunteer in the LMIC.  

4. In your view, what more needs to be done to empower pharmacists at facility level? 

We need to provide a role model for pharmacists, with training not only in the clinical aspects but also in developing leadership. Both leadership development and specific pharmacy-related development is important. To empower pharmacists is not enough to tell them about the science of AMR/AMU/AMC/PPS and how to do that, but to train them to lead on guideline development, chair meetings (e.g. AMS / Medical and Therapeutics committee meetings), set agendas, and develop policies and strategies. Give pharmacists the experience of creating a concept note and providing a position paper after reviewing literature. These are the things that pharmacists may not get the chance to do in the course of their busy work schedule. To take that empowerment to the next level is what I’m looking for and CwPAMS is in a perfect position to do that.  

5. What do you hope will be the main achievement of the next phase of the programme?  

The main achievement [of the Fleming Fund] would be that we set up these partnerships in a handful of pilot LMICs to demonstrate the clinical influence that a pharmacist can provide by bridging the two important arenas – the science of pharmacology and microbiology with the therapeutics that clinicians perform at patient level. If we can say that in a handful of countries we have trained and empowered pharmacists to comment on patient management, participate or lead on guideline development, and provide strategic direction at hospital/facility level, then that would be great achievement.