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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.

BJGP Interviews brings all these articles to you through conversations with world-leading experts.

The BJGP is the journal of the UK's Royal College of General Practitioners (RCGP). The RCGP grant full editorial independence to the BJGP and the views published in the BJGP do not necessarily represent those of the College.

For all the latest research, editorials and clinical practice articles visit BJGP.org (https://bjgp.org).

If you want all the podcast shownotes plus the latest comment and opinion on primary care and general practice then visit BJGP Life (https://www.bjgplife.com).

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  • S4 · E221
    January 27 · 40 min

    BJGP Top 10 research most read and published in 2025

    This episode, we have a round table discussion with the editorial team of Sam Merriel, Tom Round and Nada Khan. This collection of the BJGP’s top 10 research most read and published in 2025 brings together high-profile primary care research and clinical innovation. And here are the top 10 most read papers of 2025: 10 Adoption of clinical pharmacist roles in primary care: longitudinal evidence from English general practice https://doi.org/10.3399/BJGP.2024.0320 9 Factors affecting prostate cancer detection through asymptomatic prostate-specific antigen testing in primary care in England: evidence from the 2018 National Cancer Diagnosis Audit https://doi.org/10.3399/BJGP.2024.0376 8 Paramedic or GP consultations in primary care: prospective study comparing costs and outcomes https://doi.org/10.3399/BJGP.2024.0469 7 What patients want from access to UK general practice: systematic review https://doi.org/10.3399/BJGP.2024.0582 6 Technostress, technosuffering, and relational strain: a multi-method qualitative study of how remote and digital work affects staff in UK general practice https://doi.org/10.3399/BJGP.2024.0322 5 Antidepressants and risk of postural hypotension: a self-controlled case series study in UK primary care https://doi.org/10.3399/BJGP.2024.0429 4 Challenges to quality in contemporary, hybrid general practice a multi-site longitudinal case study https://doi.org/10.3399/BJGP.2024.0184 3 Low-dose amitriptyline for irritable bowel syndrome: a qualitative study of patients’ and GPs’ views and experiences https://doi.org/10.3399/BJGP.2024.0303 2 Artificial intelligence for early detection of lung cancer in GPs’ clinical notes: a retrospective observational cohort study https://doi.org/10.3399/BJGP.2023.0489 1 Effectiveness of low-dose amitriptyline and mirtazapine in patients with insomnia disorder and sleep maintenance problems: a randomised, double-blind, placebo-controlled trial in general practice (DREAMING) https://doi.org/10.3399/BJGP.2024.0173 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 - 00:01:27.500 Hello and welcome to the BJGP Top 10 podcast. So this is where we take a closer look at the most read research papers in the BJGP in 2025 and just have a discussion about what they mean for day to day general practice. I'm Nada Khan, one of the associate editors of the Journal. And in today's episode we'll be exploring some of the themes that really captured attention with the readership, I suppose. And we'll be talking about things like consultation compl complexity and workload pressures. Some work around diagnostic uncertainty and how to look, look after people with multimorbidity. And I think we're going to have a discussion a bit more, not just about what these papers found, but maybe a bit about why they resonated and maybe give a bit of editorial feedback around that. And because it's a conversation here between three clinicians as well. And I'll go around and introduce everyone in a minute, maybe a bit about what they add to the conversations we're already already having in practice and where the gaps still are. And I guess with that we'll be keeping it grounded in the messy reality of today's general practice as well. So I've introduced myself and I'm joined here by Tom Round and Sam Merrill, who are both also associate editors of the bjgp. But I'll go to Tom first. So, yeah, tell us a bit about who you are and how is your day going? Speaker B 00:01:27.720 - 00:01:59.550 Great, Nada. Thanks for having me. So, Dr. Tom Rand, I'm a GP in northeast London and an academic clinical lecturer at King's College, interested in early disease and cancer detection and also health inequality. So, yeah, pretty good. Like everyone, I've got a mild cold at the moment. I think exactly the same last year when we did this podcast, winter cold season. So I think we're all sort of feeling that a little bit in primary care with flus and other things and staff, you know, so otherwise good. Looking forward to having really interesting discussion about these papers which are really fascinating and give a real broad breadth of what we do in general practice. Speaker A 00:02:00.420 - 00:02:07.940 Great. And Sam, we'll go to you and you have some really exciting news in the background as well. So, yeah, tell us about who you are and what you're up to today. Speaker C 00:02:08.180 - 00:02:31.770 Thanks, Nad. I think, yeah, you're alluding to the fact I'm on Puppy alert because our new addition to the family in the winter is keeping us busy and making remote working a challenge. But we're getting through. But yeah, lovely to be with you guys. And I catch up and BJGP and wider podcast audience. So, yes, I'm a GP working in the Northwest of England and a clinical senior lecture at the University of Manchester. Speaker A 00:02:32.650 - 00:04:28.830 Brilliant. Okay, so let's get into the top 10 most read research and published papers of 2025 and I'm going to kick off with number 10 and number 8, just because they're on a sort of related topic. So number 10 is by Michael Anderson and colleagues. Michael's based in Manchester and at lse. And this paper looks at prescribing, quality in practices and the role of clinical pharmacists as. And I'll just point out that I'll put links to all the papers in the show notes as well. So this paper looks at the adoption of clinical pharmacist roles in English general practice and asks that question of does bringing pharmacists into the primary care workforce actually lead to improvements? Michael looked at this through a longitudinal approach. They used national practice level data from 2015 to 2019 and just looked at practices that didn't, didn't have a clinical pharmacist role. And it's really interesting, the results actually. So, not surprisingly, the proportion of practices with a clinical pharmacist increased from about 3% to over 20% over the course of the study. And the, the team found some really significant improvements across several prescribing indicators. So things like reductions in total medication costs, better opioid prescribing and prescribing for anxiety meds after pharmacists were implemented in pract, I guess, really it would be interesting to hear your thoughts, Sam and Tom, about what do you think really are the outcomes we want most from clinical pharmacists? And how do you think we should interpret these modest changes at scale? Because there's a lot else going on in terms of workforce that we need to think about in general practice, like access and continuity and not just meds optimization. Speaker C 00:04:29.310 - 00:05:41.170 I can talk from practice experience because our clinical pharmacist just left for Canada just in the last month or so. But yeah, it was really interesting, like having him part of the team. I think in a lot of ways he took a lot of burden off the gps in terms of meds monitoring, meds management, medication reviews. He builds a lot of continuity with a lot of patients because he was doing a lot of checking in. So in a lot of ways he was quite invaluable member of the team and we have sought a replacement since. At the same time, you know, there was some, some extra challenges in terms of workload and stuff, because obviously pharmacists have different training and the role of a clinical pharmacist in general practice is relatively new. So, you know, their approaches to prescribing and, you know, how close you stick to guidelines and how much you adapt for individual patient situations is slightly different. So. Yeah, but I think that was part of sort of feeling a way out with the role. But it's really noticeable when he's not around because it does affect how the workload flows and how the practice runs and how the patients, you know, interact with the practice. So, yeah, it's been really interesting at the local level. But, yeah, Michael's study also very interesting to look at the wider picture about how it's affecting quality of care. Speaker A 00:05:41.730 - 00:05:45.970 And I'll just jump now to number eight, unless, Tom, you want to add. Speaker B 00:05:45.970 - 00:06:10.770 No, just to say, obviously this, this paper is looking at the macro level up to 2019, so it'd be really interesting what happened since, because we only started having a pharmacist after that point with the induction of ARS roles. So I think, yeah, further, you know, this is giving a signal, we think that some indices are improving, but also I think it's important to be aligned with our own subjective experience, maybe qualitative and other implementation type research. But overall, I think this trend is a good thing, I think, from my own experience. Speaker A 00:06:11.570 - 00:07:55.630 Yeah, absolutely. And then I guess jumping to paper number eight, which was written by William Hollingsworth and his team from Bristol, and this is looking at comparing paramedics in general practice with gps. And the paper is asking a really practical workforce question, which is, is what happens to patient experience, safety and NHS costs when patients are seen by a paramedic in general practice rather than a gp. And this team looked at this, they used a prospective cohort study across sites in England and they looked at patients who had an urgent or same day consultation with either a paramedic or a GP and then looked at their outcomes over the next 30 days. And I guess the headline finding is that really there wasn't a clear difference in patient reported health and well being over 30 days, but there were some differences in that experience right after the consultation. So patients who saw a paramedic said that they were. Well, they reported lower confidence in their health provision, they felt there are more communication problems and maybe a lower perception of how the practice promotes safety. And there were fewer subsequent GP appointments in the paramedic group, but there weren't really any GP savings as such that were offset by higher use of other health care professionals. So I guess that you could sort of summarize that by seeing. Seeing a paramedic might lower GP pressure, but it doesn't necessarily reduce overall NHS costs. So I wonder, yeah, Tom, coming to you, what do you think should really matter when we diversify the workforce? Do you think it should be workload, cost? Yeah. Speaker B 00:07:55.710 - 00:09:28.360 Really interesting discussion, isn't it? And we talk about testification, isn't it? Sort of, you know, how do we, you know, how do we help GPs with workload? Workload, sorry. Fundamentally we need more GPs, don't we? We need to have, you know, we've got high 2,300 to 2,500 patients, sometimes even higher deprived areas. So fundamentally, I think the workforce, we do need more gps. This also debate, also, you know, obviously there's a slightly toxic now debate about physicians, associates. You know, from my own viewpoint, you know, undifferentiated initial consultations in primary care are high risk. We know that from all the evidence and the research. So you've got to be very careful about patient select selection and triage for this. And you can see, I think also this links to. We've got this big increase in the ARS roles, but then we haven't seen that increase in primary care satisfaction. So I think this comes down to people probably still want to see a GP for certain conditions. How do we get to that right model of MDT working? And I think we do need robust safety evidence. So this obviously is, you know, it's good study, but it's fairly small scale, probably need larger scale and systematic review evidence about this replacement. You know, what's the safe role? What are the guidelines? What sort of cases should these people, should other allied healthcare professionals be seeing, particularly for undifferentiated illness? And going back to the, obviously, the PA debate, we've obviously got the college position that probably PAs should not be seeing undifferentiated illness in primary care. So I think it's a nuanced discussion, but we need better, we need further studies like this to help us decide what we're doing. Speaker A 00:09:28.760 - 00:09:54.380 Absolutely. And I think that's really important as the workforce in general practice increases to diversify and policy shifts towards an increasing multidisciplinary team as well. So, yeah, be interesting to see what happens in the future. Really great. So I'm going to go over to Sam and Sam, you're talking about paper number nine, but, yeah, talk us through this. This is a bit a paper that, you know well, so tell us a. Speaker B 00:09:54.380 - 00:09:55.820 Bit more about it and your involvement. Speaker C 00:09:55.820 - 00:09:59.700 In it, first author on a BJGP top 10 paper. I'm very honored. Speaker B 00:09:59.700 - 00:10:00.460 Congratulations. Speaker C 00:10:01.020 - 00:13:14.370 Humble to all the readers out there who had looked at it. So this was a study of asymptomatic prostate cancer detection using PSA in primary care in England. And we used data from what's called the National Cancer Diagnosis Audit. This was the 2018 version. So we had about a quarter of practices in England participate in the ncda and data was gathered using a sort of standardized template on all the new cancer diagnoses in a practice in 2018. So practices participate were given that list and a template to complete and looking at the record in detail. So what happened to these patients in the lead up to their diagnosis? Were they seen in general practice? What happened? Were they investigated? Were they referred to? And it was not screen detected cases for any of these were specifically cases coming through primary care. And the strength of this data set is that we have access to both coded and free text data in the record. So a lot of large primary care research data sets like CPRD don't have free text data. So it's relying on GP coding, which we know varies between practices. So the big things that this study found we looked at. So There were nearly 10,000 prostate cancer cases in the entity. Overall, when we filtered out all the patients who had symptoms recorded at the time of presentation of primary care and the time of diagnosis, we were only left with about 1900. So the vast majority of men with prostate cancer symptoms were present at the time of diagnosis, which conflicts somewhat with existing literature out there, the quality of which is pretty variable and often not great. So that was one interesting finding. In terms of the differences between practices for asymptomatic prostate cancer detection and PSA testing, there's huge variation, something like 14 fold difference between the practices picking up the most men through asymptomatic PSA testing and the practice picking up the least. And we didn't see any obvious GP practice level factors, so it didn't matter about geography, list size, number of GPs, cough outcomes, none of that seemed to make any difference. There were patient level factors, so older men less likely picked up through that route, which kind of makes sense because symptoms are much more common in men as they get older. And PSA testing, the benefit is less generally depending on their general health, so it might be done less often. So that makes sense. Men from deprived areas were less likely to be diagnosed through this route, which we know there are significant inequalities for men deprived regions in terms of prostate cancer outcomes. Not Just PSA testing, but stage of diagnosis, treatment outcomes, we need to do better with that group. And interestingly, white men were less likely to be diagnosed through this route. Even though the sort of stereotypical person being, coming in, asking for a PSA test when there are no symptoms and maybe a low risk is a. Is an older, wealthy white male, they were less likely to diagnose through this route, which. That was an interesting finding. Yeah. So really interesting study. Obviously grabbed some interest and is a very, very, very topical issue at the moment with the NSCS recommendation that's out for consultation. And I think, you know, we still got to watch this space because I think there's going to be more coming in the year's ed. Speaker A 00:13:15.170 - 00:13:42.330 Yeah, really super topical, Sam. And just to point out, we did record a podcast talking about this paper in more detail, if anyone wants to listen to that. Tom, you work a lot in cancer diagnosis in that sort of world. I mean, obviously brilliant work from Sam and his colleagues, but I just wanted to know what your thoughts were. Just reflecting on this paper in terms of sort of the wider policy discussions and discussions around the future of prostate cancer screening. Speaker B 00:13:42.330 - 00:14:36.520 Yeah, yeah. So I think it's very topical, isn't it? There's lots of. In the press around, you know, should we be doing PSA testing? So we currently got a slightly...

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  • S4 · E220
    January 20 · 21 min

    Safety incidents in prison healthcare: Lessons from critical illness

    Today, we’re speaking to Dr Joy McFadzean,a GP in Swansea and Clinical Lecturer of Patient Safety based at Cardiff University. We’re here to talk about the paper she’s recently published here in the BJGP alongside her colleagues titled, ‘Critical illness in prisons: a multi-method analysis of reported healthcare safety incidents in England’. Title of paper: Critical illness in prisons: a multi-method analysis of reported healthcare safety incidents in England Available at: https://doi.org/10.3399/BJGP.2025.0239 Using a mixed-methods descriptive and framework analysis, this paper provides new insights into the complexity of care delivery in prisons. Results resonate with and strengthen the recommendations from recent investigations into prison healthcare by further developing an understanding of the complex intersecting factors contributing to safety incidents and quality issues in care delivery. The fundamental importance of good quality and adequately resourced primary care delivery in prisons has been highlighted. It also identifies system-wide interventions that are needed to improve care delivery, and which are likely to interest policy-makers and scrutiny bodies, commissioners and teams working in prisons to inform developments in strategic health needs assessments, workforce profiling, and training requirements for healthcare and prison teams. Funding This study/project is funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme (PR-R20-0318-21001). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders of the study had no role in study design, data collection, data analysis, data interpretation, writing of the manuscript or the decision to submit. 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 - 00:01:10.200 Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the associate editors of the bjgp. Welcome back to the first season of the BJGP podcast here in 2026. And we're starting off this season of the podcast with a chat with Dr. Joy McFadyn. Joy is a GP based in Swansea and clinical lecturer of Patient safety based at Cardiff University. We're here to talk about the paper she's recently published here in the BJGP alongside her colleagues. The paper is titled Critical Illness in Prisons A Multi Method Analysis of Reported Healthcare Safety Incidents in England. So, hi, Joy, it's really lovely to meet you and to talk about this research, but yeah, just taking a step back, I think it's fair to say that the prison population is an underserved and probably fairly under researched population as well. But you point out here in the paper that it's not only this, but that the prison population is actually at a much higher risk of early mortality as well. So can you talk us through this at all? Speaker B 00:01:10.680 - 00:02:31.010 Yeah, that's a really good point. So we know that people who reside in prison, known as prisoners, will have very high rates of physical and mental health needs. And as you say, there are concerns that they have rates of premature mortality, so they may die up to 20 years earlier than the rest of the population. But they are a population which isn't necessarily the area of focus. So even though we know the importance of supporting their healthcare as a public health concern, they are often underserved, they're quite vulnerable, and yet there hasn't been enough research to support them to have what we call equivalent health outcomes. So there are lots of definitions of what is considered to be equivalence of care for people in prisons. So the Royal College of General Practitioners Secure Environments Group, they have defined what equivalence of care is for people in prisons, thinking that they should have the same quality of care, the same level of staffing, the same resources as anyone who is residing in the community in order to get the same health outcome. And currently that is not being realised. Speaker A 00:02:31.330 - 00:02:38.210 And just as a background to all this work, how many of these early deaths do you think are preventable? Speaker B 00:02:38.930 - 00:03:39.270 So we carried out a study which was called the Avoidable Harm in Prison Study. So it was focusing very much on healthcare events where people were harmed or could have been harmed whilst they reside in prisons. So our focus is very much on these patient safety incidents, reports and incidents themselves, and ultimately the findings of the other space of the study. We haven't released yet they're still embargoed. But we were seeing within our sample of patient safety incident reports, events where prisoners were undertaking significant harm. So within our paper, we haven't seen any evidence of the deaths which could be considered to be avoidable. But our focus was very much on events where without urgent treatment, there was a high risk of death. And we considered many of those events to be avoidable. Speaker A 00:03:39.590 - 00:04:10.690 And I guess all this is tied into what you're aiming to do here in this research, which was to look at and characterize patient safety incidents in the prison population and find opportunities to improve care. So you used a really detailed approach here and looked at patient safety incidents reported in England and carefully examined and coded all of the incidents here. But I really want us to talk through what you found, what were the main sorts of incident type. And what I'm trying to get at is what really happened in these reports. Speaker B 00:04:11.410 - 00:07:08.750 Yeah, thank you. So we reviewed Originally up to 4,000 of those patient safety incident reports. And then when we focused specifically on those events where someone was at very high risk of death if they hadn't received treatment, we were looking at conditions suggestive of heart attacks, strokes, status epilepticus, diabetic ketoacidosis, for example. And what we saw is that most of the reports that were included for analysis, so about 100 of those reports, people in prison were not being able to access healthcare professionals when they needed to. So in prisons, people will have an assessment when they arrive to the prison, which is an assessment of their healthcare needs. They should also have access to nursing staff, GPS and allied healthcare professionals, as well as referrals to secondary care as needed. And what we were seeing is that when there are events where someone was critically unwell, they couldn't access the staffing when they required. So it's very much a nurse led service in the prisons. And even when there were prisoners who had collapsed, nursing staff could not access the prisoners. And that was for lots of different reasons. Some of it was related to poor communication, that there's quite a reliance on the use of radios in our reports. And so if people were trying to radio from one area of the prison to the healthcare teams, then there was too much radio traffic that their messages weren't getting through or they were using the wrong emergency codes. So actually the nursing staff weren't aware of the urgency of when they needed to get there. So there were lots of delays in actually having the healthcare teams arrive and assess the patients themselves. But also when a decision was made that someone needed to be conveyed to an emergency department, for example, due to difficulties with staffing levels, there weren't sufficient prison officer numbers to escort them from the prison to hospital. So there was significant delays. So what we could see in some of the events is that someone had collapsed. There was concern that this was suggestive of a stroke, they were dysphasic, they had facial palsy, they had tinnitus, headaches, et cetera. And nursing staff had assessed, said, no, they're unwell. Gps had said they need to be conveyed to the hospital and they weren't transferred until the following day. So those types of delays were very evident as well. So difficulty accessing the healthcare professionals in the first place and then a delay getting the correct treatment or management, even with conditions which are time critical. Speaker A 00:07:09.630 - 00:07:29.500 That all sounds really shocking, actually. But I wonder if we could just take a step back and, and could you describe to us what healthcare provision is like generally in prisons? You mentioned about a nurse led care system, but how easy is it to access other healthcare professionals like GPs in prisons generally? Speaker B 00:07:30.700 - 00:11:02.620 So I think there are two very different opinions in this. So we have the access to the patient safety incident reports, which is telling us that it's very difficult for them to access healthcare professionals as needed within the prisons that we looked at for the avoidable harm in prison study, for example, we were only focusing on prisons where health care was delivered on site and the provision is very variable. So different prisons may have NHS provision, but the majority is probably private provision as well. So it's a commission service, there's a lot of competitive tendering and there are concerns by some that a focus may be more on cost saving than it is on quality provision. So what we saw within our patient safety incident reports was evidence that it was very difficult to access the healthcare teams. So even though healthcare provision should be delivered and there are nurses, you know, round the clock, they were having lots of difficulties accessing any types of healthcare provision out of hours. Our instant reports was an overreliance often on some of the electronic E consulting systems. So the use of System 1, for example, in prisons in England, and what we could see is that people were presenting with quite significant symptoms and instead of what we would have thought would happen is someone was picking up the phone and referring them in. Lots of electronic tasks were being sent around teams without necessarily an overview as to who was completing those tasks or an overview of what that meant. So our focus is very much on these critical conditions, but some of it was related to the management of long term conditions. In the first place that if someone's diabetes was being managed appropriately, that they were having annual blood tests or having their blood pressure checked, they were making sure that they had sufficient insulin, for example, then there shouldn't have been an occasion where they were experiencing diabetic ketoacidosis and needed to be admitted. Making sure that there's appropriate management of care, but also then that organisational factors. Are there sufficient staffing numbers or are there not? And part of the concern that we could see in our incident reports was the role of locums and agency staff who perhaps were not as familiar with prisons and prison health care systems. And they would often forget their passes to even log into the system, so they couldn't see a patient's medical records. They were not familiar with the need to actually call for help, how they called for help. They didn't know that if an emergency code is coming through the radio, that meant they needed to grab the healthcare bag with all the emergency equipment and run towards a specific wing or whatever is needed. But focusing very much on these emergency conditions, there was a concern that the locum staff were not familiar with the protocols, the policies of the prison. They were not carrying out observations, they were not documenting efficiently what they had actually carried out with the person residing in the prisons and that was delaying care that was stopping them from being transferred to emergency departments when they needed to be. Yeah. Speaker A 00:11:02.620 - 00:11:15.860 And what's interesting here is that in this paper you looked at some major themes here around these different incidents. Can you talk us through this and what were the main findings here? Speaker B 00:11:16.740 - 00:17:45.240 So we were thinking about the different aspects and cogs within the healthcare system in the prison and how they all interact with each other. And we use the CEAPS model, which is the systems engineering initiative for patient safety, and it has six main domains that we were trying to understand if thinking about our patient safety incident reports and the themes within it, as well as the contributory factors, so why these events were taking place. We tried to then map them to the domains of the Systems engineering and initiatives patient safety model, which is ceps. And what we could see were the different domains were prevalent throughout the reports. So there is a concern about tools and technology. For example, so I've mentioned about the emergency radios, but also the lack of certain tools. So there wasn't a provision of life saving equipment in prisons. So there were often reports from paramedics as well as people who reside in prison to advise that when there were events where a patient may have harmed themselves or there'd been an assault and an injury. There wasn't life saving equipment within the prison, so no cannulas, no IV fluids. Obviously there was going to be no consideration. There would be blood products or anything of the like, but there was nothing that they thought would, would support major blood loss and hemorrhage. There were also, in many of the prisons, no AEDs. So if someone had collapsed, potentially having a heart attack, for example, and their heart had stopped, we know the evidence that they need to get the paddles on their chest, we need to restart their heart if it's in an appropriate rhythm. But there was nothing of that, like in many of these prisons, to actually support that. So if there is any type of delay in calling for an ambulance, an ambulance should be adhering to the same national guidance of the emerg response times. That should still be actualized within a prison too. But what was happening is that an ambulance was being called. There was some confusion as to where in the prison the prisoner actually was, which wing of the prison, which area of the prison. Once the ambulance was arriving at a gate, they couldn't actually come straight through because of security concerns that the ambulance might need to be stopped and searched to ensure that nothing was entering the prison that shouldn't be. And that was, you know, causing significant delays. And then when they were getting to patients who'd collapsed, for example, there were delays for them even conveying them out of the prison. So there was a concern that the healthcare professionals were not saying to them, you just need to convey them now they need to go to an emergency department. We do not have sufficient care for them here. So that was the concerns about tools and technology, for example, and then thinking about the organisational aspects. So that would be within a healthcare system, things like staff rotors. You know, I've mentioned already that there were some concerns with sufficient staffing levels. So there are concerns by people who work in prison. There can be quite a high turnover, perhaps an over reliance on locum and agency staff. People may become quite burnt out in the system and therefore they may leave the prison. And for some GPs who work in prisons, it may not be there full time physician. They may work elsewhere and then they may do a couple of shifts in the prison. So there isn't necessarily that continuity of care and how that might impact on prisoner healthcare. Then within the CEIBS model there's concerns about personal factors or person factors. So these are the people working in the system as well as the patients themselves. So one of our recommendations after reading all of the reports, is that perhaps they require more focused training for how to deal with emergency conditions and the response. So what we saw is that people weren't prepared to have multiple emergencies happening at the same time, which unfortunately does happen in the prison. So there were lots of reports in which there were concerns with substance use in parts of the wing, perhaps using the substance spice, for example. And then there was a report that three, four, five prisoners were all unconscious at the same time. They therefore all required set of observations, need to check their oxygen levels, probably be placed in the recovery position and observed carefully until they came round, or if they weren't coming round, they need to be conveyed to an emergency department. And then thinking about the context of the prison, we think about the internal environment. So knowing that within the prison, security constraints will often outweigh concerns with healthcare. And that is an important balance that both the prison teams, the prison officers, the governors, need to balance alongside the healthcare professionals. And so what we were seeing, for example, is that during any type of lockdown in the prison, so security concern, a wing needs to be locked down. That means the prisoners need to return to their cells. They cannot le. If something happens where someone is considered to be critically unwell, they collapse, they are complaining of chest pain, they have symptoms suggestive of a stroke, for example, they haven't got access to their insulin, so their sugars are rising, they become unwell, etc. What we could see is that the healthcare teams could not access the prisoners, they couldn't get to them. So that's the constraints of the internal environment. And then the external environment is like I was mentioning, about those commissioning gaps. So concerns where care is not being funded appropriately, if that emphasis is on the cost of a service rather than the quality and the outcomes for patients, then perhaps they're not getting appropriate care when they should be. Speaker A 00:17:45.480 - 00:18:04.580 And I think I'd suggest to anyone listening who's interested in this area, I'd suggest they go back to the paper and take a close look at box two, where you talk about the main recommendations for prisoner health as a result of this work. But what do you think are the most important...

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