BJGP Interviews

The British Journal of General Practice

Listen to BJGP Interviews for the latest updates on primary care and general practice research. Hear from researchers and clinicians who will update and guide you to the best practice. We all want to deliver better care to patients and improve health through better research and its translation into practice and policy.

The BJGP is a leading international journal of primary care with the aim to serve the primary care community. Whether you are a general practitioner or a nurse, a researcher, we publish a full range of research studies from RCTs to the best qualitative literature on primary care. In addition, we publish editorials, articles on the clinical practice, and in-depth analysis of the topics that matter. We are inclusive and determined to serve the primary care community.

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S6 · E243
Tuesday · 20 min
Local incentives and general practice: what does the evidence show?
Today, we’re speaking to Matt Conroy. Matt is a PhD fellow at the University of Manchester and also works for NHS Greater Manchester (ICB) as the Head of Primary Care Intelligence. Title of paper: Impact of local enhanced incentive schemes on the performance of general practices within the United Kingdom: a systematic review Available at: https://doi.org/10.3399/BJGP.2025.0377 Most local commissioning bodies in England, known as Integrated Care Boards (ICBs), have developed their own additional local pay-for-performance (P4P) incentive schemes alongside the Quality and Outcomes Framework (QOF). To our knowledge this is the first review to date to summarise existing evidence on the scope and effectiveness of local incentive schemes implemented in general practice in the UK with a focus on the indicators and their alignment with national schemes. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.480 - 00:01:01.140 Hi and welcome to BJGP Interviews. I'm Nada Khan and I'm the Senior Research Editor here at the bjgp. Thanks for taking the time today to listen to this podcast. Today we're talking to Matt Conroy. Matt is a PhD fellow based at the University of Manchester and he also works for NHS Greater Manchester ICB as the Head of Primary Care Intelligence. We're here to talk about the paper he's recently published in the bjgp, which is titled the Impact of Local Enhanced Incentive Schemes on the Performance of General Practices within the United A Systematic Review. So, hi, Matt, it's really nice to meet you and to talk about this work and I wonder if, just to start with, if you could explain a bit about what we mean by local incentive schemes in general practice and why you wanted to look at them, and I wonder if you wanted to draw a little bit on your additional role working for the Greater Manchester ICB as well here. Speaker B 00:01:01.220 - 00:01:54.400 Thanks. I guess by a local deep incentive scheme, we mean something that's kind of locally designed or locally commissioned within a ICB footprint to try and address any particular population health challenges or local nuances that go over and above national policy, things like the Quality and Outcomes Framework. I guess what was really insightful for us through doing this piece of work was actually through an FOI that we undertook. Like 90, 98% of ICBs actually have their own local gene for incentive schemes, but we only identified 17 schemes through the published literature, the last one being from 2018. So getting on for 10 years ago, and the fact that we know that so many ICVs are doing these things, but there's not the evidence body there, there's not the learning and sharing of best practice to really inform policy and help ICVs all try and address their local challenges. Speaker A 00:01:55.210 - 00:02:10.650 Yeah. And you've mentioned qof and I guess a lot of people are really familiar with qof, and as you mentioned, there are lots of local schemes sitting alongside it. And I wonder if you have an idea of just what sort of things they're trying to incentivize, just from sort of the background to your work. Speaker B 00:02:11.210 - 00:04:48.850 Yes. So, as part of my day job, I help design and deliver the local GP incentive scheme in Greater Manchester. It's roughly valued about £17 million for this year. And I think what we try to do is use QOF as a bit of a body of evidence, but also look at a lot of our local and national data to really highlight where we think we can make a difference with these local incentive schemes. So, for the 26, 27 financial year, we've done a piece of work to really home in on CBD and diabetes as one area, respiratory as another area, elective care. So we can get the interface between primary and secondary care and also antimicrobial stewardship. I think one of the things that's really fleshed out from that is the impact of non attenders on things like qof. So through qaff, if patients have two or one invites seven days apart, they automatically get exception reported if they don't necessarily attend. But what we found through our local data is actually there's a really strong link between those people and actually poorer CBD control and wide use of healthcare systems. So. So through our local GP insentive scheme, we've really designed almost a narrow cohort that looks at people's individual disease control, looking at things like blood pressure, HbA1c, but also where people haven't attended a review in more than 18 months. So really trying to hone in on specific cohort, acknowledging that those people are really difficult to engage with by proxy. The fact that they've had two invites and not responded. But actually through having a local GP incentive scheme that really highlights these as a specific target cohort group and having dedicated funding alongside it, we can see that from our QOF data, we've had a reduction in exception reporting and actually it's led to these people being targeted and then we can see slow improvements in overall disease control. So whilst it's being funneled through the local GP incentive scheme, there's this wider spillover effect in things like QOF as well. I think that's something that we're looking to evaluate in particular and really draw out, actually, not to say that it's easy to do this exceptional reporting and we know that patients are difficult to engage with, but actually by having a really dedicated piece of work, targets these patients with the body of evidence that these are the people who are more likely to not attend their yearly GP review, but are more likely to end up using emergency care services at that point of contact, that if there's dedicated funding and almost a dedicated cohort, to say these are the people that, as an icb, we've agreed on that we really need to focus on that we can see that those improvements are being yielded and that that is actually having a secondary impact of increasing coif achievement as well. Speaker A 00:04:49.010 - 00:05:03.310 Yeah. So really important work, I guess, being done in local area and this review tried to bring together all of the existing evidence on this, on these different schemes. So what did you find overall in your, in your review? Speaker B 00:05:03.550 - 00:07:48.730 So we found overall that there was 17 schemes that have been reviewed. Of those there was a range of different indicator types, the most of them aligning to the existing indicator types of quaff where they have a lower and upper threshold and achievement scales based on fixed cohort and payment alongside that, which isn't surprising. And I think what surprised me is that so many of the schemes almost piggybacked off QUAFF and just gave more money for existing cough indicators, which was quite surprising in a sense of well, if quaff is already there and as well bodied there was almost that assumption, well, if we provide more money that we're going to get greater achievement on the same indicators that's already there. I think this is the part of the, the push and pull of incentive schemes is that we're all aware that general practice has finite capacity and finite resource and there's almost an assumption that by providing more money you're going to get more outcomes. And it's a bit crude but the analogies, it's a bit like whack a mole and that if you try and do something over here then implicitly means that something there isn't the time and dedicated effort to do something else around the system. I think that's the real challenge with designing these schemes is that acknowledging that where there's already work that's gone in, but how do you address your local challenges and populations and that part of this might be the acceptance, that part of the money is just to give practices the time and the headspace and the workforce to deliver some of this. I think that's one of the things that we've found really locally within our scheme that when we've scaled it up in some areas quite drastically in the first couple of years, you might not see the achievement that you want because there's a lot of time to get around these schemes, to embed them and really employ the workforce to actually start to deliver them. I think the other thing that surprised me is that how little of them actually had an inequalities focus. I think that's partly down to the access to data that's available. I think through undertaking the literature review in a lot of cases people were just using aggregated EMIS extracts that just had a single denominator or numerator for an indicator. And that's something that I think we're really keen to explore throughout the rest of my PhD and that how can we really apply a, a rigorous inequalities lens to some of this and looking at tools like the index of disparity as a way of helping us understand are we in a position where it might look on the surface like achievements going up? And that's great, but is that because we sweep in generalization, are we actually targeting the white British affluent worried well and actually driving inequalities through having these schemes? I think that's something we're really keen to understand because actually what you'd want to do with these schemes is that kind of holy grail of increasing the overall average, but then really reducing those inequalities and getting to a place where as much as you can and controlling for as many factors as possible, really reducing that variation across lots of different demographic groups. Speaker A 00:07:49.050 - 00:08:02.570 Yeah. And I guess one of the findings you found that was that some local incentive schemes seem to improve process measures. But what did you mean by process measures and what did that actually look like in practice in the papers that you found? Speaker B 00:08:03.290 - 00:08:22.750 So I guess by process measure we mean something like actually the recording of blood pressure, the recording of HbA1c actually taking the reading, whereas the health outcome measures, that more nuanced thing of by a bit like we see with the hypertension measures in qof, are we actually recording the blood pressure but then checking the value and seeing whether that actually has an increase or a decrease? Speaker A 00:08:23.070 - 00:08:34.270 And I think you mentioned in the paper as well that none of the studies looked at patient reported outcomes or experiences. Do you want to talk through that and just why that's such an important gap in the literature as well? Speaker B 00:08:34.750 - 00:10:44.450 I think a lot of time we assume that by looking at diabetics and their HbA1C control, that good control means that patients actually have healthier lives, whereas poor control means that they don't. I think it's an area that we're really starting to explore as an ICB about how we can use things like personal well being scores, health confidence scores, even Things like the 3 Item Loneliness Scale as a way of actually determining are we actually improving the wider health and wellbeing of a patient. So the inference would be that if you improve their health control, that they feel more confident in their ability to manage their condition, that they understand the impact that it has on their health and well being, but that isn't a straight line. And it might be that somebody has a yearly review, but every time they have a COPD exacerbation or they feel like they go into crisis, that they aren't confident in how they have the ability to manage their condition. And that's when they might turn to urgent emergency care. Is that where, well, I panic, I don't know what I need to do, therefore, I go to the nearest place that I think can deal with me. And I guess this is something that we're trying to explore, to see if we can use these more, these measures in particular, to really understand and see if we're actually making tangible improvements. I think for general practice, it's probably quite a different way of looking at things, but if we're truly trying to think about how we can embed things like the neighbourhood model and how we can support patients in the wider community settings, that understanding, if people actually feel like they have the confidence to manage their health better, as well as the clinical markers, that's really important because it might genuinely be that somebody goes for their yearly review, they sit down in front of somebody, they explain all this technical jargon about blood pressures and for blood counts and for a patient that doesn't actually mean anything, they want to simply know, how is my health? Am I getting better, am I getting worse? And these. These measures are almost a proxy way to understand that, but almost. Then I want to see how we can track and see if that's improving, changing in time. And it might be then that this is where we start to bring in those wider health determinants. And it might be that there's things like changing housing status or personal circumstances which could very easily throw somebody's health confidence off. And that is almost a precursor to understanding whether disease control gets better or worse. Speaker A 00:10:44.850 - 00:10:55.170 I guess there's also an interesting question about what happens when you stop paying people to do something. And did you find any evidence about whether changes persist once an incentive is removed? Speaker B 00:10:56.320 - 00:13:48.940 So we did manage to find one paper that considered the impact of when a local incentive scheme was removed. And in that instance it had a lasting result. Due to the nature of the scheme and its design. I think more generally, across my icb, we do tend to find that there is quite a shift in that when incentivisation for a measure comes in, that we see that the focus shift onto that, but then when the payment focus is removed, that that drops off. So a good example is that in our scheme for this year, we've introduced some rigorous DOAC monitoring that is akin to the old pcn des Measure, SMR03. And from our data, we can very clearly see the point in which that measure was introduced as part of the PCN DES, that DOAAC monitoring really increased as soon as the SMRO3 was taken out of the PCN DES, we saw that achievement drop off and now that we've introduced that as part of our area again, that we can start to see it increase. And I think this really speaks to the. The finite capacity that exists within general practice and that unfortunate nature of having a local GP incentive scheme, that you will almost attract the focus to that, but by proxy you will also then detract focus from somewhere else. I think this is the real challenge in how, when designing both national and local GP schemes, we think about the impact of having these indicators, but also how we provide some consistency to general practice and that you're not changing the indicators every year, you're constantly moving the goalposts and in some cases, by the time practice practices have just got their heads around an indicator, you're already nearly six months throughout the year. You only then start to get the impact of those being seen, by which point, if you then remove that, you hardly get any benefits in year one of something being available. And that's something that we're hearing loud and clear from practices in Greater Manchester and that we've had a big expansion in our scheme for this year. And consistency is key, both in terms of actually embedding understanding, but also embedding the delivery. But we're also conscious about how there's lots of demands and there's lots of requests for things to put into our incentive scheme and it can't be this panacea of being able to deliver all requirements that are required across health and social care. And we need to think very carefully about how we put things into schemes. But then if we're thinking longer term about how do we make this sustainable and long term, actually, how do we then start very slowly about thinking about potentially tapering off payments or designing the elements in such a way that address the cohorts with the greatest need, and that the longer you have one of these indicators, ideally, the cohort naturally gets smaller and smaller to the point where you then can start thinking about introducing other parts so you don't end up just flooding a scheme and you almost get back to where you start and that you have something that tries to address everything and doesn't actually address anything.
- Transcript
S6 · E242
October 6 · 20 min
Diagnosing in the dark: recognising childbirth-related PTSD in general practice
Today, we’re speaking to Dr Megan Foreman, a GP and NIHR Clinical Lecturer based at the University of East Anglia. Title of paper: Diagnosing in the dark: the childbirth-related post-traumatic stress disorder GP evidence gap Available at: https://doi.org/10.3399/BJGP.2026.0269 Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.320 - 00:00:58.460 Hi and welcome to BJGP Interviews. I'm Nada Khan and I'm the Senior Research Editor here at the Journal. Thanks for taking the time today to listen to this podcast. In today's episode, we're speaking to Dr. Megan Forman, who is a GP and NIHR Clinical Lecturer based at the University of East Anglia. We're here to discuss the recent analysis piece that she and her team have published in the September issue of the Journal and it's titled Diagnosing in the Dark the Childbirth Related Post Traumatic Stress Disorder GP Evidence Gap. So, hi, Megan, it's really nice to meet you and thanks again for joining us here to talk about this article. I suppose, to start with, could you explain a little bit more about what you mean by birth trauma and childbirth related PTSD? And I suspect that these are probably terms that GPs are not as familiar with that we should be. Speaker B 00:00:59.310 - 00:01:46.360 Yeah, thank you. So birth trauma is a broader term and that can be. So we're talking here about psychological birth trauma rather than physical birth trauma in the context that we're using it in. We're talking about people who have had a difficult, potentially a pregnancy experience or a birth experience. That's not just looking at birth itself. That can cause ongoing mental health issues and psychological concerns when we talk about PTSD after pregnancy and birth. So what's often referred to as childbirth related ptsd, those are people who meet diagnostic criteria for PTSD as a result of a trauma that was related to their experience from pregnancy or birth. So birth trauma is a broader term and then PTSD is a specific diagnosis. Speaker A 00:01:46.520 - 00:02:14.480 And we were talking just before we started about the wider reach of this work and how, um, it's been picked up more in the mainstream media. But you've also had people telling you about their stories as well. And what I find quite sad in a way is that there have been a number of reviews around inadequate care in women's health. And I'm really struck by some of the poor outcomes that you mentioned in the article, like high suicide rates in women postnatally as well, which is really shocking, actually. Speaker B 00:02:14.880 - 00:03:14.130 Yeah, I mean, you mentioned the people who I've spoken to. So I've had a really involved patient participation group with the work that I've been doing, and they've talked about their own experiences, even in situations where they've had really extreme birth complications. So, for example, a neonatal loss or severe physical injury, even in those circumstances, may have struggled to access support. I've also been contacted by a member of the public since the paper was published and since there was media interest in this, talking about her own experiences of birth almost 30 years ago and difficulty in dealing with that going forward. So it clearly is a big issue. It's also important to say that even if a birth looks straightforward medically on paper, it's still possible to develop birth trauma symptoms and indeed ptsd. So it doesn't have to be a birth with serious complications or a poor outcome for somebody to develop these symptoms. Speaker A 00:03:14.620 - 00:03:37.180 Yeah, and I think that's one of the things that really struck me in the article, is that birth trauma is very subjective and that these issues can happen like, just like you're saying, just after what might appear to have been or appears to be a medically uncomplicated birth. And I think that's probably really important for GPs to understand in terms of what this will look like when women present to their gps as well. Speaker B 00:03:37.260 - 00:04:27.610 Yes. And I think an important consideration is that when women keep referring to women, but I include in that people with other gender identities who have a baby, but when women go into pregnancy, they come to pregnancy with all of their past experiences. And we know that people who have had difficult previous experiences, so for example, intimate partner violence, previous adverse childhood experiences, substance abuse or pre existing mental health problems, these people are particularly at risk of developing PTSD after birth. And it can be something that develops after what looks like a normal birth on paper. So it's really important that we consider birth trauma and PTSD in people, even when it appears that the birth is straightforward and that we still are inquiring about these symptoms to make sure that they're identified. Speaker A 00:04:27.850 - 00:04:40.970 And we'll come back onto sort of inquiring about symptoms. But what might a woman with childbirth related PTSD look like when she presents to her gp? Are there any clues that we should be looking out for, aside from asking questions about it? Speaker B 00:04:40.970 - 00:06:08.320 Well, one of the issues with PTSD is that one of the symptoms that women often experience is avoidance. So people can find that either talking about their birth experience or visiting a healthcare setting can retrigger their symptoms and can be really distressing. So a particular issue with PTSD that isn't necessarily an issue with other perinatal mental health problems is that people can be incredibly reluctant to talk about their experience and that can be with both with family members, friends and healthcare professionals. So it's something that we really need to be vigilant for. But in terms of the symptoms that people describe, essentially there are four symptom clusters. So the first would be hypervigilance so feeling constantly on edge, a constant fear that something bad is going to happen to themselves or the baby. I mentioned the avoidance, avoidance of anything that reminds them of the birth, because it can bring back very extreme, intense physical symptoms. Reliving the birth is another symptom that, that often differentiates it from anxiety and depression. So that can be symptoms like flashbacks and nightmares. And again, the flashbacks can be triggered by reminders of the birth experience. And then the last thing is alterations in mood. So that can be low mood, but it can also be things like disproportionate feelings of guilt. And so mood disturbance is a feature as well. But really, for a diagnosis of ptsd, a person would have to have symptoms from all of those symptom groups. Speaker A 00:06:08.720 - 00:06:35.280 And I suppose in primary care, GPs sometimes can be in a bit of a practice gap. So primary care really has a role in assessing and coordinating this care. But I think that sometimes we're not really sure how to do that, especially when there are other people involved, like the health visitor or the midwives and things. So what do you think that looks like in practice at the moment? So I think probably what you're going to describe is that there's a sense of fragmented care in this area. Speaker B 00:06:35.750 - 00:07:56.120 Yeah, I completely agree. And I mean the guidance. So, for example, the nice guidance on antenatal and postnatal mental health, it suggests that if, if another healthcare professional is concerned about mental health symptoms, that they should be sending people to see their gp. And obviously there's. There's perhaps this expectation that women will also be offered a six to eight week postnatal appointment. So GPs will be seeing women at these points. But absolutely. Care can be fragmented. Sometimes concerns either aren't picked up or aren't passed on. Communication between services can be limited. I know certainly from my own experience, often the information we get in a discharge summary, for example, can be very cursory, which can also make it difficult then to really to preempt you maybe having more problems. Another issue. So we know from research evidence that GPs often mistake postnatal PTSD for depression. So there have been research studies that have demonstrated that this is a common problem. Part of the issue is the overlap with depressive symptoms. So, for example, if you look at the Edinburgh Postnatal Depression Score, it does include symptoms of hypervigilance and mood, so it can easily be mistaken for other conditions. And this can be really problematic because the guidance on the treatment of PTSD and depression are quite different. Speaker A 00:07:56.470 - 00:08:24.550 And I guess just thinking about treatment, so one of the Issues I wondered about was the access to secondary care services, and this isn't always straightforward. And talking about sort of gaps in care, I wonder if some women are falling through a gap here in terms of not potentially fitting criteria for NHS talking therapies because of their symptoms, but not quite at the stage where they might access secondary care services. So what are your feelings about that and sort of the onward care that women are offered? Speaker B 00:08:25.440 - 00:09:54.790 Yeah, I completely agree. And one of the things we've really highlighted in the analysis article is the fact that there's this lack of evidence for gps or this lack of guidance for gps in how to decide who needs to be referred to secondary care services who could potentially be managed in primary care with or without specialist support from talking therapies. So although the guidance does talk about recognizing birth trauma, it doesn't talk about how to determine severity. For example, this is a big gap in the evidence. So we know that a lot of the guidance says that the mild mental health problems could be managed by gps, but that ptsd, for example, needs specialist treatments and that some women may need specialist care. But there's really no detail in that on how to decide who needs what kind of management or support or who needs referral. Because talking to women who've experienced birth trauma, one of the things that they said was that they really felt that just validation and being listened to by a GP or a healthcare professional was really, to them, the most important thing. And it may be that some women don't need referral, and it may be that a period of support with watchful waiting and sort of universal services may be enough for some women. So not everyone will necessarily require referral after a traumatic birth, but it is so important that we're able to identify the people who do. And at the moment, the guidance just doesn't give us enough information to do that. Speaker A 00:09:54.980 - 00:10:07.220 And what are your hopes in terms of the guidance? Do you feel it just needs to be more specific or more local? Because a lot of these services are somewhat patchy in different areas. But, yeah, Interested to get your thoughts on that. Speaker B 00:10:07.540 - 00:11:43.890 What we've really highlighted is that although there is some evidence included in the guidelines, firstly, the evidence in guidelines is split across multiple guidelines. So really, to bring together all of the available evidence, you'd be having to look at the NICE guidelines, the NHS England guidelines, and also at the NICE guidelines on PTSD, and trying to pull all of that information together. And it's just not realistic that GPs are going to be doing this in practice, even if you pull all of that information together. As I said, there are evidence gaps. So there are evidence gaps about which questions can be asked in primary care that will identify clinically significant symptoms. There are evidence gaps in terms of women's perceptions of, for example, the use of a screening questionnaire. So it may be that a screening questionnaire could help with a bit of diagnostic certainty for GPs and confidence in deciding who may need support, but it may be that this isn't what women want, or that, for example, at the six to eight week check, that's just not the right time to be asking it. So what we're really sort of highlighting in the analysis article is that there's need for more research to be done, led by women and involving gps to look at what's feasible, what's acceptable and what's actually going to lead to improvements in support. As you mentioned, that does then need to dovetail with available services, but that's not going to be perinatal mental health for everybody. And it may be that there are different tiers of support that a GP may consider, but they need to be given evidence based guidance on how to decide who requires what kind of support. Speaker A 00:11:44.290 - 00:12:21.540 And We've mentioned the 68 week postnatal check a few times and some people might think that that's a really obvious opportunity to ask about birth trauma, but it may well be too early for some people. And I think also in the article you've, you make the point that it's not as straightforward as simply adding a couple of screening questions. And that six to eight week check is really full. You know, you're looking at the baby, you're looking at mum, physical issues, all that. Do you have any thoughts about how we can do this differently or change what we're doing at the six to eight week check, specifically just to support women who might be experiencing these issues? Speaker B 00:12:21.860 - 00:13:57.370 I completely agree about the six to eight week check. I mean, when you look at the guidance and what we should be doing in that single appointment, in many cases it's unrealistic and often we are talking about women who've had a really difficult birth experience, which can include physical complications. So it may be that they've had other complications in the pregnancy that needs to be followed up, for example, preeclampsia or gestation, diabetes or a serious obstetric tear. So often the physical health aspect can dominate the consultation, although the guidance does say that mental health should be considered first. But another big issue is the fact that in many places this is offered as a joint appointment with the baby. And I have to also say, in some areas it's offered as a phone appointment. So particularly if it's a face to face appointment and women are attending with a baby, this can make it really difficult to have this conversation, particularly if they're by themselves. And I know that I've spoken to women who've said that even though the baby's very small, they just feel guilty and they find it incredibly difficult to talk about their mental health in front of the child. So one thing that could be a consideration is to offer these appointments as separate appointments so that people are able to be seen in a time and space that they feel safe to talk about this. But a big part of that is making sure that people know what the six to eight week check is for, because again, talking to women, a lot of women just consider it an appointment for contraception, they don't realise that it's an opportunity to talk about their mental health. So if we're offering women an appointment for themselves, they need to understand that this was an opportunity to talk about these problems. Speaker A 00:13:57.610 - 00:14:13.420 And I mean, even an appointment to talk about contraception after having a baby, I mean, that will take up a consultation. So I think, as you say, it might be well worth thinking about how to think about these different issues and prioritize mental health as well at that stage. Speaker B 00:14:13.820 - 00:15:12.840 Yeah, I completely agree. And I think another important thing is making sure that women are aware of mental health symptoms. They know what to look for and they know that mental health problems are common, but that these symptoms aren't normal. And another issue that's very specific to PTSD after childbirth is the fact that for many women, they're adjusting to having a baby, potentially recovering from a difficult birth, and often they don't realize that the symptoms that they're having aren't just a normal adjustment to having a baby. And for example, sleep disturbances can be a normal part of having a new child. So it can be really hard to separate out what's pathological and what's normal. So I think really giving women that information at any available opportunity through the maternity journey, but also making sure that they're aware of the fact that if they have symptoms they're concerned about, it is okay to talk about them and to make sure that GP consultations in general feel like a safe space to do this. Speaker A 00:15:13.080 - 00:15:33.770 And I was interested in your article about the point that sometimes asking the wrong question at the wrong time could leave women feeling more distressed or might falsely reassure a clinician. Have you got any thoughts from your work with patient groups or from your own research about what a sensitive conversation about a traumatic birth would look like? Speaker B 00:15:34.090 - 00:16:37.740 I think it's about validating people's feelings and validating their experiences. I mean, I've heard women who have been told things like, well, this is what birth is. This is a normal part of being a woman and they can have had some really difficult experiences that are dismissed or normalized. So I think really just acknowledging that somebody's having problems, acknowledging that they've had a difficult experience and just validating their feelings can be really powerful. And I think normalising can be helpful as well, of saying to somebody, it is common for people to have difficulties at this stage.
- Transcript
S6 · E241
September 29 · 14 min
Does GP income meet expectations? The impact on job satisfaction
Today, we’re speaking to Dr Ben Walker, a post-doctoral associate based at the University of Calgary, who conducted this work while working at the University of Manchester. Title of paper: Relationships of actual and expected levels of income with GP job satisfaction: repeated cross-sectional study Available at: https://doi.org/10.3399/BJGP.2025.0683 Recruitment and retention of GPs remains an issue for general practice in England. This work examined the relationship between actual income and income expectations with job satisfaction and intentions to quit. Higher actual income was found to be associated with job satisfaction, but there was little evidence to show that it was associated with intentions to quit. A key and novel finding was that higher income expectations were associated with both lower job satisfaction and higher intentions to quit. The findings suggest that policies that help GPs build accurate income expectations, such as increased transparency for incomes for different GP job roles, may be a means of addressing job dissatisfaction caused by discrepancies between expected and actual income for GPs. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:01.040 - 00:00:58.350 Hello and welcome to BJJP Interviews. I'm Nada Khan and I'm the Senior Research editor at the bjjp. Thanks for taking the time today to listen to this podcast. In today's episode we're talking to Dr. Ben Walker. Ben used to be based as a research fellow at the University of Manchester, but is now working as a postdoctoral associate at the University of Calgary in Canada. We here to talk about the paper he's just published in the BJ GP that's titled Relationships of Actual and Expected Levels of Income with GP Job Satisfaction. A Repeated Cross Sectional Study. So, hi Ben, it's really nice to meet you and to talk about this work and I guess to start us off, I just wanted to talk a little bit about the background to this paper and it's about GP income and job satisfaction, which is clearly a topic that people have plenty of opinions about. But what made you want to look at this question in a bit more detail? Speaker B 00:00:58.590 - 00:02:08.930 So, yeah, it's something we had been discussing internally as a team for a while, obviously, I mean, working in a primary care group, a lot of the driving motivation for a lot of our work is the GP recruitment and retention crisis. And we've always had, we've had this data for a while on GP income from us via our surveys. We've also had this data on GP income expectations and this has been in the survey forever and we've never, we hadn't used anything with it and basically because a lot of us are economists as well as this concept in economics of the Easterland Paradox or the idea that relative income matters more than actual income for happiness. And so we decided that, well, it would be like, like because we are interested in the GP recruitment and retention crisis, it would be interesting to look at the extent to which relative income matters for GP recruitment and retention. So job satisfaction and intentions to quit being two components of recruitment and retention. Speaker A 00:02:09.330 - 00:02:14.290 So you mentioned about a survey. So are you talking about the GP Work Life Survey that was done through Manchester? Speaker B 00:02:14.370 - 00:02:17.130 We are indeed, yeah. So the GP Work Life Survey. Speaker A 00:02:17.130 - 00:02:28.110 Yeah, yeah. So talk us through that just briefly. So what was that all about? I think, I mean there have been a few publications in the BJGP about it, but what. Who are you surveying through that? Speaker B 00:02:28.590 - 00:03:18.400 So the GP Work Life Survey has been going since I believe, 1998. It's been run by Manchester for I believe, all of its history and it's a government funded survey and when we do it we are attempting to a sample of the general GP population to basically ask about various things to do with their work life, including more sort of like formal things like their income and how many hours they're working, but also just how satisfied they are with their jobs, different aspects of their jobs. Yeah, so we collect lots of data on the GP to respond, and, yeah, we aim to get as general a sample of a population as we can. Speaker A 00:03:18.800 - 00:03:40.000 And I think one of the really interesting things about this study is that you're not just asking how much GPs actually earn, but how much they think they should earn. And you mentioned about this paradox that you're interested in in terms of health economics, and I wonder why you think that distinction is important between actual earnings and sort of relative earnings or how much people think they should earn. Speaker B 00:03:40.990 - 00:04:21.630 So I guess with a lot of things in life, and obviously from this economics paradox, a lot of things are not. It's not necessarily what you have. Absolutely. A lot of it is driven by things like peer comparison, or if you're seeing that someone else is getting paid more for doing what you believe is like, similar amount of work or similar quality work to you. So the idea of pure comparison's always just been like, important and there's lots of data out there and lots of studies looking at sort of the effect of absolute income. And this just felt like another relevant dimension to explore, basically. Speaker A 00:04:22.190 - 00:04:33.710 So I guess if we just come on to sort of the big finding. And what did you find when you looked at actual income and GP job satisfaction? What was sort of the main headline here? Speaker B 00:04:34.220 - 00:05:21.850 So, for job satisfaction, we, like, we find absolute income matters quite a lot and it has higher absolute income lead generally associated with higher job satisfaction across most, if not all domains. And for job satisfaction, absolute income matters a lot, but we found that absolute income didn't seem to have any statistically significant association with intentions to quit. So we asked them whether or not they want to leave direct patient care within five years or leave medical work entirely in five years. And we found that absolute income didn't have enough, didn't have a statistically significant association with that. Speaker A 00:05:22.170 - 00:05:41.410 So that's quite interesting, I guess, and it's a bit surprising, really. So higher actual income wasn't really associated with intentions to quit, but paying gps might make them more satisfied, but doesn't make them necessarily mean they'll stay. What do you make of that? It's kind of an interesting finding with. Speaker B 00:05:41.410 - 00:06:00.300 Job satisfaction that's obviously kind of in line with what we would expect. Intentions to quit, maybe it's just. It's a surprising finding. We would have expected it to have an effect on intention to quit, especially given that job satisfaction, intention to quit, go together. So it's a little contrary to what we might expect. Speaker A 00:06:00.940 - 00:06:17.100 I think it's quite an interesting distinction, I guess, because I guess sometimes in workforce discussions, we sometimes think about pay as one answer to recruitment and retention problems. And I think what this work is showing that maybe the picture is a little bit more complicated than that, actually. Speaker B 00:06:17.420 - 00:06:18.540 Yeah, I completely agree. Speaker A 00:06:19.100 - 00:06:27.420 So I wanted just to move on to some of your other findings. So you found something interesting when you looked at expected income. So can you talk us through that as well? Speaker B 00:06:27.920 - 00:07:00.990 So we find that higher expected income is associated with lower job satisfaction, and we actually find that has a small but positive effect on intentions to quit. So higher expected income has a small association with higher intentions to quit. I think there's obviously rationale for this. Obviously it kind of goes along with the economic theory and what studies have found in other domains with things like worse mental health, with higher gaps between actual and expected income. Speaker A 00:07:01.070 - 00:07:15.230 Yeah. So if I'm understanding that. Right, it's not simply that earning less makes you unhappy, it's about the gap between what you earn and what you feel someone else with your experience and career stage ought to be earning. So do you think that's a fair way of thinking about it? Speaker B 00:07:15.230 - 00:07:57.860 I think that's a very fair way of characterizing it, yeah. Basically, if you feel that you should be earning more, even if you're on, like a salary that, say, is pretty good, or they do things like pay the bills, if you feel that you should be earning more for the stage of your career, you're at the training you've had. I mean, gps are, obviously, they have to go through a lot of training through med school, and GP training itself is quite intense. And there's a lot of hours they have to work. So all of this builds into income expectations. And if they feel that they're earning less than they feel they should be, that leads to feeling more likely like they want to quit or, and. Or just feel less satisfied with their job in general. Speaker A 00:07:58.180 - 00:08:13.300 And you also looked at different groups of gps because you had this big database of these surveys. And were there any findings there that particularly stood out to you? So differences between partner GP partners and other GPs, or between different age groups at all? Speaker B 00:08:13.780 - 00:09:30.260 Yeah, I think the really interesting ones are probably the age groups is probably the most interesting one. So we found that our relationship between expected income, intentions to quit was stronger in younger GPs, specifically with intentions to continue medical work abroad. For GPs aged under 40 the relationship was noticeably stronger than for the other age groups. Yeah, younger GPs expected income seems to lead to sort of higher intentions to continue work abroad, which I guess makes sense, they're younger. But it also shows that maybe the gap between expected income and actual income might be more profound for younger GPs. And we also found that the relationship between actual income and job satisfaction was sort of less consistent, less pronounced in younger GPs relative to GPs over 50. I thought that was quite interesting. Maybe this is because actual income matters more to older GPs and for younger GPs, the sort of expected their expectations matter more. But it was. We thought this was interesting. Speaker A 00:09:30.740 - 00:09:53.650 Sometimes I wonder with this idea of GP salaries, I wonder if it raises some interesting questions about transparency and salary and just. Yeah, be interesting to get your thoughts on this and you might not have anything that you want to say about it, but do you think that GPs actually have a good sense of what other GPs earn, considering that, you know, everyone's working different roles and working patterns and hours and things like that? Speaker B 00:09:54.210 - 00:11:37.350 I don't have to preface any of this with by mentioning that I'm not a gp. So a lot of this is things I can just talk about, things I've learned through my research and talking to colleagues who are gps. But it feels like gps, it's harder for them to get a sense of what the income of their peers is relative to sort of to other types of doctors. Because other types of doctors, my impression is there's a bit more transparency and like sort of published rates on what these doctors are earning. Whereas, yeah, for gps we have. There is the review body on doctors and dentist remuneration report that does have sort of like average GP earnings, but it doesn't account for sort of session, like sessions worked or hours worked, which obviously is like, that's going to drive a lot of what, how gps, like how much gps feel they should be earning. So, yeah, it kind of feels like there, there isn't as much transparency and I think this would. This can lead to it being harder for gps to sort of get an accurate impression on what they should earn. Yeah. So we actually feel that, like one of the big policy recommendations from our paper or policy implications from our paper is for anything to increase transparency on GP income would be great. Specifically as regarding sort of sessional and hourly rates, there's obviously a lot of variation in what GPs earn as well, because general practices, there's obviously these are like private businesses, so there's a lot of variation and yeah, not a lot of transparency. And all of this could lead to sort of erroneous expectations. Speaker A 00:11:38.070 - 00:11:48.710 Yeah. And I guess I was going to ask about sort of the practical findings and I guess, is that sort of what you think the takeaway is for policymakers or employers in terms of how they could use the findings of this work? Speaker B 00:11:49.030 - 00:11:50.830 Yep, I think that's one of the biggest ones. Speaker A 00:11:50.830 - 00:12:08.690 Yeah, brilliant. And I think you also make the point in the paper that improving working conditions still matters. So. So I guess it's a sort of balance between income and how it sits along other things like workload and the administrative burden and having control over how you work as well in terms of retention. Speaker B 00:12:09.490 - 00:12:23.330 Yeah, absolutely. Income and income expectations are only one component of this. There's a lot of other things that are driving GP dissatisfaction as well, and intentions to quit. Speaker A 00:12:23.900 - 00:12:32.700 And I guess, finally, if you could leave gps listening to this with one main takeaway from the study, what would you like that to be? What would you like them to sort of take from this? Speaker B 00:12:33.500 - 00:13:29.310 Yeah, I think I'd want to say that actual income matters a lot. I don't want to suggest that job satisfaction is an important component of working life and the quality of care that patients get, and actual income is predictive of that. So I don't want to. Basically, I don't want to suggest that actual income doesn't matter and how much GPs are paid doesn't matter. Regarding sort of a takeaway, I think basically it's worth acknowledging that there is limited resources out there to sort of get an accurate picture of what your peers earn. I'd sort of recommend that it's worth using whatever resources you can, like the Doctors and Dentists Review Body. I realize it's hard to get accurate expectations on what your peers are earning, so hopefully that changes in future. Speaker A 00:13:30.030 - 00:13:49.320 That's great. But I think that's been a really interesting study to reflect on and some interesting findings, as you say, around sort of what GPs earn, what they expect to earn, and how that feeds into job satisfaction and intention to stay in the job. So I think that's a great place to wrap things up. But I just wanted to say thank you very much. Speaker B 00:13:49.560 - 00:13:54.040 No, thank you. Nada. And yeah, thank you so much. It was. Yeah, it was really good to talk about this. Speaker A 00:13:54.840 - 00:14:09.480 And thank you all very much for your time here and for listening to this BJGP podcast. Ben's original research article can be found on bjgp.org and the show notes and podcast audio are@bjgp life.com thanks again and bye.
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S6 · E240
September 22 · 15 min
The NHS Health Check and mortality: do they help people live longer?
Today, we’re speaking to Dr Jasjot Saund, a public health registrar based in London. Title of paper: Association of the NHS Health Check with all-cause mortality: a longitudinal cohort study in primary care Available at: https://doi.org/10.3399/BJGP.2025.0451 The NHS Health Check (NHS-HC) has been shown to improve detection and management of surrogate markers of health, such as blood pressure and cholesterol. The long-term impact, however, is less evidenced, with mortality reductions seen in a UK Biobank cohort and no mortality reduction seen in a Cochrane review of general health checks, including those outside the UK. The current study added real-world evidence from a diverse UK urban population, and a 15-year study period. Survival analysis of GP electronic health record data shows reduced mortality in those who attended an NHS-HC compared with those who did not. These findings should be interpreted cautiously given the observational nature of the study design. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:01.440 - 00:00:58.570 Hi and welcome to BJGP Interviews. I'm Nada Khan and I'm the senior research editor of the Journal. Thanks for taking the time today to listen to this podcast. In today's episode, we're talking to Dr. Jazjot Sound, a public health registrar based in London. We're here to discuss the paper she's recently published here in the BJGP titled Association of the NHS Health Check with All Cause Mortality, A Longitudinal Cohort Study in Primary Care. So thanks very much for joining us here today, Jazja. It's really great to talk about this work and I think just before we get into the study itself, we know that NHS health checks are something that most GPs will probably be very familiar with, but maybe we don't always stop and think about the evidence behind them. So, just to start off, I wonder if you can explain to us a little bit about, about what the NHS Health Check program is actually designed to do. Speaker B 00:00:59.050 - 00:02:16.370 Yeah, absolutely. So the NHS Health Check program was rolled out in 2009 and it's essentially a population level preventative initiative, focusing particularly on cardiovascular disease, but potentially wider as well. And so it's specifically targeted at people who are between the ages of 40 and 75 and who don't already have a, a cardiovascular disease or a known cardiovascular disease. And I think that's really important because it's targeting people who are potentially at risk or have undetected disease. And what this means is, so ultimately the health check itself, it consists of a check that's usually undertaken by primary care, so looking at lifestyle factors, modifiable risk factors, biochemical tests, as well as sort of just other general checks. And importantly, this is embedded into primary care pathways. So essentially it's ensuring that these patients are followed up if they are determined to be high risk and potentially put on prescriptions or followed up with lifestyle modifications. So that's generally what the health check is at the moment. Speaker A 00:02:16.690 - 00:02:31.070 Brilliant. Yeah. And I guess the big question behind this paper is, do they actually make a difference? And I wonder what did we actually know about the impact of NHS health checks before you started this work? So what was out there in the literature already? Speaker B 00:02:31.550 - 00:04:07.320 Yeah, so there is a, a huge amount of evidence in different parts of the health check. So you might be aware already that it's a multifaceted intervention. So there's, there's the process bits like uptake and invitation. So there's a big amount of evidence that's been telling us that it's really important that we even just the method of invitation can be really influential on who takes up the health check. But then there's also the specific parts of the check itself. So how we communicate risk to patients, for example, can have an impact on how people go home and take on lifestyle advice. And then there's the body of evidence that's closer to where this paper sits, which is looking at clinical outcomes. And there is a whole body of evidence looking at surrogate markers, so things like does it shift the marker on blood pressure or bmi. And then there's the evidence on mortality, for example, or clinical endpoints such as stroke. And so far the evidence is predominantly positive to say we do see a change in clinical outcomes. And more recently, there was a paper in 2024 which was using a UK Biobank cohort and shows that there was an impact, a positive impact on disease, end stage disease, as well as mortality. But as the paper sort of addresses, there's some gaps in this evidence, which is what we. What we hoped to fill. Speaker A 00:04:07.560 - 00:04:25.280 Yeah. And I guess I wondered if you could just talk us through the data used for this study, because this was a really large real world cohort from an inner city London population, wasn't it? So very different than the kind of population that might, for instance, have taken part in UK Biobank? Speaker B 00:04:26.240 - 00:05:17.420 Yeah, absolutely. So we thought it was really important to look at whether or not the health check was having an impact as it was being delivered in a real world population. And so we were lucky enough to look at a cohort going all the way back to when the health check was implemented in 2009 in Lambeth, which is a really ethnically diverse and socioeconomically diverse cohort. So, for example, we have a population in lambeth that is 40% non white, as opposed to, I think the UK Biobank participants were 96% white. So there's a real difference. And so we wanted to ensure that the population we looked at was representative of some of the inner city boroughs that have particular challenges around NHS health check uptake. Speaker A 00:05:17.660 - 00:05:27.330 Okay, so let's get into what you found. And what was the headline result when you compared people who attended at least one NHS health check with those who didn't? Speaker B 00:05:28.120 - 00:05:53.320 Yeah, so the headline result actually showed that there was a 32% relative risk reduction associated with the health checks on all cause mortality. So that's looking at any cause of death, but shows quite an impressive risk reduction. So that is a relative risk reduction as opposed to absolute. So it's important to note that overall the absolute rate of survival was high,. Speaker A 00:05:53.750 - 00:06:03.670 And that's pretty Striking, actually. So that substantially lower risk of all cause mortality, were you surprised by the size of that association? So 32% is quite big, isn't it? Speaker B 00:06:03.750 - 00:06:33.490 I think initially I was surprised, but then looking back at the evidence and the data that's already out there, it does fall in line with kind of what we were seeing, particularly in the UK Biobank cohort as well. I think there is sort of evidence that potentially looks at general health checks, which has shown a converse picture. But as we discussed in the paper, it's really different to how the NHS health check is delivered here. So that's definitely something to bear in mind. Speaker A 00:06:33.810 - 00:06:45.250 And you also looked at absolute mortality risk over 10 years and the difference seemed to be really pronounced with increasing age. So could you talk us a little bit through what you found there? Speaker B 00:06:45.650 - 00:07:39.440 Yeah, so we found that although the older population had a. A higher absolute risk reduction, they also had a higher absolute baseline risk of death as well. So it's really difficult to distinguish whether or not that finding was related to the health check being more beneficial in older patients or whether or not actually we see a bigger absolute reduction, because in our over 65 population there is a higher baseline risk of, of death. I think we, like, when looking back at the data population who was enrolled in 2009 at the youngest possible age were 40. And even though we had 14 years of follow up, they would only be 57 years old at this point now. So their absolute risk of death is still very low, which might be more difficult to pick up in a study like this. Speaker A 00:07:39.760 - 00:08:10.860 Yeah, fair enough. And I guess, you know, whenever we look at observational research, I suppose the question is whether people who attend an NHS health check are somehow different than people who don't. And that's, you know, in parallel to the studies. For instance, you know, just focusing on UK Biobank, it's sort of a different population really. And I guess people who attend a health check could potentially be more health conscious or more likely to engage with healthcare. Anyway. How did you try to account for that in this work? Speaker B 00:08:11.100 - 00:09:45.530 Yeah, and that's a really important point to pick up and something that's really challenging in observational data in general. But so, yeah, we really wanted to make sure we tried to adjust or account for this. And so, as you said, some. The healthy attender bias is something that can come up when people are more likely to attend a health check if they're more health conscious. So we used a method called propensity weighting, which is similar to propensity matching in that we look at the probability that somebody attends a health check based on their characteristics and use that probability to weight the groups to ensure that the characteristics are balanced between those who attend and those who don't attend. So that was one method, but we also saw in our descriptive analyses that actually it wasn't a uniformly healthy group of attendees. There was a higher rate of overweight and obesity in the people who attended health checks and there was a higher rate of a family history of coronary heart disease as well. To be extra sure. We also did some statistical analyses which tried to measure the level of unmeasured confounding. So obviously we can only adjust for what we can measure. So we wanted to understand how big is the unmeasured confounding, and we found that actually it would need to be twice as big as the things that we had already adjusted for to account for the full picture. So that's quite, quite large. Speaker A 00:09:45.770 - 00:10:15.510 And I was also, as you were describing, interested in the fact that the NHS health check isn't just a single intervention. So it's a check, but then there's all that stuff that happens afterwards. So identifying the risk factors, how you communicate that to people and how that impacts things, then they might have follow up or start medication or get referred onwards. And do you think that that's one of the reasons it's difficult to really pin down what part of the program is actually making a difference? Speaker B 00:10:15.830 - 00:11:04.610 Yeah, I think it's a really complex public health intervention and it does require each aspect to have its own rigorous evaluation as well as the whole picture as a whole, which is where our study sits. But that is on top of evidence behind each facet. But it does then make it quite difficult to understand which is the biggest lever. But I think far what we're seeing is definitely ensuring uptake in underserved populations, as our study also highlighted that there is a benefit across all ethnicities and imd, like deprivation quintiles as well. But also the follow up is important as well, ensuring that these health checks are embedded in clinical processes also been shown. Speaker A 00:11:04.850 - 00:11:10.050 Yeah. And I wonder if there are any other main findings from this work that you wanted to highlight. Speaker B 00:11:10.470 - 00:11:46.530 Yeah, I think I sort of touched on it just briefly. But interestingly, we ran the analysis on premature mortality as well and found that the benefit still held. And we also ran the analysis on different deprivation quintiles as well as multiple ethnicities and found that the direction of the evidence is the same, showing that health checks do improve mortality, although some of the smaller subgroups didn't reach statistical signals significance. But we think this is likely just because we're looking at small groups and those with the biggest groups did reach significance. Speaker A 00:11:47.090 - 00:12:13.160 Really interesting. And I guess overall, I wonder what your feelings are about what the implications are for general practice, because I guess sometimes it can feel like one more thing that has to be fitted into an already pretty busy system. And it's really interesting to get your perspective as a public health doctor as well. Do you think that this study should change the way that we think about the value of the health track? Speaker B 00:12:14.440 - 00:13:29.500 So definitely, potentially, yes. I think some of the wheels are already in motion as well. So this will have implications as a full body of evidence, not just this paper in isolation, at local and hopefully at national level as well. And we're starting to see changes already. So there's been rollouts of digital pilots as well as workplace based health checks as well. And so I think the evaluation of those are going to be really telling and important to see whether we're still reaching or we can reach the intended outcomes of the health check. But it also means that potentially these are pulling on those levers, such as increasing uptake and reducing those traditional barriers and ensuring that, yeah, health checks are equitable. But also I think we're seeing signs in the recently published Cardiovascular Disease Modern Service Framework, which talks about potentially expanding the scope of health checks, so looking at a more cardiovascular, renal, metabolic focus rather than just cardiovascular disease. And this is because these conditions can co occur and particularly in more underserved populations as well as, and you've mentioned. Speaker A 00:13:29.500 - 00:13:43.020 Equitable access in some underserved communities. Was there anything that you felt needed to be highlighted in terms of how health checks need to be more equitable or anything, especially given the population that you included here in this study? Speaker B 00:13:43.820 - 00:14:28.680 Yeah, so interestingly, Lambeth is obviously a very diverse population and interestingly, the uptake was pretty high in our minority ethnic groups and underserved populations. So that was really positive in knowing that, okay, it is potentially reaching the right people, but there will still be a group of populations of people that will be struggling to access these. So I think definitely this paper highlighting the fact that the mortality benefit is held across diverse populations is really important to ensure that within the borough and across other boroughs that we do continue to reach those underserved populations. Speaker A 00:14:28.840 - 00:14:40.440 And I guess finally, for gps listening to this, who might be trying to think about how to take the findings back to their own work, what's the one thing that you want them to take away from this study about NHS health checks? Speaker B 00:14:40.520 - 00:15:14.260 Yeah, I think. Well, I'm hoping it's reassuring. So I hope that. I know that there might be some people on the fence about whether or not health checks are beneficial. So I hope that this can add to the body of evidence that provides reassurance to gps that although it's very difficult to see such a complex public health intervention moving the needle on, you know, small parts of the population, that actually at the overall population level, it is making a difference or there is an association with a reduced mortality. Speaker A 00:15:14.740 - 00:15:24.440 Yeah. And it's so brilliant to see this work done, as you say, in a real world sample. And I think the findings are really striking, actually. So it's great to, to hear more about this work. Speaker B 00:15:24.600 - 00:15:25.240 Thank you. Speaker A 00:15:25.560 - 00:15:30.760 Yeah. So brilliant. I think that's a great place to wrap things up. But I just wanted to say thanks very much for joining us here today.
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S6 · E239
September 15 · 20 min
AI scribes: The impact on the consultation, the notes and relationships in practice
Today, we’re speaking to Dr Emma Ladds, a GP partner and DPhil candidate at the Nuffield Department of Primary Care Health Sciences at the University of Oxford. We’re here today to discuss the recent article she and her colleagues have written for the journal, titled, ‘Ambient scribes in general practice — help or hindrance?’ Title of paper: Ambient scribes in general practice — help or hindrance? Available at: https://doi.org/10.3399/BJGP.2026.0097 Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.320 - 00:01:15.600 Hi and welcome back to BJGP interviews after our summer off. I'm Nada Khan and I'm one of the Associate editors of the Journal. Thanks for listening to this podcast today. In today's episode, we're talking to Dr. Emma lads. Emma is a GP partner and a DPHIL candidate at the Nuffield Department of Primary Care Health Sciences at the University of Oxford. We're here today to talk about the recent article that she and her colleagues have written for the analysis section of the Journal. And the article is titled Ambient Scribes in General Practice. Help or Hindrance? So, hi again, Emma. It's lovely to speak to you about this work. And I think one of the reasons we were interested in picking up this article is that it's really highly topical and it's in an area that I think a lot of people are wondering what to do in their day to day practice. And I think that some of the issues that you've highlighted in the article do speak to some of the concerns that people are raising, but also some of the challenges with the implementation in practice. But I guess before we get onto some of the issues that you raise in the paper, can you just explain what we mean by an AI or ambient scribe? Speaker B 00:01:16.160 - 00:01:45.660 Well, it's the technologies based on artificial intelligence that detects conversations, so between the patient and gp, or between GP and other colleagues. And in consultations, it then generates a summary of what's been discussed, but also does some other things as well. So, for example, it might add some coding labels for specific things that are mentioned, and then all of that goes into the patient's electronic health record. Speaker A 00:01:45.980 - 00:02:15.130 And I think that these tools are often presented, at least to some of the GP colleagues that I know and work with, as almost like an obvious win for general practice. So less documentation, more efficiency, and maybe more time with patients. But what made you want to just take a pause and think about some of the assumptions behind some of those quick wins that people might be thinking about, thinking about. Speaker B 00:02:15.450 - 00:03:31.980 And I mean, I think it's interesting, isn't it, because ever since we started to introduce different technologies into the consultations, there's often been an assumption that every new thing would be a quick win. And even since the introduction of the computer, you make for greater efficiency and it will be easier to store data, to retrieve data, to share data, et cetera. And of course, a lot of the time what those technologies do is they drive particular activities. I think it's been interesting just to think about how introduction of different technologies and platforms and digital approaches has driven a much more transactional, quantifiable way of working. And those things that can be recorded and can be captured in technologies or enabled by technologies have been promoted, perhaps at the expense of some of the less quantifiable, more nuanced activity. So suppose it was looking at that journey of technologies and just trying to think about what this next step might also add to that picture. Speaker A 00:03:32.220 - 00:03:41.820 And one of the things you talk about in the article is that AI scribes could create what you call false efficiencies. But can you unpick what you mean by that? Speaker B 00:03:42.300 - 00:04:53.150 I think there's this assumption that actually the summaries and the codes that AI scribes will generate will be very time saving for gps. And no GP ever has enough time. So everybody's looking for, as you put it, the quick wins. And some of the challenges with the outputs from AI inscribes are that they often produce very long transcripts because they're trying to capture a summary of everything that was discussed and that gets entered into the record. And obviously it takes time for subsequent clinicians to look through those kind of summaries. So that could be a fold sufficiency. But also, I mean, it can add false labels or generate errors and that requires checking as well. So it's not that it just produces an accurate summary and then that's out there. Actually, the clinician still has to go back and double check that everything's been done correctly. So even though they don't have to do the actual typing, there's still a level of processing that they have to do of that summary. So it's not necessarily a time saving tool, really. Speaker A 00:04:53.630 - 00:05:15.390 And I think that's one of the interesting things about it because, yeah, there's that interesting point that, you know, GPS might be getting that time back in some other way, but I guess that's highlighting that that might not actually be quite that simple, that the time that you might get back from not having to type out the notes from a consultation is actually being used elsewhere. Speaker B 00:05:15.390 - 00:06:20.920 Actually, I think that's very true. And I think the other thing that's worth thinking about is what's in the notes, the actual information that's there. Yes, it's a summary of the consultation, but actually generating that summary when the clinician does it, there's a level of processing, there's a level of sort of cognitive thinking, of reflection, of thinking about what it was that was happening during the encounter between patient and gp, what was actually being said, or a lot of the time, what was not being said, and the AI scribe won't detect that. And a lot of clinical reasoning sometimes happens for gps, sometimes happens behind the scenes when they're doing that retrospective processing. And as one of my colleagues said, you know, she often thinks about other investigations she'd like to add or things that she might not have made overt to the patient, which perhaps need to be made over to the. So it's those sorts of subtleties that aren't captured in just a very superficial representation of a consultation. That's the content of a consultation. Speaker A 00:06:21.720 - 00:06:53.030 And I think that struck me that taking notes isn't simply an administrative task, it's actually part of clinical thinking. And I certainly, I've tried AI scribes, but how I do my consultations is I write on a piece of paper because I think that's how I process it, and then I move from the paper to the notes and that's part of how I work through the problem. And I guess that's what you're getting at here just in terms of sort of the clinical thinking about actually putting the notes onto the record. Is that what you're saying? Speaker B 00:06:53.350 - 00:08:00.370 Yeah, I think that's right. And I think it's a reflection about how we all develop as individual practitioners as well. I mean, the way you do your consultations may be slightly different to the way that I do my consultations, and the way that you write your notes may be slightly different to the way that I write my notes. But I think often when you've worked together with people for quite a long time, you learn hidden meanings and you pick up that they may phrase things in very particular ways and that conveys a deeper level of meaning to you because of that kind of relational knowledge that you have of your colleagues. So for example, if I write one consultation in my note, my partners know that it was an extremely long consultation that was probably quite circular. We probably didn't come to a very conclusive outcome and probably the patient is going to want to come back and see me again rather than one of them. You know, there are these subtleties in communication that actually at the moment the AI scribes aren't good enough or nuanced enough to be able to detect. And I don't know if they'll ever get to that kind of level of something. Speaker A 00:08:01.130 - 00:08:28.010 But I suppose an AI scribe is never going to really capture clinicians voice, is it? And I think that's what I see when I see some colleagues who are using AI scribes that the. There seems to be quite a lot of detail there which is great, but it doesn't have that clinician's voice in it. So it's hard to really unpick some of the hidden meaning behind sort of what's going on there. And I think that's why I don't use it, because I don't feel it reflects my thought process when I'm going back to look at notes. Speaker B 00:08:28.150 - 00:09:41.210 Yeah, yeah, no, I think that's exactly right. And I think it's extremely good at trans. At sort of capturing transactional interactions and transactional material. And I think that during my detail, I was observing a GP using one of the AI scribes, and we. I watched a series of consultations and in one, which was a very transactional discussion phone call with a patient where he was just adjusting her medication doses, he said, oh, yes, the scribe will be very good in this one. I'll just use the scribe. And it was. It was very accurate. It captured exactly what they. What they discussed. And then he had a consultation with a very complex patient with a number of comorbidities and lots of psychosocial difficulties in the background. And he actually turned the scribe off before the consultation because he just said, it won't capture this. This not the sort of thing it will be any good at. And I just thought that was very interesting, that whilst it is very good at capturing that more not simple is the wrong word, but you know, that. That much more transactional encounter, it just can't quite cope with the relational stuff that often, I think, is GP says now our bread and butter. Speaker A 00:09:41.370 - 00:09:56.020 And I think you make that point in the paper, that a consultation is sometimes much more than just the word, words that are spoken. So looking at those examples, what do you think that an AI scribe might struggle to capture in that sort of more complex or relational type of care? Speaker B 00:09:56.820 - 00:10:51.900 I mean, I think that kind of complex care, there are so many uncertainties, aren't there, ranging from sort of diagnostic uncertainty to prognostic uncertainty. There's often uncertainty, I find, in thinking about what my patient is doing, feeling about me, you know, that level of kind of psychodynamic uncertainty. And I think all of that sort of stuff is likely to be overlooked by the AI scribe. And if you take a very simple example, I mean, often in general practice we're going through a sort of process of diagnostic reasoning where we're weeding out diagnoses, or you'll do a particular investigation thinking, well, that will exclude X, but sometimes the AI scribe might actually put X into the coding as a diagnosis. There isn't that well, this is possible to be captured. So I think that can be another sort of potentially problem as well. Speaker A 00:10:52.140 - 00:11:25.470 Yeah, you talk about that quite nicely in the paper that, about this uncertainty because general practice is often about symptoms that don't fit neatly into a diagnostic category or you're wondering about a diagnosis so you're querying it as you continue with investigations and more consultations and things. And I guess that does create a challenge for AI tools that sometimes seem more designed to classify and summarize and structure information a bit differently. So I thought the example that you gave in the paper was actually very nicely done. Speaker B 00:11:25.950 - 00:12:55.130 There's a lot of talk, or there has been over the years and increasingly still in general practice about the cohort of patients who present to us for whom there is no formal diagnostic label that can be applied. And, and that doesn't mean they're not suffering and they don't have trouble and that they shouldn't be worthy of an appointment. It just means that you can't give them a hard diagnosis at the end and say, well this is X and take Y and it will get better. Actually your, your therapeutic input is through the witnessing of their distress and that kind of human connection. And I guess one of my biggest worries with AI scribes, or not of them per se, but the sort of devoted promotion of them without considering the, than the potential negatives, is that actually because they learn on the kind of data that they're designed to collect, you'll end up with a self perpetuating model where AI scribes will get much better at facilitating transactional consultations and then actually they will just be used within transactional consultations and people will get more and more and more likely to do much, much more transactional consultations in order to use the technologies. And so you'll have technologies driving our values rather than a sort of consideration of what we're actually what we want to promote in general practice, which for me is still about human connection and relationships and I guess sort of bearing witness to the human condition. Speaker A 00:12:55.610 - 00:13:07.300 And having thought about all this, I wonder if you are against the use of AI scribes or is it really about being more thoughtful about how and when we use them. What are your thoughts about that? Speaker B 00:13:07.700 - 00:13:56.690 I think it's that I'm not brilliant with technology, but I'm definitely not somebody who wants to stand in the way of this. I think technology can facilitate our sort of behaviors and our efficiencies enormously. What I don't want it to do is to drive everything. And I think My concern, for example, if you take the executive summary of the table 10 year plan, for example, the word care is used 78 times, but only one of them is as the verb to care. And I just think there's this idea that actually technologies are going to drive models of care or enable faster care, but nobody is actually thinking about what it means to care and how technologies can stand in the way of that sometimes. Speaker A 00:13:56.770 - 00:14:26.270 And I think the way that some people are using AI scribes and how it's being rolled out is a bit patchy. So I know in some practices, for instance mine, There are some GPs who are using it and I know of some practices where it's almost a requirement to use it and that's kind of the, the, the way that they've decided to go forwards. But I think we probably. AI scrubs are likely to become increasingly common. But do you have any thoughts about what good implementation would look like or what would you like to see happen in that? Speaker B 00:14:26.270 - 00:15:57.850 I think I'd like GPC been more involved in the conversations around the development of them and particularly thinking about whether it's possible to enable the technology to capture some of these nuances and subtleties that I've sort of talked about. But I think it's also important for us just to think about what the commercial models and the background is that's driving some of the development of the scribes themselves and what the different agendas might be underlying some of that development. So, for example, you have to think about what the value of data is. I mean, why are people developing such ambient scribes? Actually, it's not for the good of mankind. It's because there's a commercial interest in doing so, and that commercial interest is tied up in data. And so it's in the interests of AI scribe developers often to produce more and more and more data. And so you're looking at more and more and more content. But that might not be the most helpful thing for a practicing gp. You know, actually what we might need is for our ambient stripes to generate a very succinct portrayal of what went on that could be easily skimmed. If you look back at some of the old Lloyd George records, for example, you know, there will be chest infection, amoxicillin, and that's the extent of a consultation. And now think about how lengthy our health records are. And I sometimes wonder how much added value some of that information has brought to things. Speaker A 00:15:58.650 - 00:16:16.570 And I guess in this space, I wonder if you have any thoughts about what you would like GPS to think about before they switch on an AI scribe in their consultation room. So what could be going through someone's mind about the use or good use of it, really, before they think about using it? Speaker B 00:16:17.300 - 00:17:16.280 I think they need to think about what their consultations are for, what are the core activities that they're still trying to enable in their consultation and not to let the AI strive come in the way of them doing that. And so if it is all just about transactions or if it is just about the titration of blood pressure, I kind of argue no consultation is ever just a transaction.
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S5 · E238
July 7 · 11 min
Reflecting on the last season of the BJGP podcast
In this episode, we look back at the last season of the BJGP podcast and reflect on some of the work we’ve discussed. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.560 - 00:11:08.620 Hi, and welcome to the BJGP podcast. I'm Nada Khan, one of the associate editors of the Journal. And we've reached the end of another podcast season, and before we take a short break for the summer, we thought we'd look back at some of the papers we've covered and pick out a few highlights and common threads between them. And looking back at the different podcasts over this this past season, it seemed that although each conversation started with a completely different research question, by the end we all seemed to be talking about the same thing, and that was, how can general practice work better for patients in today's increasingly complex healthcare system? And although we talked about a wide range of different topics, we covered cancer diagnosis, dementia, women's health, medical education, and we even talked to Garth Funston about artificial intelligence. They all came back to this same underlying challenge. And we know that general practice has always dealt with complexity, and that's not really anything new, but the kind of complexity we're dealing with now feels different. Patients are living longer with multiple conditions. Care is spread even more so across increasing numbers of services than ever before. Technology is changing the way that we work, and somehow, amongst all that, we're still trying to preserve those relationships that have always sat at the heart of general practice. And I think another thing that really struck me was that very few of the papers and researchers were talking about making dramatic changes. And instead we had a lot of discussions about how we could make systems we already have, just work a little bit better. So making it easier to navigate, getting people more connected, more equitable, and more human as well. So one of the first interviews we recorded was with Katharina Savolkul about why medical students choose or don't choose a career in general practice. And on the surface, it's comes across a bit like workforce paper. We know that we need more gps, and understanding career choice is clearly important, but I think we talked about something a little bit bigger, which is, what kind of profession are we asking people to join? And this review highlighted positive GP placements, so good role models and the hidden curriculum as well. And although we often focus on recruitment targets, Katharina reminded us that students choose career because of the experiences they have and the values that they see lived out. And interestingly, continuity of care remains one of the biggest reasons people are still drawn towards becoming GPs, even though many of us worry that that's becoming harder to achieve in practice. And I think that continuity became one of those defining threads that ran through a lot of the interviews that followed. And we had Ewan Lawson join the podcast to speak to Charlotte Morris about dementia care. And what they talked about was that participants weren't really asking for more investigations or different medications. What they wanted to feel was to be known and to have someone who understood who they were before their diagnosis recognize those changes over time and stayed alongside them as their condition progressed. And I guess listening to that interview made me realize that it's not just about seeing the same gp, but it's about patients feeling that someone is carrying the thread of their story over time. And I had a really similar feeling talking to Dr. Tory Ford about recurrent vulvovaginal thrush. And these were two qualitative papers about diagnosis and healthcare experiences. But I think by the end of the interview, we were talking about something much broader. And as clinicians, we think sometimes about those bite sized consultations, but patients don't at all. At least this was the experience that I think that we drew out from Tori's work. And in this work, I think Tori highlighted that people experience illness as a continuous journey. And although in a system where continuity of care might be challenged, clinicians might see episodes of care, but patients live their whole story. And I think that's why sometimes recurrent conditions can feel so frustrating for patients, not because, particularly those individual episodes of care consultations are poor, but because if there's discontinuity, no one's joining those consultations together. And I think the more interviews we recorded, I pulled out another pattern, and that's that whether we're talking about dementia, recurrent thrush, pediatric safety or postnatal care, patients and families were doing a lot of work. So an extraordinary amount of invisible work, they were chasing referrals, following up on test results, explaining the same story repeatedly to different professionals. And although these papers weren't a criticism of general practice, and oftentimes many of the patients talked about how much they valued their GP teams. But I think that it almost made it feel as though patients and families were bridging these gaps together between increasingly fragmented services. And I think that Tom Purchase's work on pediatric patient safety really captured this beautifully. So rather than seeing patients just as recipients of health care, his study showed that they're active contributors to safer care. So they're already preventing harm. Patients and their families are identifying problems and improving systems. And I think he challenged us to think about patients as partners in care, rather than just recipients of care. Another theme that kept surfacing was inequality. And I spoke to Eliza Hutchinson about her work in inflammatory skin disease in People with skin of color. And her participants talked about delayed diagnosis, underrepresentation in medical education, and that impact of dyspigmentation as well in practice. And I think, again, what stayed with me wasn't just the clinical message, which was really helpful, and I'd encourage gps to go back to listen to that, but it's how often people really just wanted their experiences to be recognized. And similarly, I think that Claire MacDonald's work on postnatal care reminded us that women with the greatest social needs are often face the biggest barriers to access and care after birth. And ironically or sadly, this is just as services begin to step back. And I guess these two papers were asking a much broader question was how do we design healthcare systems that work equally well for everyone? And I think one of the papers that I really enjoyed, or one of the people I really enjoyed talking to, was Garth Funston and his work using large language models to analyze free text consultation records, aiming to pick up earlier signals for ovarian cancer. And I think that, you know, we. We talk a lot about artificial intelligence, but actually what we ended up talking about was how we record things in consultations. And as gps, we write huge amounts that really never get coded as read codes in the system or snowbed codes, you know, symptoms, concerns, uncertainty, those details that really make up the richness of a consultation. And I think that what Garth's work showed us was that AI might help us make better use of the information we've already recorded. But I think that actually, you know, it's worth thinking about how we're actually using technology to help recover the stories we've already written in the free text as well. And the last thing that we talked about in this season was something that probably every GP understands instinctively, but few of us have actually been explicitly taught, and that's prioritisation. And we spoke to Andrew McClary about the rapid decisions we make every day. So which patient do we call first? What referral can wait? And crucially, what do we do first? Do we tackle the difficult task or go for the quick wins? And I think that I liked the title of his work, because I suspect every GP probably immediately recognized them themselves somewhere between these two approaches. And I think we also touched upon that prioritisation isn't simply about managing workload, but it's also about managing uncertainty. And I think that if there's one thing I'll take away from this entire season and the different people that we've talked to and the great work that we've listened to, I think it's that general practice has always been about managing complexity. But these conversations reminded me that complexity isn't something we can just eliminate or fix. It's something that it's worth delving into to try to understand a little bit better. And I think, you know, whether we're talking about continuity, inequalities, patient safety, or the workforce force, another common thread I thought that ran through these, these conversations was that connection. So connecting services together, connecting research with everyday practice, and staying connected to patients and the stories that they bring with them through time, really. And I guess for me, really, every interview this season left me thinking a little bit differently about how I, how I consult and practice and about that patient that's going to be sitting in front of me. And I think that's probably a mark of how strong this research was that we covered in this season as well. So I guess on that note, I just want to say a big thank you to all of the authors who joined us this season to share their work and to all of you for listening. We'll be taking a short break for the podcast over the summer, but we'll be back in September with another season of conversations about the latest research published here in the bjgp, and importantly, what it means for everyday general practice. So, yeah, until then, thanks again for listening and we'll see you in September.
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S5 · E237
June 30 · 17 min
Quick wins or eat the frog? How GPs prioritise their day
Today, we’re speaking to Andrew McClarey, who works as a GP and Education co-ordinator Lead for General Practice in the Scottish Centre for Simulation and Clinical Human Factors. Title of paper: “Quick wins” vs “eating the frog”: Exploring general practitioners’ prioritisation dilemmas Available at: https://doi.org/10.3399/BJGP.2025.0628 Link to tactical decision making games: https://archive.johs.org.uk/article/doi/10.54531/svvw4195 This is the first study to look at the factors which experienced GPs consider when prioritising their acute workload. Several themes have emerged which highlight the importance of prioritisation training in General Practice. These themes could be used to teach prioritisation decision making to GP registrars or in the creation of continuing professional development resources for experienced GPs. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A 00:00:00.400 - 00:00:56.560 Hi and welcome to BJ GP Interviews. I'm Nada Khan and I'm one of the Associate editors of the Journal. Thanks for listening to this podcast today. In today's episode, we're speaking to Dr. Andrew McClary. Andrew is a GP partner and he also works as Education Coordinator, Lead for General Practice in the Scottish Centre for Simulation and Clinical Human Factors. We're here today to discuss the paper that he's recently published in the bjjp. And the paper is titled Quick Wins versus Eating the Frog, Exploring general practitioners Prioritization dilemmas. So, hi, Andrew, it's really nice to meet you. And this paper really stood out to us, I think, because prioritisation is something that gps do every day, but it's not really something that we discuss explicitly. I'm just interested in what made you do this work and made you interested in studying it. Speaker B 00:00:57.200 - 00:02:00.600 It's interesting, I think, that for me, I finished my GP training just after the pandemic and therefore I did a lot of my training during the COVID pandemic. And around then the face of general practice, like most things in life, changed completely overnight. We moved on to telephone consulting and being encouraged to have empty waiting rooms. And I think around the same time we realized that we probably couldn't continue doing what we had been doing, which was being everything to everyone, which brought us on to prioritizing our workload. We have to decide who needs seen, who does not, and when are they seen. And that was a real gap for me in the training that I was provided. And I found myself going into working as a fully qualified GP without really an awareness of how to prioritise in a, in a sensible way. And I think that's where this interest was born out of. Speaker A 00:02:00.760 - 00:02:42.050 And before we get into what you found, it's probably worth saying a little bit about how you approach the study. So this was a qualitative interview study involving gps from a range of practices and career stages. And what you did was you really explored how they prioritized work during the course of a typical surgery. And then I guess through those interviews you looked at sort of the strategies and influences and trade offs that shaped those decisions in everyday general practice. But one of the things I found really interesting was that prioritization wasn't just about clinical urgency. And I wonder if you could talk through some of the other factors that GPs are weighing up quickly, I suppose, when they're deciding what to tackle first. Speaker B 00:02:42.690 - 00:06:17.800 Absolutely. It was very interesting, the themes that emerged from the data and also actually how much agreement There was amongst the gps in the focus groups, as we're not traditionally a group of people who agree about very much. So one thing that GP is particularly interested in, there's five main themes. One is about the system awareness. So we're aware about our own surgeries and where the pressure points are. For example, we're low on particular acute slots today, or there's a certain type of patient that is coming in more frequently at the moment, so we're aware of that. But it's not just having that awareness, it's also being able to adjust how we consult based on the pressures that the system are under. For example, if there are a lot of children or fevers coming in, we want to see them all face to face. We ask the admin team, just bring them all in face to face and we'll see them that way, rather than setting everything up over the phone. So it's not just an awareness of the system, but actually adjusting ourselves to that demand. Another one is the time management. What's the most efficient use of my time? How am I going to get out on time this evening for nursery pickup or whatever else I have to do in the evening? But it's not just our time, it's also the system's time. So what I mean by that is, I know if I try and refer to a hospital service in the afternoon, they'll probably be at capacity. If I do that in the morning, I am much more or first thing, except an afternoon surgery. I'm much more likely to have my patient accepted and managed in a way that I think is most appropriate for them. Also, third theme, familiarity with our patients. We are more familiar with our patients and therefore we don't have to go trawl through their histories. We know, right? I know that patient, I know what that's about. I spoke to them about it last week. Let's just phone them first and move on. That's an easy thing for me to do. Then relationships. Fourth theme, relationships with patients, in that we develop a trusting relationship, particularly if you've been working in a practice for a long period of time. For example, we might be able to have a conversation on the phone saying, well, are you as bad as you were the last time, for example, when you went to hospital with your copd? Is it as bad as that? Well, no, no, Doctor, not as bad as that. And you know these patients and you trust them to tell you the story like it is. But we also not only prioritise relationships with our patients, but also with other staff members. For example, if you're interrupted during a duty doctor session and it's the practice nurse who is needing help with something, that person is there in front of you. They're a valued member of your team and you want to be able to provide input for them in a timely way. And I guess that takes us back to system awareness. We know that that nurse has also got lots of patients to see, and if there's a delay in that, then the whole system is suffering from it. And then lastly, fifth is this idea of personal preferences. Some of us like doing hard things first, so that's eating the frog. Some of us like the quick wins and the endorphin release, of actually seeing all of the columns or all of the slots in the IT system changing a different color, we get a bit of a rush from that. There's no right or wrong answer with this, but actually a lot of it does come down to that. But it's also about looking after ourselves, but also balancing that against good patient care and what needs to be done first from a clinical urgency perspective. Speaker A 00:06:18.360 - 00:06:45.170 And the title of the paper is Quick Wins versus Eating the Frog. And I find that really interesting because from my own clinical practice, sometimes I feel like I'm telling myself off if I'm only taking off the easy tasks, because I know then at the end of the day I'm going to have all the long referral letters, the things that I've really been putting off. And I think, gosh, why did I leave it to this point, really? But I wonder if you can explain what that means a bit more generally, and why it captured something important about GP decision making. Speaker B 00:06:45.570 - 00:08:12.210 I think ultimately, for me, it's about when we are at the trainee stage. We are actually honest about how we approach prioritizing our workload. And I think ultimately that comes down to personality. Some of us like doing the more difficult things first, and then we feel that we've got the wind at our back and we're able to go on about our afternoon knowing that the most difficult thing in that list is done. In fact, the quote goes, eat a live frog first thing in the morning and nothing worse will happen you for the rest of the day. And I think that's probably paraphrasing a little bit, but I think that's the thing. If the worst thing is out of the way, the afternoon suddenly seems much better versus actually some of us need that endorphin release. And the highs, I guess, of actually seeing, feeling that we're going through our afternoon at a Good rate. And we are managing things well and some of us like that. But I think ultimately, if we can have that conversation at the trainee stage to say, look, you're either a frog eater or you're a quick winner and you have to decide which you are. And maybe actually you're at the point in your career where you have the opportunity to actually try these out. Say, right, we'll do the hardest thing first, how does that feel? Versus, you know, take off a few easy things, how does that feel? And you'll get an idea of what you're like as a person. So I think that's where that comes. Speaker A 00:08:12.210 - 00:08:35.850 In for me and I just wanted to go back to unpick some of the themes that you're talking about and I wonder what your thoughts are about sort of this role of familiarity with patients. How do you think that knowing your patients really influences prioritization decisions? You took an example of knowing whether you can trust a patient, for instance. And for me that also links in a bit with continuity of care, I think. Speaker B 00:08:37.420 - 00:10:02.500 Yeah, absolutely. I think working in the same place for a more prolonged period of time allows us to develop this familiarity with patients that's impossible to have even if you're just as a trainee in a practice or new there. There's probably a few avenues we could explore here. So one is about I see your name on the list, I see what the problem is, I know what that's about and I can tick that off very easily. I can see that as a quick win almost because I'm so familiar with your story and your situation. Perhaps only me, perhaps only I can sort that out. Let's do that because I'm the best person to do that and let's do that now because I'll feel that I've achieved something, but it's a double edged sword because actually seeing the same person over and over with shortness of breath, who is copd, your bias will push you towards yes, this is copd, and you're missing something else that's perhaps serious because you're so keen to make the presentation fit into the last five times that you've saw that person. So you have to be aware of your own biases. Even though the familiarity allows you to be very quick, perhaps in your decision making, you also have to have a little bit of having the brakes on to ensure that you're not missing things. Speaker A 00:10:03.060 - 00:10:13.060 And there definitely is that tension, as you say, about experience helping GPs make rapid decisions, but also that experience can introduce bias. So I think that's a really interesting tension. Speaker B 00:10:13.540 - 00:10:14.260 Absolutely. Speaker A 00:10:15.540 - 00:10:23.300 How much of prioritisation do you think is about managing risk? And do you think some of it is just about managing workload as well? Speaker B 00:10:23.970 - 00:10:47.570 I remember actually during one of the focus groups, one of the participants said, well, yeah, if this was to be a game, it would be called risk, because actually when we are dealing with our duty, doctor There is risk everywhere. And I think that it would be impossible to actually tease apart managing risk, because it's all risk versus anything else that might come up. Speaker A 00:10:47.730 - 00:11:04.830 You've touched on this and I think that one of the most striking points in the paper is that prioritisation is a core skill that we're all doing all the time, but it often isn't formally taught. Do you have any ideas about why that is and how do you think we should teach this to our GP registrars? Speaker B 00:11:04.910 - 00:12:01.130 I think perhaps it hasn't been traditionally taught because it wasn't necessarily part of our roles. And now as time has gone on, we have to. In fact, it's one of the biggest parts of the day. And it was interesting because There was about 39 participants in the focus groups and there was a tremendous amount of agreement on how we did it, but no one had particularly received any prioritization training and it was all left on the job. And if they had done any, it was ad hoc. It was never a fixed part of the curriculum for us. We have developed a tool called a tactical decision game. A tactical decision game is a tabletop simulation exercise whereby the participants are forced to make prioritization decisions on imperfect information. Speaker A 00:12:02.250 - 00:12:03.930 Sounds like life in general practice. Speaker B 00:12:04.090 - 00:13:11.410 Absolutely. It's a duty doctor session and it lends itself beautifully to training prioritization skills to registrars. It works best as a group of seven, eight registrars with one facilitator. The participants initially prioritize as individuals the list of 12 or 13 presentations, and then actually what happens is they move into the group and ultimately it's a group decision as to which presentation is being dealt with first versus last. And it means that it's all about learning from each other and learning where their own tolerances of risk are. And it can be a really rewarding and useful session to deliver. And it's something that the registrars in particular have found useful. But actually, in my now role as the education coordinator lead, I'm now running this to fully qualified GPs in general practices. And it's amazing the amount of conversation that can be generated by playing this game together. Speaker A 00:13:11.570 - 00:13:17.360 Yeah, I'll definitely be taking that back to my Own practice. Is there a link available for that or is it widely available? Speaker B 00:13:18.160 - 00:13:26.720 Yes, it's. The game is. Yes, it's available in ijos. It was published in IJOS a few years ago. Speaker A 00:13:27.200 - 00:13:39.840 Great. We'll link to that in the show notes. That's perfect. Great. And I guess just having done this work, was there anything in the findings that changed the way that you think about your own prioritization decisions when you're at work? Speaker B 00:13:40.140 - 00:15:27.870 I think that I came at this research as a relatively junior GP who had only begun to develop my own prioritization strategies. And it was incredibly interesting to learn from those who had been doing this for years. I think a key one for me was about time management and the recognition that everything that we do in that four hour session will chip away at the time that we have available to carry out the work. So, for example, you see a set of notes and you see a slot or so you see a patient's name and a slot note and you think, oh, I wonder what that's about. And you click into a set of notes, there's a minute gone. And I know a minute is a small amount of time, but actually over an entire session, that can really add up.
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S5 · E236
June 23 · 18 min
Parents as partners - Improving paediatric safety in general practice
Today, we’re speaking to Dr Tom Purchase, a GP and Health and Care Research Wales NIHR doctoral fellow. Title of paper: Co-generating ideas for safer paediatric care in general practice with parents and stakeholders Available at: https://doi.org/10.3399/BJGP.2025.0690 Research has highlighted the important role parents play in in paediatric patient safety, for example, through mitigating safety incidents in general practice, yet their perspectives have rarely shaped system-level improvements. This study co-generated and prioritised ideas for change with parents and key stakeholders, identifying feasible and impactful strategies to improve paediatric safety in primary care. These strategies centred around practice communication, accessing care records and results, and fostering a culture of shared learning and development. Parents are willing and able to contribute meaningfully to safety improvement efforts, and their insights align with national patient safety priorities. Clinicians and policy makers can use these findings to strengthen collaboration with families, tailor safety interventions to local needs, and embed parent voices into the design of safer care systems. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.480 - 00:00:49.500 Hello and welcome today to BJGP Interviews. I'm Nada Khan and I'm one of the Associate editors of the Journal. Thanks for listening again to this podcast. In today's episode, we're talking to Dr. Tom Purchase. Tom is a GP and a health and Care Research Wales NIHR Doctoral Fellow. We're here today to talk about the paper he's just published in the bjgp and the paper is titled Co Generating Ideas for Safer Pediatric Care in General Practice with Parents and Stakeholders. So, hi, Tom, it's really great to meet you and to talk about your work, but before we talk about the study itself, I'm interested to know what first got you interested in pediatric patient safety in general practice. Speaker B 00:00:50.060 - 00:02:26.850 Thanks. It's born, I think, out of an extension of the work that we've been doing within the patient safety team within Cardiff University. So a lot of what we do is looking at incident reports, safety incident reports, and trying to pick out what are the, you know, high level key learning points and takeaway messages from those. And then within the team, we started to think about, as well as the types of incidents and the types of harms that are occurring within pediatric incidents. For example, how are parents involved? And it was a bit of a novel approach to what we normally do, trying to have that extra aspect within the incidents and figuring out how parents were either helping to contribute or to mitigate against the incidents, not just looking at the incidents themselves. So that was the starting point, really. And then once we'd started digging into that data and identifying that, actually the majority of the time, which is in one of the papers that was published last year in BJGP, 77% of the reports we were looking at specifically around general practice showed that parents were taking these mitigatory actions that, you know, positive actions that were able to prevent harm or further harm from occurring to their child, for example, chasing results or chasing referrals or importantly, being able to speak up. And then that highlighted, I think, the importance of parents being able to have a voice and advocating on behalf of their child. And that really sparked, I think, the interest, and therefore this part of the. Speaker A 00:02:26.850 - 00:02:46.490 Project, and I think that's a really interesting thing about this paper, is that it focuses on parents and parents not just as observers of care, but as active contributors to safety. And I wonder what your thoughts are about why that's an important shift in how we think about these things. I think you've touched on it a bit, but yeah, I'm interested to know a bit more about that. Speaker B 00:02:46.810 - 00:03:55.980 I think it is a really important aspect of care, but also particularly safety, which maybe is untapped in terms of parents as a resource as to how we can keep children safe. We know that children on the whole are more, maybe not more vulnerable, but certainly are a vulnerable group when it comes to patient care in general and patient safety. And that's because they're so heavily reliant on others to speak on their behalf, to make sure somebody else is looking out for their healthcare needs. And therefore they are probably playing a part within the world of patient safety. And there are good studies from hospital relating to incident reports that show that parents are capable of picking up issues early on. They're able to detect issues that maybe other parts or people within the system aren't detecting. And as I mentioned, our paper from last year specifically looking at general practice showed that parents are able to prevent harms from reaching their children. So they're playing a substantial part already. And from a systems perspective, that is mainly parents figuring out workarounds within a system that really isn't, I don't think, designed to support them as well as it could be. Speaker A 00:03:56.460 - 00:04:33.810 And I guess that's kind of the crux of what you were doing here. So I guess before we get into findings, just, you know, a quick word about the methods because you worked here with groups of parents to develop ideas for improving pediatric patient safety in, in general practice, in primary care, and then you explored those ideas with a wider group of stakeholders and that included clinicians, managers and policymakers, and then brought them all together to co generate ideas for safer care. And it was really interesting because the parents generated 16 different ideas for improving safety. And were there any that particularly surprised you and jumped out at you? Speaker B 00:04:34.450 - 00:05:33.980 I don't think necessarily any were too surprising on the basis that we. I don't think I really had any thoughts going into it as to what they might say. But I guess what did surprise me more was that some of the ideas that we then took forward to the stakeholder group kind of highlighted some disparities or some clear disagreements between the parents who were accessing our services and the people who work within the services. And how we viewed, I suppose, viewed what's actually happening, that kind of work is imagined and how we think things are going and the work is done. I guess what the parents were trying to do to come up with the idea is to bridge that gap unknowingly. I suppose maybe what's surprising is that none of them, I didn't think any of the ideas were necessarily too resource intensive. You know, I think what was quite reassuring is that lots of what the parents were saying were actually relatively simple things that we might be able to enact or at least adopt or adapt, you know, to our own environments. Speaker A 00:05:34.540 - 00:05:47.730 And a lot of the ideas seem to center, I think, around communication, access to records and test results, and actually just helping parents to speak up. And why do you think those themes emerge so strongly? Speaker B 00:05:48.450 - 00:07:24.990 I think that comes back to maybe that difference between how we like to think the system's functioning and how parents think the system's functioning as healthcare professionals and parents. Because we know from a thematic analysis we did, which is also going to be published in bjgp, from these discussions we've had with the parents, that a lot of them said they felt the need to fight in order to be heard. So although within, say, pediatrics and GP training programmes and CBDs and everything we have to do for revalidation, taking ideas, concerns, expectations, collateral histories, making sure we're really considering that the holistic approach is all considered clinically, what you're then getting, I suppose, from the parents is that maybe we're not doing it as well as we could be. And one parent within the workshop said, I know as a parent you are expected to advocate for your child, but what it surprises me is how regularly you have to do it and sometimes it feels like a full time job. And I think that one really struck a chord in terms of really emphasizing how much extra effort and how much work parents are feeling they need to put in. And I think that also implies that the system isn't making it as easy as possible for them to be able to do the right thing. So I can't necessarily explain unfortunately why they feel that those areas needed to be targeted. I guess it's because there are barriers that we are not tackling correctly in order to help parents to speak up more efficiently and certainly to be listened to. Speaker A 00:07:26.840 - 00:07:35.160 And one of the stakeholder priorities was this idea of a designated parent advocate. Can you tell us a bit more about that idea and why it resonated? Speaker B 00:07:35.640 - 00:09:21.810 Yeah, sure. I really liked that one and I thought it was an interesting one because again, it highlighted, I think, a number of issues that we could discuss in a lot more detail. I know this podcast isn't ours. I think we could talk about it for a long time. So that one, I think came out of the need that parents were identifying to sometimes just want to clarify something if they weren't quite sure how to access something or they didn't really know how something worked. We know that our systems are complicated and one of the issues we found was parents found that just navigating that system was an issue. So it's one way of trying to work around that. If there's someone that you can speak to who understands the system, maybe working within the practice or even as a third party, you know, you could go to them and get some advice. But they also specifically said it's not just kind of system advice, it's also advocacy, help, well being. If they wanted to give feedback or raise a concern. It's someone who is very importantly separate from that complaints process. Because I know I keep talking about the system and how it's designed, but the complaints process, for example, is very specific. And what we found talking to the stakeholders is that they, they felt that what the parents were asking for here kind of already existed, but in the form of maybe the complaint system, which obviously has a particular purpose, isn't always easy to use. You know, if you've got to email the practice manager, that might not be something that you want to do. And parents worried about coming across as a nuisance or having some negative repercussions on them. So it was an idea of here is someone who's maybe a bit more independent, they know how things work. I'll be able to get some sound advice from them and that might be able to help me progress or to get my voice heard in a way that wouldn't have a negative repercussion on me. Speaker A 00:09:21.890 - 00:09:38.050 And I think a lot of GPS listening will be thinking about what this work might mean for their own practice. And which of the proposed changes do you think are most achievable at practice level? Is it that about a parent advocate or are there any other ideas that you thought could be achievable? Speaker B 00:09:40.360 - 00:11:56.550 Thankfully, that was one of the questions that we were asking the stakeholders. So when we took all of these, the 16 ideas to the stakeholders you mentioned, we specifically said of these ones, which do you think are the most doable and which ones will be the most impactful? And then we went through each one in turn and plotted them on a matrix to say, you know, to try and come up with an arbitrary way of saying, well, which ones do we think are the most impactful and most doable that we could then suggest to, as you say, practices or readers in a meaningful way. Where there was most agreement between the parents and the stakeholders, as well as being positioned as the most doable and the most impactful, was asking parents for solutions and feedback. So parents felt that they weren't being asked enough for their opinions and their experiences when it comes to, well, lots of parts of the process, but obviously in relation to safety. And then the stakeholders also strongly agreed that actually, if we're going to improve our way of working and integrate the parent voice more, we obviously need to be asking them. And in lots of other industries, we're obviously asking for feedback all the time, and we don't necessarily do it very well in the NHS or within general practice specifically. So I think it reflects maybe, you know, a broader issue about patient and public involvement that in. Specifically in the context of parents, because child safety is so important to them, I think their involvement is therefore seen as a really important role that maybe they're not currently being given the opportunity to fulfill the disagreement or not disagreement. But the discussions that happened in the stakeholder meeting around this, everyone agreed that it was a good idea, but it was. How it was then implemented was maybe going to be obviously based on where you are and your population, but also what you were actually asking the parents for. So whether it's a case of doing something similar to us, where you maybe have a focus group or workshop, or whether you just send out a survey with some specific questions, or if you speak to some individuals with one stakeholder, highlighting that if you do have a significant event or some safety incidents that you've been looking at, are you then talking to the people who've been involved, those parents, and trying to identify the gems that sometimes come out of that in order to identify where you can make improvements that could lead to a meaningful change? Speaker A 00:11:57.330 - 00:12:08.290 Yeah, I like that idea of involving parents in significant event meetings, or at least taking the results of those two parents, because often I feel like those meetings are kind of closed within the practice, aren't they? They're not. Speaker B 00:12:08.770 - 00:12:30.960 Yeah, absolutely. And there's no reason necessarily that we couldn't. I think it's just maybe we haven't thought about whether we could or we should. And then once you start to have those ideas, you know, you can then start thinking about, well, how feasible is it? How could I manage this? Or even quality improvement projects or any kind of safety activities, you know, probably could have parent involvement as well. We're just not necessarily thinking about it in those terms. Speaker A 00:12:31.440 - 00:12:39.440 One thing I thought was really interesting is that the paper talks about parents as a source of resilience within the healthcare system. What did you mean by that? Speaker B 00:12:39.920 - 00:14:07.020 So what we mean by system resilience normally is how adaptable is that system to any change or unpredictability which within all of healthcare, being the complex socio technical system that it is, we are constantly facing unpredictable scenarios. And you know, those, those interactions between us, the parents, the children, all the other staff, our technologies are always changing, the organizational structures are always changing. You never quite know how the interactions between all those elements are going to come to fruition or what's going to emerge as a result. So resilience is facing all of those changes. If something was to happen, how well can you know you bounce back as a practice or how well are you going to be able to cope with an issue or an event? And parents being an important part of that system. Resilience is because not just as a safety net, but also as an information source and somewhere to go or someone to talk to who would be able to, as we mentioned earlier, pick up on when something isn't quite going right, or if they want to challenge a decision. And from a human factors and ergonomics point of view, we know that when someone is able to advocate or speak up or challenge or help to correct something that supports resilience. So it's giving the systems all of the opportunities to continue to function safely and correctly that it can. Speaker A 00:14:07.180 - 00:14:15.340 And I guess having done this work, what do you think is the one thing you'd most like gps to take away about working with parents to improve safety? Speaker B 00:14:15.730 - 00:15:03.200 If I had to choose one, I think it would be encouraging parents to speak up. Lots of things we've talked about obviously in this podcast around how we could incorporate them in other ways, but just the simplicity of validating their concerns and considering their concerns as clinically meaningful. But then creating a culture within the practice where a parent speaking up or asking a question isn't viewed as a criticism, which I think is often the case, or a hindrance and welcoming and proactively seeking out parents insights. So trying to shift the thought process from parents being passive participants within our system to actively trying to incorporate their voices into what we're doing on a daily basis. Speaker A 00:15:03.520 - 00:15:15.510 And I'm going to ask sort of a similar question but in a slightly different way. But if you could implement just one of the ideas from the workshop in your own practice, which one would it be do you think? And why? Speaker B 00:15:15.830 - 00:16:23.070 It's tricky because what we say in the paper is that I think choosing a selection of them would be the most beneficial on the basis that you'd be able to target different areas. I think personally, what I would be interested to see, whether it makes a difference or not, would be some sort of just simple display or poster to Kind of encourage parents to speak up as part of fostering that culture of saying it's okay to voice your opinion and to share any thoughts or concerns that you have with us. So within the stakeholder event, one of the stakeholders described it as being a useful idea because it almost gives parents that permission to be able to speak up if they need to. And I think that's a very good starting point to then build upon.
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S5 · E235
June 16 · 15 min
From symptoms to signals: Using AI for early diagnosis of ovarian cancer
Today, we’re speaking to Dr Garth Funston, a GP and Clinical Senior Lecturer in Primary Care Cancer Research at Queen Mary University of London. Title of paper: Using large language models to identify pre-diagnostic clinical features of ovarian cancer from healthcare records: a population-based case-control study Available at: https://doi.org/10.3399/BJGP.2025.0366 Most women with ovarian cancer present with symptoms, but many symptoms are recorded only in free text healthcare records and missed by studies and clinical decision support tools that rely on coded data. We found that using large language models (LLMs) to extract symptoms from free text records substantially increased symptom detection and strengthened associations with ovarian cancer. Incorporating LLM-extracted symptom information into research and clinical decision tools may support identification of women at higher risk of cancer and aid appropriate investigation. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.800 - 00:00:50.940 Hi and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate editors of the Journal. Thanks for listening to this podcast today. In today's episode, we're talking to Dr. Garth Funston, who is an academic GP and clinical senior Lecturer in Primary Care Research at Queen Mary University of London. We're here to talk about his recent paper in the BJDP which is titled Using Large Language Models to Identify Pre Diagnostic Clinical Features of Ovarian and Cancer from Healthcare Records. So, Garth, thanks so much for talking to us again today, but I wonder, just before we get into the AI side of this paper, can you briefly explain the clinical problem you're trying to address here with ovarian cancer diagnosis in general practice? Speaker B 00:00:51.500 - 00:01:55.010 So most women with ovarian cancer are diagnosed after they develop symptoms and see their doctor. The challenge is that most symptoms are really non specific. There's no real red flag symptoms for ovarian cancer. That makes it a real clinical challenge for the GP to kind of recognize it and perform tests. So the symptoms are things like abdominal and pelvic pain, persistent bloating, urinary urgency and frequency, things that we see really frequently in gp. So knowing when to consider ovarian cancer is the big challenge. And we know that certainly a proportion of women see their GP multiple times before the diagnosis. Now we're lucky for ovarian cancer in that we have reasonably good triage tests and CA125 and transvaginal ultrasound. So the challenge really is to identify women with these non specific symptoms early so as we can work out who to test and hopefully improve early diagnosis and on outcomes in that way. Speaker A 00:01:55.250 - 00:02:14.530 Yeah, and I'm sure you're well aware of sort of the body work around this area and people like Willie Hamilton, who's done work around early diagnosis of ovarian cancer, along with Claire Bankhead, and they did some really interesting work around things like bloating, didn't they? But that was slightly different, I think, and a little bit that's some time ago now, isn't it? Speaker B 00:02:14.930 - 00:02:39.230 Yeah, it was some time ago. I think all of that is, you know, fundamental and still holds true. And they did a lot of work around things like IBS and in women over, over 50 and things like that that are kind of these subtle signs that we need to be aware of with ovarian cancer. So, yeah, we know there's lots of features that are associated with ovarian cancer, but it's recognizing when to invest to get those features because they're so common. Speaker A 00:02:39.630 - 00:02:49.310 Yeah. And do you think that's why it's described as difficult to diagnose early in general practice? Is it because the symptoms are so common? What are your thoughts on that? Speaker B 00:02:49.390 - 00:03:48.750 I think there's a few reasons. I think ovarian cancer used to be called, certainly in the media, the kind of the silent killer and terminology, which I really, really frustrates me, because we know it's not. We know that most women of symptoms for diagnosis. We actually know that from this paper and other papers that are symptoms in early stage cancer. But that kind of thought around ovarian cancer still holds. Secondly, the symptoms are nonspecific, they're reasonably common. I mean, you know, I probably see a. A patient with abdominal pain most days and it's kind of working out which ones to investigate for ovarian cancer. Yeah. And so I think those are the main things. And thirdly, it's, you know, it's not the most common common cancer. GP will see people probably only encounter a case of ovarian cancer every three to five years, a new case. And that's the extra challenge. It's kind of suspecting it when it's a rare thing in primary care. Speaker A 00:03:49.100 - 00:04:03.500 Yeah. And one thing I found really interesting about this work is that you're using free text clinical records rather than just coded data. So can you tell us a little bit about the data you accessed here and why it was so important to use this free text data? Speaker B 00:04:04.220 - 00:05:09.600 So a lot of the work that we do with primary care data focuses on coded data and certainly within the uk, because that's really the data we can actually access within UK for research purposes. But up to 80% of clinical information is not in that coded format, it's in the free text. And work from people like Sarah Price in the past have shown that often subtle things that we need to pick up are in the free text and GPS don't code that. So it's something I've been really keen to use in research for many years now to try and look at what extra information is there in the free text that could help us in both research and clinical practice and kind of picking up these cancers. And the data we accessed was from the United States, it was from healthcare clinics associated with the University of Washington. And that included kind of coded data, but also the free text medical records of patients which had been anonymized and were accessed in a kind of a safe and appropriate way. Speaker A 00:05:10.000 - 00:05:40.140 Yeah. And I think a lot of clinical staff listening to this will certainly, certainly appreciate that a Lot goes into the notes that we just type in that doesn't really get coded. So it's phenomenal that you're able to access that data. And this paper uses large language models or LLMs, which some people might associate, associate with tools like ChatGPT, but just at a very basic level. Can you just talk us through what actually is a large language model and what sort of it was used for in this, in this study? Speaker B 00:05:40.950 - 00:06:49.130 Large language models, lots of people use them on a daily basis. Absolutely right. Things like ChatGPT, they're essentially a tool for our purposes which we use to extract information from the free text medical records. Now natural language processing approaches have been used actually for many years, kind of rule based approaches. Other models, these require lots of training. You need to lots of highly annotated records and notes to train the models. Advantage of large language models, things like GPT, is they need less annotated notes and we did still do some of that, but they require less and that makes them much easier to apply and use in practice. We use them in this setting to effectively pull out key information on symptoms. We predefined a list of 17 symptoms from the literature which were associated with ovarian cancer and we used the large language models to go through the notes, pull out information on those symptoms that we could use in the study alongside the coded data. Speaker A 00:06:50.090 - 00:07:03.350 And I think that as we've been discussing, these large language models are probably really useful for this kind of data. I think especially because a lot of general practice is narrative and contextual as we've been discussing as well. Speaker B 00:07:03.350 - 00:07:38.940 Yeah, I think, I mean there's two challenges with using free text data. One is access requirements because there's lots of concerns around confidentiality. The other is just the volume of it. You've got these massive records that you know, contain lots of information, lots of writing, go back years. How do you actually process that to find the key information that you need? I think large language models are a really useful tool here because with a bit of training you can use them to actually extract the information that's pertinent to your kind of question. Speaker A 00:07:39.340 - 00:07:48.620 So let's go into what you found and I'm really interested to know about what kind of patterns or features was this model able to identify before an ovarian cancer diagnosis. Speaker B 00:07:49.180 - 00:09:06.690 So we looked at 17, 17 features. We find actually that 14 of the features were more frequently recorded within the free text and coded information. And often those were the more non specific features. Things like appetite loss, actually things like weight loss as well and urinary symptoms, whereas actually pelvic mass was pretty frequently coded. And 40% of bloating, for example, was was recorded in free text and not recorded in codes at all. And the model was able to pull out those features. And when we combined the extracted information from the pretext with the information from the coded data, we find that 14 of the features were actually associated with ovarian cancer in the regression models. Now, if we only used coded information, didn't use the information extracted from using the large language models, six of those features were no longer associated. So really it showed that applying large amount language models, pulling out those extra features made a big difference in terms of the associations that we were able to identify. Speaker A 00:09:07.730 - 00:09:13.970 And did any of those findings surprise you in terms of the associations from a clinical point of view at all? Speaker B 00:09:13.970 - 00:09:42.430 I think we focused on 17 features that had been reported in some studies. Some are only reported in a few studies. Pretty non specific, not always in nice guidelines, but I think I was not completely surprised by any, but things like appetite loss and things like that, which are more subtle, I was excited that we were able to identify that even within a relatively small study like this because we had access to that free text data and were able to kind of pull out that information. Speaker A 00:09:43.070 - 00:10:03.630 Yeah. And I know there has been some work done done about how GPs enter information into patient records and things like symptoms often don't get coded and they are in the free text. So I'm interested to know your thoughts about what this kind of approach adds beyond these existing symptom based risk tools that might be just based on coded data. Speaker B 00:10:03.950 - 00:11:27.920 Absolutely. I mean, we know that, you know, for certainly some symptoms. Sarah Price's work has shown that 43% of symptoms are not coded in her work too. So I think really chimes with that. I see kind of the use of this in two ways. One is research context and one is kind of a clinical context. And in the research context, I think moving towards using these LLMs to pull information out of the record could really be game changing in how we understand disease, how we understand the symptomatology of disease, actually how we understand risk factors as well, which aren't always coded either. So I think not just for cancer, but applying this across different diseases, we could do some really exciting work looking at risk factors and predictors of disease. And secondly, in the clinical setting at the minute we use tools fairly frequently such as qrisk Q Cancer and those are developed based on coded data and they pull coded data from the GP record and then GP gives and enters in extra details. I think there's real potential here to use LLMs to inform those risk prediction models. So you could have those LLMs extract information, add it to the model. There's a potential here to give more accurate predictions and guidance for gps. Speaker A 00:11:28.080 - 00:11:51.180 And, you know, you mentioned that this is a really exciting area and I think there is a lot of excitement around AI in healthcare at the moment. Where do you think the opportunities are now in general practice, especially with, as you mentioned, some of the difficulties around accessing free text data and this kind of approach to identifying symptoms or things in the free text that clinicians are entering in? Speaker B 00:11:51.260 - 00:13:02.640 Yeah, so I think there's a lot of work going on using the free text in different countries. So in the US already and Scandinavia, the Netherlands, there's been a lot of work actually using free text applying and natural language processing approaches to kind of do the studies and build that into models. So I think already we're, we're going to start to see potential impacts from this. There's models out there looking at pancreatic cancer, for example, which have shown free textiles considerably work, actually probably going to be bjgp, also looking at lung cancer using freetext. So I think for me, the opportunities are to start to do these studies that are pretty novel, certainly in the uk, to kind of identify factors that associated with disease, identify symptoms, but then also move from that to incorporate them into models and put them into practice, which is a challenge, certainly with the infrastructure, governance and other restrictions, and has to be done properly and ethically. But I think if we don't start using this data, now that we have the tools, it's a real missed opportunity. Speaker A 00:13:02.720 - 00:13:20.540 And what are the next steps for this work? So you've identified these factors that are associated with an ovarian cancer diagnosis, and as you mentioned, there are a few features that were found above and beyond just what you might expect to find from the coded data. So where are you taking this next? How do you want to put this into practice? Speaker B 00:13:21.260 - 00:14:05.700 Yeah, so in this work we looked only at symptoms, whether they're present or absent. Actually, large language models can do much more than that. They can look at duration of symptoms, they can look at information on severity, and that's quite powerful. We can't capture that encoded data at all, or risk prediction models don't capture that. I'm really interested in starting to look at that information, see what we can pull out from that and see how it affects risk of cancer. So I think the next step for this work is to look at that look at other cancers and diseases as well, and also start to move from a proof of concept that we can do this into building risk prediction models to actually try and make something that we can move into primary care. Speaker A 00:14:06.100 - 00:14:12.260 Yeah. And for any gps listening to this, what's the main thing you'd want them to take away from this current study? Speaker B 00:14:13.080 - 00:14:44.120 So I think from ovarian cancer perspective, to recognise that actually ovarian cancer has symptoms, they're often subtle, they can occur in early stage disease. So to be aware of symptoms such as persistent bloating, abdominal pain, urinary changes, and to be aware of those and recognise them, particularly if women have worsening symptoms or it doesn't seem right or there's no obvious cause, and perform investigations such as CA125 and. Or ultrasound. Speaker A 00:14:44.600 - 00:14:50.920 Any other final thoughts that you want to add just based on this work or anything that you want to sort of highlight from this paper? Speaker B 00:14:51.400 - 00:15:22.150 So, for me, this work shows how much information, how much important information is contained in that free text. I think from a UK perspective, we need to work with governance bodies, we need to work with data providers to look at how we can make this data available in the uk. UK has some of the best healthcare resources in the world, but if we're unable to access and use this free text data, it's a real missed opportunity. It's a real opportunity to use it to benefit patients on the nhs. Speaker A 00:15:22.630 - 00:15:31.830 Brilliant. Thanks very much for that, Garth. It's a great paper. So, yeah, I'd recommend anyone listening to go back and have a listen to it, but I just wanted to say thanks very much for your time. Speaker B 00:15:32.390 - 00:15:33.270 Thank you very much. Speaker A 00:15:34.630 - 00:15:49.800 And thank you all very much for your time here and for listening to this podcast today. Garth's original research article can be found on bjgp. Org and the show notes and podcast audio are at bjgplive. Com. Thanks again. Bye.
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S5 · E234
June 9 · 21 min
When mothers need more: Postnatal care and complex social needs
Today, we’re speaking to Dr Clare Macdonald, an Academic Clinical Lecturer in General Practice based at the University of Birmingham. Title of paper: Complex social needs and maternal postnatal care: what can primary care do? Available at: https://doi.org/10.3399/BJGP.2026.0069 Throughout the discussion we use the terms ‘woman’ and ‘women’, but we know that not all those who give birth will identify as women and intend this to mean all those who give birth. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.480 - 00:00:51.740 Hello and welcome to BJ GP Interviews. I'm Nada Khan and I'm one of the Associate Editors of the Journal. Thanks for listening to this podcast today. In today's episode, we're speaking to Dr. Claire MacDonald. Claire is an academic clinical lecturer in general practice, and she's based at the University of Birmingham. We're here today to talk about the editorial she's just published in the May issue of the bjgp, and it's titled Complex Social Needs and Maternal Postnatal Care. What Can Primary Care Do? So, hi, Clare, it's lovely to meet you and to talk about this brilliant editorial, but before we get into the editorial itself, I wonder if you can just talk us through what you actually mean by complex social needs in the context of postnatal care. Speaker B 00:00:51.980 - 00:02:21.290 Yeah. So I think when we talk about social complexity in the postnatal population, we're talking about women who have multiple factors that might be influencing how they can access care or influencing the clinical and social risks that they have. So for most people, the time after they've had a baby results in some social change. Even in the most straightforward, most brilliantly supported, most physically well person, there are big social changes. And that is a period of a complex time to navigate and finding your way and your identity as a family with a new baby and so on. When we talk about complex social needs, we're talking about women who face other aspects of adversity. So it might be that they have housing instability, it might be that they have experienced domestic abuse or they continue to experience domestic abuse, that they have a history of safeguarding issues, safeguarding for themselves or safeguarding concern, concerns about other children or other family members. And when we see women who have overlapping social risk factors that produces this kind of network of complexity that puts them at compounded additional risk and they need additional help in navigating their health needs in that time. Speaker A 00:02:21.450 - 00:02:47.310 And I wonder why you felt that this was an important issue to highlight right now. So is there anything in particular that makes you think that this is the right time to sort of look into this? I know that there's a complex picture in terms of sort of maternal care, and if we look at things like the cost of living crisis, which is compounding a lot of the pressures that people are facing. But talk me through what your impetus was in thinking about this as a now issue. Speaker B 00:02:48.110 - 00:05:26.470 Yeah, that's right. So maternity services are really high profile in the news a lot at the moment, but from a secondary care perspective, and quite rightly, there's a spotlight on the poor care that some women and their families and their babies receive from secondary care. And there are, you know, huge pieces of work being done to improve that, to improve outcomes and to improve people's experiences. But that focus tends to be on intrapartum care. So the care that people receive in hospital around the time of birth, sometimes there's a little bit of focus on antenatal care as well and reducing risk during pregnancy, there's a lot less focus on what looks like the less exciting time of preconception care and then postnatal care. So after women get discharged from maternity services, we know that they're often left feeling a little bit isolated in the healthcare context. Some qualitative research that we've done in the past, looking at women's experiences of postnatal care, women told us that they were surprised about they'd had so many appointments during pregnancy and then so much healthcare retention in the first few days after birth, and then they were just surprised. No, you know, they had a baby and no one was really interested in their health anymore. And that genuinely came as a surprise to them. We know that maternal mortality in the uk, which, thankfully, in absolute numbers, is. Is quite small, but it's certainly higher than it could be and maybe should be, particularly compared to other kind of similar European countries. And there are actually more maternal deaths postnatally, so in the sort of later postnatal period, six weeks to a year after birth, than there are in that sort of antenatal, intrapartum and early postnatal period. And all of the political drive tends to be about reducing maternal mortality in its traditional definition of being up to six weeks after birth. But as GPs, where we can really have an impact is in those late maternal deaths. And of course, very few of us, thankfully, will be involved in the care of a woman who dies in that period, because they are small in absolute numbers. But there are all the women who do not die, but have those risk factors and have that complexity. And the longer they live with those sort of adverse health conditions and adverse social conditions, that is dramatically reducing their quality life course health. And we can really step in, in that postnatal period to look at how we can influence that. Speaker A 00:05:26.870 - 00:05:49.080 Yeah, and you've mentioned about the kind of care that women get in during their pregnancy. And sometimes, I'm sure for some women, the postnatal period can feel already pretty fragmented for those reasons. But how do you think that that fragmentation can become amplified for women with complex social needs? Do you have any thoughts about that? Speaker B 00:05:50.280 - 00:08:25.320 Absolutely. So a Lot of people will know how to contact their gp, right? I think if you ask people, most people have probably got that number saved in their phone or they know where their GP practice is. But after you have a baby, women are then given all these kind of new healthcare professionals who are interested and involved and it's impossible to know how that all fits together. So the midwife will typically follow women up for that kind of, you know, 10 to 14 days postnatally, usually just at the time the midwife is giving you the final sign off appointment. Within a day or two, you have an appointment with the health visitor, which again is somebody new, and then you might have a follow up. For example, if a woman's had a third degree tear or is having some additional hospital follow up because of hypertension or gestational diabetes, then the hospital are involved and then they come back to the GP. And I often feel like, for us as GPs, women, as soon as they're pregnant, they can generally self refer to the midwife and they get kind of lifted out of the primary care system to an extent. We might not see them through their whole pregnancy, then they have a baby, we might or might not get a discharge summary that gives us some details about the birth and then we invite them for their postnatal consultation and in that time, you know, they've had an entire pregnancy, a huge life changing event, and then we get to see them for this one appointment. And it's so complicated. Often for women who are not sure where they're going to get their next meal from, how can they be giving any kind of cognitive time to figuring out if the midwife told the health visitor and if the health visitor told the GP and if they're worried that their bleeding's gone on for a bit too long, do they try and phone the woman who came on Thursday or the woman who came on Monday, or do they come back to their gp? We're asking a lot and we also place a lot of burden on women to retell their story because information transfer is not always timely, it's not always sufficiently detailed. And again, for women who are living in more precarious social situations, that burden then of having to, you know, they're juggling and the, you know, the mental load of everything they're trying to figure out. And then we're asking them, can you remember if your blood pressure was high during your pregnancy? Whereas we should know that we should have that information from those other services. So that fragmentation in services really means that the burden is unduly placed on women to kind of patch that up. And we need to find a better way of dealing with that. Speaker A 00:08:25.640 - 00:08:38.260 One of the things I think that comes through really strongly is that some of the women with the greatest needs often face the biggest barriers, care. And what kind of barriers are we talking about here that these women are facing? Speaker B 00:08:38.980 - 00:10:06.270 The Embrace report, which is well, well worth a look at at least their infographics, I think for every gp, it's just a couple of minutes to read. Actually, their infographics are really excellent. So. So this is the annual report that's produced called Mothers and Babies Reducing Risk through audits and confidential inquiries across the uk. So Embrace Talk about this notion of a constant isolation of biases. So in all of the cases that they reviewed and reported on in their most recent study, they found that 91% of them faced multiple interrelated challenges. So the women who died tended not to just have maybe one big risk factor. Lots of them had multiple interrelated challenges, and these were factors like being overweight or obese, being known to use substances, having had experience of domestic abuse. Ethnic minority groups as well, and migrant women particularly, face substantial barriers to accessing good maternity care. And language barriers are really critical. And I think we can do quite a good job of that in primary care, because our appointments, particularly the postnatal consultation, tend to be pre booked and pre planned. And that's somewhere where we can really make sure that we're providing those interpreter services and giving women that kind of culturally supportive access to healthcare and then. Speaker A 00:10:06.270 - 00:10:26.270 Thinking more about the role of general practice. And I wonder what you think. I mean, you've given us some pointers about, you know, that postnatal check and things, but what do you think in terms of the role that general practice can actually realistically play in improving postnatal care for women facing social disadvantage? Do you have any ideas about that? Speaker B 00:10:26.270 - 00:14:44.070 There are lots of practical, innovative things that can be done at practice level, and they are things about, principally about access to care. And there are tools and resources to help with this. So NHS England produced a document which is a guideline intended for icbs. Actually, it's a toolkit rather than a guideline called Improving Postnatal Care that gives some really specific pointers about the groups who are at particular risk and the groups who have more adverse outcomes. So at practice level, it would be quite straightforward to look at, you know, who are we providing postnatal consultations to? We know from past research that nationally, younger mothers and ethnic minority mothers are less likely to have postnatal consultations compared with others. So at practice level, it's possible to look and say, hang on, are we reaching those women who stand to gain the most from postnatal consultations? So using resources like that to see what's happening. Some people have looked at how their invitations to postnatal consultations are working. So there's confusion amongst women. And this is probably understandable because every practice does it a little bit differently. So women tend not to know, am I going to get sent an appointment? Do I need to make an appointment for myself? And there's vast majority variation and that's fine because different practices know their populations and they can do it whichever way works. But I think that's the key. It has to work and it has to be really clear. So it might be that when we get the birth discharge summary, is there a standard text message we could send out saying, we are going to invite you for this appointment, but if you need us before that, please contact as usual, kind of giving permission and inviting that contact if it's needed. Which helps women to kind of understand and navigate their way through. We talk in the editorial as well about utilisation of other members of the primary care team. So social prescribers, for example, are quite underutilised in this population. And although they absolutely have the skill set, could social prescribers maybe have a role in connecting women with groups? You know, if it's your first baby, particularly how do you know where the local baby group is? Do you know if there's kind of baby yoga class on this day or, you know, postnatal exercise class or whatever it is you might be interested in, Social prescribers would be really, you know, excellent professionals to help connect women. And then it can be a two way thing because if they maybe pick up from a woman who they're supporting that her mood seems lower this time than it did last time, they have this bidirectional ability to be able to contact back the GP and say, I'm a bit worried about this woman, maybe you need to ask the health to see her, maybe you need, maybe she needs a GP follow up. Her mood seemed a bit lower, whatever it might be. So I think there's definitely some practical things we can do. There are moving beyond a practice level. There are things that kind of PCN level and beyond. So there's a PCN in Leeds who are kind of recognizing this social need for women in the postnatal period and they are providing a sort of a drop in session. So like a session that's like a two hour monthly session led by PCM care coordinators and supported, I think, by a third sector organization as well, to bring together a whole range of health services so that women can meet, they can be with their babies, they can have that community support, but also potentially access to sexual health services and signposting and they can be self referred or they can be referred by their gp. So it's about knowing your population and looking for those little innovative ways. A practice that I worked at a long time ago used to have like a stay and play baby session during the immunization clinic. And that was an opportunity, you know, it was very little for the practice to do in terms of organization. It's a few toys and I think some of the receptionists used to be on, on hand. But it was a really great kind of innovative project to just give women the chance to meet each other for a little bit of informal peer support. Speaker A 00:14:44.710 - 00:15:10.660 Yeah. And I think that goes to show that, you know, maybe current models of postnatal care, either at a higher level, at a PCN practice level, aren't necessarily always at the moment designed around the needs of women most at risk, but these sort of small, innovative practices could actually help, especially with connecting women across different services, because I think that's often quite difficult to do in general practice, across maternity, mental health and community services as well. Speaker B 00:15:11.700 - 00:16:30.900 And it's hard for GPs to know who and where to refer women to. So we found this in some research that we did around GPs doing postnatal consultations. It was really common that GPs said they wanted better referral pathways, they needed to understand. So if you don't know what you're going to do when you find a problem, you're less likely to inquire about it as a gp. So, for example, take pelvic health. If you don't know what to do if a woman reports a problem, you're probably not going to be so inclined to directly inquire about it. And we know that for intimate problems like that, disclosure is increased when direct questions are asked. So a woman might not feel able to raise it herself, but if the GP can sensitively directly inquire about it, she's more likely to, to raise it. It can then be addressed. But is the GP going to ask if they're thinking, well, I don't know where to refer it to? So that kind of local knowledge of pathways and for women who are the most vulnerable and the most socially complex, the chances of them being at your postnatal consultation in the first place are less. And then if you don't know what the appropriate referral pathways are, you're less likely to inquire about it. And it's just these kind of stepward missed opportunities that we see most in those who are more vulnerable. Speaker A 00:16:31.620 - 00:16:46.580 I think that's a really good point about just asking those very direct questions. And I wanted to know, just from your perspective for gps listening to this, do you think that there are any small changes that could make the biggest difference for women with complex social needs after giving birth? Speaker B 00:16:47.300 - 00:18:56.370 I think what would make a difference in primary care is women being able to access care and women being heard. And sometimes that might mean we have to go to them. We need ways in our practices of identifying them. So there needs to be a stratified way of when a woman has a baby, you know, if there are a certain number of risk factors that gets flagged and they somehow get like a different level of invite. We also need to, to think about those who are more vulnerable because they've not got their baby with them, for example.
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S5 · E233
June 2 · 15 min
Seeing skin differently: Eczema, acne and psoriasis in skin of colour
Today, we’re speaking to Dr Eliza Hutchinson, a dermatology registrar and academic clinical fellow based at the Centre for Applied Excellence in Skin and Allergy Research at the University of Bristol. Title of paper: Eczema, acne, and psoriasis in people with skin of colour: a qualitative UK-based study Available at: https://doi.org/10.3399/BJGP.2025.0720 This study is the first, to the authors’ knowledge, to explore the experiences of living with an inflammatory dermatosis specifically in people with skin of colour. We generated eight themes important to participants: delayed or missed diagnosis; preferences regarding healthcare professionals; lack of online information and social media use; misunderstandings in cultural communities; concerns about treatment and lack of research; complementary medicine use; experiences and impact of dyspigmentation; and challenges with structural racism. These findings offer insight into the complex experiences and challenges faced by UK adults with skin of colour living with eczema, acne, and psoriasis. Our practical points for primary care clinicians are a step towards facilitating mutual understanding and improving care for people with skin of colour. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.560 - 00:00:53.150 Hi and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate editors of the BJGP. In today's episode, we're speaking to Dr. Eliza Hutchinson. Eliza is a dermatology registrar and an academic clinical fellow and she's based at the Centre for Applied Excellence in Skin and Skin Allergy Research at the University of Bristol. We're here to talk about the paper she's just published in the bjgp and the paper is titled Eczema Acne and Psoriasis in People with Skin of Color. A Qualitative UK based Study. So, Eliza, it's lovely to meet you and thanks again for joining us to talk about this paper. But before we talk about the paper itself, I'm just wondering what made you specifically interested in researching skin conditions in skin of color? Speaker B 00:00:53.550 - 00:01:34.700 Yeah, thank you so much for having me. So I think people with skin of color have been and still are massively underrepresented in kind of medical curricula, learning resources, clinical trials. And I certainly remember when I was at medical school, I don't think I had any teaching on diverse skin tones at all. And so it was as I sort of learned more dermatology, I just became very aware that they are so underrepresented. And I think earlier work in this area, I really tried to improve education for medical students and healthcare professionals around skin of color. That was kind of my starting point. And then I realised actually there's very little, if anything actually on the experiences of people with skin of colour, which is kind of what led me to this project. Speaker A 00:01:35.820 - 00:01:38.380 And you work in dermatology, is that right? Speaker B 00:01:38.460 - 00:01:42.300 Yes, yes, I'm a dermatology registrar based in the Bristol Bath area. Speaker A 00:01:42.540 - 00:02:06.890 Great. So it's wonderful to have your expertise in this especially. And we may get into this sort of about sort of your perspective from secondary care as well, looking back into general practice as well. But this paper focuses on eczema, acne and psoriasis and these are conditions that we see a lot as gps. So why did you feel that this was an important area to look at for people with skin of colour? Speaker B 00:02:07.290 - 00:02:41.470 Yes, I mean, as you said, we know that skin conditions are super common. They make up over 14% of GP consultations and eczema, acne and psoriasis are some of the most common inflammatory skin conditions we see and we know that they have a significant burden on everyone that experiences them. But I think particularly in people with skin of colour, we already know that these people experience kind of increasing things like Dispigmentation, so skin tone getting lighter or darker from their skin condition. And yeah, I think I just wanted to focus on some of the more common conditions that are seen kind of day to day in primary care. Speaker A 00:02:42.110 - 00:02:54.890 And this was a qualitative study and you emphasized that you really wanted to understand the experiences of people here. So talk us through a bit what you did. You spoke to people who had these conditions and had skin of colour? Speaker B 00:02:55.050 - 00:03:26.060 Yes. So we recruited using online methods for a couple of reasons, but really wanted to get kind of diverse range of experiences from across the uk. So we started off with an online survey and that was open to people of all skin tones. And we have written this up as a separate paper which should be out hopefully in the next few months. But based on these responses, we then kind of purposefully recruited people with skin of color to take part in an online one to one interview. And so we spoke to 20 different people with skin of colour as part of this. Speaker A 00:03:26.460 - 00:03:40.300 And I think one of the really interesting things that came out and is running as a strong theme through the paper is that skin conditions can present really differently in skin of colour. Can you explain a bit about what that means in practice as well? Speaker B 00:03:40.700 - 00:04:49.210 Yeah. So we know that skin conditions can look and behave very differently in people with skin of colour compared to white skin. So for example, eczema is typically in a kind of flexural distribution in people with white skin, so like in the elbow creases behind the knees. But in people with skin of colour it might be more likely to be on the extensor surfaces, it might be in a sort of discoid type pattern, so kind of well defined round patches or sort of a follicular pattern is another one we see. So if you look at medical textbooks and what we're taught at medical school, we just don't see pictures of these presentations. And I think another big thing is obviously redness is much less obvious in skin of colour. So that's typically what we would associate with skin inflammation is redness and it is much less obvious. And instead in darker skin tones it might look kind of purpley. Brownie might not be as obvious. And certainly in the interviews we found that patients were aware of this as well. So they were looking at their own skin and not picking up that it was kind of actively inflamed. They didn't know what it was and they'd go and see a GP or another healthcare professional in primary care and they also wouldn't know. And then it's just kind of leading to Delayed diagnosis, misdiagnoses. Speaker A 00:04:50.140 - 00:05:16.780 Yeah, And I think that's certainly something. So the people you spoke to described these delays in diagnosis and also this uncertainty from clinicians. And I do wonder if that is reflected in what we learn and what the wider public understand is what inflammation might look like as well. So I wonder what really stood out to you from these experiences. So how did people and clinicians sort of navigate those delays and uncertainty as well? Speaker B 00:05:17.320 - 00:05:44.760 What was quite shocking was in terms of the misdiagnosis a lot of the time, infection and infestation. So, for example, scabies was a big one that people were misdiagnosed with, and that in some circumstances did lead to kind of stigmatisation, psychological distress, embarrassment, and then people were more afraid to seek help. Further delays in diagnosis. Yeah, I think that was the thing that struck me the most in terms of this problem. Speaker A 00:05:45.240 - 00:06:00.040 And you've mentioned this, you talked about dyspigmentation, and that came through as well very strongly in the interviews. And I think that's probably a problem that's specific to skin of color as well. And can you talk through why that came up as such an important issue for patients in this study? Speaker B 00:06:00.760 - 00:06:46.890 Yeah, of course. So I think we already know that dyspigmentation. So skin tone usually getting darker, but sometimes lighter as a result of skin inflammation, we know that it is more common in darker skin tones just because they've got more melanin there to start with. But the thing that struck me in these interviews was just the profound impact that this can have on patients. So embarrassment, isolation, body dysmorphia. There's a lot of misunderstanding as well, kind of within certain communities about what causes it. And some people experience negative comments from within their own community, from friends and family, which really exacerbated that kind of psychosocial impact even more. And obviously, skin tone is massively tied into kind of identity, and the impact on people's wellbeing was just. Yeah, it was huge. Speaker A 00:06:47.690 - 00:06:58.490 And coming from a general practice perspective, it sometimes feels like the treatment options for dyspigmentation are really limited as well in what we can offer patients. So that must come out as a frustration as well, I'm sure. Speaker B 00:06:58.650 - 00:07:34.310 Yeah, I think people. People were very aware that it just wasn't talked about with healthcare professionals. And, I mean, it is really difficult because we know there are limited treatment options. But actually, a lot of people just said that they wanted it to be acknowledged and discussed. So just a simple explanation of, you know, this is because of the inflammation in your skin it should settle as we get your condition under control. It might take months or years to settle. An important thing that gps can do is sun protection is really important, so UV light can kind of exacerbate the pigmentation further. So even just a brief discussion about that I think patients would find really helpful. Speaker A 00:07:34.790 - 00:07:40.790 And coming out of all this, were there any specific findings that really surprised you from these interviews? Speaker B 00:07:41.400 - 00:08:27.550 Some of the issues I was sort of. I was sort of expecting just from my own clinical practice. So the issues around delayed diagnosis and kind of lack of representation online, those were things I'd already come across. But I think the main thing was just the profound impact that factors outside of the clinic room can have on patients that I think, as clinicians, we don't ask about or aren't aware of. So a big one for me, I think, was just misunderstandings within cultural communities about sort of what causes the skin condition. And as I said, this then leads to kind of stigma and isolation and psychological problems. So I think just the misunderstandings, which can be, you know, just through some simple education and community initiatives, we could really tackle this and improve people's experiences. Speaker A 00:08:27.950 - 00:08:54.490 And you've touched upon this. But this paper highlights big gaps in dermatology education and how clinical images are portrayed in textbooks, for instance, that we might learn from. And I wonder, from your own perspective, how much do you think, think that that underrepresentation in teaching materials contributes to this diagnostic uncertainty that people have around what eczema might look like in a patient? Speaker B 00:08:55.130 - 00:09:50.080 Yeah, I think it's a really important factor and certainly through kind of previous work I've done, we know that people just still aren't getting exposed to these images. Things are changing, so curricula are being diversified and textbooks, but it is still a big problem. And we know that this then translates into kind of lower clinician confidence when assessing people with skin of colour. There are increasing resources out there, I think. So. You know, websites like skindeet, there's something called the Global Skin Atlas, which has kind of freely accessible images that clinicians can look at to find examples in darker skin tones, you know, patient information leaflets. But as some of the participants said in the. In the studies, it still often is just a sentence. So, you know, in black and brown skin, it might look less obvious and then that's it. So I think there's still a lot more work to be done for both patients and clinicians. Speaker A 00:09:50.480 - 00:10:02.560 Yeah, and I guess that leads me to get your perspective on what do you think that good dermatology education in skin of color should look like just from your background in dermatology and teaching as well? Speaker B 00:10:02.960 - 00:10:39.060 Yeah, I think just more images, more examples and just like an open discussion about how it can look different. And this is what it might look like in darker skin tones compared to white skin. So you've got kind of the whole how do skin conditions present? But then obviously we do need more research on treatments. We know that, you know, people with skin of color are underrepresented in clinical trials. So, you know, how do we know that all of these new treatments work? So I think it's, yeah, it's like a multifaceted process, but just a good starting point is just incorporating lots of images, lots of discussion in undergraduate curricula and postgraduate training as well as. Speaker A 00:10:39.610 - 00:10:53.690 And coming up from these interviews, were there any examples where patients described really positive consultations or what made those encounters work really well? So any sort of examples of good practice so people can sort of take those sort of pointers away as well? Speaker B 00:10:54.010 - 00:11:29.500 Yeah, so definitely, you know, some people said that there wasn't actually a delay at all, you know, straight away they were seen and the clinician knew what it was. So yeah, it definitely wasn't all negative. And there was also some discussion about kind of preferences for healthcare professionals. So both in terms of the type of clinician someone sees and also their ethnic background. And certainly some people had really positive experiences in primary care and particularly kind of nurses, people had positive things to say, but it was quite a mixed bag. So, you know, everyone had different experiences, positives and negatives, to discuss. Speaker A 00:11:30.380 - 00:11:46.680 And for gps listening to this, what do you think could be some key practical take home messages from this work for people to take back to their consulting room if they were faced with a bit of uncertainty around a diagnosis or if someone with skin of colour came to see them with a skin condition. Speaker B 00:11:46.760 - 00:12:34.300 Yeah. So as part of this work, so we generated kind of eight themes from the interviews and then condensed these into sort of seven practical points for primary care clinicians. So I would encourage people to have a look at the paper because we have a concise table with all of these points with examples for each one. But just some examples would be looking out for and being prepared to discuss pigmentation changes with your patient. So kind of recognizing that it's there, explaining what it is and just simple things patients can do to help, kind of asking about complementary treatments, being aware that use is more common in certain ethnic groups and you know, what potential driving factors might be. So there are just some quite quick and easy things that People can do, I think, to try and improve patients experiences. Speaker A 00:12:34.910 - 00:12:50.510 And from your perspective in secondary care, how do you feel that this has sort of changed your practice or is there anything that you're particularly doing differently as a result of doing these interviews? I'm just interested to know sort of from your own personal point, whether you've picked up something in your practice that you've changed. Speaker B 00:12:50.590 - 00:13:29.790 Yeah, 100%. Yeah. I think it's really difficult when you're in a busy consultation because you've got so many things to try and discuss and tick off. But certainly when I'm seeing people with skin of color, I'm definitely more aware about, you know, have they got hyperpigmentation? Do they understand what that is? They're using any alternative treatments? Do they understand what's caused their condition? Where are they looking for their information? Are they looking online? Because a lot of people trying to, you know, look on social media to find out stuff which has its pros and cons. But yeah, I definitely think in secondary care as well, it's all really relevant and kind of highlights things that we should be doing. But it's easy to forget in the moment. But it is really important. Speaker A 00:13:30.810 - 00:13:46.130 Absolutely. I think that's the thing. It's just sometimes having a nugget or a thought in the back of your mind when you're faced with this, even if it's a busy consultation, sometimes you can add a lot just by asking one extra question or asking about one extra perspective or what really matters to the patient as well.
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S5 · E232
May 26 · 17 min
‘It’s not just thrush’: Navigating recurrent vulvovaginal thrush in primary care
Today, we’re speaking to Dr Tori Ford, a qualitative researcher based at the Nuffield Department of Primary Care Health Sciences at the University of Oxford. Title of papers: ‘Accumulative Experiences: Navigating Healthcare for Recurrent Vulvovaginal Thrush from Patient and Clinician Perspectives’ and ‘It’s not just thrush, it’s recurrent thrush’: Patient and Clinician Perspectives on Diagnosing Recurrent Vulvovaginal Candidiasis’. Available at: https://doi.org/10.3399/BJGP.2025.0437 and https://doi.org/10.3399/BJGP.2025.0531 Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:01.280 - 00:01:15.200 Hi, and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the associate editors of the journal. Thanks again for listening to this podcast today. In today's episode, we're speaking to Dr. Tori Ford, who is a qualitative researcher based at the Nuffield Department of Primary Care Health Sciences at the University of Oxford. We're going to talk today about two linked papers that she and her team have published here in the bjgp. The first one is titled Accumulative Navigating Healthcare for Recurrent Vulvovaginal Thrush from Patient and Clinician Perspectives. And the second paper is it's not just thrush, it's recurrent thrush. Patient and Clinician Perspectives on Diagnosing Recurrent Vulva Vaginal Candidiasis. So, Tori, thanks very much for joining us here today. And this might come from a slightly unscientific perspective, but my feeling is that I'm seeing a lot more recurrent thrush in practice. And we know that it's incredibly common. I think, despite that, it's not something we hear discussed very often in primary care research. So my first question is, what made you want to study it? Speaker B 00:01:15.520 - 00:01:54.060 So, like you say, recurrent thrush is an increasingly common condition. We know that 1.2 million women in the UK live with it, 6% of people globally, and I just happen to have been one of them. So my paper came out of lived experience of living with recurrent thrush over many years and having a diagnostic journey of, you know, seeing different healthcare professionals looking for answers. And like you say, those feelings of shame and stigma that keep you feeling alone were all too familiar for me. So that's what actually led me into starting my PhD, looking at recurrent thrush and then wanting to hear other patient experiences as well. Speaker A 00:01:54.460 - 00:02:22.220 And we're looking at two of your papers here that were published in the bjgp, and they're both looking at the patient and the clinician perspective. And one thing that comes through really strongly in both papers is that recurrent thrush is often treated as if it's just repeated acute episodes rather than a condition in its own right. Why do you think that that distinction matters to patients and probably to clinicians as well, or should do? Speaker B 00:02:22.380 - 00:03:55.420 I think when we hear about thrush, it's often something that's seen as trivial or mundane, and that's often because it's through this lens of acute, transient, episodic, episod, and most of the time it is right. 75% Of people with Vaginas will have thrush at some point in their life. It's usually self managed over the counter with pharmacy care and symptoms resolved within a few days. But where recurrent thrush differs is when those symptoms keep coming back so that itching, burning pain and irritation becomes sometimes cyclical, sometimes repetitive. And I spoke to three or two patients who all had different durations of heat know, happening every two weeks, every month. And what they often found was because they were accessing fragmented care. So, you know, going to the pharmacy, sometimes going to the gp, sometimes maybe seeing sexual health, it was often seen as again, that mundane, one off, trivial case. And it was really hard to trace those patterns across care, especially due to a lack of continuity. Right. If you're trying to track a pattern but nobody is following you up, it's really difficult to, to capture those. So I think it's a few layers of one. I explore how these sort of social dimensions keep it seen as something maybe less long term, but then also in the ways that sort of care was fragmented made it harder for those patterns to be picked up and then to transition the care moving away from, you know, acute one off prescriptions of an antifungal medication to something that required repeat, repetitive, enduring, you know, testing, treatment, retesting of treatments. Speaker A 00:03:56.060 - 00:04:09.970 Absolutely. And I think what's interesting is that your papers describe recurrent thrush as something that's accumulative and cyclical over time. And you mentioned that it's not just these sort of one off episodes. Can you explain what patients meant by that? Speaker B 00:04:10.210 - 00:05:13.850 Yeah. So often, I think when we talk about healthcare, journeys are presented in a way that's quite linear and straightforward that, you know, you see a healthcare professional, you get treatment, you go home, you start to feel better. But with recurrence, something interesting happens where people aren't, you know, returning to the start. It's not that you go back to a blank page and then restart your healthcare journey every time you're carrying with you everything, everything that's amassed through healthcare encounters, what you've seen online, what you discuss with friends, and that is all carrying through to those consultations. And I think what was really important there was acknowledging that for many people there was a lot to unpack there and often they felt that it wasn't being acknowledged in those clinical spaces. It was seen as, oh, it's just thrush. And that's why in one of the papers the title is, it's not just thrush, it's recurrent thrush. And that's a quote from One of the participants who was speaking about the importance of labeling and distinguishing this condition, especially in terms of the impacts it had on people's lives and also the approaches and pathways that would be needed to properly treat it. Speaker A 00:05:14.330 - 00:05:32.570 And this is an issue that we see across clinical care and women's healthcare. But a lot of participants described feeling dismissed or not listened to. And I wanted to just get your perspective from your wider sort of work in this area is how much of that reflected wider issues in women's health care, do you think? Speaker B 00:05:33.170 - 00:06:46.980 Yeah, I mean, we know there's increasing conversations, right, with the women's health strategy, with the Cumberlage report, about how people's pain is often dismissed based on their gender. And that definitely came across in the studies. But I think what was interesting was that both patients and clinicians were aware of this. And something that is quite interesting was in the diagnostic paper, we look at sort of those moments where there were sort of miscommunication or differing expectations between patients and clinicians, clinicians, where clinicians were, you know, operating on a standard guideline that requires two swabs, two positive swabs for a thrush within a year to diagnose recurrent thrush. But when that wasn't communicated to the patient, of being told we need to accumulate these number of swabs, what the patients thought was happening was, oh, they're swabbing me again, they're not listening to me, they don't believe me. So it was interesting where the dismissal was often in those moments of, you know, it wasn't healthcare professionals saying, this isn't important, or please don't come see me about this. It was really in those sort of small details where patients were operating on one framework and clinicians on another. And there were these gaps in communication. And that's why our papers seek to address some of those gaps with some recommendations as well. Speaker A 00:06:47.620 - 00:07:04.640 Yeah, and as you mentioned, one of the papers is called it's not just thrush, it's recurrent thrush. And I wonder what you felt were the key challenges around actually recognizing recurrence in primary care, as opposed to it just being a, a one off episode. Speaker B 00:07:04.720 - 00:09:30.220 There's multiple layers to this, I think, in terms of the. The papers are sort of split in terms of the diagnostic journey and then the healthcare journey. But that's sort of an artificial split in some ways, because what we saw a lot was, you know, patients trying to seek out continuity of care to get someone to notice the pattern that they were starting to see and assign a label to it and we saw some hesitancy with this in clinicians who said, you know, I'm not going to use the term recurrence because that sounds like it's something serious or sounds like it's chronic. And they saw that being helpful. But then for patients they found that really challenging because they said, you know, they just see it as thrush, they just see it as a one off case, they're not recognizing it when often the clinicians had, you know, made note of it, but they didn't feel that using that label would be helpful to patients. So simple things like that, even just the language that we use can make such a big difference in helping people feel seen. And then the diagnostic journey. So the tests that we have are not perfect. There's also a lot of problems with self treatment before testing that wasn't always disclosed by participants. So these cycles right of you have symptoms, you make a doctor's appointment, the symptoms are unbearable is what we heard all the time. So people went and self treated over the counter with, with pharmaceuticals, over the counter antifungals, or even off the shelf at pharmacies, different options or supermarkets, and then would go in, be swabbed for a test, the test would come up negative. And then it was really hard to build a case, right. For recurrent thrush when there wasn't sort of that EV evidence there. But often what patients weren't doing was sharing that they had self treated. Because often for patients, they don't know all the factors that go into a test or they're not going to know what influences it. And then there was a lot of difficulty. Right. Often we hear vulval itching and we go right to thrush. But there's so many other conditions along the way of lichen sclerosis, of dermatological conditions, of vulvodynia that also need to be addressed and identified. So trying to have those moments where clinicians could be ruling out, you know, is it thrush, is it not thrush? And then is it recurrent thrush? And having that second question be front of mind was really important because it does change people's trajectories. And we heard from people that, you know, were able to get that recognition early on and were able to get appropriate treatment and have symptoms resolved. So we know it's possible, but we know that that recognition is challenging. Speaker A 00:09:31.190 - 00:09:49.630 Yeah, and you touched on this a bit earlier, but continuity seems really important in both of these papers and you've just spoken about recognition and I wonder what your thoughts are about recurrent thrush and how it's almost exposing sort of this issue around fragmented care really. Speaker B 00:09:49.630 - 00:12:16.920 So clearly, I think continuity was one of the most interesting topics to explore and it was fascinating seeing how clinicians were seen fragmented systems and trying to overcome them. So, you know, some clinicians who said, I want to see you again, I'm going to book you into a clinic, I want you to come back on this date, we're going to figure this out together and how valuable that was for patients and other times where, you know, maybe a GP wasn't in a position to be offering follow up appointments in that same way they could offer informational continuity. So that looked like writing notes to sexual health, that looked like sharing notes with patients, sharing test results with patients. It looked like pulling up the guidelines and actually working through together, you know, what the steps were, what the timelines were being realistic. So many times patients thought the start of the journey, I'm going to go in, there's going to be a magic cure and I'm going to be okay. And they actually really valued when clinicians said, it's an ongoing journey, it's going to take time, but we're going to work it up together. And that really helped patients keep coming back. In the paper about accumulative experiences, we talk about that of not only is it about the times where recurrent thrush care needed to be different than acute care, but also about those really important moments where you could be making those differences, you could be making those transitions and acknowledging it and building that continuity. Because I think, yeah, with acute conditions, you have acute conditions and you have chronic conditions and recurrence falls somewhere in between. In this really interesting space where chronic conditions often are, have quite established guidelines, they've got secondary care involved, they've got sort of continuity built into them, right. With the chronicity and then acute cases, you've got the one off self managed, often treated as quite trivial conditions. And then recurrence is interesting because it kind of spans both of those and jumps between them in different ways. And we saw that a lot and it helped kind of expose that fragmentation, right, of people that would go see the pharmacist and they would say, how many episodes have you had in the last year? And then the patients would say, you know, I've had four or more, which is the definition of recurrent thrush. And often pharmacists were aware of that and would say, oh, you're going to have to go see your GP to get this medication. And then the patients reported going to see their GP who said, oh, you can just treat this over the counter with pharmacy care. And sort of these loops that were occurring between GP and pharmacy, which were really interesting. And then seeing also where sexual health could fit in as well. Speaker A 00:12:17.240 - 00:12:28.760 Yeah. And thinking about that, as you say, patients moved between pharmacies, general practice and sexual health services, but how well connected did those pathways feel? Or did they not feel well connected at all? Speaker B 00:12:29.320 - 00:14:13.680 No, I think by design the pharmacy, sexual health and GP practices are kept quite separate and I think there's good reasons for doing that. For example, in sexual health you can access care anonymously, you don't have to share any personal information. They by design don't share notes with your primary care professional. There's different systems that are set up that are in practice, right, to protect patient privacy, to make people feel comfortable, to help, maybe reduce some shame and stigma. But at the same time that can make it really difficult when people are accessing care in many different spaces. And we saw that quite often and people aren't speaking to one another. And I think the best care we saw was when people were able to reach across those lines and say to the patients, you know, in sexual health, would you mind if I maybe looped in your primary care professional? Would that be okay? Or asking directly about when was last time you self treated, when was last time you were using over the counter remedies? Have you been reading things online when you can sort of have that whole picture? And joint up care was really incredible. And something we saw too was in the diagnostics paper where GPs were able to say, you know, I'm not able to see, you know, microscopy, I'm not able to offer the same level of testing that somewhere like sexual health might be. Would you reopen? Exploring that option and sort of signposting people to different places was really powerful. But that, that wasn't one obvious to patients or clinicians always. It really differed by region and commissioning and what was available. And then also patients reported feeling really confused. If you know, who am I supposed to see, in what order, in what combination and what is sort of the appropriate route. So trying to figure out those, those questions as well. Speaker A 00:14:14.160 - 00:14:26.560 And I wonder what your thoughts are after doing this research and even from your own lived experience. But for gps, listening to this, what do you think are the practical take home messages from, from this body of work that you've done? Speaker B 00:14:26.960 - 00:15:46.300 So the first thing that we're recommending for GPS is to be asking patients about recurrence. We heard from patients saying that sometimes they didn't disclose how many episodes they'd have because they said I just wasn't asked the right question. And I think that's how it often gets treated. As acute cases, we really have been recommending prioritizing continuity of care whenever possible. But when it's not thinking about creative ways of having informational continuity, whether that looks like writing letters, having patient approved note sharing, providing patients with their own notes so they can follow up with practitioners as well as. And then also in terms of the diagnostic routes of making sure that you're asking patients about self treatment before doing testing, offering patient initiated self swabs whenever possible, and also acknowledging some of the limitations that exist within our current health systems and also within testing and making sure that you're recognizing both the cumulative impacts that people have with recurrent thrush, but also ruling out other conditions and sort of not falling into that trap where any vulval itch falls into recurrent thrush. So it's a complex condition, but there's some, like I've been saying, there's some really simple changes in terms of communication, but also in just having a scan of what resources are available and what services might be able to be best suited to treat these conditions as well.
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S5 · E231
May 19 · 13 min
‘They knew me’: Relationships, continuity and dementia care
Today, we’re speaking to Dr Charlotte Morris, a GP and academic based at the University of Manchester. Title of paper: Experiences of primary care for people with dementia from socioeconomically disadvantaged areas: a qualitative study Available at: https://doi.org/10.3399/BJGP.2025.0407 Existing national guidance recommends primary care-led dementia health care, but little is known about the experience of this for people living in socioeconomically deprived areas. This study highlights that people with dementia, and their carers, in socioeconomically disadvantaged areas want to maintain identity and understand their decline. Support from healthcare services often diminishes over time, with difficulties accessing and navigating healthcare systems when needed. There was uncertainty about primary care’s role in dementia health care. Clearer communication and proactive support from primary care may improve experiences for these patients. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.320 - 00:00:32.850 Hello and welcome to BJ GP Interviews. I'm Ewan Lawson and I'm the editor of the BJ gp. Thanks for listening to the podcast today. In this episode, we are speaking to Charlotte Morris. Charlotte is a GP and doctoral research fellow at the University of Manchester and we have recently published her paper, Experiences of Primary Care for People with Dementia from Socioeconomically Disadvantaged Areas A Qualitative Study. So, Charlotte, first of all, what I'd like to ask you is how did you come to focus on people with dementia in deprived areas specifically, and what surprised you most in the interviews? Speaker B 00:00:33.170 - 00:02:03.470 Thanks, Ewan. Thanks so much to you and the BJGP for inviting me to do the podcast and publishing the paper. So, I guess my interest in people with dementia started when I finished my foundation training and I did a clinical fellowship year in London where I worked on a ward with people with dementia specifically. And at that time I wanted to be a care of the elderly doctor. But I was struck by how many people kept coming in and out of hospital with dementia regularly. We'd spend ages trying to get them home. They go home for maybe one or two days and then sadly come back on this cycle. And I think in reality, a lot of those people would probably have been better at home, even if that shortened their lives very sadly. And it made me realise I wanted to work in the community with people with dementia, trying to improve healthcare in terms of advanced care planning and kind of planning for progression. So that's where my interest in dementia came in. And I work in a practice in a relatively deprived area of Greater Manchester, and I always had an interest in health equity for kind of various reasons and health equity in terms of various lenses as well. So when I was designing my PhD project, I decided to kind of focus on both aspects, so health inequalities in terms of deprivation and primary care for people with dementia. Speaker A 00:02:03.870 - 00:02:08.270 I mean, I know we're going to touch another on some other stuff, but. Yeah. What surprised you most in the interviews? Speaker B 00:02:09.390 - 00:02:47.530 I think in terms of what surprised me most in the interviews, I think I was actually struck by how much people wanted more health care from their primary care teams. It's not like they felt they were getting the best care or they were really kind of thrilled with what they were getting in lot of times. But they were actually very trusting of their primary care teams and they really, really wanted more of that health care, which kind of struck me, really. And I actually found it kind of quite touching and humbling, as a practicing GP myself, to know that we were really valued and that the care that we provide, people tend to want more of it rather than less. Speaker A 00:02:47.610 - 00:03:21.390 Yeah, so that leads in nicely, because I wanted to ask you about one of the themes in your paper, which was the kind of proactive continuity. And several of your participants described your wanting their GP to take the initiative, you know, to call them, to know them, so just to anchor their sense of self while the dementia progresses. There was a one man who had Alzheimer's who named it Ali. Was a kind of a. Was a striking example. You know, what, what kind of sense? What does that tell us about what primary care needs to be doing? I mean, you mentioned there about how much it was appreciated, but what kind of. What do you think they can do more of? Speaker B 00:03:22.000 - 00:04:42.080 Yeah, I think that kind of theme of proactive continuity splits into two, really. So I think the idea of being proactive is really important and people wanted their GPs not only to know them, but to actively contact them. Sorry, I mean, not just their gps, actually their whole primary care team recognising that we all work together in our practices as well as that proactivity. They wanted somebody who knew them, knew their family, knew their kind of history, knew the kind of outside of their life, rather than just their medical condition or their dementia. And that was really striking and came through kind of very strongly from most people who were interviewed, really. And I interviewed people with dementia and carers and from both sides. That idea of being known by their primary care team did come through very strongly. And I think for me as the interviewer and for me as a practicing gp, I also really like that side. You know, knowing our patients, knowing that person, and being there for the kind of entire journey of a diagnosis to dementia all the way through to that progressing. It's a real privilege and I think it's something really precious for us as, as primary care teams, that continuity. Speaker A 00:04:42.240 - 00:05:02.930 There was a bit of a gap. There wasn't. There's this kind of, oh, you know, there's potential gap in that. And you mentioned this in the paper about the falling away support, that sometimes participants went to the memory clinic, then they were discharged, and then they felt a little bit like they, you know, they weren't picked up necessarily. I wondered if you could tell us a little bit more how that showed up in your interviews. Speaker B 00:05:03.570 - 00:06:27.830 Yeah, yeah, for sure. So I guess everybody, everyone did describe a kind of different journey. And I don't want to just generalize, but the sentiment or the feeling I got from most people was that there was concern around a possible diagnosis, a kind of flurry of activity around when the diagnosis was made, referral to memory clinic, lots of calls. Somebody described a mind boggling array of things being offered around that time of diagnosis and then after that things seeming to kind of fall away. So somebody described the specialist dropped them and they were seen by memory clinic, started on medication and then just left back to the gp. So that idea of kind of there being a flurry of activity and then things gradually dropping away and that being a paradox because actually people felt that their needs generally increased as time went on. So that was very interesting really. And I've also done. It's kind of not a published paper yet and it's still being worked up, but I've done some interviews with primary care providers as well and that seemed to kind of come through as well from them and that there is a flurry of activity around one point around diagnosis. But then as time goes on do things do seem to kind of drop off and change. So it's perhaps felt from both sides as well. Speaker A 00:06:27.830 - 00:07:03.200 Yeah. Let's talk a little bit about when sometimes it doesn't happen so much or people who knew the system. And there was definitely an interesting rather novel finding that came out and I guess it's something we might be aware of, but I haven't seen too many papers that have highlighted it, that if there was someone in the family who knew the system, that was often perceived as crucial and it sort of implies a system rewards social capital or maybe it's just very specific to medical systems. But I wondered if you could, you know, how worried should we be about that? What can primary care do to address it or to flatten those kind of. Those kind of flatten it out. If there is a. If it is an inequality. Speaker B 00:07:04.000 - 00:08:54.200 Yeah, I think a great question and I also thought this was one of the most interesting themes to come out of the paper actually. So just to kind of describe it, a lot of people described how if they had a family member or a friend who knew a little bit about the healthcare system, so if they'd worked in research or if they'd worked in social care, they would be called upon to kind of navigate this complexity of the system and it kind of came through that they would know who to contact, know how much to push, know what strings to pull to get somebody seen. And that insider knowledge, how we termed it, seemed crucial in kind of getting things done. And, and that was described in detail by one participant in particular. But they hadn't necessarily learned that through a professional role, they'd learnt it over years of caring for somebody with dementia and they kind of had learnt these little workarounds and trade offs that they had to make in order to get timely, safe, accessible primary care for that person. And I think in terms of us as primary care providers, I would say what we could do to change that is maybe avoiding what I termed a computer says, no approach. So if somebody asks for an appointment or a little bit of flexibility, rather than saying, oh, there's nothing available today, you'll have to call back tomorrow at 8am, perhaps recognising that there needs to be that flexibility in the system and perhaps in those situations, try to do whatever you can, whether that be signposting, asking for a little bit of advice from kind of a clinical colleague, or even squeezing somebody in at the end of the day, which I know we all try to do and sometimes isn't feasible. But for people who struggle with dementia and their carers, life is often very difficult and we can sometimes make it a little bit easier by what might not be a huge tweak to our working day. Speaker A 00:08:54.840 - 00:09:38.040 It's fascinating, isn't it, because so many of the papers that we cover and have conversations that they. I mean, it's all related to access and pressure on the system and how the most vulnerable people navigate through the systems. And as the pressure ramps up, it's almost. It feels almost like it's been inevitable and certainly I've written about this in the past, that these difficulties of people, you know, the system gets more complex and, you know, the more complex patients are harmed by, you know, the most complex systems. And when there's pressure on the system, how do you. How do you think your sense of being a GP fed into, you know, you must be aware of that from the other side as well, from the. Obviously in the. How it fed into, how you went about the interviews. So that reflexivity side of things, how did. Speaker B 00:09:38.040 - 00:09:38.360 Yeah. Speaker A 00:09:38.360 - 00:09:42.560 What did you bring to it that you felt that was you. You. That was very notable to you, Charlotte? Speaker B 00:09:43.590 - 00:11:30.840 Yes, I think it's a great question. And with any qualitative research, and indeed sometimes even with quantitative research, it's really important to consider your reflexivity, your own biases, kind of how you're situated within that research. For me, it goes back to the first question you asked me, really. I went into these interviews with a kind of a bias, I suppose, or an idea that I feel primary care is the right place to be providing this health care for people with dementia. I think we're well suited to it because of our longitudinal relationships. The Fact that our job is rooted in compassion for people that we know and care about within our communities. And so I kind of did go at it at that angle, really, that I felt we should be providing this care and trying our best to do it as well as possible. And kind of interestingly as well, the participants picked up on me as a gp, but it didn't stop them kind of really telling me the truth, I think. And they'd often preface things with, oh, I know you're a gp, but this, this and this happened. And I found that quite nice, really, that they kind of felt they could open up a little bit more, particularly towards the end of interviews. And also I'm originally from a relatively deprived part of the UK as well, so that kind of idea of being within the group that I was. That were participating in the research was also quite interesting and I think was recognised by the participants as well, enabling them to open up a little bit more about their experiences, perhaps, and somebody who they perceived as being outside that group. And so, yeah, I mean, fascinating sociologically, really, my role in the interview, how I was perceived by the people I was being interviewed. I was interviewing as well. Speaker A 00:11:31.000 - 00:11:45.570 Yeah. Okay, so if a gp, someone else in primary care is listening, listening to this, and they're seeing someone with dementia later on this week or in this, you know, whenever they're in clinic, what's the single thing your study would suggest they do differently? Speaker B 00:11:46.450 - 00:12:51.000 I think it goes back to the proactivity and continuity. And from the interviews, I think what came through most strongly is people want to be known and they want to feel cared for as their condition progresses. So I would say a regular check in or phone call could be very meaningful to that person with dementia or their carer. It would probably take less than five minutes of our working day, but just putting a note on the calendar to ring in three or six months time. How are you getting on? Is there anything that we can do? Could the care coordinator come out and help, checking that the care plans are all in place and that people are kind of ticking along? Okay. We'd be unlikely to make any significant changes, but that feeling of being cared for and having somebody with them on that journey, I think could perhaps be. Be very meaningful. So that would be the one thing I would suggest, really, that kind of proactive continuity and making an effort to communicate that healthcare around dementia, really. Speaker A 00:12:51.400 - 00:12:58.360 Charlotte, I think that's a really excellent note to finish on. It's a lovely study. Thank you very much for taking the time to speak to us today. We're very grateful. Thank you. Speaker B 00:12:59.080 - 00:12:59.960 Thanks Ewan. Speaker A 00:13:00.600 - 00:13:15.890 And thank you all very much for your time and for listening to this BJGP podcast. Charlotte's original research article can be found on bjgp. Org and the show notes and podcast audio can be found at bjgplife. Com. Thanks again for listening.
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S5 · E230
May 12 · 15 min
Choosing general practice: What shapes medical student decisions?
Today, we’re speaking to Catharina Savelkoul, a DPhil student in Health Economics based at the Nuffield Department of Primary Care Health Sciences at the University of Oxford. Title of paper: Factors Influencing UK Medical Students’ Choice of General Practice: A Systematic Review Available at: https://doi.org/10.3399/BJGP.2025.0226 The UK faces a projected shortage of approximately 15,000 GPs by 2036/37, with a declining proportion of UK medical graduates pursuing general practice. Previous research has identified various contributing factors but lacked a contemporary synthesis within a coherent theoretical framework. This systematic review examines factors influencing UK medical students' career decisions, finding three critical influences: curricula that inadequately represents general practice, a persistent negative hidden curriculum, and the impact of clinical placement quality. Our revised Bland-Meurer model incorporates these findings, providing a comprehensive framework to improve GP recruitment. This systematic review identifies the factors that shape UK medical students’ intentions toward general practice. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:01.120 - 00:00:59.530 Hi and welcome to BJJP Interviews. I'm Nada Khan, one of the associate editors of the bjjp. Thanks for listening to this podcast today. In today's episode, we're speaking to Katharina Savalcool. Katharina is a DPHIL student in Health Economics based at the Nuffield Department of Primary Care Health Sciences at the University of Oxford. We're here today to talk about the paper she's recently published in the BJJP titled Factors Influencing UK Medical Students Choice of General A Systematic Review. So, hi Katharine, it's lovely to meet you and to talk about your work. This is a super interesting area to study because we know that there is a push to increase the number of GPs in practice and I guess that does really start from medical school and people's intentions there. But just to start off, could you talk us through why you decided to do this work and what were you aiming to look at here? Speaker B 00:01:00.050 - 00:03:17.090 Yeah, of course. So the goal of this piece of research, of the systematic review was to synthesize the empirical evidence on the factors that influence medical students, GP, career intention. Because we know that the general practice is what makes the NHS functions. It handles over 300 million consultations annually, manages the long term, most long term conditions, issues over a billion prescriptions per year. And we also know that healthcare systems with a strong, with strong primary care achieve like, better population health in general. But at the same time, right now the projected shortages for the UK are approximately 15,000 GPs by 2036, which is of course a large number and shows like a workforce crisis. And then if we look at the policy response to this, they've been like quite ambitious but also largely unsuccessful. So for instance, Health Education England mandated that 50% of all new medical graduates should enter general practice. And this target has never been met. The same goes for the NHS long term workforce plan to increase GP training places by 50% to 6,000 places in 2031. And the interesting part about this is that the policy responses are all about setting this goal. Right? It's about, you know, we're shifting, we're shifting care to the community, we're expanding training places, more medical students should become a gp. But that's all. Yeah, setting like these, these, these strategies, but at the end it almost seems like the, we're achieving the reverse. So that, that kind of brought me to the question of if we want to, you know, make sure that we have a healthy primary care workforce, that the general practice avoids this large crisis in the future, then maybe Instead of setting these ambitious goals, we should look into the question of what draws medical students to the general practice and also what are some of the reasons why they might not become a gp? And I think if we zoom into those factors at medical school, during medical education, you get a lot more interesting insights that can actually inform more effective policy. I think that's the kind of. That was the reason I conducted this systematic review. Speaker A 00:03:17.970 - 00:03:42.850 That's a great summary of what's been going on with GP recruitment in the past little while in terms of policy and the push to increase the number of gps. And this was, as you mentioned, a systematic review that followed pretty conventional review processes. But I wonder if you could tell us a bit about this bland mirror model. It's a framework used in terms of organizing the results and how this informed how you structured the results. Speaker B 00:03:43.990 - 00:04:47.410 Yeah, I think it's for this specific research question, looking into factors that influence decision making. I decided to look up different theoretical frameworks in order to understand this, because decision making at the end of the days is, of course, something that's influenced by many things at the same time. This model specifically, which was, I think first published in 1995, helped a lot with like, systematically categorizing the findings because it identified three principal domains. One is the student characteristics, such as, like, personal values, maybe personality traits. The second one is the specialty characteristics. So what is the. What are the professional opportunities? And the third one is, like, the influences during medical school. And I think if those are the three kind of domains we saw in this across these, like, 30 years of research, and I think it was the most useful way to kind of theorize these factors. Speaker A 00:04:48.210 - 00:05:01.970 Great. So I guess just talk us through what you found, and I suppose it might be helpful to just talk through the different aspects of that model you've just described. So what were the sort of student characteristics that you found in the literature that influenced and informed specialty choice? Speaker B 00:05:02.640 - 00:06:37.050 Yeah, so I think the findings from this came from different types of studies. I think the largest ones were the ones that used a data set called UK met, which kind of has the data on all UK medical students in such demographic variables, but also more information about their educational performance in medical school. And I think these studies showed us like, the kind of the social, demographic, individual characteristics that are associated with a higher likelihood of pursuing a career in a general practice. And then there's these smaller studies which kind of like looked at personal preferences and personality traits. And I think that that's another really interesting question. Right. Because about this, like, specialty choice and Kind of individual preferences, personality traits. A lot of international research is talking about altruism or do people who enjoy social contact more, are they more likely to become gps? And I think this type of research is quite undeveloped in terms of the UK literature, but it was still interesting to look at it and compare it to different studies. And I think for the demographic factors we saw specifically that female students were more likely to choose gender practice graduates on entry. So age was another one we saw. Yeah, so there's like these different kind of demographic factors or personality traits that seem to predispose you to career in a general practice. Speaker A 00:06:37.290 - 00:06:51.930 And what about the characteristics of the specialty itself or working in general practice specifically that drew some medical students to think about it. So these are potentially medical students looking at gps and thinking, oh, I want that lifestyle or I don't or I want that work. Really? Yeah. Speaker B 00:06:52.150 - 00:07:48.350 On this question, first of all, a lot has changed recently. So I think work life balance was something that was mentioned in like the earlier studies, but right now it has changed so much that that's almost like not something we can, yeah, we can use anymore. But another interesting one, and I think one that we should really take seriously, is that a lot of one of the things that draws students to the general practice is the like, long term patient relationships. So continuity of care. And of course right now with the landscape changing and specifically like the prioritization of access over continuity of care, it might be important to kind of, you know, reconsider those changes in light of the fact that a lot of medical students decide on a career in a general practice because of this like continuity of care aspect that's so unique to primary care. So I think that's another really important one. Speaker A 00:07:48.990 - 00:08:13.560 Yeah, I can definitely relate to that. I think one of the reasons I figured out that general practice was for me was that when I was working in A E, I would flag all the patients I'd seen and clarked in and then wanted to know what happened in their journey. And I thought, oh, well, I'm not really getting this here in my hospital job in specialty, but maybe that's something I can get in general practice. So as you say, it's a shame that potentially that's something that's being eroded a bit in current practice. Speaker B 00:08:14.040 - 00:09:22.490 Yeah, exactly. Yeah, that's a really, really important one. And that's another study of mine is a very simple survey where I ask more than a thousand gps what they found most rewarding about their career. And it's an open text response and over 45% of respondents wrote down continuity of care. And in a lot of the discussions we have around continuity of care and its benefits, it's very much patient centered because we know that the quality of improves for patients if they see the same gp. But that kind of. We haven't really thought about that reversed. So we haven't really thought about what does it mean for a GP to provide continuity of care, to see the same patients. And clearly now with like, the retention crisis, it's also important that we look at, like, the positive factors, like what do gps really enjoy about the career, what were the reasons why, why they want to become a gp, and how do we kind of protect those things or improve them even more? And I think continuity of care is a very important one there. And I think something we should really, really consider during these policy changes and. Speaker A 00:09:22.490 - 00:09:44.780 One of the more interesting areas, and maybe one where we can try to make a change or difference in curriculum in medical schools, is those medical school influences that you captured in the literature. And I know, for instance, where I studied, we had really early GP placements in year one of our medical training. But talk us through how medical school influences impacted on career choices and decisions. Speaker B 00:09:45.180 - 00:12:06.380 Yeah, so medical school is. Is extremely, like an extremely important time. It's a. It's a time that, of course, you go from like, knowing about these specialties, knowing about the different career pathways, to actually experiencing them. The most important thing is probably exposure to TP placements. And actually, like, early exposure was associated with a higher likelihood of pursuing a career in a general practice. So it's not only the timing, but it's also the quality, which is kind of hard to measure, but a very important thing there was positive role modeling. So if a medical student during the GP placement is exposed to what they see as a positive role model, then they're more likely to, you know, want to pursue that career as well. And positive role modeling is also, of course, comes down to how much resources is this GP teacher provided with to facilitate the teaching. So, for instance, a really interesting change is that until 2022, undergraduates GP placements in England received substantially less funding than hospital placements. And right now there's been a change. It's called the Harmonized Undergraduates Medical Tariff, which for the first time has established equal funding for primary care and secondary care or like the education and placements. And it would be interesting to see whether, like, improved funding for these GP placements actually also improves the ability of a GP teacher to, you know, give more, maybe more teaching or to. Yeah, to Kind of improve the quality of that. I think that's another one because it's easy to say, oh, it comes down to just a positive role model or not. But I think it all comes down to the resources they provide, with the time they get, the amount of students they get. And I think once again, if we set such mandates such as 50% of medical students should become a GP, I think that's the wrong way to go about it. I think it's more, how can we improve the resources for GP teaching and placements such that students have a. An experience that's fair and that they enjoy? I think those are the kind of policy changes we should think about. And I think the Harmonized Education Tariff is a very, very positive step in that direction. Speaker A 00:12:06.780 - 00:12:13.260 And I guess. Are there any other key findings you want to pull out from this paper before we move on to some of the implications and stuff? Speaker B 00:12:13.420 - 00:12:52.880 I think another one is also the hidden curriculum, and I think that's one that we also. Kind of. Well, I'm actually like, I don't really have any new insights on that, but I think it was by choice, not by chance. Report from 2016 is still as relevant today as it was when it was published. And I think the kind of. The policy recommendations from that report are still super important, such as monitoring and addressing the hidden curriculum and also supporting GP role models to counter the misconceptions. Those two kind of policy recommendations are still really, really important. Speaker A 00:12:53.360 - 00:13:06.480 And I guess, given what you found here, what do you think are your recommendations or what's coming up from the literature about suggestions for how medical students might choose or prioritize general practice as a career choice? Speaker B 00:13:07.280 - 00:14:38.510 Yeah, I think it comes down to the kind of the two buckets that were also identified by the blend mirror framework. One is the. Well, one is the individual, which I think. Well, actually you could also look at the individual and see if you promote more diverse recruitment, then maybe the group or the cohorts of medical students are also more diverse and maybe that might represent. That might be helpful with addressing some of the workforce shortages in the future. And I think very specific thing we should consider there and that we've learned from a lot of, like the US Literature, Australian literature and Canadian literature is specifically the recruitment of medical students from more deprived rural areas, because then according to, like the US literature, Canadian literature and Australian literature, they're more likely to serve in underserved communities. So I think that's the first bucket that the second one is the medical schools. And I've just said, I think funding there is really important for GP teaching and also like monitoring and addressing the hidden curriculum. And I think the third is like the specialty attributes. So we already talked about continuity of care. That seems to be a very, very important reason why medical students pursue a career in general practice. So I think we should consider protecting that more, improving it more, especially on the changes we get with like prioritizing access over continuity of care. Speaker A 00:14:38.670 - 00:15:04.820 Brilliant. And it's been really interesting work and I think that this hopefully will help bolster some of the evidence around how we can increase the recruitment of future GPs into practice. So really important work and I think it will have lots of strong policy influences sort of in the future going forward. So well done with all the this work. But I think that's a great place to wrap things up. So I just wanted to say thanks very much for your time here and for talking about your work. Speaker B 00:15:05.300 - 00:15:07.300 Thank you so much. I really enjoyed it. Speaker A 00:15:08.580 - 00:15:23.380 And thank you all very much for your time here and for listening to this bjjp podcast. Katharina's original research article can be found on bjgp.org and the show notes and podcast audio can be found@bjgplife.com thanks again for listening.
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S4 · E229
March 24 · 12 min
Looking back at the BJGP Research Conference 2026
Today, we’re going to back at the recent BJGP Research Conference, which was held just last week on the 20st of March 2025 in Bristol. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.960 - 00:00:39.550 Hello and welcome to this BJGP podcast. I'm Nada Khan and I'm one of the Associate Editors of the Journal. Thanks for listening today. In today's episode we're going to look back at the recent BJGP Research Conference which we held just last week on 20th March in Bristol. It was absolutely brilliant to welcome the BJGP team and people who attended to the Southwest. And in today's episode I'm just going to talk about some the highlights and really focus on what the conference is about and maybe have a chat about how to get involved in the future. But first, here's a welcome to the conference from our Editor in Chief, Ewan Lawson. Speaker B 00:00:40.270 - 00:01:16.520 My name's Ewan Lawson, I'm editor of the bjgp. So that means basically I'm the one person that the Journal would probably run without and everyone else does all the work. But I do have to stand up here and say hello to you and I want to offer you the warmest of welcomes to the conference. Been running this for a few years and it's always really nice to get together and just try to help each other, you know, get involved. It's not in a very scholarly way, you know, whether you're involved in research or whether you're interested in putting research into practice. We think we can offer you quite a lot more than just the fact that we publish research at BJGP and BJGP Open. So I hope you have a fantastic day. Speaker A 00:01:17.320 - 00:03:26.850 So this was the seventh run of the BJGP Research Conference and this year we had a particular focus on a few different areas. We took a bit of a deep dive into patient involvement, new and emerging research in general practice, general practice policy and how to get research into impact. And this year, as always, quite a bit around writing and also public speaking in academia. The conference kicked off this year with an absolutely brilliant talk by Professor Martin Marshall, who some of you may know as the Chair of the Nuffield Trust. But he's also Emeritus professor of Healthcare Improvement at UCS and non Exec Director at the Royal Devon University Healthcare trust. And until 2022, Martin was also the Chair of the Royal College of GPs and a GP in New East London. So definitely someone worth listening to about his experiences as well. And Martin really focused in his talk on the relationship between general practice and policy and asked a really important question, which is how good are we as a profession at influencing decision decision makers? And in his talk, Martin reflected on the fact that while the value of general practice is really well established for patients, communities and the wider nhs. It's often still misunderstood or undervalued at a policy level. And in his talk he challenged whether that's purely down to policymakers or whether, as Julian Tudor Hart once put it, there's also an element of political literacy within the profession itself. And what really followed was a thoughtful discussion about how both national leaders and individual clinicians can do more to shape policy, and whether that's through better communication, stronger advocacy, or even engaging more actively with the systems around us. It was a really thought provoking structure of the conference and linked closely to that broader theme of impact that ran throughout the day. Here's just a short snippet of Martin speaking at the conference. Speaker C 00:03:27.570 - 00:04:45.260 I wish I could have my career again and I'd be more influential than I was. I've learned a lot along the way, but this is what I've learned. First of all, as I've described, influencing is about far more than informy. It's not about telling, it's about getting inside people's heads and understanding what's important to them. A lot of influencing is about timing. How do we decide when to influence? I think it's really important. Policy windows is an interesting concept. So sometimes just a window opens that allows you to do something. And a good example of this would be the evidence around Continuity of care, which is actually pretty strong in General practice was largely ignored by policymakers and politicians until the pandemic came along and they were looking for a way of delivering the vaccination program. And we made the case based on evidence that trust is really important to the success of uptake of vaccination programs. And that's why government decided that general practice would deliver their program largely, rather than setting up a separate body to deliver it. So there's an example, another example of ways of change. The NUFRE is doing some really important work around the distribution, the resource distribution formula for general practice, something which the Conservative governments of the past were not interested in, the Labour government is very interested in. So now is our time to push it while we can. Speaker A 00:04:46.460 - 00:11:57.780 So it was a great start to the conference from Martin, which really focused down on how GPs and primary care researchers can get the most impact from their work to effect change. So in addition to the keynote sessions, we had a series of parallel sessions where people presented posters and talks about their work. And what really struck me, listening to different talks and looking at the different posters that were on display, was just how strong the work was across the board, especially from medical students. And early career researchers. There's clearly a lot of exciting work coming through and I wouldn't be surprised to see some of it published in the BJJP in the near future. At the conference, we then had a series of workshops and these looked at patient and public involvement, writing for the BJGP and public speaking in academia. I attended Lucy Potter and the Bridging Gap team's excellent workshop on meaningful patient and public involvement in research. Their team did an absolutely brilliant job at highlighting a familiar but important issue that those with the greatest health needs often face the biggest barriers to care and are probably the least likely to be involved meaningfully in research. And what made this session stand out for me was that it was delivered alongside women with lived experience, which brought, I felt, a real deal, a real depth and authenticity to the discussion. And the workshop was a absolutely powerful reminder of the importance of meaningful involvement and offered some really practical ideas for how we can better include marginalized patients in our work. And going on to one of the regular features of the conference, which is the Right for Life workshop, led by our deputy editor at BJGP Life, Andrew Papaniktis and Tom Round. It's a really engaging session that encourages people to write and reflect on their experiences in general practice. And I often describe JGP Life, the website, as sort of the coffee room of the journal. It's a space for more sort of reflective conversation and debate. And here we're also always keen to receive some submissions from across the GP community, and it's probably worth pointing out that some of these pieces then go on to be published in the print journal too. And finally, the third workshop was led by Professor Graham Easton, who looked at public speaking for academics. And I just want to touch on Graham's really interesting background that he was able to draw upon here. So, Graham was a senior producer for BBC Science Unit for many years and presented Case Notes, which is Radio 4's flagship medical program. He's also a regular contributor to BBC Health Check and has quite a strong interest in the use of narratives and storytelling in medical education, which is a topic he looked at in depth in his doctoral work. So, looking back to his workshop, it focused on something we've all experienced, which is sitting through a talk or presentation where the key message gets lost in really dense slides and you just lose the audience. And Graham's session was all about how to communicate our work more clearly and make it engaging, using things like storytelling, simplifying your core message and using visuals that actually support you're saying, rather than Overwhelming it. It was a really practical session with lots of tips to take away and use straight away. And I think that everyone who attended, who attended learned something new about how to present their research in an engaging and meaningful way. So that's a roundup of the workshops. And finally we had the last keynote speaker of the conference, Dr. Rebecca Payne. And Rebecca really brought together one of the central themes of the conference, which was impact going back to Martin Marshall's talk as well. And Rebecca's talk focused on what happens after publication and challenged the idea that getting a paper accepted as the endpoint. Instead, she kind of framed it as the beginning. So that's the point at which the real work of influencing practice and policy starts. Rebecca's got a lot of experience in research, but for this talk she drew specifically on examples from The Remote by Default 2 study, which explored how the shift towards remote consulting and general practice has played out in reality. And this includes some of the benefits, but also some of the unintended consequences for access, continuity and patient experience. It was a really helpful example of how complex system changes can't be understood through simple metrics alone and how research, like the Remote to Default study, can help unpack those nuances. I guess what Rebecca's trying to point out is that if we want research to make a difference, we need to think more deliberately, like much more deliberately, about how it's communicated, who it reaches, and how it feeds into decision making. And that could include things like engaging with policymakers, working with the media, or translating findings into more accessible formats. And just going back to Martin Marshall's talk, he talked about how at the Nuffield Trust, they have a pretty strong allocation in their budgets towards dissemination. And I think that's a pointer to take away for researchers. So when you're developing budgets or research programs, think really carefully at the outset about putting aside that funding and that money to get sort of your message across more widely. So going back to Rebecca's talk, it felt like a really fitting way to close conference and a strong reminder that the value of research really lies in whether it leads to meaningful change in practice. So, yeah, just I just wanted to come back finally to that point. About one of the things that we consistently hear about the BJGP research conference is how welcoming and approachable it is. It's a really easy space to strike up conversations with people at all stages of their careers. So from students to early career researchers through to more senior academics and members of the BJJP editorial team who always attend. And I think it's always just been a really great opportunity to have those informal conversations that sometimes often spark new ideas or collaborations. So I guess what I'm trying to say is if you're interested in meeting like minded colleagues in general practice or primary care research or thinking about getting involved in research and publishing, it's definitely one to consider for next year. So a really big thank you to everyone who came along this year. I hope you all found it as engaging and inspiring as I did and it was lovely to meet so many of you throughout the day as well. And with that, that's the end of this season of the BJGP podcast, so we'll be taking a short break over Easter, but we'll be back soon with a new series where as always, we'll be discussing the latest research published in the BJGP and what it means for practice. We're planning to come back in early May, so do keep an eye out for that. But as always, thank you again for listening.
- Transcript
S4 · E228
March 17 · 18 min
Skill mix and patient trust in general practice
Today, we’re speaking to Dr Charlotte Paddison, who is currently non-executive director at Royal Papworth Hospital, and formerly a Senior Fellow and co-lead for Primary Care at the Nuffield Trust. Title of paper: Implications of skill-mix change in general practice: secondary analysis of data from the GP Patient Survey Available at: https://doi.org/10.3399/BJGP.2025.0360 To the authors’ knowledge, no previous studies have investigated the impact on patient trust or perception of needs met when patients are unsure what type of health professional they have seen. Using data from a large national survey, this study found that patients expressed lower confidence and trust, and were less likely to report their needs were met in general practice consultations when they were not sure who their appointment was with. The results are novel in demonstrating that the combination of not knowing who you saw and a remote appointment is particularly problematic for patient trust. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:01.600 - 00:00:58.530 Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate editors of the Journal. Thanks for taking the time today to listen to this podcast. In today's episode, we're speaking to Dr. Charlotte Patterson, who is currently non Executive Director at Royal Papworth Hospital and formerly a Senior fellow and co lead for Primary Care at the Nuffield Trust. We're here to discuss the paper she's recently published here in the BJGP titled Implications of Skill Mix Change in General Practice Secondary Analysis of Data from the GP Patient Survey. So, hi, Charlotte, it's really lovely to meet you and to talk about your work and I just really wanted to start by exploring how we know that the composition of the general practice team is evolving with the increasing scope of multidisciplinary work. Really? And I wondered if you could just give us some of the context for this work and what you wanted to do here. Speaker B 00:00:58.850 - 00:02:04.870 Absolutely. Nada. So what we really wanted to understand was how two big shifts in policy are shaping the experience of patients care when they come to the GP practice. Why do we think that was interesting or potentially important? Basically, we've seen two big changes happening at the same time in the last five years. So. So we've seen the shift to multi professional team working with many more different types of health professionals working in general practice and at the same time, separately, we've seen a massive increase in the number of appointments delivered remotely. So what we wanted to know is what those changes really mean for patients. We also know that some patients feel confused about who they're seeing and when they turn up to a GP appointment at the surgery, whether that's an appointment with a GP or a physician's associate or a social prescriber. And this led on to another really important question for us in this study, which is what happens when patients are confused or uncertain about who they've seen and what does that mean for patient trust? Those are the kinds of questions we wanted to answer. Speaker A 00:02:05.350 - 00:02:39.730 So this was an analysis of the 2023 GP Patient Survey, which is sent to patients registered in English general practices. And I think the key thing for this work and what you've outlined just in terms of what you're saying right here, was that the survey asks people who their last general practice appointment was with and whether they had confidence and trust in that person and if their needs were met. And just given what you were describing, I wanted to move straight on to what you found. What did the patient say about trust and how did it Vary by different patient characteristics. Speaker B 00:02:40.050 - 00:03:27.890 Sure. So what we found in relation to trust. Nada. Is that while every 2, 2 in every 3 patients reported they definitely had trust and confidence in the health professional they saw at their GP practice. And that's very positive. We also found at the same time, there's a minority of patients, around 7%, who reported they did not at all have confidence and trust in their last GP practice appointment. And we found that trust is lower among patients who are younger, from minoritised ethnic backgrounds and living in more deprived areas. So that's what we found in relation to trust. We also found that patients are confused about different roles of health professionals working in general practice. And we've found this is likely to affect around one in every 20 patients. Speaker A 00:03:28.370 - 00:03:30.290 That seems quite a lot, actually, doesn't it? Speaker B 00:03:30.530 - 00:04:26.740 Yes. And it's also we found, looking at the GP general practice patient survey, we found that the proportion of patients who feel confused about who they're seeing has gone up over time. What I can tell you is that if we look backwards over time, the national survey data shows the percentage of patients who are unsure who their last appointment was with has more than doubled in six years. In 2018, it was around 1.9% of patients. In the 2024 survey, this had gone up to 5% of patients. And at the same time, we've also seen a decline in confidence and trust. So what we can say there is that confidence has declined by around 5% over that same time period. So 5 percentage points from 69% of patients saying, yes, definitely they had confidence and trust in the health professional they saw in 2018. But by 2025 that's dropped to 64%. Speaker A 00:04:27.220 - 00:04:46.100 And I think that almost reflects what's happening in practice with the increasing number of other roles working in general practice as well. And I think one of the really striking findings here is that patients reported much lower trust when they weren't sure which professional they saw. Do you want to talk us through that and why you think that is? Speaker B 00:04:46.630 - 00:06:26.190 Absolutely. So what we've seen in terms of context here is that a lot of change happening in general practice, much of it taking place at the same time. So we've seen in terms of multi professional team working, there are 40,000 additional non GP non nurse staff working in general practice, which is a whopping 387% per patient increase over a nine year period. At the same time, we've also seen this huge policy focus on rapid access, delivering more remote appointments, working at scale and a shift to digital and online as well. So there's a lot going on in general practice all at the same time. And we can also see alongside this changes in patients confidence and satisfaction with how general practice is working. So that's sort of a zoomed out, bigger picture lens. We can see that in terms of the British Social attitude survey in 2024, almost half of all people said they were quite dissatisfied with how general practice was working. But looking back in time, if we look back to 1983, we see that only 13% of people were dissatisfied with how general practice was running. And even looking back just 10 years ago, in 2016, that figure is 16% of the of people in the British Social Attitude Survey who were dissatisfied with general practice. So we're seeing massive shifts across multiple aspects of general practice. At the same time, we're seeing a significant shift in the proportion of people who feel that they are satisfied with what's happening in terms of the care they're receiving from general practices. Speaker A 00:06:27.070 - 00:06:35.070 And I guess that relates to some of the issues with trust and potentially not knowing who people are seeing in practice as well. Speaker B 00:06:36.170 - 00:07:12.390 Absolutely. So in our findings, what we found was that the combination of not knowing who you saw and a remote appointment is really problematic for patients in terms of trust and confidence. So to give a flavour of this, when patients were not sure what health professional, what type of health professional they saw or spoke to, and this was a remote appointment, so an appointment by phone or video or message, the likelihood of reporting confidence and trust decreased by up to 80% when compared to patients who saw a GP in person at their practice. Speaker A 00:07:12.470 - 00:07:48.910 And we did a podcast with Richard Baker talking about trust in healthcare professionals as well. And one of the things he highlighted was that actually trust is really important in that patient clinician interaction, because, you know, that trust actually builds some foundation towards whether people might want to come back to the practice, they might want to take up that advice or management that's been suggested by the clinician they see. So I think not only are you seeing these associations, but it's actually really drilling down to why trust is so important as well in these interactions. Speaker B 00:07:49.710 - 00:09:55.280 Absolutely, you're 100% right. And I think we can see. And Richard Baker spoke to this. So high trust means that people are less likely to overuse services, so they're less likely to repeatedly seek appointments from different health professionals for the same problem. But importantly, they're also less likely to underuse services, because high trust means people are more likely to feel confident in presenting themselves as good candidates for care. For example, trust is Also important for other reasons in general practice. So about a quarter of all appointments at GP practices are for medically unexplained symptoms. And that work of managing undifferentiated symptoms is hugely important. And much of that rests on trust, the trust between a patient and health professional, when actually it's not the right thing to refer for further investigations or treatment. A lot of that rests on trusting relationships. And we know that relationship based care, where the patient's more likely to see the same doctor over time, somebody they know, is hugely important. But at the same time, we've seen a massive drop off and continuity of care. So if I can speak to the general practice patient survey, what we know is that in the last eight years, continuity of care as reported by patients in England has gone down by around 10 percentage points over the past seven years. So it was 50% of patients in 2018 who said they were able to see or speak to a preferred doctor. They had a preferred doctor and they were able to see or speak to them either almost or all of the time. By 2055, that had reduced and dropped to just 39%. That's a really meaningful change for patients. And I think if we look at our study and the results of our study, and we sit that alongside the work of a paper published by Carol Sinot and colleagues recently, we can see that there's real questions about whether the kind of model of care we have is delivering the types of appointments many patients want and need. Speaker A 00:09:56.240 - 00:10:18.680 And I think Richard Baker talked about this in terms of two kind of different models of care almost. So this sort of access, dependent, transactional kind of care model on one side, where there are lots of different people working in practice and access, quick access is prioritized, and then the more traditional sort of relationship based care that you're describing as well, that appears to be in decline. Speaker B 00:10:18.680 - 00:10:52.380 Sadly, the evidence does show that we've seen a significant decline in continuity of care in general practice in the last five, six, seven years. And that is really challenging for patients as well as for health professionals, because there's good evidence that relationship based care adds to meaning and work. Joy at work, satisfaction in your job. It also makes it time efficient to be able to speak and meet with patients whom you already know, particularly if those patients with complex care. Speaker A 00:10:52.700 - 00:10:57.020 Were there any results from your work here that surprised you when you looked at the data? Speaker B 00:10:57.260 - 00:12:58.379 That's a really good question. Nada. And I think while we understood that there had been so much change in general practice in recent years, trying to map out what that means for patients using evidence. If I'm honest, I don't think we expected to see the magnitude of the effects. We saw the likelihood of reporting trust and confidence decreasing by 80%. When you have an appointment where the patient's not sure who they've seen, they're confused about that and it's a remote appointment, that's a big effect size. And if I'm honest, that did surprise me. I think there's things from here that I possibly worried were real and the results confirmed that, so they weren't so much surprising. But that doesn't take away at all from the level of concern about those. So one of the things that has concerned me from here, from the results of our study, is that we know that almost 1 in 10 patients said their needs were not at all met in their last general practice appointment. That's really worrying. And it's worrying mostly because, well, even more worrying because those living in deprived areas and those with a chronic illness were more likely to report that their needs weren't met. So that suggests that some of the shifts we've seen in the way that care is organised and delivered may be contributing to the inverse care law. And that raises some really deep questions about what is the purpose of general practice and how do we ensure that we orientate service delivery models to provide care for patients not only who might prefer or need rapid access for a more transactional type of problem, at the same time as ensuring there's continuity of care and relationship based care for patients who need and will benefit from that model of care. So these are difficult but important questions for general practice. Speaker A 00:12:58.860 - 00:13:06.620 And I wonder what your thoughts are about how much of this issue is about communication and expectations rather than the roles themselves. Speaker B 00:13:07.020 - 00:15:03.940 I think there's a very important element that you're picking up on there. Nada. And I do think that communication is a hugely important part of embedding skill mix change successfully into general practice. So I think it's a complex picture here. What we can see is that it's really important that GP practices have good systems in place so that when a health professional introduces himself to a new patient, it's expected that they can say, you know, my name is X and I'm a physiotherapist working in this practice, or I'm a physician's associate working in this practice so patients can be clear. We need clarity on that at both local practice level and also support for that at a national level in terms of successfully implementing some of these changes. I also think that it's not just about communicating roles. Well, although that's a very important part of what needs to happen here, we also need to recognise that it's more difficult to establish trust and build rapport in situations where care is delivered remotely. So thinking about practical strategies to support that sort of building of trust and confidence and knowing who it is that you're seeing when the appointment might be remote. I think we also need to recognise that the public really worry about not knowing who they're seeing. And there's a element of social media in contributing to this. We've seen some high profile cases leading up to a patient's death where the family and the patient have been confused about who it was the patient saw. And that's hugely upsetting. It's a significant issue of real public concern. And I think we need to address those worries and communicate and provide assurance and reassurance for patients, both when they come into practice, but also thinking through how changes are implemented at a national level and whether there's things to learn from some of those experiences. Speaker A 00:15:04.580 - 00:15:23.540 Yeah, and I just wanted to pick up on that, especially going back to your role and experiences working at the Nuffield Trust. And we know that national policy is strongly encouraging multi professional teams in general practice. And do you have any thoughts about what your findings suggest policymakers should think about as these teams expand? Speaker B 00:15:24.100 - 00:17:48.710 That's a great question, Nana. I think what we can see is that multidisciplinary team working in primary care is not new, and we do know that it can offer a mix of potential benefits for staff and patients. But we also know that desired outcomes are not always delivered and we can see that implementation has been really challenging. So I think there's important reflections there and lessons to be learned about, for example, the importance of building trust and clearly communicating new roles to patients, but also supporting staff and embedding new roles into practice and thinking about the cost of supervisory time to support new roles, to coordinate care, to ensure and avoid fragmenting care. When you have different members of a team working together to support an individual patient.
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S4 · E227
March 10 · 13 min
What happens in general practice before an emergency lung cancer diagnosis?
Today, we’re speaking to Marta Berglund, a Research Assistant and PhD candidate at University College London. Title of paper: Pre-diagnostic primary care consultations and imaging in emergency-diagnosed vs referred lung cancer patients Available at: https://doi.org/10.3399/BJGP.2025.0369 It has been postulated that emergency diagnoses of cancer (which occurs frequently and confers a poorer prognosis) may relate to suboptimal diagnostic management in primary care, but evidence to support or refute this hypothesis is sparse. We found that emergency-diagnosed patients with lung cancer were less likely to present with relevant respiratory symptoms and had fewer chest imaging investigations before diagnosis compared to patients diagnosed via referred routes, indicating an important role of disease factors in emergency diagnosis. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:01.200 - 00:01:06.690 Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate editors of the Journal. Thanks for listening to this podcast today. In today's episode, we're speaking to Marta Bergland. Marta is a research assistant and PhD candidate at university College London. She's recently published a paper here in the BJGP titled Pre Diagnostic Primary Care Consultations and Imaging in Emergency Diagnosed versus Referred Lung Cancer Patients. So, hi, Marta, it's really lovely to meet you and it's great to talk to you about cancer diagnosis, which is a really important area for general practice and also a topic we publish on quite a lot here in the bjgp. It's been fascinating reading this paper and it tackles a cancer that we really don't do well with here in the UK in terms of early diagnosis. But I wonder if you could just start off by telling us a little bit more about lung cancer and how it's actually often diagnosed, which can sometimes lead to some of those poor outcomes. Speaker B 00:01:07.010 - 00:02:26.970 So, as you said, lung cancer is one of the cancer sites in the UK where the majority or a large proportion of patients are diagnosed through the emergency route, also known as emergency presentations, which is when a patient is diagnosed after they present through an urgent hospital admission or an A and E attendance in the 30 days before diagnosis. And that could look like someone who has had a persistent cough for, say, two weeks, but didn't actually go to their gp, and then suddenly they have a more severe onset of symptoms like shortness of breath, and then they go to A and E and are referred to a chest X ray and then get diagnosed, which is a pathway that is associated with worse prognosis and worse outcomes after diagnosis. And the more preferred route, if you will, in England to diagnose patients is through primary care. So through the GP routine referral or the urgent suspected referral route. And that could look like someone who presents to primary care with cough or dyspneasia again, but then their GP refers them to a chest X ray and then they're diagnosed with lung cancer. Speaker A 00:02:27.130 - 00:02:45.290 And I guess I wanted to just before we talk about what you found, I wanted to just cover here again, what you mean by this term, that's diagnostic window, because you mentioned that a few times in the paper. But what does this actually mean? And it relates a bit back to some of what you're talking about, about people presenting with symptoms, isn't that right? Speaker B 00:02:45.530 - 00:03:09.880 So, for us, it's a measure of healthcare use before diagnosis, and it could be any healthcare use Measure like consultations, symptoms, blood test use, anything like that. And it's measuring when that changes compared to baseline before diagnosis, which can signal increased healthcare use associated with the subsequent diagnosis. Speaker A 00:03:10.040 - 00:03:16.840 Okay, so it just, I guess it's what it says on the tin. It's just that window, isn't it, of potentially being able to pick up a change. Speaker B 00:03:17.490 - 00:03:25.970 Exactly. So the idea is that if there is an increase long before diagnosis, then possibly there is an opportunity to diagnose these patients earlier. Speaker A 00:03:26.450 - 00:04:09.190 So this was a really big study using the CPRD and this is a database that a lot of the listeners will be familiar with. And you had a sample of a million patients registered with UK General Practice and then you looked at people diagnosed with cancer and their pre diagnosis rates of consultation like you were talking about, and also chest imaging by the different possible diagnosis routes. So either as an emergency, a routine or an urgent referral. But I really want to move straight to what you found here. Can you give us just an overview of how the different people in this analysis were eventually diagnosed with lung cancer? So were there a lot of emergency diagnoses here? Speaker B 00:04:09.350 - 00:05:46.240 Yes, I believe we had around 30% of patients who were diagnosed through the emergency route, compared to 20 something percent in the urgent referral route and the GP routine referral route. That aligns with the national data in NCRAS and also the Rapid Cancer Registry data. I guess that's what we expected to see. We found that the majority of patients do present to primary care, which then disproves this hypothesis that has been presented in the literature that patients who are diagnosed through the emergency pathway don't present to primary care at all and therefore there wouldn't really be a chance to intervene and improve these patients diagnostic pathway. I think that is one of the key findings, although it is a simple finding. Then we also found that there are short term similar diagnostic windows across these routes. Patients who are diagnosed as emergencies had similar opportunity to intervene earlier as patients from the other routes, just because of the timing at which things changed. However, we also looked at the rates and those were consistently lower for emergency diagnosed patients, even though the timing at which things change at the lower rates mean that these patients present less frequently. And so because they present less frequently, there are simpler, fewer chances in primary care to also like see warning signs earlier. Speaker A 00:05:46.480 - 00:05:56.480 Yeah, so you looked at those consultations rates. So is that what you're describing here? So is that what those findings show in terms of potential opportunities for earlier diagnosis? Speaker B 00:05:57.280 - 00:06:17.190 Yeah, so what I had in mind was mostly the consultations and the consultations with symptoms, but then acknowledging that we measured two different things. So the timing at which things change, the diagnostic windows as well as the rates of these consultations, how frequently they were occurring for patients by route. Speaker A 00:06:17.430 - 00:06:27.510 And what you're suggesting is that people who were diagnosed via emergency had lower rates. So that sort of is a bit counterintuitive. So can you talk us through that again a bit? Speaker B 00:06:27.590 - 00:07:06.880 It's a bit contradicting. Well, it would seem that it is because these patients do present to primary care and then when things start going wrong, let's say they happen around a similar time as for patients who are diagnosed through the other routes. But what sets the emergency diagnosed patients apart is that they present less frequently. So they may still have cough and may still go to their gp, but they may not do so as often as someone who's referred on a two week wait, for example, or now urgent suspected referral, which then means that there are fewer chances for gps to pick up on persistent symptoms and then refer those patients. Speaker A 00:07:07.200 - 00:07:19.780 And I guess just. Were there any other main findings that you found in terms of sort of the diagnostic window or sort of consultations before diagnosis via the different routes? Speaker B 00:07:19.940 - 00:09:14.860 Yeah, so I think one of the most interesting ones as well to the overall finding of patients presenting to primary care is that patients presented with non specific symptoms around 10 to five months before diagnosis across the routes, which is still quite a while before they're diagnosed. So potentially this could mean that something could have been done differently to, for example, refer these patients earlier in like say month nine before diagnosis rather than nine months later. But again, as you said, this is also in lung cancer patients, which is a very difficult cancer site to diagnose early. And part of that reason is because the symptoms that patients present with are non specific symptoms. So it's also understandable that it is difficult to make that call based on someone presenting with cough in primary care, which is why there's more like work to be done and we need to better understand where the thresholds are for referral, like how many times someone comes in with the same symptoms, something like that. But the work does show that that is like a common characteristic that is shared among, like across lung cancer patients, even diagnosed by the different routes. And then another finding was also similar to the non specific symptoms, was that patients had chest imaging, so chest X rays around six to four months before diagnosis, which again is still a while before they're diagnosed. And because these are chest X rays, then it could mean that they have negative chest X rays before diagnosis and then are again perhaps referred back to primary care with symptoms or they have an another chest X ray within those months where things are increasing, like month four to zero before diagnosis. Maybe there's a learning to be found from that. Speaker A 00:09:15.100 - 00:09:32.620 Yeah, absolutely. And I wanted to just touch on those findings around imaging. And I wonder what thoughts you had about the role of access to chest CTs for GPs, just given what you've described here about chest X rays and potential potentially negative chest X rays as well in this cohort. Speaker B 00:09:33.180 - 00:10:02.380 Well, I do think that it's also pretty well documented in the literature that chest X rays aren't necessarily the best and most accurate diagnostic test for lung cancer and that improving access to low dose CT in England has helped diagnose lung cancer patients. So I think improving access to chest imaging and CT scans specifically could also present an opportunity to diagnose patients earlier. Speaker A 00:10:02.830 - 00:10:16.990 And I wonder, just given all this information, what you found in this study, what do you think are the main implications for potentially opportunities to diagnose lung cancer earlier and not via emergency routes for these patients? Speaker B 00:10:17.390 - 00:11:07.090 Again, I think the picture is complex because as you've also mentioned, the paper doesn't have kind of like a clear finding of something that was very different in the emergency diagnosed route. But actually patients who are diagnosed through the emergency route look quite similar to the, the primary care referred routes. Then I think what we can do is focus on the things that were similar for all patients, meaning that there's also a similar opportunity to diagnose patients earlier across all routes. Those things include being more vigilant about the non specific symptoms that patients present with and perhaps having a lower threshold for referral or more thorough follow up. And then I also think improving access to chest CTs could also help diagnose Speaker A 00:11:07.090 - 00:11:22.290 patients earlier in the paper you touch very briefly on screening. Is there anything that you want to mention here about sort of potentials for lung cancer screening or what might already be in play in terms of potential policy for screening for lung cancer? Speaker B 00:11:22.850 - 00:12:16.370 Yeah, I mean, I think lung cancer screening is very important and it's definitely going to change the way things look in terms of how patients are diagnosed. And I think we're already seeing that since I think around like 2022 when the program started being rolled out. There's around 7% of patients who are diagnosed through screening now, which we can see in the Rapid Cancer Registry data set that's actually publicly available as well. So with that being said, it is still a bit difficult to know what that means because we need to let it play out for a few more years until we know what that means for diagnoses through the other routes. Hopefully it will mean that some patients who would be diagnosed through an emergency route won't be. But of course we also don't know to what extent emergency diagnoses are completely avoidable. Speaker A 00:12:16.610 - 00:12:23.280 And I think it's important to point out probably that the lung cancer screening programs are really targeted at the moment as well, aren't they? Speaker B 00:12:23.360 - 00:12:50.190 Yeah, exactly. I believe there were patients who are eligible are those aged 55 to 74 and who have a history of smoking. So for example, in our study that was 38% of patients who are diagnosed as emergency patients. So there's still 62% of emergency diagnosed patients who would not have been eligible for the screening pathway regardless. Speaker A 00:12:50.910 - 00:13:11.950 And I think what you say here about actually not just focusing on what you found amongst the patients who were diagnosed with lung cancer via the emergency routes, but actually looking at everyone who's diagnosed with lung cancer and trying to improve care for all is really important in terms of extrapolating the findings here. It's been really great talking to you about this work. So thanks to again for joining me. Speaker B 00:13:11.950 - 00:13:12.590 Thank you. Speaker A 00:13:13.390 - 00:13:29.310 And thank you all very much for your time here and for listening to this BJGP podcast. Marta's original research article can be found on bjgp.org and the show notes and podcast audio can be found@bjgplife.com thanks again for listening and bye.
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S4 · E226
March 3 · 24 min
Designing neighbourhood urgent care: A general practice perspective
Today, we’re speaking to Dr Mike Holmes, a GP in Yorkshire and Chair of Nimbuscare, a local GP-led multi-neighbourhood provider. Title of paper: Neighbourhood delivery of urgent care in North Yorkshire, UK Available at: https://bjgp.org/content/76/764/133 Neighbourhood-based urgent care, led by GP Multineighbourhood providers, can reduce reliance on hospitals and NHS 111. Delivering urgent care in community settings is more cost effective than Urgent Treatment Centre and Emergency Departments attendances. Digital integration and shared clinical systems improve safety, responsiveness, and patient experience. Co-locating operational and clinical teams streamlines service delivery and enables operational and quality oversight. Sustained impact requires recurrent funding and performance measures that reflect system-wide improvement rather than single-provider metrics.
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S4 · E225
February 24 · 19 min
Delayed, declined, or disengaged? Understanding childhood vaccination patterns
Today, we’re speaking to Dr Karol Basta, a Public Health Registrar based in London. Title of paper: Predictors of Childhood Vaccination Uptake and Timeliness in a Diverse Urban Population Available at: https://doi.org/10.3399/BJGP.2025.0319 Childhood vaccination rates have declined in the UK, with inequalities in urban, deprived, and ethnically diverse populations. Previous studies have lacked individual-level clinical data or did not explore both uptake and timeliness. We analysed 13 years of routinely collected primary care data for over 37,000 children in a diverse London borough to identify predictors of uptake and timeliness. Distinct sociodemographic and clinical factors were associated with incomplete and delayed vaccination, offering timely insights as responsibility for vaccination services shifts closer to local systems and place-based commissioning. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.880 - 00:00:52.000 Hi and welcome to BJJP Interviews. I'm Nada Khan and I'm one of the associate editors of the Journal. Thanks for taking the time to listen to this podcast today. In today's episode, we're speaking to Dr. Carol Basta. Carol is a public health registrar based in London and we're here to talk about the paper she's recently published here in the bjgp, which is titled Predictors of Childhood Vaccination Uptake and Timeliness in a Diverse Urban Population. So, hi, Carol, it's really lovely to meet you and to talk about this work. And I guess just to start, I wanted to put this work into context. We know that in the uk, overall childhood vaccination rates have unfortunately been declining. Could you talk us through some of the current challenges around vaccination, especially in urban and diverse areas? Speaker B 00:00:52.720 - 00:02:06.750 Yep. So we know vaccinations are really powerful and cost effective tools we have in giving children the best start in life life. But unfortunately, in the UK, since 2012, the uptake has been declining and actually since 2021, none of the vaccines in England have reached the 95% target recommended by the WHO to stop communicable disease outbreaks. And the kind of negative consequences of this aren't just sort of future hypothetical risks. We've already been seeing vaccine preventable diseases such as measles and whooping cough resurgences, and this is especially in certain parts of the uk, such as London or the northwest of England. So no uptake of vaccines is decreasing and vaccine preventable diseases are increasing. But that's not the full picture. We also know, for example, following work done by, at the time, Public health England in 2017, there are avoidable inequalities across the childhood vaccination program nationally, for example, linked to deprivation, geography and ethnicity. However, what was missing was really kind of contemporary granular evidence on the social and clinical factors associated with unequal vaccine outcomes, especially in diverse urban environments. Speaker A 00:02:06.990 - 00:02:16.670 And I know this was highlighted as well during COVID but there is a mistrust of health services amongst some communities as well, which might be playing into this. Speaker B 00:02:17.470 - 00:03:11.120 Yeah, exactly. So at the time when I was working in Lamb of Council, we knew qualitatively from talking to our community and talking to our local GP partners, that there was kind of sense of rising mistrust in healthcare services, but also rising difficulties with actually access to services. And that doesn't just affect whether or not people can get the vaccine, for example, it also affects whether they can have conversations about vaccines and the kind of continuity of care and building up those relationships. And so this is what we had kind of on a local level, but we knew that there was also national feelings and sentiments around mistrust, not just national, but actually globally vaccination mistrust from the COVID 19 pandemic. And there were worries that this had run off into the childhood vaccination program as well, that it hadn't just confined itself to Covid vaccines. Speaker A 00:03:11.440 - 00:03:41.490 So this was a study looking at predictors of routine childhood vaccination from 40 general practices in Lambeth and London, which is a pretty ethnically and socioeconomic demographically diverse borough. And you looked here at the vaccination uptake and timeliness and some of the predictors for these. This was a really big sample. But just to underline the population here, tell us more about the demographics in Lambeth as a borough in terms of ethnicity, because that's where you were based when this work was done. Speaker B 00:03:41.890 - 00:04:32.250 Yeah, exactly. So Lambeth is an inner London borough and it is very ethnically diverse, it's very densely populated, but it also has some of the highest levels of deprivation in the country. And part of the strengths of this study is that we were able to use detailed ethnic subgroup breakdowns. So, for example, rather than using the broad category of South Asian, we were able to split this down into Pakistani, Bangladeshi, Indian, et cetera. And this was really important because this aligns with national health equity guidance. We know that health outcomes actually vary between the details, subgroups. There's some evidence to suggest that, but it was also important following local community engagement work, where people repeatedly told us these kind of big, broad groups don't reflect how we self identify. Speaker A 00:04:32.490 - 00:04:39.530 And I wanted to just move on to the results here, so can you start talking us through some of the associations based on deprivation to start with? Speaker B 00:04:39.690 - 00:06:22.410 Yeah, sure. So we looked at two main outcomes. We looked at vaccination uptake, so that's whether children had received their vaccines at any time point during the study. And we also looked at vaccination timeliness. And vaccination timeliness is important because although a child might eventually go on to receive their vaccine, it leaves them. They're late, it leaves them unprotected for at times when they're most potentially likely to get unwell. And what we found with deprivation in uptake, there was really clear patterns associated by deprivation. There was actually children living in more deprived areas were progressively less likely to be vaccinated compared with those living in the least deprived areas. So, for example, children living in the most deprived 20% of our population were about a third less likely to be fully vaccinated compared to those living in the least deprived areas. This kind of wasn't just a straight out deprivation. There was also lower uptake linked to other markers of social vulnerability, such as being born outside of eco, or such as children having safeguarding involvement. And so that was what we found for uptake. But what was interesting is the findings for timeliness didn't mirror this. So whilst those living deprivation were less likely to be vaccinated, if we zoom in on just the population that were vaccinated and think about were they vaccinated on time, we didn't find that children living in deprivation were less likely to be vaccinated on time. We found no difference. And there was a similar pattern for other markers of social vulnerability, such as safeguarding involvement. They have a lower uptake, but it wasn't associated with kind of untimely vaccination. Speaker A 00:06:22.650 - 00:06:31.210 And you've touched upon this, but there was a really striking result here in terms of children who were born outside of the uk. So can you talk us through this? Speaker B 00:06:31.530 - 00:06:59.060 Yeah. So we also found that children born outside of the UK were much less likely to be vaccinated compared to children born inside the uk. However, if again, we zoom in on just those vaccinated and look at timeliness, we actually find the opposite. So if you were born outside of the uk, you were more likely to have your vaccine delivered on time compared to those who were born in the uk? Speaker A 00:06:59.380 - 00:07:03.380 Sure, yeah. So talk us through some of the reasons that you think that this might be happening. Speaker B 00:07:03.380 - 00:08:30.800 Yeah, I think these findings, the difference between uptake and timeliness, not having the same predictors and in some case having the opposite patterns being shown are really quite interesting. And they're kind of a few possible explanations as to why this might be. One is perhaps potentially there's a form of selection going on. So when we look at only children who get vaccinated in groups with lower overall uptake, for example, children of non white British ethnicity, or as we've said, children not born in the uk, the children who do get vaccinated may represent more engaged, health literate or well supported families. And that same engagement may also support timely vaccination. But in groups of higher overall uptake, for example, children of white British ethnicity or children born in the uk, the groups who do get vaccinated may include a kind of broader, more mixed group of families, including some who vaccinate later, which can then reduce their overall level of timeliness. And this raises the possibility that our kind of existing recall and catch up systems may work better for some groups over others and in doing so may actually unintentionally reinforce inequalities rather than reduce them. But there are other alternative explanations and I think what's really key here is future research is really important. Timeliness has generally been less well described and these findings potentially raise important questions. So it's definitely an area where both qualitative work and also future quantitative work I think would be helpful. Speaker A 00:08:31.040 - 00:08:45.360 And you've touched a bit about the deprivation and children born outside of the uk and in this cohort, as you said, you were able to get quite detailed information about ethnicity rather than sort of the broad brush groups. Speaker B 00:08:45.760 - 00:08:46.200 Yeah. Speaker A 00:08:46.200 - 00:08:52.560 What did you find here in terms of ethnicity and uptake? So did it mirror some of the findings around children born outside the uk? Speaker B 00:08:53.530 - 00:11:05.920 Yeah. So compared to children of white British ethnicity, lower uptake was observed with all other ethnic groups. The largest gap was seen among children of black Caribbean ethnicity, whose odds of being fully vaccinated were around 70% lower than those of white British children. But other groups such as Indian, Pakistani, Bangladeshi, Chinese, Arab and several other mixed ethnic groups also had lower uptakes, ranging between 30 to 50% lower than white British children. And so all, although all groups had a lower uptake compared to white British, it suggests that the kind of barriers may not be experienced in the same way or to the same extent and could potentially reflect a combination of different structural, cultural and service related factors. I think with all of these findings, I think it's. I think there's two important things to note, is one, we found all of the inequalities were present for both individual vaccines. And then because we looked at overall patterns across the schedule, they weren't just kind of isolated to one vaccine, they were found for all the vaccines for all different sorts of combinations. And this was important for us to find, as some of our work qualitatively, but also some findings nationally suggested perhaps some communities have lower uptake relating to just the MMR vaccine, for example, but we didn't find that. So this suggests that kind of these inequalities are unlikely to be driven by really specific parental concerns about one vaccine, but it's kind of more wider barriers to accessing vaccination services. So I think that's one important thing to be aware of. And then the second thing is that these inequalities are persisting after adjustment for a wide range of socio, demographic and clinical factors, as well as age as well as GP practice. So that kind of indicates a Certain level of robustness to measured confounding. But however, as of any observational study, there are unmeasured factors that might be influencing things. For example, in this case, things like parental education or family size, which we weren't able to explore but would be interesting to do in further studies. Speaker A 00:11:06.080 - 00:11:25.620 It's interesting. You're talking about access as potentially quite a major contributing factor. And one thing I was wondering was that, is it that there's more outreach needed to certain communities, or do you think it is sort of a matter of access to health care or an understanding about healthcare and what's being offered? Really? Speaker B 00:11:26.500 - 00:12:25.010 Yeah. Research shows that it's often. It's not necessarily just one thing, it's not necessarily just access, but it could be access combined with kind of vaccination misinformation or mistrust in the system. So there's often multiple things going on which can combine to cause vaccination inequalities. I think, though, given the kind of strong findings across the vaccination pathways showing structural and social influences on vaccination inequalities, access is going to be definitely part of the story. And we also know this from qualitative research as well. And so I think there are a number of things, not just general, general practices, but kind of different bodies that support general practice, such as national policy or integrated care boards. I think there are definitely things that can be done in this space. Speaker A 00:12:25.250 - 00:12:45.120 And I think, as you're pointing out, this study has shown some of those persistent inequalities present with vaccination uptake. I think that actually your work as a public health doctor is really important to draw on here. What do you think needs to be done at both the local or national level to start to tackle these inequalities? Speaker B 00:12:46.160 - 00:13:02.720 Yeah, I think it's one of those things that requires a whole range of groups to play their part. So I'd say there are kind of implications for GPs, implications for local teams, local integrated care boards, implications on a national level, and also implications for the research community. Speaker A 00:13:03.040 - 00:13:14.150 It would be great to start with, what do you think that gps should be doing? Because these are people coming in to see us or families that we might know over time. So it would be really interesting to hear your thoughts on that. Speaker B 00:13:14.550 - 00:15:25.730 Yeah, yeah. We've hopefully established that this study has shown a broad range of social and structural determinants of vaccination, and these are across the pathway. So I think practices are likely to have a greater impact by strengthening the overall vaccination pathway to work better for families. Facing those barriers rather than focusing on individual vaccines or short term campaigns. There are a number of ways this can be done. Firstly, it's about making access easier, not more demanding. So people who, families who are under vaccinated aren't necessarily even against vaccination, but they're juggling multiple competing pressures. Life is challenging. So practical changes like flexible appointment times, opportunistic vaccination during other consultations, walk in clinics, simpler booking and recall systems could make a real difference. But it's not just the kind of process booking. I think the experience of the appointment itself also matters, especially if it's kind of one of earlier on ones. Feeling welcome, not rushed and having questions taken seriously makes families more likely to return and stay engaged with a vaccination program. But I think there's kind of secondly work that beyond the practice walls that gps can take. So having stronger links with health visitors, children's centres and safeguarding teams can help reach families who are just going to find it really hard to consistently engage with general practices. And in some cases vaccination outside the surgery, for example, community settings or through health visitors, may be more effective. And I think thirdly for practice, it's about building trust and continuity, which can sound kind of nebulous and difficult, but things like seeing a familiar clinician or having conversations in culturally sensitive ways can support engagement. And I think people who might have concerns about vaccines kind of not to expect that suddenly one consultation is going to solve all their problems. But it's kind of about visit upon visit building that trust and engagement. I've said all of that, but I'm very aware that this is very resource intensive and requires upfront investment, which I think it also needs to be supported by national policy and changing some of the funding mechanisms. Speaker A 00:15:26.130 - 00:15:41.870 I think, I mean, that's really the main point that I wanted to highlight was, you know, you're talking about things like health visitors or children's centers and things like that, and we know that funding for those areas is tight and being cut and I think possibly that this is where the impact is being felt. Speaker B 00:15:42.270 - 00:16:40.150 Yes, yes. And I think even before we get to things like children's centers and health visitors, which definitely their funding is being cut and needs to be, we can talk a lot about vaccination as uptake. We need to use community centres, health visitors, but if the money's not there, it's not going to happen. But I think even for general practice, funding for vaccination is linked to the number of vaccines given. But if you're in a Deprived practice, a very ethnically diverse urban with lots of challenges. You're going to have a harder job trying to vaccinate your population and you're also going...
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S4 · E224
February 17 · 15 min
From swabs to urine sampling: Rethinking cervical screening in general practice
Today, we’re speaking to Prof Emma Crosbie, Professor of Gynaecological Oncology based at the University of Manchester. Title of paper: Urine human papillomavirus testing for cervical screening in a UK general screening population: a diagnostic test accuracy study Available at: https://doi.org/10.3399/BJGP.2025.0105 The switch from primary cytology to primary human papillomavirus testing has enabled innovations in self-sampling for cervical screening. This study shows that urine self-collected with a first-void urine collection device has similar diagnostic test accuracy and acceptability to cervical sampling in a general screening population. Urine self-sampling has real-world potential as an alternative cervical screening option. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:01.440 - 00:01:07.140 Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate Editors of the bjgp. Thanks for listening to this podcast today. In today's episode, we're speaking to Professor Emma Crosby, who is professor of Gynecological Oncology based at the University of Manchester. We're here to talk about her really exciting paper that's recently been published in the December 2025 issue of the BJGP. The paper is titled Urine Human Papillovirus Testing for Cervical Screening in UK General Screening Population A Diagnostic Test Accuracy Study. So, hi Emma, it's lovely to meet you and to talk about this paper. I really just wanted to start off talking a bit around cervical screening in the uk, and you mentioned this in the introduction to the paper as well, that cervical screening really does have variable uptake rates and we know that there are some, some barriers to access. But can you talk us through these and tell us a bit about why you decided to do this research? Speaker B 00:01:07.940 - 00:03:41.440 So, as you've just really nicely summarised, cervical screening is really important weapon against cervical cancer. So we know that it prevents cervical cancer and since the introduction of the NHS Cervical Screening program in the UK, we've seen deaths from cervical cancer drop by around 70%. So we know that it's very effective. But in the uk, the number of people attending is declining year on year and currently, currently only around 68% of those people who are eligible for cervical screening actually attend. There are a whole range of different reasons for non attendance. These include things to do with the speculum examination, so having to have an intimate examination to be examined. The anticipated embarrassment or fear of pain related to that procedure, I think are important barriers. But there are also barriers associated with access to reaching screening appointments, taking time off work, having childcare and so on and so forth. So we thought that there was some really important barriers there that could potentially be addressed by self sampling. Now, vaginal self sampling is actually been incorporated in many cervical screening programs around the world. Some cervical screening programs are using it just for people who are non attenders or underscreened by traditional screening routes and other countries are using it as a choice for everybody. Now, in the uk, we haven't yet taken up vaginal self sampling sampling, but it will be introduced this year in 2026, principally for under screened groups. And there is some work looking at whether or not it will be introduced as a choice for everyone in the future. But we know from research that's been done in the UK that only around 12 to 13% of people who are offered vaginal self sampling who are under screened actually return a sample. And therefore it clearly doesn't address all the barriers to cervical screening. And we wondered whether a urine test would have more app. It would have the same benefits of vaginal self sampling in that it can be collected at home and posted to the laboratory. So it removes that need for an intimate examination. It removes the need for, you know, making an appointment at a healthcare facility to have your screen taken, but it perhaps, you know, removes some of the barriers towards putting a swab inside the vagina that might be culturally or religiously unacceptable to some groups. And so we thought that a urine self sample could be another option for people who currently aren't screened. And so we wanted to see how accurate it was in this study. Speaker A 00:03:42.320 - 00:04:03.760 And those issues around access are really important, especially in this population of women who are juggling lots of caring responsibilities with young children or caring for older relatives as well. So sometimes it is just difficult to get to an appointment and, you know, juggling work hours and things which often then coincide with GP opening hours as well. Speaker B 00:04:03.920 - 00:04:41.960 Yeah, absolutely. And we, we have seen a drop in people, you know, in the youngest age group of people who are invited for screening, attending SCRE, their rates of attendance are even lower than the 68% that I quoted. And probably a lot of that is to do with having very busy lives, not seeing this as a priority, imagining that you're not at risk and seeing cervical cancer as something that affects older people, perhaps. So there are additional barriers related to certain age groups. But I definitely think that making time for a screening appointment, juggling all the different millions of things that we have to do every day, is a really important barrier that something like a urine based test could help to overcome. Speaker A 00:04:42.120 - 00:05:10.680 Yeah, fair enough. So this was quite a big prospective study of over 1500 women carried out across the northwest of England. So women provided both regular speculum based cervical samples alongside urine sample too. And the main thing you were looking at here was the accuracy of the urine based HPV testing for cervical cancer. But just in case people aren't completely aware of all this, can you talk us through first why we're now only looking at HPV in these samples? Speaker B 00:05:11.060 - 00:06:30.230 Yeah. So, I mean, in 2019 in the UK, we changed from primary cytology based cervical screening to primary HPV based cervical screening. So that means that the sample taken from your cervix is tested first for hpv and only if that is HPV positive is it then looked at under the microscope. To see if there are changes in the cells. And this was based on a very large study done in the UK that showed that HPV testing is a much more sensitive test than cytology as the primary scre. And by that what we mean is it's much more likely not to miss abnormal cells than cytology, which is very effective when there is a large lesion, if you will, that can be sampled with a cervical swab, but not so good at picking up smaller lesions. And so there is the chance that cytology might miss an abnormality. But HPV is really good at showing that somebody is at risk. So we now do all primary screening by HPV testing. And of course this is what has opened up the opportunity for us to do different sample types. So a vaginal swab tested for HPV or a urine sample tested for hpv, you know, could also be an effective way of screening people to see if they are at high risk of cervical pre cancers. Speaker A 00:06:30.390 - 00:06:37.830 So talk us through the results. So how well did the urine based testing perform? So both in terms of how sensitive and specific the results were? Speaker B 00:06:38.130 - 00:09:24.670 Well, first of all, it's really important to say that this piece of work followed on from another piece of work that looked at a high risk population. And in that other piece of work we were able to show that it's really important how the urine sample is collected. So absolutely must be collected with a colipy device or a similar device that collects the first fraction of urine sampled. And that's important because the HPV isn't in the urine itself. The urine is flushing cervical mucus that is accumulated around the urethra into the sample. And so if you don't collect that very first flush of urine, then you're likely to miss the hpv. So on that background, using the COLIP device in this study and collecting that urine sample prior to the routine clinician obtained cervical sample, we were able to obtain two samples from each person that we were then able to test with the same HPV test. And we were able to compare absolutely how accurate the urine was compared to the matched cervical sample. And because we were using a general population, so this is anybody that's due cervical screening rather than a high risk population, we knew that we weren't going to see very many people who had CIN2 plus, which is the cervical pre cancer that we want to identify and treat. And actually what we were looking for here was to see, you know, what prevalence of HPV infections do we pick up using the two tests, you know, the urine test and the Cervical test and how well matched are they at terms of, you know, telling somebody that they're HPV negative and at low risk of cervical cancer and how well matched out they are picking up HPV positive people who also have cytological abnormalities that need to be referred to colposcopy. So if we take all of that information on board, then the bottom line figure is that urine picked up around 16% of people as having an HPV infection, while a cervical sample picked up around 13.5%. So you can see that we picked up slightly more HPV infections with urine than we did with the matched cervical sample. But when we look at, you know, how many of those had CIN2 plus, it was just a very small number. So only 25 of our 15, 17 people actually had a CIN2 plus lesion, and urine picked up 24 of those. So when we look at the relative specificity, if you like, of urine versus cervical sampling for HPV detection in this population, it was really good. It was 97% relative sensitivity specificity. And when we look at sensitivity, you know, we're a little bit underpowered because, like I said, we only had 25 CIN2 plus lesions, but urine picked up 24 of those 25. So it had really excellent sensitivity as well, even bearing in mind small numbers. Speaker A 00:09:24.830 - 00:09:43.940 And I think one of the main things to look at here and to point out was what the participants felt about the different forms of testing. And you looked and asked them what they thought about the cervical screening using a urine sample instead of the more traditional based speculum based testing. And what did they feel about that in terms of sort of acceptability? Speaker B 00:09:44.740 - 00:10:51.420 Well, I mean, as we might expect, most of them were quite happy with attending for routine cervical screening appointments. This probably is not the population for whom a urine based test is intended. It's probably, at least in the first instance, intended for people that are under screened. But it's perhaps not surprising that people who do go for routine cervical screening are more than happy to continue doing so. So we found that around 42% would prefer to continue to for their screening appointment and to have a sample taken by a healthcare professional. Interestingly, around 30% would prefer to switch to a urine based cervical screening test. And another sort of 30% or so had no particular preference over screening method. And this is quite interesting because it suggests that we probably need to have a menu of choices for people that, you know, one option for everybody is not going to answer the problems of reduced uptake of cervical screening and that if we had a menu of choices whereby people could choose the way that they would be screened in the future, that this might have the best way of increasing the number of people who are screened. Speaker A 00:10:51.500 - 00:10:55.180 Any other key findings from the paper that you want to touch on at all? Speaker B 00:10:55.420 - 00:11:42.680 Well, I think the main thing is that we were really impressed with the performance of urine. This is kind of. We didn't directly compare it to a vaginal swab result, which, as I'd already mentioned, is going to be introduced by the NHS Cervical Screening Program from 2026 for under screened women. But if we compare how urine has performed in study, especially if we look at it in combination with the study that was done in a high risk population, and then compare it with the recently published HP Validate study that compared different vaginal swabs with HPV testing results, we can see that urine performs at least as well as vaginal self sampling, if not slightly better. So we were, we were a little bit surprised that it performs better than vaginal swab, but extremely excited that this paves the way for further research in this area. Speaker A 00:11:43.190 - 00:12:02.710 And based on this study, and you've talked a bit about the introduction of vaginal self sampling this year as well, what do you think is the future for cervical cancer screening in the uk? You've mentioned about having a menu of options, but you've also touched on the fact that there might be some groups for whom this is actually the preferred method of screening. Speaker B 00:12:03.510 - 00:13:54.680 Yes, I mean, I think initially the cervical screening program's decision to offer vaginal self sampling to under screen populations is a really good one because it can't do any harm. These people are not being screened by definition and so offering them another option to help them to be screened is fantastic. From previous research, we might expect only around 8 to 13% of those people to actually take up the offer of vaginal self sampling. So it might be that we actually need to introduce another option for under screened people, such as urine based sampling. So I definitely see it as having a role for people who couldn't be screened in other ways. And there are plenty of people that have been, for example, victims of sexual violence, people for whom putting a swab in the vagina is culturally or religiously taboo, people who have pelvic pain conditions, vaginismus, painful vulval conditions and so on. I can definitely see that urine based sampling, if we can show it's as accurate as vaginal based sampling, has a place. But in terms of whether or not we're going to offer different ways of self sampling, for everybody in the cervical screening program, I think that needs a little bit of a more careful consideration. And the reason that I say that is that if, for example, vaginal self sampling and urine self sampling are even a tiny bit less accurate than cervical self sampling, and what we find is that by introducing these self sampling methods to the general screening population doesn't really increase the number of people being screened, but does substantially influence people to switch from regular screening to urine or vaginal based cell sampling. We might actually see a deterioration in the cervical screening program. We might actually see more cervical cancers and deaths from cervical cancers. So we really need to do more research in this area before we just introduce it as other countries have done. Speaker A 00:13:54.920 - 00:14:05.240 And I guess that's the next thing I want to touch on is what's the next steps for you and your team in this area? Are you planning any further research and looking at urine based HPV testing? Speaker B 00:14:05.560 - 00:15:06.700 Yes. So we have done two other large studies. One is looking at under screened women. So we have randomized women to receive either a vaginal self sampling kit sent to their home address, a urine based self sampling kit sent to the home address, or an offer of the choice between a vaginal or a urine self sampling kit, or an offer of vagina self sampling kit or an offer of a urine self sampling kit. So five different groups basically asking the question of whether we really need the option of vaginal versus urine self sampling or whether, you know, one type of option is going to be effective for everybody. And can urine based self sampling actually help people to to be able who are under screened to turn up for screening? So that's the first study that we've done. And then another study that we have done is looking at the acceptability in a much larger population. So several thousands of people who have tried urine based self sampling, what do they think about it? Compared to vaginal self sampling and compared to routine screening? Speaker A 00:15:07.180 - 00:15:30.040 Brilliant. That sounds like all really exciting work and as you say, it's tackling those challenges around the decrease in people taking up cervical cancer screening. So I think this is really important work and it's been great to hear about it and look forward to hearing about the results from those other studies you're working on. But I just wanted to say that's I think a great place to wrap things up. So thanks very much for your time, Emma. Speaker B 00:15:30.120 - 00:15:30.760 Thank you. Speaker A 00:15:31.240 - 00:15:52.770 And thank you all very much for your time here and for listening to this BJ GP podcast. Emma's original research article can be found on bjgp.org and the show notes and podcast audio are@bjgplife.com it's been great hearing about Emma's research in this area, and I hope you all enjoyed listening as well. Thanks again for your time and bye.
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