BJGP Interviews

Today, we’re speaking to Cate McCarter and Amanda Williams. We’re here to discuss the research they’ve recently published here in the BJGP titled, ‘Understanding chronic pelvic pain in women survivors of sexual violence: a qualitative study’.

Title of paper: Understanding chronic pelvic pain in women survivors of sexual violence: a qualitative study

Available at: https://doi.org/10.3399/BJGP.2026.0057

Chronic pelvic pain (CPP) is common and can be difficult to treat. Some women with CPP are survivors of sexual violence. How such women understood their pain was strongly influenced by feeling ignored by doctors and shamed by both CPP and sexual violence. According to women in our study, a ‘good enough’ response from GPs involved being seen as a whole person, being asked about sexual violence, pain being adequately investigated, and the GP acknowledging what is not understood about CPP and sexual violence. This allowed the negotiation of a pain explanation that validated the woman’s experience and integrated her social context with medical results, delivered with empathy and understanding.

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

00:00:00.240 - 00:00:56.560

Hi, and welcome to BJGP Interviews.

I'm Nada Khan and I'm the senior research editor here at the bjgp.

Thanks for listening to this podcast today.

In today's episode, we're Speaking to Kate McCarter, a clinical psychologist and Professor Amanda Williams.

Amanda is emeritus professor of Clinical Health psychology based at ucl, and we're here to discuss the paper that they've recently published here in the bjgp, which is titled Understanding Chronic Pelvic Pain in Women Survivors of Sexual Violence A Qualitative Study.

So, Kate, I think I'll start with you.

And we were talking just about, you know, how important this work is, and perhaps we could just start by talking about why you wanted to explore the experiences of women with chronic pelvic pain who have also experienced sexual violence.

What did you feel was missing from what we already know in this area?

Speaker B

00:00:57.650 - 00:02:15.360

Yeah, I suppose the.

I approached this research topic with anecdotal evidence, having worked with survivors of nursing and sexual violence for about 10 years before I started researching this.

Just anecdotal evidence that lots of women also lived with chronic pelvic pain.

And I didn't, you know, I hadn't any thoughts about the association really, or whether it was causal or what, but I just noticed that the women I was supporting before training as a psychologist, they were living with chronic pelvic pain, and a lot of them had found it very difficult to seek health care and to receive health care for that.

So I just started speaking to Amanda about that, and from our conversations, we started thinking about the meaning of pain and how there's an established association within the literature about chronic pain, chronic pelvic pain after sexual violence.

But what's the meaning of that for the women who live with it?

That felt missing.

And because meaning, personal meaning, is so key to understanding a personal lived experience of pain, it felt like a gap that we could begin to address by asking women, how do you make sense of the pain that you're living with?

Came from there, really.

Speaker A

00:02:15.440 - 00:02:24.400

And your background is as a clinical psychologist.

So interpreting what pain means is quite a personal thing for a lot of women, isn't it?

I guess.

Speaker B

00:02:24.480 - 00:03:23.180

Yeah, absolutely.

Yeah.

Is very personal and.

And complex as well.

The.

The attempts to understand exactly what pain means to a woman is, you know, you take into account those experiences of trauma very often, but not always, and you take into account the social context and what's going on around them, how sort of how they've come to be in the situation they're in.

So, yeah, it is Highly personal and effective treatment can't really start until that's understood because the way that a woman will approach her attempts to seek health care is very much led by how she makes sense of it.

So if she's.

Some of the women in the study linked it to surviving sexual violence, then the meaning is wrapped up in that.

Has she disclosed that to her healthcare provider?

Does she feel able to.

It's an incredibly difficult thing to talk about.

Has she been asked?

So, so yeah, very personal, absolutely.

Speaker C

00:03:23.820 - 00:04:12.840

And I think often sort of co created in the encounter with healthcare professionals and that can go either way and in the paper are examples of both.

But women are looking for information and understanding to incorporate into the meanings of pain and that doesn't always happen.

Or they get multiple different accounts which are incompatible.

People really struggle.

I mean, I've worked in pain for 35 years and I hear this in all sorts of pain, but I think particularly where there isn't anything very definite, no tissue damage to identify, nothing to show for it, as it were.

Speaker A

00:04:12.920 - 00:04:36.579

And this is a really sensitive area.

And you interviewed 10 women about both their pain and their experiences of sex, sexual violence.

I just wanted to touch on how you approached these conversations and how you learned from listening to women in this way, sort of taking both of these things into account.

And we'll go a little bit more in depth into the themes that you discovered.

But yeah, just as a sort of overview.

I wonder if you wanted to comment on that.

Speaker B

00:04:36.739 - 00:05:54.960

I suppose it started with I believe that you've been sexually assaulted.

There was no question about that.

And I think the reason I say that is because that's.

That's often disbelieved or dismissed or minimized by anyone.

It's not specific to healthcare at.

By anyone that a woman tells about her experience.

So I think it started from that even before we had a conversation.

The advertisement, the information sheet about consenting into the study was.

I tried to make it as validating as possible.

It was an opportunity to talk in depth about a topic, topics that are taboo, that are not spoken about, that are shamefully hidden.

And I think giving women the opportunity in a space where they felt believed meant that women perhaps relaxed into the conversation as we got talking.

I think also it helped that it was a semi structured interview so I was very much able to follow where that woman was going.

But I think also the women were so motivated to talk to me, they really encouraged me to publish.

I wasn't.

I don't love writing.

Amanda's very good at writing.

I don't love it, but I really wanted to do it for them.

I said I would and therefore I did.

Speaker A

00:05:55.360 - 00:06:05.120

And one of your main themes was attempts at silencing women.

What did women mean by that and what were they experiencing when they tried to get healthcare for their pain?

Speaker B

00:06:05.600 - 00:07:28.130

So this, this was a finding that really fitted with both experiences of pain and of surviving sexual violence.

And women were talking about being actively told not to talk about those things.

So sometimes they're disclosed to a family member and they'd been told, I don't believe you, or don't talk about that.

That's just something that women have to go through.

But also, unfortunately, some encounters with health care professionals as well.

So not being believed, not being asked as well.

That was a really significant part of some of the women's narratives, that if you don't ask, then I won't tell you.

And that's, that's not a new finding that's fairly established within primary care.

The women in this study really just backed up that finding that women want to be asked that it's, it facilitates disclosure of difficult experiences, sexual violence being one of those.

So if they'd, if they'd been asked, then they were more likely to disclose.

But, yeah, it's the responses to that disclosure that were, that was silencing and that fitting within a societal context of minimizing sexual violence, of minimizing particularly women's pain, particularly in the pelvic area.

And the message of just get on with it, really.

Speaker A

00:07:28.850 - 00:07:44.440

And I wonder just a little bit, I mean, that comes through quite strongly, that experience of not being believed or of having pain attributed to mental health problems.

But why do you have any thoughts, either of you, about why that happens, particularly with chronic pelvic pain in women?

Speaker B

00:07:44.840 - 00:07:46.120

What do you think, Amanda?

Speaker C

00:07:46.680 - 00:09:04.999

Well, it's very common for any chronic pain to be attributed because even if there are some detectable signs, which there very rarely are in chronic pelvic pain, the pain doesn't match those, the pattern doesn't match.

And women have always been accused of exaggerating what's wrong with them, fussing a lot, not understanding their bodies and so on.

And there are, you know, both lay and scientific theories of psychosomatic pain, which are just nonsense.

You know, if one understands the, the science of pain, pain's an emotional experience as much as a sensory one.

It's aversive, it's emotional.

And so having a model that tries to split the physical and the psychological makes no sense at all.

But that model being used makes women often and this came up in the paper makes women quite unwilling to say, well, when I'm stressed, it's worse, or when I'm upset, it's worse, or when I'm having a really nice time with friends.

I realize I haven't been aware of my pain because that feels like it fits into this either or model, which is so unhelpful.

So unhelpful.

Speaker A

00:09:05.370 - 00:09:19.850

And I was struck in the paper by the distinction between treating the symptoms and treating the whole woman.

And your participants talked about that.

What do you think that the women in your study felt was missing when their care was fragmented in that way?

Speaker B

00:09:20.490 - 00:10:05.590

Well, an understanding of them as a whole person really, as they said.

So if their pain was more attributed to psychological reasons, they might be completely denied physical investigation.

So not a single test, not a single examination offered and even refused.

And then everything bounced back to the.

The mental health team.

So we can't do anything for her physical pain because it's all psychological.

And as Amanda said, that just doesn't make sense.

And it is incredibly frustrating for everyone involved because it, it's disempowering for the.

For the woman first and foremost.

But also it means that the, you know, the mental health team are really stuck as well.

It just.

It's just really unhelpful, particularly because, I.

Speaker C

00:10:05.590 - 00:10:48.840

Mean, people think of pain as a sign of damage.

And of course, lots of pains are a sign of damage, and we respond appropriately.

But not every pain is a sign of damage.

It can be a sign of the whole system having got stuck on pain.

And also after rape and sexual assault, women can feel damaged.

And I think it's really important to reassure women otherwise they're likely to go on worrying that something awful has happened.

I mean, many women who seek hysterectomy, it turns out, you know, are feeling that they have in some way been damaged, and they think the only way to deal with chronic pelvic pain is to get rid of the uterus.

Speaker B

00:10:49.240 - 00:10:57.920

And some of the women did speak about.

Speak to that, really, didn't they?

That my.

Just a complete fear that their body was rotten, defective.

Didn't.

Speaker C

00:10:57.920 - 00:10:58.240

Yes.

Speaker B

00:10:58.240 - 00:11:04.740

Anymore.

And even that, you know, one of the women who talked along that theme had training in healthcare.

Speaker A

00:11:04.900 - 00:11:21.140

And your third theme is really interesting.

So that woman's place in.

Is in the resistance.

And there was a sense of women really having to fight to be heard, as we've talked about, and to find appropriate care.

What do you think that says about the way our healthcare systems are working, that women feel that way?

Speaker B

00:11:21.460 - 00:13:17.590

Yeah, such A strong theme of women just pushing, pushing, pushing.

Yeah, well, I think it speaks to.

To women's pain being dismissed, to being normalized.

Women live with pain.

That's just normal.

There's not particularly anything we can do about this.

But also I suppose that failure to integrate, as Amanda's already spoken to, that failure to integrate mental and physical health teams, the fact that they are so separate, that a pain clinic is not found in every corner of the uk and the multidisciplinary approach to understanding pain is not the norm.

I think it also speaks to.

Perhaps in the paper we speak about rape culture and rape myths and the way that we are all, as members of society, are subject to the same, you know, narratives, unhelpful and true narratives around true victims, you know, perpetrators, what a real rape is and how there was, you know, difficulty to get past that for some women, that this is something that I'm, you know, I have been through and was difficult because it was rape, for example.

And it's also, I suppose, how busy GPs are.

There was very much that recognition that GPs are busy, that they have very limited time to spend exploring the complexity of a woman's presentation and may feel really ill equipped to respond, which, again, is not a new finding, but it's been spoken about in other spaces.

But perhaps a training need and a systemic problem to do with how we approach trauma and how we think about trauma, informed care and how we put that into practice, because we know.

We know what.

What works.

We know that, but there's something that's stopping that happening.

And I expect that's to do with time, resources, confidence and.

Yeah, the medical model and a limited understanding of pain dominating.

Speaker C

00:13:19.030 - 00:13:52.830

I think.

I think that's true.

And what came out of this, and I've seen in many other pain studies, is interviewees.

Participants are very able to say what constituted good care and to give credit for it.

They're very keen to do so and to say what they need.

And it's not unlimited time or unlimited treatment, which I think is a fear of understandable fear of a healthcare professional.

It's often much simpler about listening and respect and integration.

Speaker A

00:13:53.390 - 00:14:15.870

And one thing that you found was that many women hadn't been asked about sexual violence, even though when there were some indications that previous trauma might be relevant.

And just from your background, I wonder if you feel that gps should routinely be asking about sexual violence when women present with chronic pelvic pain and if you have any ideas about how gps can do that sensitively.

Speaker B

00:14:16.520 - 00:14:23.080

Yeah, I think there's so many different points in a woman's journey towards health care that, that it would be appropriate to ask.

Speaker C

00:14:23.560 - 00:14:24.080

I don't know.

Speaker B

00:14:24.080 - 00:16:13.760

I'm a bit wary of saying routinely ask about anything because then it loses its thinking power, doesn't it?

Today, we’re speaking to Dr Rupinder Bajwa, a Research Fellow based in the centre for Academic Primary Care at the University of Nottingham.

Title of paper: Unpacking barriers to and facilitators for research leadership for Black primary care researchers: a qualitative study

Available at: https://doi.org/10.3399/BJGP.2026.0175

Researchers of Black heritage are underrepresented in primary care research leadership, and there is limited evidence on their lived experiences of why this underrepresentation exists. This study addresses this evidence gap and highlights how systemic inequities, racism, and inequitable academic practices contribute to this lack of representation. This study also presents practical enablers to improve progression and retention, such as proactive leadership, tailored career support, and increasing visibility of Black role models in academic primary care. These findings emphasise the need to foster inclusive research environments that strengthen the diversity and relevance of primary care evidence.

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 - 00:00:54.620

Hi and welcome to BJGP Interviews.

I'm Nada Khan, I'm the Senior Research editor at the BJ gp.

And thanks very much for joining me here to listen to this podcast.

In today's episode, we're speaking to Dr. Rupinder Bajwa.

Rupinder is a research fellow based in the Centre for Academic Primary Care at the University of Nottingham.

We're here to talk about the paper she's recently published in the BJGP titled Unpacking Barriers to and Facilitators for Research Leadership for Black Primary Care A Qualitative Study.

So, hi, Rupinder, it's really great to meet to talk about this work and I wonder if we could just start by talking through what prompted you and your team to look at the experiences of black researchers in academic primary care.

And I'm wondering what we already knew in this area and what you felt was missing from the picture.

Speaker B

00:00:55.260 - 00:01:34.840

Firstly, thank you so much for having me on to talk about the work that we did so the way this sort of came about.

So primary care serves some of the most diverse communities in the uk, but what we realised is, when you look at primary care, researchers of black heritage remain largely underrepresented, especially in more senior academic and leadership roles.

And so because of that, we wanted to understand, well, why does this gap exist and, you know, what can we do to improve representation but also improve retention of researchers of black heritage and their career progression as well?

Speaker A

00:01:34.920 - 00:01:43.320

And you spoke to people from a black background, is that right?

So talk us through just who you discussed this project with and how you got those.

Speaker B

00:01:43.640 - 00:03:01.100

Yeah.

So to start with the project team itself, there's myself, I'm a researcher of South Asian heritage.

We had Adwa and Ralph, who are researchers of black heritage.

Manpreet Rains is a researcher of South Asian heritage.

We have Professor Joe Kai on the team, who is also of Asian Heritage.

And we had Professor Christian Mallon on the team as well, who is a senior leader at the School for primary Care research.

And so we had sort of that diversity within the study team.

We predominantly wanted to speak to researchers of black heritage who are working in academic primary care across all levels, so from junior up to senior.

And we also spoke to leaders of departments where, you know, they're leading academic primary care departments as well.

And we, you know, really wanted to explore what, especially with the researchers, you know, barriers that they've experienced or barriers that they know of as well as what's gone well for them as well, you know, for their progression opportunities that they've had, but also, you know, what their thoughts and feelings were around the current level of representation and what could be done and with leaders as well.

We sort of spoke about some of the barriers, but also some of the work that might be going on on to address some of these barriers as well.

Speaker A

00:03:01.340 - 00:03:25.340

Just the introduction to your paper and work that's been done more widely in this area.

We do know that the underrepresentation of researchers of black heritage drops off, particularly as sort of more senior levels of academia.

And I wonder what you heard from the experiences of researchers as they move through their careers and why does that progression seem to become more difficult?

Speaker B

00:03:26.280 - 00:04:51.480

Yes.

So a lot of what we found in the project isn't just an academic primary care problem.

I'll start with that.

It does speak to wider challenges across academia.

So when you look at academia as a whole, I think it's around 1% of professors are of black heritage.

So that's quite a small number.

Speaking to researchers around their progression.

We wanted to understand what some of those challenges are.

And what came through was there are a lot of structural and systemic barriers that continue.

So structural and systemic racism is one key challenge.

And when we were speaking to researchers, what this looked like.

You know, it was more, it could be subtle microaggressions being passed up for opportunities, stereotypes, but also sometimes the academic culture could be quite exclusionary and researchers found that it was sometimes difficult to find opportunities.

There was limited access to some development opportunities as well.

And especially for a junior level, sort of the short term contracts and the funding insecurity made that progression difficult.

And for those who were sort of mid career researchers and thinking about the next steps, it was, you know, well, what does that look like?

What support is available?

Is there any support available?

And there was challenges around that is finding adequate support, adequate mentorship and sponsorship as well.

Speaker A

00:04:51.810 - 00:05:10.690

And you know, you're talking about these structural and interpersonal barriers as well.

But I wonder how that impacts things like academic funding or recognition and how that's distributed.

Did they talk about barriers to getting funding or grants and recognition for the work they were doing?

Speaker B

00:05:10.770 - 00:06:02.430

Yeah, so this was a, this was a concern as well that came up and researchers were keen to highlight that, you know, this is a challenge across the board in terms of research funding.

A lot has changed in the last few years.

Pools of funding have got smaller, but it seems to be there's additional challenges involved for minoritised researchers in terms of how to get that funding, how to apply for that funding, you know, how to position yourself for that Funding, unless you know it, you don't know it.

And it can be even more challenging if you're a minoritised researcher where you may be starting off on a slightly different footing, coming into the space.

And that can make it really difficult for funding.

But more recently, I know NIHR and funding bodies are now looking at this and making proactive steps to address that, which is really positive.

Speaker A

00:06:02.910 - 00:06:18.030

And one thing that really struck me was the difficulty that some people felt in speaking up about discrimination.

So what did the people that you spoke to tell you about raising concerns?

And I wonder whether that says something about sort of the culture within academic institutions as well.

Speaker B

00:06:18.400 - 00:07:15.700

Yeah, this came up across levels as well.

So it wasn't just junior researchers, but senior researchers reflected on their experiences as junior researchers as well.

And there was a concern around the impact that raising issues could have on their careers, but also concerns around actually, will anything be done about it?

If I raise it, what's going to come out of this?

And so people might not report it then if they a, feel it will impact their career and impact their trajectory.

But then also if they feel that actually, you know, I don't really have faith that the system will address this or anything will change that then will leave them feeling like actually it's not worth reporting it.

And that in itself is challenging because if you've been, you know, if you've experienced that, you should be able to go somewhere that's impartial and that will take your experiences seriously and look into it and address that.

Speaker A

00:07:16.190 - 00:07:31.070

And you mentioned that when you conducted this study, you also wanted to look at things that helped people to stay and progress.

So I wonder if you could talk through just some of these different areas because there are, I think, some really important findings here about what worked well or what people thought would work well.

Speaker B

00:07:31.390 - 00:08:41.189

Yeah.

So researchers were really keen to share some of the, you know, the positive experiences that they'd had.

And say researchers talked about the importance of proactive leadership.

So this was line manager and senior colleagues around them who supported their development and looked out for their development and helped them to either identify opportunities and find those, but also act as sponsors in the sense that they advocated for the researchers in opportunities and helped to open doors as well.

And so I think through that it became really evident that, you know, with the right management support, researchers were able to find routes for progression.

But again, that's, that's really, really important is that it's, it's having that right support there.

And I think the other thing that researchers sort of spoke about were things that they think could help in terms of networking opportunities, development programs around leadership and also potential targeted funding schemes as well.

And they were keen to also sort of explore what that might look too.

Speaker A

00:08:41.429 - 00:09:04.789

And we talked about discrimination earlier and you mentioned that researchers sometimes worried that things wouldn't be acted on or they had concerns about raising their concerns.

Do you have any ideas or did the participants talk about what they felt that might make reporting discrimination safer or more meaningful?

I wonder if you had any thoughts about that as well.

Speaker B

00:09:05.429 - 00:09:48.670

Yeah.

So I think in terms of addressing racism and discrimination, and in terms of the reporting of it, one of the key things that kind of came up was improved processes for investigating incidences of racism, along with kind of mechanisms for independent review, perhaps somebody that comes in independently and reviews and looks at that.

And also the need for more accountability from leaders and organisations as well.

That was spoke about.

But I think more work is needed to look exactly what that model should look like and how that should be operationalised in a safe way that's impartial and effective.

Speaker A

00:09:48.670 - 00:10:10.830

And I was really interested in the emphasis on visibility and role models.

And you talked about the fact that there are very few very senior researchers or professors of black heritage.

But I wonder how important it was for researchers to see people like themselves in senior academic roles and what part that played really, in influencing their careers.

Speaker B

00:10:11.200 - 00:11:36.800

Yeah, we talked about this quite a bit in terms of representation, because obviously it's very low, but also why representation is important and why that visibility is so key.

And researchers and leaders alike shared that actually seeing people from a similar background to you succeed can be really powerful and it can inspire future generations.

It can also challenge assumptions as well about who belongs in these spaces and encourage more people to pursue careers.

And I think, and researchers sort of spoke about not seeing enough people there, sort of left them questioning whether it was the right path for them.

And so it can affect belongingness as well, sort of, do I belong there?

And so I think actually having more role models more visibly available would be really helpful for retention of existing researchers who are already in the space, but also for their progression as well.

You can see, actually somebody before me has done this.

I can do that too.

And as well as that, actually having more visible role models would be really great for trying to attract new talent as well.

If they can see themselves in this space.

They think I might have a look into that.

Let me have a look at what this is.

So, yeah, so this was one of the key things that really came out of the discussions, is actually People who are already there in these spaces, we need to make them visible, but visible in a safe way.

Speaker A

00:11:37.060 - 00:11:56.020

And one thing we were talking about just before we started was the importance of having a diverse research group, really, in terms of the research that we're doing and the research questions that we're asking as well.

So I wonder if you had any thoughts about why it's important for us to have that diversity in terms of the research that we're producing as well.

In primary care?

Speaker B

00:11:56.420 - 00:13:30.800

Yeah, 100% in primary care and more widely, there's a real focus on addressing health inequalities for diverse communities across the uk.

And we know all the evidence and what that looks like.

And so one of the key focuses has been improving diversity in research.

So that's clinical trials, who's being enrolled on those trials, who's participating in the trials, and other clinical and health research, who are the participants, who are taking part and how do we make that more inclusive and accessible for diverse communities?

But as well as that, the other angle we also need to consider is looking at the research teams, research departments, do they reflect the communities that we're trying to serve?

And that can be incredibly powerful, actually, because if you have a diverse research team, you're bringing in lots of different perspectives, lots of different experiences, and it means that the questions that you're asking are being sense checked, they're more relevant to those communities and more representative.

And I think, you know, in my experience as a researcher, I found that people are perhaps more willing to have a conversation with you when they see somebody who looks like them delivering the research.

And that's really important too, because sometimes we can then get, not sometimes, but actually by having a more diverse research team, we might be able to get more diverse perspectives in our research data.

And I think that's really important as well.

So as well as looking at who is our study sample, we also need to look at the team and the wider department as well.

Speaker A

00:13:30.960 - 00:13:50.380

And I guess based on the findings from this work, I wonder if you had any thoughts about if you were asking university leaders or senior primary care academics to change one or two things tomorrow.

I mean, what would you prioritise based on this?

What do you think are the sort of key things that we can try to make use to make a difference now?

Speaker B

00:13:51.180 - 00:14:46.840

So from the report and from some of our recommendations, leadership has acted on it, actually.

So towards the end of September, 22nd and 23rd of September, we had our inaugural event for black researchers in primary care research.

It was a two day event where we bought researchers of Black heritage working in primary care sort of together in a space where they could network and discuss the issues and discuss what's next and sort of prioritise where we'd like to go next.

And so one of the things that came out of that is actually developing a network for these researchers to keep in touch and stay in touch, share opportunities, but also connect with one another about challenges they may be having and also about their career development as well.

So that's kind of been sort of two key things that have already come out of this work.

Speaker A

00:14:47.160 - 00:14:57.640

Fantastic.

That's really great progress based on that.

And having something really actionable out of it is really great to hear.

Was there anything else you wanted to add on this topic or from this research at all?

Speaker B

00:14:57.720 - 00:16:05.360

The key message really here is the underrepresentation of researchers of Black heritage isn't sort of an individual issue.

Today, we’re speaking to Professor Miriam Santer, a GP in Dorset and Professor of Primary Care Research based at the University of Southampton.

Title of paper: Non-antibiotic interventions to prevent recurrent urinary tract infections in women: overview of systematic reviews of randomised controlled trials

DOI: https://doi.org/10.3399/BJGP.2026.0055

Recurrent urinary tract infection (UTI) is very common and defined as two or more UTIs in the last six months or three or more UTIs in the last 12 months. Long-term antibiotic prophylaxis is widely used but other preventative strategies have been suggested. This overview of systematic reviews found good evidence for some treatments but identified unresolved questions such as treatment adherence for vaginal oestrogen, questions about long-term use for methenamine hippurate and optimal dosage for cranberry. Increased fluid intake has been shown to be of benefit for women drinking less than 1.5 litres at baseline but is without robust evidence in other groups. The evidence base is still developing for other treatments, such as vaccines.

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 - 00:00:55.830

Hi and welcome today to BJJP interviews.

I'm Nada Khan and I'm the Senior Research editor for the bjgp.

In today's episode, we're talking to Professor Miriam Santer, a GP in Dorset and Professor of Primary care research based at the University of Southampton.

We're here to discuss the recent paper she's published here in the BJJP titled Non Antibiotic Interventions to Prevent Recurrent Urinary Tract Infections in Women.

An Overview of Systematic Reviews of Randomized Controlled Trials.

So, hi Miriam, it's nice to see you again.

And I suppose to start with, it's worth acknowledging that recurrent UTIs are something that we see incredibly often as GPs, but they can also have a really big impact on women's lives and I guess I just wanted to go through what prompted you to take this angle in this review and think about non antibiotic options for preventing them?

Speaker B

00:00:56.520 - 00:02:38.580

Well, it was exactly that, that I had a colleague, a non clinical colleague who had recurrent UTI and I guess I hadn't really appreciated the massive impact that they had in terms of, you know, keeping, being ill, keeping missing work, everything else.

And it did make me think again about my own practice, whether I really manage recurrent UTI or whether I just manage it as a series of one off events.

So it made me think about my own practice.

And then also the reason we looked at non antibiotic options was because the Primary Care Research Centre in Southampton where I work, we do a lot of work on infections and on antimicrobial stewardship and we were aware that prophylactic antibiotics tend to be quite well used and also series of one off antibiotic episodes are quite well used but that the non antibiotic interventions, we felt they were less well used and just wanted to know the evidence behind it.

Apart from doing infections research, we also do a lot of research on how to support people self manage long term conditions and we thought we could make a brilliant resource or online intervention to help people prevent urinary tract infection.

And as part of that we just wanted to know a bit more about the evidence based and in some ways we were a little disappointed that there wasn't much evidence for some of the very commonly advised things, but also surprised that for some things like methenamine and vaginal estrogen, actually the evidence base is, is pretty well established now.

So it was interesting.

Speaker A

00:02:38.900 - 00:03:04.080

Yeah.

And as you said, there's a huge number of things that women are told might help prevent recurrent UTIs and this was an umbrella review that brought together evidence from 27 systematic reviews.

But let's just talk through what.

So you mentioned about vaginal oestrogen, because this seems to be one of the clearest messages from the review.

Talk us through what you found and how strong is the evidence here?

Speaker B

00:03:04.480 - 00:04:07.360

So there were seven systematic reviews covering vaginal estrogen and they were pretty positive and especially the most recent one.

To be fair, most of the evidence is in post menopausal women, but the NICE guideline changed in 2024 to say perimenopausal and postmenopausal, because there's awareness in the rest of the menopause literature that actually genital urinary symptoms in menopause are often do present before menopause.

So it's a slightly confusing message.

The evidence base for prevention of UTIs is postmenopausal, but the guidelines are perimenopausal and postmenopausal.

But the evidence is pretty strong.

It's been amassing over a number of years.

Seven systematic reviews have been positive about it.

Unlike systemic oestrogen, where systematic reviews have been pretty conclusive that systemic estrogen doesn't make a difference in preventing recurrence.

But of course, women can take both at the same time if they need to.

Speaker A

00:04:07.520 - 00:04:21.750

And one thing I found really interesting was that there was particularly low uptake of vaginal estrogen in more deprived areas.

Do you think that there's something driving that and what can we do to try to prevent that sort of inequity in access?

Speaker B

00:04:21.990 - 00:05:59.500

And it's tempting to say more research needed.

And that was something we found in the literature, that there's a suggestion that vagina strings are less used in the UK than elsewhere.

They're less used in areas of greater socioeconomic deprivation.

And also it's not very well understood whether it's a prescribing issue or whether it's an uptake and adherence or acceptability issue.

There's.

So for prescribers, there's some things that are off putting.

So I don't really understand why vagina are not licensed for prevention of uti, given the evidence base for women.

It's a number of other things.

Sometimes, you know, not having had a sufficiently informed discussion about all the different types, you know, gel cream, pessaries, and sometimes it's also that the patient information leaflet that comes with the packet describes it as hrt, where it's really very little of it is systemically absorbed.

So it, it is, it's safer than hrt.

I mean, of course HRT is Pretty safe.

Vaginal estrogen is even safer.

But that message doesn't always get across.

And then also maybe it's because the information leaflet and all the other information tends to focus on genital urine symptoms of the menopause that people don't necessarily link it in their minds.

And I'm talking about prescribers as well as women with preventing UTI and maybe just don't keep using it long enough.

So more research needed.

But I think there's a number of barriers to uptake regarding vaginal estrogen and.

Speaker A

00:05:59.500 - 00:06:22.180

I can think of a lot of conversations I've had with women with recurrent UTIs and suggesting vaginal estrogen and often they're quite surprised but quite happy that I'm suggesting something that could work.

So I think there is a bit of a information asymmetry there between what some prescribers are doing, maybe people who are really used to prescribing these things and patients as well.

Speaker B

00:06:22.340 - 00:06:41.460

And I've also certainly met a few women who said, oh, was I meant to keep using that?

They don't necessarily see it as a, as something they need to take in the long term to keep preventing it, you know, which is.

And for something which you're only doing twice a week, that is a slightly challenging behavior to keep remembering to use it.

Speaker A

00:06:41.790 - 00:06:52.350

And I guess one other thing that you also found really good evidence for was methanomine.

Talk us through how we should be thinking about methanamine in relation to long term prophylaxis as well.

Speaker B

00:06:52.670 - 00:07:29.200

So methenamine has also made it into the nice guideline on preventing recurrent uti.

And I think I might have forgotten to say so that's anyone who's had two UTIs in six months or three UTIs in 12 months.

And the evidence is pretty good for methenamine as well as vaginase drinks.

As someone who hasn't responded to basic lifestyle advice, we might come on to that.

The evidence is a little bit poor, but it's still suggested that you discuss lifestyle advice first.

Should, if they're perimenopausal or menopausal, consider vaginal estrogen, but at all ages consider methenamine.

Speaker A

00:07:29.760 - 00:07:39.680

Interesting.

And do you think that I don't know if there's any evidence in these reviews about how they're used or whether they're underused or do you think gps are confident in prescribing these?

Speaker B

00:07:40.310 - 00:08:15.880

Anecdotally I've heard that.

Well, and going on social media would suggest that some women are still finding it hard to obtain from their gp.

Having said that, if you look at UK data like open prescribing, you can see there's a pretty steep rise in prescribing for methadone.

So I think the rates are going up and I suspect that means more GPs are prescribing it because it can't all be coming from urologists.

So we didn't find evidence in this review, but.

But my understanding from having looked at the data is that actually it is being increasingly used.

Speaker A

00:08:16.360 - 00:08:40.820

Yeah.

And that's on the back of some pretty good clinical trials evidence as well, I think the Ultra trial, I think, in that area.

Great.

And I think cranberry is really interesting because it's something that people often ask about and I think when people think about UTIs, they often think about, oh, I should be drinking some cranberry juice.

What does the evidence actually tell us?

Does.

Is there anything about cranberry or type or dose of cranberry that people use?

Speaker B

00:08:41.540 - 00:09:18.420

Well, we found six different systematic reviews on cranberry and the evidence on dose is not particularly strong, so it's quite reasonable.

The nice guideline concludes that it's worth discussing it, but it can't be prescribed.

It's probably safe to say that juice is not particularly effective.

Cranberry tablets.

More of the evidence is around cranberry tablets where there's going to be a more consistent dose than from just drinking juice.

But, no, the optimal dose is not yet known, but it probably does help.

Speaker A

00:09:18.660 - 00:09:31.300

And I guess we've talked, we touched on just sort of lifestyle advice and what about something as simple as drinking more water?

Is that the kind of lifestyle advice that we should routinely be giving women with recurrent UTIs, or do you think it's a bit more nuanced than that?

Speaker B

00:09:31.840 - 00:10:41.740

So there's two systematic reviews that included fluid intake, but both of them only really found one substantial trial.

And it's quite interesting.

They only included women who drank 1.5 liters or less per day, which actually is below average.

And the intervention there was, they were giving people bottled water to drink with every meal.

So people who have low fluid intake should definitely be drinking more.

But when you read advice, that's like two or three liters a day, we really don't know that.

And it can feel a little bit blamey, a lot of the quality.

We didn't do a qualitative study, but if you read the qualitative evidence around uti, because women have quite often been given this message for a current UTI on a number of occasions, it can Add to the feeling of it being a little bit stigmatizing, a bit dismissive and a bit as though it was.

It was your fault that you didn't do this.

Whereas actually, we don't really know how much difference it makes for people who are drinking more than 1.5 liters a day initially.

Speaker A

00:10:42.059 - 00:11:04.760

And we were talking just before we started about Tory Ford's work on recurrent thrush and about how she's conceptualizing it not just as single episodes of thrush, but as recurrent thrush as a specific condition.

And I suppose maybe the qualitative of evidence, although you didn't look at that specifically here, but we were reflecting on some of the parallels, weren't we, just before we started.

Speaker B

00:11:05.320 - 00:11:45.530

Yeah, yeah.

And the qualitative evidence is so strikingly similar.

This feeling that it's a mundane, trivial thing, feeling dismissed and the cumulative experience of a number of consultations and feeling a bit hopeless about it after a while, a bit hopeless, not just about the recurrent uti, but about the feeling that it's not really being managed or looked after is.

Is.

Is.

I was so struck at the similarities, really.

And, yeah, again, you do wonder a little bit, is that because it's a women's health care issue and it's seen as a bit, dare I say it, trivial.

Speaker A

00:11:45.930 - 00:12:05.910

And there are some interventions that are really popular with.

With women, so particularly D Mannose and probiotics, and people can buy those just from the pharmacy review suggests that the evidence isn't really strong enough to recommend them.

Do you have any thoughts about that evidence and maybe what we should be advising people who are asking about it?

Speaker B

00:12:06.390 - 00:13:22.790

It's really tricky.

And so the reviews mostly concluded for D. Mannose probiotics, vaccines, that more evidence was needed.

The interesting thing about doing a review of reviews or an umbrella review, as we did, is, is that recent trials haven't yet been.

If they've not yet been included in a systematic review, they're not yet included in the overview of systematic reviews.

And the most recent trial on D. Mannose suggested that it probably isn't effective, but some people with UTI really feel it is effective.

So it's a really hard one.

There were some adherence issues in that trial.

It may be that it works for some people and not others.

A few studies have suggested that things like cranberry may work better in younger women.

And it's possible that D. Mannose, which is essentially a type of sugar, works in a similar way.

And obviously we can't prescribe it like cranberry.

D Mannose is something that women will be buying themselves.

So if someone wanted to try it, I certainly wouldn't put them off.

But it definitely doesn't have the same strength of evidence as methenamine or vaginal estrogen, for instance.

Speaker A

00:13:23.100 - 00:13:49.340

And you've touched upon this and I guess one thing that struck me from your paper was how little we know about whether women actually want to use these treatments and whether they can stick with them.

And we've talked a bit about sort of fluid intake and also the different over the counter treatments as well.

Have you got any thoughts about what we need to know about the adherence and acceptability in this area and I guess why it's kind of limiting our understanding of whether these treatments work?

Speaker B

00:13:49.710 - 00:15:24.930

I think there's, there's questions about how long people need to stay on methenamine for.

You mentioned the very good trials.

They weren't terribly long trials.

I think we need to know a lot more about the acceptability and adherence to different vaginal estrogens.

I'd love to see more evidence on cranberry and what dose and what formulation we should be saying.

I would be interested also to know more about evidence for other things, like, you know, all the things that other people are told like washing before and after sex, going to do a pee before and after sex.

Very hard to do in rct, but at the moment it's in the guidelines, but it's not in all the guidelines.

If you look internationally, some international guidelines don't include them because there's no evidence for them and because it's potentially stigmatizing.

So I think a bit slightly more nuanced conversations when people may have had that message repeatedly.

Wiping to front to back is a common one as well that people might be told repeatedly.

And certainly in some of the qualitative studies I've read, people just say this just feels so patronizing to be told that again and again.

I think how we communicate those sorts of messages also needs more thought, more sensitivity, more, you know, how can we do that?

Well, to make sure that people are fully informed but they don't feel like they're just being told the same slightly stigmatizing advice again and again and often.

Speaker A

00:15:24.930 - 00:15:32.010

I suppose that women who are having recurrent UTIs will be the expert in their condition and how they feel and how they treat it as well.

Speaker B

00:15:32.170 - 00:15:38.480

Yeah, absolutely.

They will heard these messages before.

They may well have tried quite a lot of them before.

Speaker A

00:15:38.800 - 00:15:41.520

Any other key findings you want to pull out from this review?

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.

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.

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.

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.

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.

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.

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.