BJGP Interviews

Today, we’re speaking to Dr Tom Purchase, a GP and Health and Care Research Wales NIHR doctoral fellow.

Title of paper: Co-generating ideas for safer paediatric care in general practice with parents and stakeholders

Available at: https://doi.org/10.3399/BJGP.2025.0690

Research has highlighted the important role parents play in in paediatric patient safety, for example, through mitigating safety incidents in general practice, yet their perspectives have rarely shaped system-level improvements. This study co-generated and prioritised ideas for change with parents and key stakeholders, identifying feasible and impactful strategies to improve paediatric safety in primary care. These strategies centred around practice communication, accessing care records and results, and fostering a culture of shared learning and development. Parents are willing and able to contribute meaningfully to safety improvement efforts, and their insights align with national patient safety priorities. Clinicians and policy makers can use these findings to strengthen collaboration with families, tailor safety interventions to local needs, and embed parent voices into the design of safer care systems.

Transcript

This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A

00:00:00.480 - 00:00:49.500

Hello and welcome today to BJGP Interviews. I'm Nada Khan and I'm one of the Associate editors of the Journal. Thanks for listening again to this podcast.

In today's episode, we're talking to Dr. Tom Purchase. Tom is a GP and a health and Care Research Wales NIHR Doctoral Fellow.

We're here today to talk about the paper he's just published in the bjgp and the paper is titled Co Generating Ideas for Safer Pediatric Care in General Practice with Parents and Stakeholders.

So, hi, Tom, it's really great to meet you and to talk about your work, but before we talk about the study itself, I'm interested to know what first got you interested in pediatric patient safety in general practice.

Speaker B

00:00:50.060 - 00:02:26.850

Thanks. It's born, I think, out of an extension of the work that we've been doing within the patient safety team within Cardiff University.

So a lot of what we do is looking at incident reports, safety incident reports, and trying to pick out what are the, you know, high level key learning points and takeaway messages from those.

And then within the team, we started to think about, as well as the types of incidents and the types of harms that are occurring within pediatric incidents. For example, how are parents involved?

And it was a bit of a novel approach to what we normally do, trying to have that extra aspect within the incidents and figuring out how parents were either helping to contribute or to mitigate against the incidents, not just looking at the incidents themselves. So that was the starting point, really.

And then once we'd started digging into that data and identifying that, actually the majority of the time, which is in one of the papers that was published last year in BJGP, 77% of the reports we were looking at specifically around general practice showed that parents were taking these mitigatory actions that, you know, positive actions that were able to prevent harm or further harm from occurring to their child, for example, chasing results or chasing referrals or importantly, being able to speak up. And then that highlighted, I think, the importance of parents being able to have a voice and advocating on behalf of their child.

And that really sparked, I think, the interest, and therefore this part of the.

Speaker A

00:02:26.850 - 00:02:46.490

Project, and I think that's a really interesting thing about this paper, is that it focuses on parents and parents not just as observers of care, but as active contributors to safety. And I wonder what your thoughts are about why that's an important shift in how we think about these things.

I think you've touched on it a bit, but yeah, I'm interested to know a bit more about that.

Speaker B

00:02:46.810 - 00:03:55.980

I think it is a really important aspect of care, but also particularly safety, which maybe is untapped in terms of parents as a resource as to how we can keep children safe.

We know that children on the whole are more, maybe not more vulnerable, but certainly are a vulnerable group when it comes to patient care in general and patient safety.

And that's because they're so heavily reliant on others to speak on their behalf, to make sure somebody else is looking out for their healthcare needs. And therefore they are probably playing a part within the world of patient safety.

And there are good studies from hospital relating to incident reports that show that parents are capable of picking up issues early on. They're able to detect issues that maybe other parts or people within the system aren't detecting.

And as I mentioned, our paper from last year specifically looking at general practice showed that parents are able to prevent harms from reaching their children. So they're playing a substantial part already.

And from a systems perspective, that is mainly parents figuring out workarounds within a system that really isn't, I don't think, designed to support them as well as it could be.

Speaker A

00:03:56.460 - 00:04:33.810

And I guess that's kind of the crux of what you were doing here.

So I guess before we get into findings, just, you know, a quick word about the methods because you worked here with groups of parents to develop ideas for improving pediatric patient safety in, in general practice, in primary care, and then you explored those ideas with a wider group of stakeholders and that included clinicians, managers and policymakers, and then brought them all together to co generate ideas for safer care. And it was really interesting because the parents generated 16 different ideas for improving safety.

And were there any that particularly surprised you and jumped out at you?

Speaker B

00:04:34.450 - 00:05:33.980

I don't think necessarily any were too surprising on the basis that we. I don't think I really had any thoughts going into it as to what they might say.

But I guess what did surprise me more was that some of the ideas that we then took forward to the stakeholder group kind of highlighted some disparities or some clear disagreements between the parents who were accessing our services and the people who work within the services. And how we viewed, I suppose, viewed what's actually happening, that kind of work is imagined and how we think things are going and the work is done.

I guess what the parents were trying to do to come up with the idea is to bridge that gap unknowingly. I suppose maybe what's surprising is that none of them, I didn't think any of the ideas were necessarily too resource intensive.

You know, I think what was quite reassuring is that lots of what the parents were saying were actually relatively simple things that we might be able to enact or at least adopt or adapt, you know, to our own environments.

Speaker A

00:05:34.540 - 00:05:47.730

And a lot of the ideas seem to center, I think, around communication, access to records and test results, and actually just helping parents to speak up. And why do you think those themes emerge so strongly?

Speaker B

00:05:48.450 - 00:07:24.990

I think that comes back to maybe that difference between how we like to think the system's functioning and how parents think the system's functioning as healthcare professionals and parents.

Because we know from a thematic analysis we did, which is also going to be published in bjgp, from these discussions we've had with the parents, that a lot of them said they felt the need to fight in order to be heard.

So although within, say, pediatrics and GP training programmes and CBDs and everything we have to do for revalidation, taking ideas, concerns, expectations, collateral histories, making sure we're really considering that the holistic approach is all considered clinically, what you're then getting, I suppose, from the parents is that maybe we're not doing it as well as we could be.

And one parent within the workshop said, I know as a parent you are expected to advocate for your child, but what it surprises me is how regularly you have to do it and sometimes it feels like a full time job.

And I think that one really struck a chord in terms of really emphasizing how much extra effort and how much work parents are feeling they need to put in. And I think that also implies that the system isn't making it as easy as possible for them to be able to do the right thing.

So I can't necessarily explain unfortunately why they feel that those areas needed to be targeted.

I guess it's because there are barriers that we are not tackling correctly in order to help parents to speak up more efficiently and certainly to be listened to.

Speaker A

00:07:26.840 - 00:07:35.160

And one of the stakeholder priorities was this idea of a designated parent advocate. Can you tell us a bit more about that idea and why it resonated?

Speaker B

00:07:35.640 - 00:09:21.810

Yeah, sure.

I really liked that one and I thought it was an interesting one because again, it highlighted, I think, a number of issues that we could discuss in a lot more detail. I know this podcast isn't ours. I think we could talk about it for a long time.

So that one, I think came out of the need that parents were identifying to sometimes just want to clarify something if they weren't quite sure how to access something or they didn't really know how something worked. We know that our systems are complicated and one of the issues we found was parents found that just navigating that system was an issue.

So it's one way of trying to work around that.

If there's someone that you can speak to who understands the system, maybe working within the practice or even as a third party, you know, you could go to them and get some advice. But they also specifically said it's not just kind of system advice, it's also advocacy, help, well being.

If they wanted to give feedback or raise a concern. It's someone who is very importantly separate from that complaints process.

Because I know I keep talking about the system and how it's designed, but the complaints process, for example, is very specific.

And what we found talking to the stakeholders is that they, they felt that what the parents were asking for here kind of already existed, but in the form of maybe the complaint system, which obviously has a particular purpose, isn't always easy to use. You know, if you've got to email the practice manager, that might not be something that you want to do.

And parents worried about coming across as a nuisance or having some negative repercussions on them. So it was an idea of here is someone who's maybe a bit more independent, they know how things work.

I'll be able to get some sound advice from them and that might be able to help me progress or to get my voice heard in a way that wouldn't have a negative repercussion on me.

Speaker A

00:09:21.890 - 00:09:38.050

And I think a lot of GPS listening will be thinking about what this work might mean for their own practice. And which of the proposed changes do you think are most achievable at practice level?

Is it that about a parent advocate or are there any other ideas that you thought could be achievable?

Speaker B

00:09:40.360 - 00:11:56.550

Thankfully, that was one of the questions that we were asking the stakeholders.

So when we took all of these, the 16 ideas to the stakeholders you mentioned, we specifically said of these ones, which do you think are the most doable and which ones will be the most impactful?

And then we went through each one in turn and plotted them on a matrix to say, you know, to try and come up with an arbitrary way of saying, well, which ones do we think are the most impactful and most doable that we could then suggest to, as you say, practices or readers in a meaningful way.

Where there was most agreement between the parents and the stakeholders, as well as being positioned as the most doable and the most impactful, was asking parents for solutions and feedback.

So parents felt that they weren't being asked enough for their opinions and their experiences when it comes to, well, lots of parts of the process, but obviously in relation to safety.

And then the stakeholders also strongly agreed that actually, if we're going to improve our way of working and integrate the parent voice more, we obviously need to be asking them.

And in lots of other industries, we're obviously asking for feedback all the time, and we don't necessarily do it very well in the NHS or within general practice specifically. So I think it reflects maybe, you know, a broader issue about patient and public involvement that in.

Specifically in the context of parents, because child safety is so important to them, I think their involvement is therefore seen as a really important role that maybe they're not currently being given the opportunity to fulfill the disagreement or not disagreement. But the discussions that happened in the stakeholder meeting around this, everyone agreed that it was a good idea, but it was.

How it was then implemented was maybe going to be obviously based on where you are and your population, but also what you were actually asking the parents for.

So whether it's a case of doing something similar to us, where you maybe have a focus group or workshop, or whether you just send out a survey with some specific questions, or if you speak to some individuals with one stakeholder, highlighting that if you do have a significant event or some safety incidents that you've been looking at, are you then talking to the people who've been involved, those parents, and trying to identify the gems that sometimes come out of that in order to identify where you can make improvements that could lead to a meaningful change?

Speaker A

00:11:57.330 - 00:12:08.290

Yeah, I like that idea of involving parents in significant event meetings, or at least taking the results of those two parents, because often I feel like those meetings are kind of closed within the practice, aren't they? They're not.

Speaker B

00:12:08.770 - 00:12:30.960

Yeah, absolutely. And there's no reason necessarily that we couldn't. I think it's just maybe we haven't thought about whether we could or we should.

And then once you start to have those ideas, you know, you can then start thinking about, well, how feasible is it? How could I manage this?

Or even quality improvement projects or any kind of safety activities, you know, probably could have parent involvement as well. We're just not necessarily thinking about it in those terms.

Speaker A

00:12:31.440 - 00:12:39.440

One thing I thought was really interesting is that the paper talks about parents as a source of resilience within the healthcare system. What did you mean by that?

Speaker B

00:12:39.920 - 00:14:07.020

So what we mean by system resilience normally is how adaptable is that system to any change or unpredictability which within all of healthcare, being the complex socio technical system that it is, we are constantly facing unpredictable scenarios.

And you know, those, those interactions between us, the parents, the children, all the other staff, our technologies are always changing, the organizational structures are always changing. You never quite know how the interactions between all those elements are going to come to fruition or what's going to emerge as a result.

So resilience is facing all of those changes.

If something was to happen, how well can you know you bounce back as a practice or how well are you going to be able to cope with an issue or an event? And parents being an important part of that system.

Resilience is because not just as a safety net, but also as an information source and somewhere to go or someone to talk to who would be able to, as we mentioned earlier, pick up on when something isn't quite going right, or if they want to challenge a decision.

And from a human factors and ergonomics point of view, we know that when someone is able to advocate or speak up or challenge or help to correct something that supports resilience. So it's giving the systems all of the opportunities to continue to function safely and correctly that it can.

Speaker A

00:14:07.180 - 00:14:15.340

And I guess having done this work, what do you think is the one thing you'd most like gps to take away about working with parents to improve safety?

Speaker B

00:14:15.730 - 00:15:03.200

If I had to choose one, I think it would be encouraging parents to speak up.

Lots of things we've talked about obviously in this podcast around how we could incorporate them in other ways, but just the simplicity of validating their concerns and considering their concerns as clinically meaningful.

But then creating a culture within the practice where a parent speaking up or asking a question isn't viewed as a criticism, which I think is often the case, or a hindrance and welcoming and proactively seeking out parents insights.

So trying to shift the thought process from parents being passive participants within our system to actively trying to incorporate their voices into what we're doing on a daily basis.

Speaker A

00:15:03.520 - 00:15:15.510

And I'm going to ask sort of a similar question but in a slightly different way. But if you could implement just one of the ideas from the workshop in your own practice, which one would it be do you think? And why?

Speaker B

00:15:15.830 - 00:16:23.070

It's tricky because what we say in the paper is that I think choosing a selection of them would be the most beneficial on the basis that you'd be able to target different areas.

I think personally, what I would be interested to see, whether it makes a difference or not, would be some sort of just simple display or poster to Kind of encourage parents to speak up as part of fostering that culture of saying it's okay to voice your opinion and to share any thoughts or concerns that you have with us.

So within the stakeholder event, one of the stakeholders described it as being a useful idea because it almost gives parents that permission to be able to speak up if they need to. And I think that's a very good starting point to then build upon.

Today, we’re speaking to Dr Garth Funston, a GP and Clinical Senior Lecturer in Primary Care Cancer Research at Queen Mary University of London.

Title of paper: Using large language models to identify pre-diagnostic clinical features of ovarian cancer from healthcare records: a population-based case-control study

Available at: https://doi.org/10.3399/BJGP.2025.0366

Most women with ovarian cancer present with symptoms, but many symptoms are recorded only in free text healthcare records and missed by studies and clinical decision support tools that rely on coded data. We found that using large language models (LLMs) to extract symptoms from free text records substantially increased symptom detection and strengthened associations with ovarian cancer. Incorporating LLM-extracted symptom information into research and clinical decision tools may support identification of women at higher risk of cancer and aid appropriate investigation.

Transcript

This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A

00:00:00.800 - 00:00:50.940

Hi and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate editors of the Journal. Thanks for listening to this podcast today.

In today's episode, we're talking to Dr. Garth Funston, who is an academic GP and clinical senior Lecturer in Primary Care Research at Queen Mary University of London.

We're here to talk about his recent paper in the BJDP which is titled Using Large Language Models to Identify Pre Diagnostic Clinical Features of Ovarian and Cancer from Healthcare Records.

So, Garth, thanks so much for talking to us again today, but I wonder, just before we get into the AI side of this paper, can you briefly explain the clinical problem you're trying to address here with ovarian cancer diagnosis in general practice?

Speaker B

00:00:51.500 - 00:01:55.010

So most women with ovarian cancer are diagnosed after they develop symptoms and see their doctor. The challenge is that most symptoms are really non specific. There's no real red flag symptoms for ovarian cancer.

That makes it a real clinical challenge for the GP to kind of recognize it and perform tests.

So the symptoms are things like abdominal and pelvic pain, persistent bloating, urinary urgency and frequency, things that we see really frequently in gp. So knowing when to consider ovarian cancer is the big challenge.

And we know that certainly a proportion of women see their GP multiple times before the diagnosis. Now we're lucky for ovarian cancer in that we have reasonably good triage tests and CA125 and transvaginal ultrasound.

So the challenge really is to identify women with these non specific symptoms early so as we can work out who to test and hopefully improve early diagnosis and on outcomes in that way.

Speaker A

00:01:55.250 - 00:02:14.530

Yeah, and I'm sure you're well aware of sort of the body work around this area and people like Willie Hamilton, who's done work around early diagnosis of ovarian cancer, along with Claire Bankhead, and they did some really interesting work around things like bloating, didn't they? But that was slightly different, I think, and a little bit that's some time ago now, isn't it?

Speaker B

00:02:14.930 - 00:02:39.230

Yeah, it was some time ago. I think all of that is, you know, fundamental and still holds true.

And they did a lot of work around things like IBS and in women over, over 50 and things like that that are kind of these subtle signs that we need to be aware of with ovarian cancer.

So, yeah, we know there's lots of features that are associated with ovarian cancer, but it's recognizing when to invest to get those features because they're so common.

Speaker A

00:02:39.630 - 00:02:49.310

Yeah. And do you think that's why it's described as difficult to diagnose early in general practice? Is it because the symptoms are so common?

What are your thoughts on that?

Speaker B

00:02:49.390 - 00:03:48.750

I think there's a few reasons.

I think ovarian cancer used to be called, certainly in the media, the kind of the silent killer and terminology, which I really, really frustrates me, because we know it's not. We know that most women of symptoms for diagnosis. We actually know that from this paper and other papers that are symptoms in early stage cancer.

But that kind of thought around ovarian cancer still holds. Secondly, the symptoms are nonspecific, they're reasonably common. I mean, you know, I probably see a.

A patient with abdominal pain most days and it's kind of working out which ones to investigate for ovarian cancer. Yeah. And so I think those are the main things. And thirdly, it's, you know, it's not the most common common cancer.

GP will see people probably only encounter a case of ovarian cancer every three to five years, a new case. And that's the extra challenge. It's kind of suspecting it when it's a rare thing in primary care.

Speaker A

00:03:49.100 - 00:04:03.500

Yeah. And one thing I found really interesting about this work is that you're using free text clinical records rather than just coded data.

So can you tell us a little bit about the data you accessed here and why it was so important to use this free text data?

Speaker B

00:04:04.220 - 00:05:09.600

So a lot of the work that we do with primary care data focuses on coded data and certainly within the uk, because that's really the data we can actually access within UK for research purposes. But up to 80% of clinical information is not in that coded format, it's in the free text.

And work from people like Sarah Price in the past have shown that often subtle things that we need to pick up are in the free text and GPS don't code that.

So it's something I've been really keen to use in research for many years now to try and look at what extra information is there in the free text that could help us in both research and clinical practice and kind of picking up these cancers. And the data we accessed was from the United States, it was from healthcare clinics associated with the University of Washington.

And that included kind of coded data, but also the free text medical records of patients which had been anonymized and were accessed in a kind of a safe and appropriate way.

Speaker A

00:05:10.000 - 00:05:40.140

Yeah.

And I think a lot of clinical staff listening to this will certainly, certainly appreciate that a Lot goes into the notes that we just type in that doesn't really get coded. So it's phenomenal that you're able to access that data.

And this paper uses large language models or LLMs, which some people might associate, associate with tools like ChatGPT, but just at a very basic level. Can you just talk us through what actually is a large language model and what sort of it was used for in this, in this study?

Speaker B

00:05:40.950 - 00:06:49.130

Large language models, lots of people use them on a daily basis. Absolutely right.

Things like ChatGPT, they're essentially a tool for our purposes which we use to extract information from the free text medical records. Now natural language processing approaches have been used actually for many years, kind of rule based approaches.

Other models, these require lots of training. You need to lots of highly annotated records and notes to train the models.

Advantage of large language models, things like GPT, is they need less annotated notes and we did still do some of that, but they require less and that makes them much easier to apply and use in practice. We use them in this setting to effectively pull out key information on symptoms.

We predefined a list of 17 symptoms from the literature which were associated with ovarian cancer and we used the large language models to go through the notes, pull out information on those symptoms that we could use in the study alongside the coded data.

Speaker A

00:06:50.090 - 00:07:03.350

And I think that as we've been discussing, these large language models are probably really useful for this kind of data. I think especially because a lot of general practice is narrative and contextual as we've been discussing as well.

Speaker B

00:07:03.350 - 00:07:38.940

Yeah, I think, I mean there's two challenges with using free text data. One is access requirements because there's lots of concerns around confidentiality. The other is just the volume of it.

You've got these massive records that you know, contain lots of information, lots of writing, go back years. How do you actually process that to find the key information that you need?

I think large language models are a really useful tool here because with a bit of training you can use them to actually extract the information that's pertinent to your kind of question.

Speaker A

00:07:39.340 - 00:07:48.620

So let's go into what you found and I'm really interested to know about what kind of patterns or features was this model able to identify before an ovarian cancer diagnosis.

Speaker B

00:07:49.180 - 00:09:06.690

So we looked at 17, 17 features. We find actually that 14 of the features were more frequently recorded within the free text and coded information.

And often those were the more non specific features. Things like appetite loss, actually things like weight loss as well and urinary symptoms, whereas actually pelvic mass was pretty frequently coded.

And 40% of bloating, for example, was was recorded in free text and not recorded in codes at all. And the model was able to pull out those features.

And when we combined the extracted information from the pretext with the information from the coded data, we find that 14 of the features were actually associated with ovarian cancer in the regression models.

Now, if we only used coded information, didn't use the information extracted from using the large language models, six of those features were no longer associated.

So really it showed that applying large amount language models, pulling out those extra features made a big difference in terms of the associations that we were able to identify.

Speaker A

00:09:07.730 - 00:09:13.970

And did any of those findings surprise you in terms of the associations from a clinical point of view at all?

Speaker B

00:09:13.970 - 00:09:42.430

I think we focused on 17 features that had been reported in some studies. Some are only reported in a few studies.

Pretty non specific, not always in nice guidelines, but I think I was not completely surprised by any, but things like appetite loss and things like that, which are more subtle, I was excited that we were able to identify that even within a relatively small study like this because we had access to that free text data and were able to kind of pull out that information.

Speaker A

00:09:43.070 - 00:10:03.630

Yeah.

And I know there has been some work done done about how GPs enter information into patient records and things like symptoms often don't get coded and they are in the free text.

So I'm interested to know your thoughts about what this kind of approach adds beyond these existing symptom based risk tools that might be just based on coded data.

Speaker B

00:10:03.950 - 00:11:27.920

Absolutely. I mean, we know that, you know, for certainly some symptoms. Sarah Price's work has shown that 43% of symptoms are not coded in her work too.

So I think really chimes with that. I see kind of the use of this in two ways. One is research context and one is kind of a clinical context.

And in the research context, I think moving towards using these LLMs to pull information out of the record could really be game changing in how we understand disease, how we understand the symptomatology of disease, actually how we understand risk factors as well, which aren't always coded either.

So I think not just for cancer, but applying this across different diseases, we could do some really exciting work looking at risk factors and predictors of disease.

And secondly, in the clinical setting at the minute we use tools fairly frequently such as qrisk Q Cancer and those are developed based on coded data and they pull coded data from the GP record and then GP gives and enters in extra details. I think there's real potential here to use LLMs to inform those risk prediction models.

So you could have those LLMs extract information, add it to the model. There's a potential here to give more accurate predictions and guidance for gps.

Speaker A

00:11:28.080 - 00:11:51.180

And, you know, you mentioned that this is a really exciting area and I think there is a lot of excitement around AI in healthcare at the moment.

Where do you think the opportunities are now in general practice, especially with, as you mentioned, some of the difficulties around accessing free text data and this kind of approach to identifying symptoms or things in the free text that clinicians are entering in?

Speaker B

00:11:51.260 - 00:13:02.640

Yeah, so I think there's a lot of work going on using the free text in different countries.

So in the US already and Scandinavia, the Netherlands, there's been a lot of work actually using free text applying and natural language processing approaches to kind of do the studies and build that into models. So I think already we're, we're going to start to see potential impacts from this.

There's models out there looking at pancreatic cancer, for example, which have shown free textiles considerably work, actually probably going to be bjgp, also looking at lung cancer using freetext.

So I think for me, the opportunities are to start to do these studies that are pretty novel, certainly in the uk, to kind of identify factors that associated with disease, identify symptoms, but then also move from that to incorporate them into models and put them into practice, which is a challenge, certainly with the infrastructure, governance and other restrictions, and has to be done properly and ethically. But I think if we don't start using this data, now that we have the tools, it's a real missed opportunity.

Speaker A

00:13:02.720 - 00:13:20.540

And what are the next steps for this work?

So you've identified these factors that are associated with an ovarian cancer diagnosis, and as you mentioned, there are a few features that were found above and beyond just what you might expect to find from the coded data. So where are you taking this next? How do you want to put this into practice?

Speaker B

00:13:21.260 - 00:14:05.700

Yeah, so in this work we looked only at symptoms, whether they're present or absent. Actually, large language models can do much more than that.

They can look at duration of symptoms, they can look at information on severity, and that's quite powerful. We can't capture that encoded data at all, or risk prediction models don't capture that.

I'm really interested in starting to look at that information, see what we can pull out from that and see how it affects risk of cancer.

So I think the next step for this work is to look at that look at other cancers and diseases as well, and also start to move from a proof of concept that we can do this into building risk prediction models to actually try and make something that we can move into primary care.

Speaker A

00:14:06.100 - 00:14:12.260

Yeah. And for any gps listening to this, what's the main thing you'd want them to take away from this current study?

Speaker B

00:14:13.080 - 00:14:44.120

So I think from ovarian cancer perspective, to recognise that actually ovarian cancer has symptoms, they're often subtle, they can occur in early stage disease.

So to be aware of symptoms such as persistent bloating, abdominal pain, urinary changes, and to be aware of those and recognise them, particularly if women have worsening symptoms or it doesn't seem right or there's no obvious cause, and perform investigations such as CA125 and. Or ultrasound.

Speaker A

00:14:44.600 - 00:14:50.920

Any other final thoughts that you want to add just based on this work or anything that you want to sort of highlight from this paper?

Speaker B

00:14:51.400 - 00:15:22.150

So, for me, this work shows how much information, how much important information is contained in that free text.

I think from a UK perspective, we need to work with governance bodies, we need to work with data providers to look at how we can make this data available in the uk. UK has some of the best healthcare resources in the world, but if we're unable to access and use this free text data, it's a real missed opportunity.

It's a real opportunity to use it to benefit patients on the nhs.

Speaker A

00:15:22.630 - 00:15:31.830

Brilliant. Thanks very much for that, Garth. It's a great paper.

So, yeah, I'd recommend anyone listening to go back and have a listen to it, but I just wanted to say thanks very much for your time.

Speaker B

00:15:32.390 - 00:15:33.270

Thank you very much.

Speaker A

00:15:34.630 - 00:15:49.800

And thank you all very much for your time here and for listening to this podcast today. Garth's original research article can be found on bjgp. Org and the show notes and podcast audio are at bjgplive. Com. Thanks again. Bye.

Today, we’re speaking to Dr Clare Macdonald, an Academic Clinical Lecturer in General Practice based at the University of Birmingham.

Title of paper: Complex social needs and maternal postnatal care: what can primary care do?

Available at: https://doi.org/10.3399/BJGP.2026.0069

Throughout the discussion we use the terms ‘woman’ and ‘women’, but we know that not all those who give birth will identify as women and intend this to mean all those who give birth.

Transcript

This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A

00:00:00.480 - 00:00:51.740

Hello and welcome to BJ GP Interviews. I'm Nada Khan and I'm one of the Associate Editors of the Journal. Thanks for listening to this podcast today.

In today's episode, we're speaking to Dr. Claire MacDonald. Claire is an academic clinical lecturer in general practice, and she's based at the University of Birmingham.

We're here today to talk about the editorial she's just published in the May issue of the bjgp, and it's titled Complex Social Needs and Maternal Postnatal Care. What Can Primary Care Do?

So, hi, Clare, it's lovely to meet you and to talk about this brilliant editorial, but before we get into the editorial itself, I wonder if you can just talk us through what you actually mean by complex social needs in the context of postnatal care.

Speaker B

00:00:51.980 - 00:02:21.290

Yeah.

So I think when we talk about social complexity in the postnatal population, we're talking about women who have multiple factors that might be influencing how they can access care or influencing the clinical and social risks that they have. So for most people, the time after they've had a baby results in some social change.

Even in the most straightforward, most brilliantly supported, most physically well person, there are big social changes. And that is a period of a complex time to navigate and finding your way and your identity as a family with a new baby and so on.

When we talk about complex social needs, we're talking about women who face other aspects of adversity.

So it might be that they have housing instability, it might be that they have experienced domestic abuse or they continue to experience domestic abuse, that they have a history of safeguarding issues, safeguarding for themselves or safeguarding concern, concerns about other children or other family members.

And when we see women who have overlapping social risk factors that produces this kind of network of complexity that puts them at compounded additional risk and they need additional help in navigating their health needs in that time.

Speaker A

00:02:21.450 - 00:02:47.310

And I wonder why you felt that this was an important issue to highlight right now. So is there anything in particular that makes you think that this is the right time to sort of look into this?

I know that there's a complex picture in terms of sort of maternal care, and if we look at things like the cost of living crisis, which is compounding a lot of the pressures that people are facing. But talk me through what your impetus was in thinking about this as a now issue.

Speaker B

00:02:48.110 - 00:05:26.470

Yeah, that's right.

So maternity services are really high profile in the news a lot at the moment, but from a secondary care perspective, and quite rightly, there's a spotlight on the poor care that some women and their families and their babies receive from secondary care. And there are, you know, huge pieces of work being done to improve that, to improve outcomes and to improve people's experiences.

But that focus tends to be on intrapartum care.

So the care that people receive in hospital around the time of birth, sometimes there's a little bit of focus on antenatal care as well and reducing risk during pregnancy, there's a lot less focus on what looks like the less exciting time of preconception care and then postnatal care. So after women get discharged from maternity services, we know that they're often left feeling a little bit isolated in the healthcare context.

Some qualitative research that we've done in the past, looking at women's experiences of postnatal care, women told us that they were surprised about they'd had so many appointments during pregnancy and then so much healthcare retention in the first few days after birth, and then they were just surprised. No, you know, they had a baby and no one was really interested in their health anymore. And that genuinely came as a surprise to them.

We know that maternal mortality in the uk, which, thankfully, in absolute numbers, is. Is quite small, but it's certainly higher than it could be and maybe should be, particularly compared to other kind of similar European countries.

And there are actually more maternal deaths postnatally, so in the sort of later postnatal period, six weeks to a year after birth, than there are in that sort of antenatal, intrapartum and early postnatal period. And all of the political drive tends to be about reducing maternal mortality in its traditional definition of being up to six weeks after birth.

But as GPs, where we can really have an impact is in those late maternal deaths.

And of course, very few of us, thankfully, will be involved in the care of a woman who dies in that period, because they are small in absolute numbers. But there are all the women who do not die, but have those risk factors and have that complexity.

And the longer they live with those sort of adverse health conditions and adverse social conditions, that is dramatically reducing their quality life course health. And we can really step in, in that postnatal period to look at how we can influence that.

Speaker A

00:05:26.870 - 00:05:49.080

Yeah, and you've mentioned about the kind of care that women get in during their pregnancy. And sometimes, I'm sure for some women, the postnatal period can feel already pretty fragmented for those reasons.

But how do you think that that fragmentation can become amplified for women with complex social needs? Do you have any thoughts about that?

Speaker B

00:05:50.280 - 00:08:25.320

Absolutely. So a Lot of people will know how to contact their gp, right?

I think if you ask people, most people have probably got that number saved in their phone or they know where their GP practice is.

But after you have a baby, women are then given all these kind of new healthcare professionals who are interested and involved and it's impossible to know how that all fits together.

So the midwife will typically follow women up for that kind of, you know, 10 to 14 days postnatally, usually just at the time the midwife is giving you the final sign off appointment. Within a day or two, you have an appointment with the health visitor, which again is somebody new, and then you might have a follow up.

For example, if a woman's had a third degree tear or is having some additional hospital follow up because of hypertension or gestational diabetes, then the hospital are involved and then they come back to the GP.

And I often feel like, for us as GPs, women, as soon as they're pregnant, they can generally self refer to the midwife and they get kind of lifted out of the primary care system to an extent.

We might not see them through their whole pregnancy, then they have a baby, we might or might not get a discharge summary that gives us some details about the birth and then we invite them for their postnatal consultation and in that time, you know, they've had an entire pregnancy, a huge life changing event, and then we get to see them for this one appointment. And it's so complicated.

Often for women who are not sure where they're going to get their next meal from, how can they be giving any kind of cognitive time to figuring out if the midwife told the health visitor and if the health visitor told the GP and if they're worried that their bleeding's gone on for a bit too long, do they try and phone the woman who came on Thursday or the woman who came on Monday, or do they come back to their gp?

We're asking a lot and we also place a lot of burden on women to retell their story because information transfer is not always timely, it's not always sufficiently detailed.

And again, for women who are living in more precarious social situations, that burden then of having to, you know, they're juggling and the, you know, the mental load of everything they're trying to figure out. And then we're asking them, can you remember if your blood pressure was high during your pregnancy?

Whereas we should know that we should have that information from those other services. So that fragmentation in services really means that the burden is unduly placed on women to kind of patch that up.

And we need to find a better way of dealing with that.

Speaker A

00:08:25.640 - 00:08:38.260

One of the things I think that comes through really strongly is that some of the women with the greatest needs often face the biggest barriers, care. And what kind of barriers are we talking about here that these women are facing?

Speaker B

00:08:38.980 - 00:10:06.270

The Embrace report, which is well, well worth a look at at least their infographics, I think for every gp, it's just a couple of minutes to read. Actually, their infographics are really excellent. So.

So this is the annual report that's produced called Mothers and Babies Reducing Risk through audits and confidential inquiries across the uk. So Embrace Talk about this notion of a constant isolation of biases.

So in all of the cases that they reviewed and reported on in their most recent study, they found that 91% of them faced multiple interrelated challenges. So the women who died tended not to just have maybe one big risk factor.

Lots of them had multiple interrelated challenges, and these were factors like being overweight or obese, being known to use substances, having had experience of domestic abuse. Ethnic minority groups as well, and migrant women particularly, face substantial barriers to accessing good maternity care.

And language barriers are really critical.

And I think we can do quite a good job of that in primary care, because our appointments, particularly the postnatal consultation, tend to be pre booked and pre planned.

And that's somewhere where we can really make sure that we're providing those interpreter services and giving women that kind of culturally supportive access to healthcare and then.

Speaker A

00:10:06.270 - 00:10:26.270

Thinking more about the role of general practice. And I wonder what you think.

I mean, you've given us some pointers about, you know, that postnatal check and things, but what do you think in terms of the role that general practice can actually realistically play in improving postnatal care for women facing social disadvantage? Do you have any ideas about that?

Speaker B

00:10:26.270 - 00:14:44.070

There are lots of practical, innovative things that can be done at practice level, and they are things about, principally about access to care. And there are tools and resources to help with this. So NHS England produced a document which is a guideline intended for icbs.

Actually, it's a toolkit rather than a guideline called Improving Postnatal Care that gives some really specific pointers about the groups who are at particular risk and the groups who have more adverse outcomes. So at practice level, it would be quite straightforward to look at, you know, who are we providing postnatal consultations to?

We know from past research that nationally, younger mothers and ethnic minority mothers are less likely to have postnatal consultations compared with others. So at practice level, it's possible to look and say, hang on, are we reaching those women who stand to gain the most from postnatal consultations?

So using resources like that to see what's happening. Some people have looked at how their invitations to postnatal consultations are working. So there's confusion amongst women.

And this is probably understandable because every practice does it a little bit differently. So women tend not to know, am I going to get sent an appointment? Do I need to make an appointment for myself?

And there's vast majority variation and that's fine because different practices know their populations and they can do it whichever way works. But I think that's the key. It has to work and it has to be really clear.

So it might be that when we get the birth discharge summary, is there a standard text message we could send out saying, we are going to invite you for this appointment, but if you need us before that, please contact as usual, kind of giving permission and inviting that contact if it's needed. Which helps women to kind of understand and navigate their way through.

We talk in the editorial as well about utilisation of other members of the primary care team. So social prescribers, for example, are quite underutilised in this population.

And although they absolutely have the skill set, could social prescribers maybe have a role in connecting women with groups? You know, if it's your first baby, particularly how do you know where the local baby group is?

Do you know if there's kind of baby yoga class on this day or, you know, postnatal exercise class or whatever it is you might be interested in, Social prescribers would be really, you know, excellent professionals to help connect women.

And then it can be a two way thing because if they maybe pick up from a woman who they're supporting that her mood seems lower this time than it did last time, they have this bidirectional ability to be able to contact back the GP and say, I'm a bit worried about this woman, maybe you need to ask the health to see her, maybe you need, maybe she needs a GP follow up. Her mood seemed a bit lower, whatever it might be. So I think there's definitely some practical things we can do.

There are moving beyond a practice level. There are things that kind of PCN level and beyond.

So there's a PCN in Leeds who are kind of recognizing this social need for women in the postnatal period and they are providing a sort of a drop in session.

So like a session that's like a two hour monthly session led by PCM care coordinators and supported, I think, by a third sector organization as well, to bring together a whole range of health services so that women can meet, they can be with their babies, they can have that community support, but also potentially access to sexual health services and signposting and they can be self referred or they can be referred by their gp. So it's about knowing your population and looking for those little innovative ways.

A practice that I worked at a long time ago used to have like a stay and play baby session during the immunization clinic. And that was an opportunity, you know, it was very little for the practice to do in terms of organization.

It's a few toys and I think some of the receptionists used to be on, on hand. But it was a really great kind of innovative project to just give women the chance to meet each other for a little bit of informal peer support.

Speaker A

00:14:44.710 - 00:15:10.660

Yeah.

And I think that goes to show that, you know, maybe current models of postnatal care, either at a higher level, at a PCN practice level, aren't necessarily always at the moment designed around the needs of women most at risk, but these sort of small, innovative practices could actually help, especially with connecting women across different services, because I think that's often quite difficult to do in general practice, across maternity, mental health and community services as well.

Speaker B

00:15:11.700 - 00:16:30.900

And it's hard for GPs to know who and where to refer women to. So we found this in some research that we did around GPs doing postnatal consultations.

It was really common that GPs said they wanted better referral pathways, they needed to understand. So if you don't know what you're going to do when you find a problem, you're less likely to inquire about it as a gp.

So, for example, take pelvic health. If you don't know what to do if a woman reports a problem, you're probably not going to be so inclined to directly inquire about it.

And we know that for intimate problems like that, disclosure is increased when direct questions are asked. So a woman might not feel able to raise it herself, but if the GP can sensitively directly inquire about it, she's more likely to, to raise it.

It can then be addressed. But is the GP going to ask if they're thinking, well, I don't know where to refer it to?

So that kind of local knowledge of pathways and for women who are the most vulnerable and the most socially complex, the chances of them being at your postnatal consultation in the first place are less. And then if you don't know what the appropriate referral pathways are, you're less likely to inquire about it.

And it's just these kind of stepward missed opportunities that we see most in those who are more vulnerable.

Speaker A

00:16:31.620 - 00:16:46.580

I think that's a really good point about just asking those very direct questions.

And I wanted to know, just from your perspective for gps listening to this, do you think that there are any small changes that could make the biggest difference for women with complex social needs after giving birth?

Speaker B

00:16:47.300 - 00:18:56.370

I think what would make a difference in primary care is women being able to access care and women being heard. And sometimes that might mean we have to go to them. We need ways in our practices of identifying them.

So there needs to be a stratified way of when a woman has a baby, you know, if there are a certain number of risk factors that gets flagged and they somehow get like a different level of invite. We also need to, to think about those who are more vulnerable because they've not got their baby with them, for example.

Today, we’re speaking to Dr Eliza Hutchinson, a dermatology registrar and academic clinical fellow based at the Centre for Applied Excellence in Skin and Allergy Research at the University of Bristol.

Title of paper: Eczema, acne, and psoriasis in people with skin of colour: a qualitative UK-based study

Available at: https://doi.org/10.3399/BJGP.2025.0720

This study is the first, to the authors’ knowledge, to explore the experiences of living with an inflammatory dermatosis specifically in people with skin of colour. We generated eight themes important to participants: delayed or missed diagnosis; preferences regarding healthcare professionals; lack of online information and social media use; misunderstandings in cultural communities; concerns about treatment and lack of research; complementary medicine use; experiences and impact of dyspigmentation; and challenges with structural racism. These findings offer insight into the complex experiences and challenges faced by UK adults with skin of colour living with eczema, acne, and psoriasis. Our practical points for primary care clinicians are a step towards facilitating mutual understanding and improving care for people with skin of colour.

Transcript

This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A

00:00:00.560 - 00:00:53.150

Hi and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate editors of the BJGP. In today's episode, we're speaking to Dr. Eliza Hutchinson.

Eliza is a dermatology registrar and an academic clinical fellow and she's based at the Centre for Applied Excellence in Skin and Skin Allergy Research at the University of Bristol. We're here to talk about the paper she's just published in the bjgp and the paper is titled Eczema Acne and Psoriasis in People with Skin of Color.

A Qualitative UK based Study. So, Eliza, it's lovely to meet you and thanks again for joining us to talk about this paper.

But before we talk about the paper itself, I'm just wondering what made you specifically interested in researching skin conditions in skin of color?

Speaker B

00:00:53.550 - 00:01:34.700

Yeah, thank you so much for having me.

So I think people with skin of color have been and still are massively underrepresented in kind of medical curricula, learning resources, clinical trials. And I certainly remember when I was at medical school, I don't think I had any teaching on diverse skin tones at all.

And so it was as I sort of learned more dermatology, I just became very aware that they are so underrepresented. And I think earlier work in this area, I really tried to improve education for medical students and healthcare professionals around skin of color.

That was kind of my starting point.

And then I realised actually there's very little, if anything actually on the experiences of people with skin of colour, which is kind of what led me to this project.

Speaker A

00:01:35.820 - 00:01:38.380

And you work in dermatology, is that right?

Speaker B

00:01:38.460 - 00:01:42.300

Yes, yes, I'm a dermatology registrar based in the Bristol Bath area.

Speaker A

00:01:42.540 - 00:02:06.890

Great. So it's wonderful to have your expertise in this especially.

And we may get into this sort of about sort of your perspective from secondary care as well, looking back into general practice as well. But this paper focuses on eczema, acne and psoriasis and these are conditions that we see a lot as gps.

So why did you feel that this was an important area to look at for people with skin of colour?

Speaker B

00:02:07.290 - 00:02:41.470

Yes, I mean, as you said, we know that skin conditions are super common.

They make up over 14% of GP consultations and eczema, acne and psoriasis are some of the most common inflammatory skin conditions we see and we know that they have a significant burden on everyone that experiences them.

But I think particularly in people with skin of colour, we already know that these people experience kind of increasing things like Dispigmentation, so skin tone getting lighter or darker from their skin condition. And yeah, I think I just wanted to focus on some of the more common conditions that are seen kind of day to day in primary care.

Speaker A

00:02:42.110 - 00:02:54.890

And this was a qualitative study and you emphasized that you really wanted to understand the experiences of people here. So talk us through a bit what you did. You spoke to people who had these conditions and had skin of colour?

Speaker B

00:02:55.050 - 00:03:26.060

Yes. So we recruited using online methods for a couple of reasons, but really wanted to get kind of diverse range of experiences from across the uk.

So we started off with an online survey and that was open to people of all skin tones. And we have written this up as a separate paper which should be out hopefully in the next few months.

But based on these responses, we then kind of purposefully recruited people with skin of color to take part in an online one to one interview. And so we spoke to 20 different people with skin of colour as part of this.

Speaker A

00:03:26.460 - 00:03:40.300

And I think one of the really interesting things that came out and is running as a strong theme through the paper is that skin conditions can present really differently in skin of colour. Can you explain a bit about what that means in practice as well?

Speaker B

00:03:40.700 - 00:04:49.210

Yeah. So we know that skin conditions can look and behave very differently in people with skin of colour compared to white skin.

So for example, eczema is typically in a kind of flexural distribution in people with white skin, so like in the elbow creases behind the knees.

But in people with skin of colour it might be more likely to be on the extensor surfaces, it might be in a sort of discoid type pattern, so kind of well defined round patches or sort of a follicular pattern is another one we see. So if you look at medical textbooks and what we're taught at medical school, we just don't see pictures of these presentations.

And I think another big thing is obviously redness is much less obvious in skin of colour. So that's typically what we would associate with skin inflammation is redness and it is much less obvious.

And instead in darker skin tones it might look kind of purpley. Brownie might not be as obvious. And certainly in the interviews we found that patients were aware of this as well.

So they were looking at their own skin and not picking up that it was kind of actively inflamed. They didn't know what it was and they'd go and see a GP or another healthcare professional in primary care and they also wouldn't know.

And then it's just kind of leading to Delayed diagnosis, misdiagnoses.

Speaker A

00:04:50.140 - 00:05:16.780

Yeah, And I think that's certainly something. So the people you spoke to described these delays in diagnosis and also this uncertainty from clinicians.

And I do wonder if that is reflected in what we learn and what the wider public understand is what inflammation might look like as well. So I wonder what really stood out to you from these experiences.

So how did people and clinicians sort of navigate those delays and uncertainty as well?

Speaker B

00:05:17.320 - 00:05:44.760

What was quite shocking was in terms of the misdiagnosis a lot of the time, infection and infestation.

So, for example, scabies was a big one that people were misdiagnosed with, and that in some circumstances did lead to kind of stigmatisation, psychological distress, embarrassment, and then people were more afraid to seek help. Further delays in diagnosis. Yeah, I think that was the thing that struck me the most in terms of this problem.

Speaker A

00:05:45.240 - 00:06:00.040

And you've mentioned this, you talked about dyspigmentation, and that came through as well very strongly in the interviews. And I think that's probably a problem that's specific to skin of color as well.

And can you talk through why that came up as such an important issue for patients in this study?

Speaker B

00:06:00.760 - 00:06:46.890

Yeah, of course. So I think we already know that dyspigmentation.

So skin tone usually getting darker, but sometimes lighter as a result of skin inflammation, we know that it is more common in darker skin tones just because they've got more melanin there to start with. But the thing that struck me in these interviews was just the profound impact that this can have on patients.

So embarrassment, isolation, body dysmorphia. There's a lot of misunderstanding as well, kind of within certain communities about what causes it.

And some people experience negative comments from within their own community, from friends and family, which really exacerbated that kind of psychosocial impact even more. And obviously, skin tone is massively tied into kind of identity, and the impact on people's wellbeing was just. Yeah, it was huge.

Speaker A

00:06:47.690 - 00:06:58.490

And coming from a general practice perspective, it sometimes feels like the treatment options for dyspigmentation are really limited as well in what we can offer patients. So that must come out as a frustration as well, I'm sure.

Speaker B

00:06:58.650 - 00:07:34.310

Yeah, I think people. People were very aware that it just wasn't talked about with healthcare professionals.

And, I mean, it is really difficult because we know there are limited treatment options. But actually, a lot of people just said that they wanted it to be acknowledged and discussed.

So just a simple explanation of, you know, this is because of the inflammation in your skin it should settle as we get your condition under control. It might take months or years to settle.

An important thing that gps can do is sun protection is really important, so UV light can kind of exacerbate the pigmentation further. So even just a brief discussion about that I think patients would find really helpful.

Speaker A

00:07:34.790 - 00:07:40.790

And coming out of all this, were there any specific findings that really surprised you from these interviews?

Speaker B

00:07:41.400 - 00:08:27.550

Some of the issues I was sort of. I was sort of expecting just from my own clinical practice.

So the issues around delayed diagnosis and kind of lack of representation online, those were things I'd already come across.

But I think the main thing was just the profound impact that factors outside of the clinic room can have on patients that I think, as clinicians, we don't ask about or aren't aware of. So a big one for me, I think, was just misunderstandings within cultural communities about sort of what causes the skin condition.

And as I said, this then leads to kind of stigma and isolation and psychological problems.

So I think just the misunderstandings, which can be, you know, just through some simple education and community initiatives, we could really tackle this and improve people's experiences.

Speaker A

00:08:27.950 - 00:08:54.490

And you've touched upon this.

But this paper highlights big gaps in dermatology education and how clinical images are portrayed in textbooks, for instance, that we might learn from.

And I wonder, from your own perspective, how much do you think, think that that underrepresentation in teaching materials contributes to this diagnostic uncertainty that people have around what eczema might look like in a patient?

Speaker B

00:08:55.130 - 00:09:50.080

Yeah, I think it's a really important factor and certainly through kind of previous work I've done, we know that people just still aren't getting exposed to these images. Things are changing, so curricula are being diversified and textbooks, but it is still a big problem.

And we know that this then translates into kind of lower clinician confidence when assessing people with skin of colour. There are increasing resources out there, I think. So.

You know, websites like skindeet, there's something called the Global Skin Atlas, which has kind of freely accessible images that clinicians can look at to find examples in darker skin tones, you know, patient information leaflets. But as some of the participants said in the. In the studies, it still often is just a sentence.

So, you know, in black and brown skin, it might look less obvious and then that's it. So I think there's still a lot more work to be done for both patients and clinicians.

Speaker A

00:09:50.480 - 00:10:02.560

Yeah, and I guess that leads me to get your perspective on what do you think that good dermatology education in skin of color should look like just from your background in dermatology and teaching as well?

Speaker B

00:10:02.960 - 00:10:39.060

Yeah, I think just more images, more examples and just like an open discussion about how it can look different. And this is what it might look like in darker skin tones compared to white skin. So you've got kind of the whole how do skin conditions present?

But then obviously we do need more research on treatments. We know that, you know, people with skin of color are underrepresented in clinical trials.

So, you know, how do we know that all of these new treatments work?

So I think it's, yeah, it's like a multifaceted process, but just a good starting point is just incorporating lots of images, lots of discussion in undergraduate curricula and postgraduate training as well as.

Speaker A

00:10:39.610 - 00:10:53.690

And coming up from these interviews, were there any examples where patients described really positive consultations or what made those encounters work really well? So any sort of examples of good practice so people can sort of take those sort of pointers away as well?

Speaker B

00:10:54.010 - 00:11:29.500

Yeah, so definitely, you know, some people said that there wasn't actually a delay at all, you know, straight away they were seen and the clinician knew what it was. So yeah, it definitely wasn't all negative. And there was also some discussion about kind of preferences for healthcare professionals.

So both in terms of the type of clinician someone sees and also their ethnic background.

And certainly some people had really positive experiences in primary care and particularly kind of nurses, people had positive things to say, but it was quite a mixed bag. So, you know, everyone had different experiences, positives and negatives, to discuss.

Speaker A

00:11:30.380 - 00:11:46.680

And for gps listening to this, what do you think could be some key practical take home messages from this work for people to take back to their consulting room if they were faced with a bit of uncertainty around a diagnosis or if someone with skin of colour came to see them with a skin condition.

Speaker B

00:11:46.760 - 00:12:34.300

Yeah.

So as part of this work, so we generated kind of eight themes from the interviews and then condensed these into sort of seven practical points for primary care clinicians. So I would encourage people to have a look at the paper because we have a concise table with all of these points with examples for each one.

But just some examples would be looking out for and being prepared to discuss pigmentation changes with your patient.

So kind of recognizing that it's there, explaining what it is and just simple things patients can do to help, kind of asking about complementary treatments, being aware that use is more common in certain ethnic groups and you know, what potential driving factors might be. So there are just some quite quick and easy things that People can do, I think, to try and improve patients experiences.

Speaker A

00:12:34.910 - 00:12:50.510

And from your perspective in secondary care, how do you feel that this has sort of changed your practice or is there anything that you're particularly doing differently as a result of doing these interviews? I'm just interested to know sort of from your own personal point, whether you've picked up something in your practice that you've changed.

Speaker B

00:12:50.590 - 00:13:29.790

Yeah, 100%. Yeah. I think it's really difficult when you're in a busy consultation because you've got so many things to try and discuss and tick off.

But certainly when I'm seeing people with skin of color, I'm definitely more aware about, you know, have they got hyperpigmentation? Do they understand what that is? They're using any alternative treatments? Do they understand what's caused their condition?

Where are they looking for their information? Are they looking online? Because a lot of people trying to, you know, look on social media to find out stuff which has its pros and cons.

But yeah, I definitely think in secondary care as well, it's all really relevant and kind of highlights things that we should be doing. But it's easy to forget in the moment. But it is really important.

Speaker A

00:13:30.810 - 00:13:46.130

Absolutely. I think that's the thing.

It's just sometimes having a nugget or a thought in the back of your mind when you're faced with this, even if it's a busy consultation, sometimes you can add a lot just by asking one extra question or asking about one extra perspective or what really matters to the patient as well.

Today, we’re speaking to Dr Tori Ford, a qualitative researcher based at the Nuffield Department of Primary Care Health Sciences at the University of Oxford.

Title of papers: ‘Accumulative Experiences: Navigating Healthcare for Recurrent Vulvovaginal Thrush from Patient and Clinician Perspectives’ and ‘It’s not just thrush, it’s recurrent thrush’: Patient and Clinician Perspectives on Diagnosing Recurrent Vulvovaginal Candidiasis’.

Available at: https://doi.org/10.3399/BJGP.2025.0437 and https://doi.org/10.3399/BJGP.2025.0531

Transcript

This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A

00:00:01.280 - 00:01:15.200

Hi, and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the associate editors of the journal. Thanks again for listening to this podcast today.

In today's episode, we're speaking to Dr. Tori Ford, who is a qualitative researcher based at the Nuffield Department of Primary Care Health Sciences at the University of Oxford. We're going to talk today about two linked papers that she and her team have published here in the bjgp.

The first one is titled Accumulative Navigating Healthcare for Recurrent Vulvovaginal Thrush from Patient and Clinician Perspectives. And the second paper is it's not just thrush, it's recurrent thrush.

Patient and Clinician Perspectives on Diagnosing Recurrent Vulva Vaginal Candidiasis. So, Tori, thanks very much for joining us here today.

And this might come from a slightly unscientific perspective, but my feeling is that I'm seeing a lot more recurrent thrush in practice. And we know that it's incredibly common. I think, despite that, it's not something we hear discussed very often in primary care research.

So my first question is, what made you want to study it?

Speaker B

00:01:15.520 - 00:01:54.060

So, like you say, recurrent thrush is an increasingly common condition. We know that 1.2 million women in the UK live with it, 6% of people globally, and I just happen to have been one of them.

So my paper came out of lived experience of living with recurrent thrush over many years and having a diagnostic journey of, you know, seeing different healthcare professionals looking for answers. And like you say, those feelings of shame and stigma that keep you feeling alone were all too familiar for me.

So that's what actually led me into starting my PhD, looking at recurrent thrush and then wanting to hear other patient experiences as well.

Speaker A

00:01:54.460 - 00:02:22.220

And we're looking at two of your papers here that were published in the bjgp, and they're both looking at the patient and the clinician perspective.

And one thing that comes through really strongly in both papers is that recurrent thrush is often treated as if it's just repeated acute episodes rather than a condition in its own right. Why do you think that that distinction matters to patients and probably to clinicians as well, or should do?

Speaker B

00:02:22.380 - 00:03:55.420

I think when we hear about thrush, it's often something that's seen as trivial or mundane, and that's often because it's through this lens of acute, transient, episodic, episod, and most of the time it is right. 75% Of people with Vaginas will have thrush at some point in their life.

It's usually self managed over the counter with pharmacy care and symptoms resolved within a few days.

But where recurrent thrush differs is when those symptoms keep coming back so that itching, burning pain and irritation becomes sometimes cyclical, sometimes repetitive. And I spoke to three or two patients who all had different durations of heat know, happening every two weeks, every month.

And what they often found was because they were accessing fragmented care.

So, you know, going to the pharmacy, sometimes going to the gp, sometimes maybe seeing sexual health, it was often seen as again, that mundane, one off, trivial case. And it was really hard to trace those patterns across care, especially due to a lack of continuity. Right.

If you're trying to track a pattern but nobody is following you up, it's really difficult to, to capture those. So I think it's a few layers of one.

I explore how these sort of social dimensions keep it seen as something maybe less long term, but then also in the ways that sort of care was fragmented made it harder for those patterns to be picked up and then to transition the care moving away from, you know, acute one off prescriptions of an antifungal medication to something that required repeat, repetitive, enduring, you know, testing, treatment, retesting of treatments.

Speaker A

00:03:56.060 - 00:04:09.970

Absolutely. And I think what's interesting is that your papers describe recurrent thrush as something that's accumulative and cyclical over time.

And you mentioned that it's not just these sort of one off episodes. Can you explain what patients meant by that?

Speaker B

00:04:10.210 - 00:05:13.850

Yeah.

So often, I think when we talk about healthcare, journeys are presented in a way that's quite linear and straightforward that, you know, you see a healthcare professional, you get treatment, you go home, you start to feel better. But with recurrence, something interesting happens where people aren't, you know, returning to the start.

It's not that you go back to a blank page and then restart your healthcare journey every time you're carrying with you everything, everything that's amassed through healthcare encounters, what you've seen online, what you discuss with friends, and that is all carrying through to those consultations.

And I think what was really important there was acknowledging that for many people there was a lot to unpack there and often they felt that it wasn't being acknowledged in those clinical spaces. It was seen as, oh, it's just thrush. And that's why in one of the papers the title is, it's not just thrush, it's recurrent thrush.

And that's a quote from One of the participants who was speaking about the importance of labeling and distinguishing this condition, especially in terms of the impacts it had on people's lives and also the approaches and pathways that would be needed to properly treat it.

Speaker A

00:05:14.330 - 00:05:32.570

And this is an issue that we see across clinical care and women's healthcare. But a lot of participants described feeling dismissed or not listened to.

And I wanted to just get your perspective from your wider sort of work in this area is how much of that reflected wider issues in women's health care, do you think?

Speaker B

00:05:33.170 - 00:06:46.980

Yeah, I mean, we know there's increasing conversations, right, with the women's health strategy, with the Cumberlage report, about how people's pain is often dismissed based on their gender. And that definitely came across in the studies. But I think what was interesting was that both patients and clinicians were aware of this.

And something that is quite interesting was in the diagnostic paper, we look at sort of those moments where there were sort of miscommunication or differing expectations between patients and clinicians, clinicians, where clinicians were, you know, operating on a standard guideline that requires two swabs, two positive swabs for a thrush within a year to diagnose recurrent thrush.

But when that wasn't communicated to the patient, of being told we need to accumulate these number of swabs, what the patients thought was happening was, oh, they're swabbing me again, they're not listening to me, they don't believe me.

So it was interesting where the dismissal was often in those moments of, you know, it wasn't healthcare professionals saying, this isn't important, or please don't come see me about this. It was really in those sort of small details where patients were operating on one framework and clinicians on another.

And there were these gaps in communication. And that's why our papers seek to address some of those gaps with some recommendations as well.

Speaker A

00:06:47.620 - 00:07:04.640

Yeah, and as you mentioned, one of the papers is called it's not just thrush, it's recurrent thrush.

And I wonder what you felt were the key challenges around actually recognizing recurrence in primary care, as opposed to it just being a, a one off episode.

Speaker B

00:07:04.720 - 00:09:30.220

There's multiple layers to this, I think, in terms of the. The papers are sort of split in terms of the diagnostic journey and then the healthcare journey.

But that's sort of an artificial split in some ways, because what we saw a lot was, you know, patients trying to seek out continuity of care to get someone to notice the pattern that they were starting to see and assign a label to it and we saw some hesitancy with this in clinicians who said, you know, I'm not going to use the term recurrence because that sounds like it's something serious or sounds like it's chronic. And they saw that being helpful.

But then for patients they found that really challenging because they said, you know, they just see it as thrush, they just see it as a one off case, they're not recognizing it when often the clinicians had, you know, made note of it, but they didn't feel that using that label would be helpful to patients. So simple things like that, even just the language that we use can make such a big difference in helping people feel seen.

And then the diagnostic journey. So the tests that we have are not perfect.

There's also a lot of problems with self treatment before testing that wasn't always disclosed by participants. So these cycles right of you have symptoms, you make a doctor's appointment, the symptoms are unbearable is what we heard all the time.

So people went and self treated over the counter with, with pharmaceuticals, over the counter antifungals, or even off the shelf at pharmacies, different options or supermarkets, and then would go in, be swabbed for a test, the test would come up negative. And then it was really hard to build a case, right. For recurrent thrush when there wasn't sort of that EV evidence there.

But often what patients weren't doing was sharing that they had self treated. Because often for patients, they don't know all the factors that go into a test or they're not going to know what influences it.

And then there was a lot of difficulty. Right. Often we hear vulval itching and we go right to thrush.

But there's so many other conditions along the way of lichen sclerosis, of dermatological conditions, of vulvodynia that also need to be addressed and identified. So trying to have those moments where clinicians could be ruling out, you know, is it thrush, is it not thrush? And then is it recurrent thrush?

And having that second question be front of mind was really important because it does change people's trajectories.

And we heard from people that, you know, were able to get that recognition early on and were able to get appropriate treatment and have symptoms resolved. So we know it's possible, but we know that that recognition is challenging.

Speaker A

00:09:31.190 - 00:09:49.630

Yeah, and you touched on this a bit earlier, but continuity seems really important in both of these papers and you've just spoken about recognition and I wonder what your thoughts are about recurrent thrush and how it's almost exposing sort of this issue around fragmented care really.

Speaker B

00:09:49.630 - 00:12:16.920

So clearly, I think continuity was one of the most interesting topics to explore and it was fascinating seeing how clinicians were seen fragmented systems and trying to overcome them.

So, you know, some clinicians who said, I want to see you again, I'm going to book you into a clinic, I want you to come back on this date, we're going to figure this out together and how valuable that was for patients and other times where, you know, maybe a GP wasn't in a position to be offering follow up appointments in that same way they could offer informational continuity. So that looked like writing notes to sexual health, that looked like sharing notes with patients, sharing test results with patients.

It looked like pulling up the guidelines and actually working through together, you know, what the steps were, what the timelines were being realistic. So many times patients thought the start of the journey, I'm going to go in, there's going to be a magic cure and I'm going to be okay.

And they actually really valued when clinicians said, it's an ongoing journey, it's going to take time, but we're going to work it up together. And that really helped patients keep coming back.

In the paper about accumulative experiences, we talk about that of not only is it about the times where recurrent thrush care needed to be different than acute care, but also about those really important moments where you could be making those differences, you could be making those transitions and acknowledging it and building that continuity. Because I think, yeah, with acute conditions, you have acute conditions and you have chronic conditions and recurrence falls somewhere in between.

In this really interesting space where chronic conditions often are, have quite established guidelines, they've got secondary care involved, they've got sort of continuity built into them, right. With the chronicity and then acute cases, you've got the one off self managed, often treated as quite trivial conditions.

And then recurrence is interesting because it kind of spans both of those and jumps between them in different ways.

And we saw that a lot and it helped kind of expose that fragmentation, right, of people that would go see the pharmacist and they would say, how many episodes have you had in the last year? And then the patients would say, you know, I've had four or more, which is the definition of recurrent thrush.

And often pharmacists were aware of that and would say, oh, you're going to have to go see your GP to get this medication. And then the patients reported going to see their GP who said, oh, you can just treat this over the counter with pharmacy care.

And sort of these loops that were occurring between GP and pharmacy, which were really interesting. And then seeing also where sexual health could fit in as well.

Speaker A

00:12:17.240 - 00:12:28.760

Yeah.

And thinking about that, as you say, patients moved between pharmacies, general practice and sexual health services, but how well connected did those pathways feel? Or did they not feel well connected at all?

Speaker B

00:12:29.320 - 00:14:13.680

No, I think by design the pharmacy, sexual health and GP practices are kept quite separate and I think there's good reasons for doing that. For example, in sexual health you can access care anonymously, you don't have to share any personal information.

They by design don't share notes with your primary care professional.

There's different systems that are set up that are in practice, right, to protect patient privacy, to make people feel comfortable, to help, maybe reduce some shame and stigma. But at the same time that can make it really difficult when people are accessing care in many different spaces.

And we saw that quite often and people aren't speaking to one another.

And I think the best care we saw was when people were able to reach across those lines and say to the patients, you know, in sexual health, would you mind if I maybe looped in your primary care professional? Would that be okay? Or asking directly about when was last time you self treated, when was last time you were using over the counter remedies?

Have you been reading things online when you can sort of have that whole picture? And joint up care was really incredible.

And something we saw too was in the diagnostics paper where GPs were able to say, you know, I'm not able to see, you know, microscopy, I'm not able to offer the same level of testing that somewhere like sexual health might be. Would you reopen? Exploring that option and sort of signposting people to different places was really powerful.

But that, that wasn't one obvious to patients or clinicians always. It really differed by region and commissioning and what was available. And then also patients reported feeling really confused.

If you know, who am I supposed to see, in what order, in what combination and what is sort of the appropriate route. So trying to figure out those, those questions as well.

Speaker A

00:14:14.160 - 00:14:26.560

And I wonder what your thoughts are after doing this research and even from your own lived experience. But for gps, listening to this, what do you think are the practical take home messages from, from this body of work that you've done?

Speaker B

00:14:26.960 - 00:15:46.300

So the first thing that we're recommending for GPS is to be asking patients about recurrence.

We heard from patients saying that sometimes they didn't disclose how many episodes they'd have because they said I just wasn't asked the right question. And I think that's how it often gets treated. As acute cases, we really have been recommending prioritizing continuity of care whenever possible.

But when it's not thinking about creative ways of having informational continuity, whether that looks like writing letters, having patient approved note sharing, providing patients with their own notes so they can follow up with practitioners as well as.

And then also in terms of the diagnostic routes of making sure that you're asking patients about self treatment before doing testing, offering patient initiated self swabs whenever possible, and also acknowledging some of the limitations that exist within our current health systems and also within testing and making sure that you're recognizing both the cumulative impacts that people have with recurrent thrush, but also ruling out other conditions and sort of not falling into that trap where any vulval itch falls into recurrent thrush.

So it's a complex condition, but there's some, like I've been saying, there's some really simple changes in terms of communication, but also in just having a scan of what resources are available and what services might be able to be best suited to treat these conditions as well.

Today, we’re speaking to Dr Charlotte Morris, a GP and academic based at the University of Manchester.

Title of paper: Experiences of primary care for people with dementia from socioeconomically disadvantaged areas: a qualitative study

Available at: https://doi.org/10.3399/BJGP.2025.0407

Existing national guidance recommends primary care-led dementia health care, but little is known about the experience of this for people living in socioeconomically deprived areas. This study highlights that people with dementia, and their carers, in socioeconomically disadvantaged areas want to maintain identity and understand their decline. Support from healthcare services often diminishes over time, with difficulties accessing and navigating healthcare systems when needed. There was uncertainty about primary care’s role in dementia health care. Clearer communication and proactive support from primary care may improve experiences for these patients.

Transcript

This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A

00:00:00.320 - 00:00:32.850

Hello and welcome to BJ GP Interviews. I'm Ewan Lawson and I'm the editor of the BJ gp. Thanks for listening to the podcast today. In this episode, we are speaking to Charlotte Morris.

Charlotte is a GP and doctoral research fellow at the University of Manchester and we have recently published her paper, Experiences of Primary Care for People with Dementia from Socioeconomically Disadvantaged Areas A Qualitative Study.

So, Charlotte, first of all, what I'd like to ask you is how did you come to focus on people with dementia in deprived areas specifically, and what surprised you most in the interviews?

Speaker B

00:00:33.170 - 00:02:03.470

Thanks, Ewan. Thanks so much to you and the BJGP for inviting me to do the podcast and publishing the paper.

So, I guess my interest in people with dementia started when I finished my foundation training and I did a clinical fellowship year in London where I worked on a ward with people with dementia specifically. And at that time I wanted to be a care of the elderly doctor.

But I was struck by how many people kept coming in and out of hospital with dementia regularly. We'd spend ages trying to get them home. They go home for maybe one or two days and then sadly come back on this cycle.

And I think in reality, a lot of those people would probably have been better at home, even if that shortened their lives very sadly.

And it made me realise I wanted to work in the community with people with dementia, trying to improve healthcare in terms of advanced care planning and kind of planning for progression. So that's where my interest in dementia came in.

And I work in a practice in a relatively deprived area of Greater Manchester, and I always had an interest in health equity for kind of various reasons and health equity in terms of various lenses as well.

So when I was designing my PhD project, I decided to kind of focus on both aspects, so health inequalities in terms of deprivation and primary care for people with dementia.

Speaker A

00:02:03.870 - 00:02:08.270

I mean, I know we're going to touch another on some other stuff, but. Yeah. What surprised you most in the interviews?

Speaker B

00:02:09.390 - 00:02:47.530

I think in terms of what surprised me most in the interviews, I think I was actually struck by how much people wanted more health care from their primary care teams. It's not like they felt they were getting the best care or they were really kind of thrilled with what they were getting in lot of times.

But they were actually very trusting of their primary care teams and they really, really wanted more of that health care, which kind of struck me, really.

And I actually found it kind of quite touching and humbling, as a practicing GP myself, to know that we were really valued and that the care that we provide, people tend to want more of it rather than less.

Speaker A

00:02:47.610 - 00:03:21.390

Yeah, so that leads in nicely, because I wanted to ask you about one of the themes in your paper, which was the kind of proactive continuity.

And several of your participants described your wanting their GP to take the initiative, you know, to call them, to know them, so just to anchor their sense of self while the dementia progresses. There was a one man who had Alzheimer's who named it Ali. Was a kind of a. Was a striking example. You know, what, what kind of sense?

What does that tell us about what primary care needs to be doing? I mean, you mentioned there about how much it was appreciated, but what kind of. What do you think they can do more of?

Speaker B

00:03:22.000 - 00:04:42.080

Yeah, I think that kind of theme of proactive continuity splits into two, really. So I think the idea of being proactive is really important and people wanted their GPs not only to know them, but to actively contact them.

Sorry, I mean, not just their gps, actually their whole primary care team recognising that we all work together in our practices as well as that proactivity.

They wanted somebody who knew them, knew their family, knew their kind of history, knew the kind of outside of their life, rather than just their medical condition or their dementia. And that was really striking and came through kind of very strongly from most people who were interviewed, really.

And I interviewed people with dementia and carers and from both sides. That idea of being known by their primary care team did come through very strongly.

And I think for me as the interviewer and for me as a practicing gp, I also really like that side.

You know, knowing our patients, knowing that person, and being there for the kind of entire journey of a diagnosis to dementia all the way through to that progressing. It's a real privilege and I think it's something really precious for us as, as primary care teams, that continuity.

Speaker A

00:04:42.240 - 00:05:02.930

There was a bit of a gap. There wasn't. There's this kind of, oh, you know, there's potential gap in that.

And you mentioned this in the paper about the falling away support, that sometimes participants went to the memory clinic, then they were discharged, and then they felt a little bit like they, you know, they weren't picked up necessarily. I wondered if you could tell us a little bit more how that showed up in your interviews.

Speaker B

00:05:03.570 - 00:06:27.830

Yeah, yeah, for sure. So I guess everybody, everyone did describe a kind of different journey.

And I don't want to just generalize, but the sentiment or the feeling I got from most people was that there was concern around a possible diagnosis, a kind of flurry of activity around when the diagnosis was made, referral to memory clinic, lots of calls.

Somebody described a mind boggling array of things being offered around that time of diagnosis and then after that things seeming to kind of fall away. So somebody described the specialist dropped them and they were seen by memory clinic, started on medication and then just left back to the gp.

So that idea of kind of there being a flurry of activity and then things gradually dropping away and that being a paradox because actually people felt that their needs generally increased as time went on. So that was very interesting really. And I've also done.

It's kind of not a published paper yet and it's still being worked up, but I've done some interviews with primary care providers as well and that seemed to kind of come through as well from them and that there is a flurry of activity around one point around diagnosis. But then as time goes on do things do seem to kind of drop off and change. So it's perhaps felt from both sides as well.

Speaker A

00:06:27.830 - 00:07:03.200

Yeah. Let's talk a little bit about when sometimes it doesn't happen so much or people who knew the system.

And there was definitely an interesting rather novel finding that came out and I guess it's something we might be aware of, but I haven't seen too many papers that have highlighted it, that if there was someone in the family who knew the system, that was often perceived as crucial and it sort of implies a system rewards social capital or maybe it's just very specific to medical systems. But I wondered if you could, you know, how worried should we be about that? What can primary care do to address it or to flatten those kind of.

Those kind of flatten it out. If there is a. If it is an inequality.

Speaker B

00:07:04.000 - 00:08:54.200

Yeah, I think a great question and I also thought this was one of the most interesting themes to come out of the paper actually.

So just to kind of describe it, a lot of people described how if they had a family member or a friend who knew a little bit about the healthcare system, so if they'd worked in research or if they'd worked in social care, they would be called upon to kind of navigate this complexity of the system and it kind of came through that they would know who to contact, know how much to push, know what strings to pull to get somebody seen. And that insider knowledge, how we termed it, seemed crucial in kind of getting things done.

And, and that was described in detail by one participant in particular.

But they hadn't necessarily learned that through a professional role, they'd learnt it over years of caring for somebody with dementia and they kind of had learnt these little workarounds and trade offs that they had to make in order to get timely, safe, accessible primary care for that person.

And I think in terms of us as primary care providers, I would say what we could do to change that is maybe avoiding what I termed a computer says, no approach.

So if somebody asks for an appointment or a little bit of flexibility, rather than saying, oh, there's nothing available today, you'll have to call back tomorrow at 8am, perhaps recognising that there needs to be that flexibility in the system and perhaps in those situations, try to do whatever you can, whether that be signposting, asking for a little bit of advice from kind of a clinical colleague, or even squeezing somebody in at the end of the day, which I know we all try to do and sometimes isn't feasible.

But for people who struggle with dementia and their carers, life is often very difficult and we can sometimes make it a little bit easier by what might not be a huge tweak to our working day.

Speaker A

00:08:54.840 - 00:09:38.040

It's fascinating, isn't it, because so many of the papers that we cover and have conversations that they. I mean, it's all related to access and pressure on the system and how the most vulnerable people navigate through the systems.

And as the pressure ramps up, it's almost.

It feels almost like it's been inevitable and certainly I've written about this in the past, that these difficulties of people, you know, the system gets more complex and, you know, the more complex patients are harmed by, you know, the most complex systems. And when there's pressure on the system, how do you.

How do you think your sense of being a GP fed into, you know, you must be aware of that from the other side as well, from the. Obviously in the. How it fed into, how you went about the interviews. So that reflexivity side of things, how did.

Speaker B

00:09:38.040 - 00:09:38.360

Yeah.

Speaker A

00:09:38.360 - 00:09:42.560

What did you bring to it that you felt that was you. You. That was very notable to you, Charlotte?

Speaker B

00:09:43.590 - 00:11:30.840

Yes, I think it's a great question.

And with any qualitative research, and indeed sometimes even with quantitative research, it's really important to consider your reflexivity, your own biases, kind of how you're situated within that research. For me, it goes back to the first question you asked me, really.

I went into these interviews with a kind of a bias, I suppose, or an idea that I feel primary care is the right place to be providing this health care for people with dementia. I think we're well suited to it because of our longitudinal relationships.

The Fact that our job is rooted in compassion for people that we know and care about within our communities. And so I kind of did go at it at that angle, really, that I felt we should be providing this care and trying our best to do it as well as possible.

And kind of interestingly as well, the participants picked up on me as a gp, but it didn't stop them kind of really telling me the truth, I think. And they'd often preface things with, oh, I know you're a gp, but this, this and this happened.

And I found that quite nice, really, that they kind of felt they could open up a little bit more, particularly towards the end of interviews. And also I'm originally from a relatively deprived part of the UK as well, so that kind of idea of being within the group that I was.

That were participating in the research was also quite interesting and I think was recognised by the participants as well, enabling them to open up a little bit more about their experiences, perhaps, and somebody who they perceived as being outside that group. And so, yeah, I mean, fascinating sociologically, really, my role in the interview, how I was perceived by the people I was being interviewed.

I was interviewing as well.

Speaker A

00:11:31.000 - 00:11:45.570

Yeah.

Okay, so if a gp, someone else in primary care is listening, listening to this, and they're seeing someone with dementia later on this week or in this, you know, whenever they're in clinic, what's the single thing your study would suggest they do differently?

Speaker B

00:11:46.450 - 00:12:51.000

I think it goes back to the proactivity and continuity.

And from the interviews, I think what came through most strongly is people want to be known and they want to feel cared for as their condition progresses. So I would say a regular check in or phone call could be very meaningful to that person with dementia or their carer.

It would probably take less than five minutes of our working day, but just putting a note on the calendar to ring in three or six months time. How are you getting on? Is there anything that we can do?

Could the care coordinator come out and help, checking that the care plans are all in place and that people are kind of ticking along? Okay.

We'd be unlikely to make any significant changes, but that feeling of being cared for and having somebody with them on that journey, I think could perhaps be. Be very meaningful.

So that would be the one thing I would suggest, really, that kind of proactive continuity and making an effort to communicate that healthcare around dementia, really.

Speaker A

00:12:51.400 - 00:12:58.360

Charlotte, I think that's a really excellent note to finish on. It's a lovely study. Thank you very much for taking the time to speak to us today. We're very grateful. Thank you.

Speaker B

00:12:59.080 - 00:12:59.960

Thanks Ewan.

Speaker A

00:13:00.600 - 00:13:15.890

And thank you all very much for your time and for listening to this BJGP podcast. Charlotte's original research article can be found on bjgp. Org and the show notes and podcast audio can be found at bjgplife. Com.

Thanks again for listening.

Today, we’re speaking to Catharina Savelkoul, a DPhil student in Health Economics based at the Nuffield Department of Primary Care Health Sciences at the University of Oxford.

Title of paper: Factors Influencing UK Medical Students’ Choice of General Practice: A Systematic Review

Available at: https://doi.org/10.3399/BJGP.2025.0226

The UK faces a projected shortage of approximately 15,000 GPs by 2036/37, with a declining proportion of UK medical graduates pursuing general practice. Previous research has identified various contributing factors but lacked a contemporary synthesis within a coherent theoretical framework. This systematic review examines factors influencing UK medical students' career decisions, finding three critical influences: curricula that inadequately represents general practice, a persistent negative hidden curriculum, and the impact of clinical placement quality. Our revised Bland-Meurer model incorporates these findings, providing a comprehensive framework to improve GP recruitment. This systematic review identifies the factors that shape UK medical students’ intentions toward general practice.

Transcript

This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A

00:00:01.120 - 00:00:59.530

Hi and welcome to BJJP Interviews. I'm Nada Khan, one of the associate editors of the bjjp. Thanks for listening to this podcast today.

In today's episode, we're speaking to Katharina Savalcool. Katharina is a DPHIL student in Health Economics based at the Nuffield Department of Primary Care Health Sciences at the University of Oxford.

We're here today to talk about the paper she's recently published in the BJJP titled Factors Influencing UK Medical Students Choice of General A Systematic Review. So, hi Katharine, it's lovely to meet you and to talk about your work.

This is a super interesting area to study because we know that there is a push to increase the number of GPs in practice and I guess that does really start from medical school and people's intentions there. But just to start off, could you talk us through why you decided to do this work and what were you aiming to look at here?

Speaker B

00:01:00.050 - 00:03:17.090

Yeah, of course.

So the goal of this piece of research, of the systematic review was to synthesize the empirical evidence on the factors that influence medical students, GP, career intention. Because we know that the general practice is what makes the NHS functions.

It handles over 300 million consultations annually, manages the long term, most long term conditions, issues over a billion prescriptions per year. And we also know that healthcare systems with a strong, with strong primary care achieve like, better population health in general.

But at the same time, right now the projected shortages for the UK are approximately 15,000 GPs by 2036, which is of course a large number and shows like a workforce crisis. And then if we look at the policy response to this, they've been like quite ambitious but also largely unsuccessful.

So for instance, Health Education England mandated that 50% of all new medical graduates should enter general practice. And this target has never been met. The same goes for the NHS long term workforce plan to increase GP training places by 50% to 6,000 places in 2031.

And the interesting part about this is that the policy responses are all about setting this goal. Right?

It's about, you know, we're shifting, we're shifting care to the community, we're expanding training places, more medical students should become a gp. But that's all. Yeah, setting like these, these, these strategies, but at the end it almost seems like the, we're achieving the reverse.

So that, that kind of brought me to the question of if we want to, you know, make sure that we have a healthy primary care workforce, that the general practice avoids this large crisis in the future, then maybe Instead of setting these ambitious goals, we should look into the question of what draws medical students to the general practice and also what are some of the reasons why they might not become a gp?

And I think if we zoom into those factors at medical school, during medical education, you get a lot more interesting insights that can actually inform more effective policy. I think that's the kind of. That was the reason I conducted this systematic review.

Speaker A

00:03:17.970 - 00:03:42.850

That's a great summary of what's been going on with GP recruitment in the past little while in terms of policy and the push to increase the number of gps. And this was, as you mentioned, a systematic review that followed pretty conventional review processes.

But I wonder if you could tell us a bit about this bland mirror model. It's a framework used in terms of organizing the results and how this informed how you structured the results.

Speaker B

00:03:43.990 - 00:04:47.410

Yeah, I think it's for this specific research question, looking into factors that influence decision making.

I decided to look up different theoretical frameworks in order to understand this, because decision making at the end of the days is, of course, something that's influenced by many things at the same time.

This model specifically, which was, I think first published in 1995, helped a lot with like, systematically categorizing the findings because it identified three principal domains. One is the student characteristics, such as, like, personal values, maybe personality traits. The second one is the specialty characteristics.

So what is the. What are the professional opportunities? And the third one is, like, the influences during medical school.

And I think if those are the three kind of domains we saw in this across these, like, 30 years of research, and I think it was the most useful way to kind of theorize these factors.

Speaker A

00:04:48.210 - 00:05:01.970

Great.

So I guess just talk us through what you found, and I suppose it might be helpful to just talk through the different aspects of that model you've just described. So what were the sort of student characteristics that you found in the literature that influenced and informed specialty choice?

Speaker B

00:05:02.640 - 00:06:37.050

Yeah, so I think the findings from this came from different types of studies.

I think the largest ones were the ones that used a data set called UK met, which kind of has the data on all UK medical students in such demographic variables, but also more information about their educational performance in medical school.

And I think these studies showed us like, the kind of the social, demographic, individual characteristics that are associated with a higher likelihood of pursuing a career in a general practice. And then there's these smaller studies which kind of like looked at personal preferences and personality traits.

And I think that that's another really interesting question. Right. Because about this, like, specialty choice and Kind of individual preferences, personality traits.

A lot of international research is talking about altruism or do people who enjoy social contact more, are they more likely to become gps?

And I think this type of research is quite undeveloped in terms of the UK literature, but it was still interesting to look at it and compare it to different studies. And I think for the demographic factors we saw specifically that female students were more likely to choose gender practice graduates on entry.

So age was another one we saw. Yeah, so there's like these different kind of demographic factors or personality traits that seem to predispose you to career in a general practice.

Speaker A

00:06:37.290 - 00:06:51.930

And what about the characteristics of the specialty itself or working in general practice specifically that drew some medical students to think about it. So these are potentially medical students looking at gps and thinking, oh, I want that lifestyle or I don't or I want that work. Really? Yeah.

Speaker B

00:06:52.150 - 00:07:48.350

On this question, first of all, a lot has changed recently.

So I think work life balance was something that was mentioned in like the earlier studies, but right now it has changed so much that that's almost like not something we can, yeah, we can use anymore.

But another interesting one, and I think one that we should really take seriously, is that a lot of one of the things that draws students to the general practice is the like, long term patient relationships. So continuity of care.

And of course right now with the landscape changing and specifically like the prioritization of access over continuity of care, it might be important to kind of, you know, reconsider those changes in light of the fact that a lot of medical students decide on a career in a general practice because of this like continuity of care aspect that's so unique to primary care. So I think that's another really important one.

Speaker A

00:07:48.990 - 00:08:13.560

Yeah, I can definitely relate to that.

I think one of the reasons I figured out that general practice was for me was that when I was working in A E, I would flag all the patients I'd seen and clarked in and then wanted to know what happened in their journey. And I thought, oh, well, I'm not really getting this here in my hospital job in specialty, but maybe that's something I can get in general practice.

So as you say, it's a shame that potentially that's something that's being eroded a bit in current practice.

Speaker B

00:08:14.040 - 00:09:22.490

Yeah, exactly. Yeah, that's a really, really important one.

And that's another study of mine is a very simple survey where I ask more than a thousand gps what they found most rewarding about their career. And it's an open text response and over 45% of respondents wrote down continuity of care.

And in a lot of the discussions we have around continuity of care and its benefits, it's very much patient centered because we know that the quality of improves for patients if they see the same gp. But that kind of. We haven't really thought about that reversed.

So we haven't really thought about what does it mean for a GP to provide continuity of care, to see the same patients.

And clearly now with like, the retention crisis, it's also important that we look at, like, the positive factors, like what do gps really enjoy about the career, what were the reasons why, why they want to become a gp, and how do we kind of protect those things or improve them even more? And I think continuity of care is a very important one there. And I think something we should really, really consider during these policy changes and.

Speaker A

00:09:22.490 - 00:09:44.780

One of the more interesting areas, and maybe one where we can try to make a change or difference in curriculum in medical schools, is those medical school influences that you captured in the literature. And I know, for instance, where I studied, we had really early GP placements in year one of our medical training.

But talk us through how medical school influences impacted on career choices and decisions.

Speaker B

00:09:45.180 - 00:12:06.380

Yeah, so medical school is. Is extremely, like an extremely important time. It's a.

It's a time that, of course, you go from like, knowing about these specialties, knowing about the different career pathways, to actually experiencing them. The most important thing is probably exposure to TP placements.

And actually, like, early exposure was associated with a higher likelihood of pursuing a career in a general practice.

So it's not only the timing, but it's also the quality, which is kind of hard to measure, but a very important thing there was positive role modeling.

So if a medical student during the GP placement is exposed to what they see as a positive role model, then they're more likely to, you know, want to pursue that career as well. And positive role modeling is also, of course, comes down to how much resources is this GP teacher provided with to facilitate the teaching.

So, for instance, a really interesting change is that until 2022, undergraduates GP placements in England received substantially less funding than hospital placements. And right now there's been a change.

It's called the Harmonized Undergraduates Medical Tariff, which for the first time has established equal funding for primary care and secondary care or like the education and placements.

And it would be interesting to see whether, like, improved funding for these GP placements actually also improves the ability of a GP teacher to, you know, give more, maybe more teaching or to. Yeah, to Kind of improve the quality of that.

I think that's another one because it's easy to say, oh, it comes down to just a positive role model or not. But I think it all comes down to the resources they provide, with the time they get, the amount of students they get.

And I think once again, if we set such mandates such as 50% of medical students should become a GP, I think that's the wrong way to go about it. I think it's more, how can we improve the resources for GP teaching and placements such that students have a.

An experience that's fair and that they enjoy? I think those are the kind of policy changes we should think about.

And I think the Harmonized Education Tariff is a very, very positive step in that direction.

Speaker A

00:12:06.780 - 00:12:13.260

And I guess. Are there any other key findings you want to pull out from this paper before we move on to some of the implications and stuff?

Speaker B

00:12:13.420 - 00:12:52.880

I think another one is also the hidden curriculum, and I think that's one that we also. Kind of. Well, I'm actually like, I don't really have any new insights on that, but I think it was by choice, not by chance.

Report from 2016 is still as relevant today as it was when it was published. And I think the kind of.

The policy recommendations from that report are still super important, such as monitoring and addressing the hidden curriculum and also supporting GP role models to counter the misconceptions. Those two kind of policy recommendations are still really, really important.

Speaker A

00:12:53.360 - 00:13:06.480

And I guess, given what you found here, what do you think are your recommendations or what's coming up from the literature about suggestions for how medical students might choose or prioritize general practice as a career choice?

Speaker B

00:13:07.280 - 00:14:38.510

Yeah, I think it comes down to the kind of the two buckets that were also identified by the blend mirror framework. One is the. Well, one is the individual, which I think.

Well, actually you could also look at the individual and see if you promote more diverse recruitment, then maybe the group or the cohorts of medical students are also more diverse and maybe that might represent. That might be helpful with addressing some of the workforce shortages in the future.

And I think very specific thing we should consider there and that we've learned from a lot of, like the US Literature, Australian literature and Canadian literature is specifically the recruitment of medical students from more deprived rural areas, because then according to, like the US literature, Canadian literature and Australian literature, they're more likely to serve in underserved communities. So I think that's the first bucket that the second one is the medical schools.

And I've just said, I think funding there is really important for GP teaching and also like monitoring and addressing the hidden curriculum. And I think the third is like the specialty attributes. So we already talked about continuity of care.

That seems to be a very, very important reason why medical students pursue a career in general practice.

So I think we should consider protecting that more, improving it more, especially on the changes we get with like prioritizing access over continuity of care.

Speaker A

00:14:38.670 - 00:15:04.820

Brilliant.

And it's been really interesting work and I think that this hopefully will help bolster some of the evidence around how we can increase the recruitment of future GPs into practice. So really important work and I think it will have lots of strong policy influences sort of in the future going forward.

So well done with all the this work. But I think that's a great place to wrap things up. So I just wanted to say thanks very much for your time here and for talking about your work.

Speaker B

00:15:05.300 - 00:15:07.300

Thank you so much. I really enjoyed it.

Speaker A

00:15:08.580 - 00:15:23.380

And thank you all very much for your time here and for listening to this bjjp podcast.

Katharina's original research article can be found on bjgp.org and the show notes and podcast audio can be [email protected] thanks again for listening.

Today, we’re going to back at the recent BJGP Research Conference, which was held just last week on the 20st of March 2025 in Bristol.

Transcript

This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A

00:00:00.960 - 00:00:39.550

Hello and welcome to this BJGP podcast. I'm Nada Khan and I'm one of the Associate Editors of the Journal. Thanks for listening today.

In today's episode we're going to look back at the recent BJGP Research Conference which we held just last week on 20th March in Bristol. It was absolutely brilliant to welcome the BJGP team and people who attended to the Southwest.

And in today's episode I'm just going to talk about some the highlights and really focus on what the conference is about and maybe have a chat about how to get involved in the future. But first, here's a welcome to the conference from our Editor in Chief, Ewan Lawson.

Speaker B

00:00:40.270 - 00:01:16.520

My name's Ewan Lawson, I'm editor of the bjgp. So that means basically I'm the one person that the Journal would probably run without and everyone else does all the work.

But I do have to stand up here and say hello to you and I want to offer you the warmest of welcomes to the conference. Been running this for a few years and it's always really nice to get together and just try to help each other, you know, get involved.

It's not in a very scholarly way, you know, whether you're involved in research or whether you're interested in putting research into practice. We think we can offer you quite a lot more than just the fact that we publish research at BJGP and BJGP Open. So I hope you have a fantastic day.

Speaker A

00:01:17.320 - 00:03:26.850

So this was the seventh run of the BJGP Research Conference and this year we had a particular focus on a few different areas.

We took a bit of a deep dive into patient involvement, new and emerging research in general practice, general practice policy and how to get research into impact. And this year, as always, quite a bit around writing and also public speaking in academia.

The conference kicked off this year with an absolutely brilliant talk by Professor Martin Marshall, who some of you may know as the Chair of the Nuffield Trust. But he's also Emeritus professor of Healthcare Improvement at UCS and non Exec Director at the Royal Devon University Healthcare trust.

And until 2022, Martin was also the Chair of the Royal College of GPs and a GP in New East London. So definitely someone worth listening to about his experiences as well.

And Martin really focused in his talk on the relationship between general practice and policy and asked a really important question, which is how good are we as a profession at influencing decision decision makers?

And in his talk, Martin reflected on the fact that while the value of general practice is really well established for patients, communities and the wider nhs. It's often still misunderstood or undervalued at a policy level.

And in his talk he challenged whether that's purely down to policymakers or whether, as Julian Tudor Hart once put it, there's also an element of political literacy within the profession itself.

And what really followed was a thoughtful discussion about how both national leaders and individual clinicians can do more to shape policy, and whether that's through better communication, stronger advocacy, or even engaging more actively with the systems around us. It was a really thought provoking structure of the conference and linked closely to that broader theme of impact that ran throughout the day.

Here's just a short snippet of Martin speaking at the conference.

Speaker C

00:03:27.570 - 00:04:45.260

I wish I could have my career again and I'd be more influential than I was. I've learned a lot along the way, but this is what I've learned. First of all, as I've described, influencing is about far more than informy.

It's not about telling, it's about getting inside people's heads and understanding what's important to them. A lot of influencing is about timing. How do we decide when to influence? I think it's really important. Policy windows is an interesting concept.

So sometimes just a window opens that allows you to do something.

And a good example of this would be the evidence around Continuity of care, which is actually pretty strong in General practice was largely ignored by policymakers and politicians until the pandemic came along and they were looking for a way of delivering the vaccination program. And we made the case based on evidence that trust is really important to the success of uptake of vaccination programs.

And that's why government decided that general practice would deliver their program largely, rather than setting up a separate body to deliver it. So there's an example, another example of ways of change.

The NUFRE is doing some really important work around the distribution, the resource distribution formula for general practice, something which the Conservative governments of the past were not interested in, the Labour government is very interested in. So now is our time to push it while we can.

Speaker A

00:04:46.460 - 00:11:57.780

So it was a great start to the conference from Martin, which really focused down on how GPs and primary care researchers can get the most impact from their work to effect change. So in addition to the keynote sessions, we had a series of parallel sessions where people presented posters and talks about their work.

And what really struck me, listening to different talks and looking at the different posters that were on display, was just how strong the work was across the board, especially from medical students. And early career researchers.

There's clearly a lot of exciting work coming through and I wouldn't be surprised to see some of it published in the BJJP in the near future.

At the conference, we then had a series of workshops and these looked at patient and public involvement, writing for the BJGP and public speaking in academia. I attended Lucy Potter and the Bridging Gap team's excellent workshop on meaningful patient and public involvement in research.

Their team did an absolutely brilliant job at highlighting a familiar but important issue that those with the greatest health needs often face the biggest barriers to care and are probably the least likely to be involved meaningfully in research.

And what made this session stand out for me was that it was delivered alongside women with lived experience, which brought, I felt, a real deal, a real depth and authenticity to the discussion.

And the workshop was a absolutely powerful reminder of the importance of meaningful involvement and offered some really practical ideas for how we can better include marginalized patients in our work.

And going on to one of the regular features of the conference, which is the Right for Life workshop, led by our deputy editor at BJGP Life, Andrew Papaniktis and Tom Round. It's a really engaging session that encourages people to write and reflect on their experiences in general practice.

And I often describe JGP Life, the website, as sort of the coffee room of the journal. It's a space for more sort of reflective conversation and debate.

And here we're also always keen to receive some submissions from across the GP community, and it's probably worth pointing out that some of these pieces then go on to be published in the print journal too. And finally, the third workshop was led by Professor Graham Easton, who looked at public speaking for academics.

And I just want to touch on Graham's really interesting background that he was able to draw upon here. So, Graham was a senior producer for BBC Science Unit for many years and presented Case Notes, which is Radio 4's flagship medical program.

He's also a regular contributor to BBC Health Check and has quite a strong interest in the use of narratives and storytelling in medical education, which is a topic he looked at in depth in his doctoral work.

So, looking back to his workshop, it focused on something we've all experienced, which is sitting through a talk or presentation where the key message gets lost in really dense slides and you just lose the audience.

And Graham's session was all about how to communicate our work more clearly and make it engaging, using things like storytelling, simplifying your core message and using visuals that actually support you're saying, rather than Overwhelming it. It was a really practical session with lots of tips to take away and use straight away.

And I think that everyone who attended, who attended learned something new about how to present their research in an engaging and meaningful way. So that's a roundup of the workshops. And finally we had the last keynote speaker of the conference, Dr. Rebecca Payne.

And Rebecca really brought together one of the central themes of the conference, which was impact going back to Martin Marshall's talk as well. And Rebecca's talk focused on what happens after publication and challenged the idea that getting a paper accepted as the endpoint.

Instead, she kind of framed it as the beginning. So that's the point at which the real work of influencing practice and policy starts.

Rebecca's got a lot of experience in research, but for this talk she drew specifically on examples from The Remote by Default 2 study, which explored how the shift towards remote consulting and general practice has played out in reality. And this includes some of the benefits, but also some of the unintended consequences for access, continuity and patient experience.

It was a really helpful example of how complex system changes can't be understood through simple metrics alone and how research, like the Remote to Default study, can help unpack those nuances.

I guess what Rebecca's trying to point out is that if we want research to make a difference, we need to think more deliberately, like much more deliberately, about how it's communicated, who it reaches, and how it feeds into decision making. And that could include things like engaging with policymakers, working with the media, or translating findings into more accessible formats.

And just going back to Martin Marshall's talk, he talked about how at the Nuffield Trust, they have a pretty strong allocation in their budgets towards dissemination. And I think that's a pointer to take away for researchers.

So when you're developing budgets or research programs, think really carefully at the outset about putting aside that funding and that money to get sort of your message across more widely.

So going back to Rebecca's talk, it felt like a really fitting way to close conference and a strong reminder that the value of research really lies in whether it leads to meaningful change in practice. So, yeah, just I just wanted to come back finally to that point.

About one of the things that we consistently hear about the BJGP research conference is how welcoming and approachable it is. It's a really easy space to strike up conversations with people at all stages of their careers.

So from students to early career researchers through to more senior academics and members of the BJJP editorial team who always attend.

And I think it's always just been a really great opportunity to have those informal conversations that sometimes often spark new ideas or collaborations.

So I guess what I'm trying to say is if you're interested in meeting like minded colleagues in general practice or primary care research or thinking about getting involved in research and publishing, it's definitely one to consider for next year. So a really big thank you to everyone who came along this year.

I hope you all found it as engaging and inspiring as I did and it was lovely to meet so many of you throughout the day as well.

And with that, that's the end of this season of the BJGP podcast, so we'll be taking a short break over Easter, but we'll be back soon with a new series where as always, we'll be discussing the latest research published in the BJGP and what it means for practice. We're planning to come back in early May, so do keep an eye out for that. But as always, thank you again for listening.

Today, we’re speaking to Dr Charlotte Paddison, who is currently non-executive director at Royal Papworth Hospital, and formerly a Senior Fellow and co-lead for Primary Care at the Nuffield Trust.

Title of paper: Implications of skill-mix change in general practice: secondary analysis of data from the GP Patient Survey

Available at: https://doi.org/10.3399/BJGP.2025.0360

To the authors’ knowledge, no previous studies have investigated the impact on patient trust or perception of needs met when patients are unsure what type of health professional they have seen. Using data from a large national survey, this study found that patients expressed lower confidence and trust, and were less likely to report their needs were met in general practice consultations when they were not sure who their appointment was with. The results are novel in demonstrating that the combination of not knowing who you saw and a remote appointment is particularly problematic for patient trust.

Transcript

This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A

00:00:01.600 - 00:00:58.530

Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate editors of the Journal. Thanks for taking the time today to listen to this podcast.

In today's episode, we're speaking to Dr. Charlotte Patterson, who is currently non Executive Director at Royal Papworth Hospital and formerly a Senior fellow and co lead for Primary Care at the Nuffield Trust.

We're here to discuss the paper she's recently published here in the BJGP titled Implications of Skill Mix Change in General Practice Secondary Analysis of Data from the GP Patient Survey.

So, hi, Charlotte, it's really lovely to meet you and to talk about your work and I just really wanted to start by exploring how we know that the composition of the general practice team is evolving with the increasing scope of multidisciplinary work. Really? And I wondered if you could just give us some of the context for this work and what you wanted to do here.

Speaker B

00:00:58.850 - 00:02:04.870

Absolutely. Nada.

So what we really wanted to understand was how two big shifts in policy are shaping the experience of patients care when they come to the GP practice. Why do we think that was interesting or potentially important?

Basically, we've seen two big changes happening at the same time in the last five years. So.

So we've seen the shift to multi professional team working with many more different types of health professionals working in general practice and at the same time, separately, we've seen a massive increase in the number of appointments delivered remotely. So what we wanted to know is what those changes really mean for patients.

We also know that some patients feel confused about who they're seeing and when they turn up to a GP appointment at the surgery, whether that's an appointment with a GP or a physician's associate or a social prescriber.

And this led on to another really important question for us in this study, which is what happens when patients are confused or uncertain about who they've seen and what does that mean for patient trust? Those are the kinds of questions we wanted to answer.

Speaker A

00:02:05.350 - 00:02:39.730

So this was an analysis of the 2023 GP Patient Survey, which is sent to patients registered in English general practices.

And I think the key thing for this work and what you've outlined just in terms of what you're saying right here, was that the survey asks people who their last general practice appointment was with and whether they had confidence and trust in that person and if their needs were met. And just given what you were describing, I wanted to move straight on to what you found.

What did the patient say about trust and how did it Vary by different patient characteristics.

Speaker B

00:02:40.050 - 00:03:27.890

Sure. So what we found in relation to trust. Nada.

Is that while every 2, 2 in every 3 patients reported they definitely had trust and confidence in the health professional they saw at their GP practice. And that's very positive.

We also found at the same time, there's a minority of patients, around 7%, who reported they did not at all have confidence and trust in their last GP practice appointment. And we found that trust is lower among patients who are younger, from minoritised ethnic backgrounds and living in more deprived areas.

So that's what we found in relation to trust. We also found that patients are confused about different roles of health professionals working in general practice.

And we've found this is likely to affect around one in every 20 patients.

Speaker A

00:03:28.370 - 00:03:30.290

That seems quite a lot, actually, doesn't it?

Speaker B

00:03:30.530 - 00:04:26.740

Yes.

And it's also we found, looking at the GP general practice patient survey, we found that the proportion of patients who feel confused about who they're seeing has gone up over time.

What I can tell you is that if we look backwards over time, the national survey data shows the percentage of patients who are unsure who their last appointment was with has more than doubled in six years. In 2018, it was around 1.9% of patients. In the 2024 survey, this had gone up to 5% of patients.

And at the same time, we've also seen a decline in confidence and trust. So what we can say there is that confidence has declined by around 5% over that same time period.

So 5 percentage points from 69% of patients saying, yes, definitely they had confidence and trust in the health professional they saw in 2018. But by 2025 that's dropped to 64%.

Speaker A

00:04:27.220 - 00:04:46.100

And I think that almost reflects what's happening in practice with the increasing number of other roles working in general practice as well. And I think one of the really striking findings here is that patients reported much lower trust when they weren't sure which professional they saw.

Do you want to talk us through that and why you think that is?

Speaker B

00:04:46.630 - 00:06:26.190

Absolutely. So what we've seen in terms of context here is that a lot of change happening in general practice, much of it taking place at the same time.

So we've seen in terms of multi professional team working, there are 40,000 additional non GP non nurse staff working in general practice, which is a whopping 387% per patient increase over a nine year period.

At the same time, we've also seen this huge policy focus on rapid access, delivering more remote appointments, working at scale and a shift to digital and online as well. So there's a lot going on in general practice all at the same time.

And we can also see alongside this changes in patients confidence and satisfaction with how general practice is working. So that's sort of a zoomed out, bigger picture lens.

We can see that in terms of the British Social attitude survey in 2024, almost half of all people said they were quite dissatisfied with how general practice was working. But looking back in time, if we look back to 1983, we see that only 13% of people were dissatisfied with how general practice was running.

And even looking back just 10 years ago, in 2016, that figure is 16% of the of people in the British Social Attitude Survey who were dissatisfied with general practice. So we're seeing massive shifts across multiple aspects of general practice.

At the same time, we're seeing a significant shift in the proportion of people who feel that they are satisfied with what's happening in terms of the care they're receiving from general practices.

Speaker A

00:06:27.070 - 00:06:35.070

And I guess that relates to some of the issues with trust and potentially not knowing who people are seeing in practice as well.

Speaker B

00:06:36.170 - 00:07:12.390

Absolutely.

So in our findings, what we found was that the combination of not knowing who you saw and a remote appointment is really problematic for patients in terms of trust and confidence.

So to give a flavour of this, when patients were not sure what health professional, what type of health professional they saw or spoke to, and this was a remote appointment, so an appointment by phone or video or message, the likelihood of reporting confidence and trust decreased by up to 80% when compared to patients who saw a GP in person at their practice.

Speaker A

00:07:12.470 - 00:07:48.910

And we did a podcast with Richard Baker talking about trust in healthcare professionals as well.

And one of the things he highlighted was that actually trust is really important in that patient clinician interaction, because, you know, that trust actually builds some foundation towards whether people might want to come back to the practice, they might want to take up that advice or management that's been suggested by the clinician they see.

So I think not only are you seeing these associations, but it's actually really drilling down to why trust is so important as well in these interactions.

Speaker B

00:07:49.710 - 00:09:55.280

Absolutely, you're 100% right. And I think we can see. And Richard Baker spoke to this.

So high trust means that people are less likely to overuse services, so they're less likely to repeatedly seek appointments from different health professionals for the same problem.

But importantly, they're also less likely to underuse services, because high trust means people are more likely to feel confident in presenting themselves as good candidates for care. For example, trust is Also important for other reasons in general practice.

So about a quarter of all appointments at GP practices are for medically unexplained symptoms. And that work of managing undifferentiated symptoms is hugely important.

And much of that rests on trust, the trust between a patient and health professional, when actually it's not the right thing to refer for further investigations or treatment. A lot of that rests on trusting relationships.

And we know that relationship based care, where the patient's more likely to see the same doctor over time, somebody they know, is hugely important. But at the same time, we've seen a massive drop off and continuity of care.

So if I can speak to the general practice patient survey, what we know is that in the last eight years, continuity of care as reported by patients in England has gone down by around 10 percentage points over the past seven years. So it was 50% of patients in 2018 who said they were able to see or speak to a preferred doctor.

They had a preferred doctor and they were able to see or speak to them either almost or all of the time. By 2055, that had reduced and dropped to just 39%. That's a really meaningful change for patients.

And I think if we look at our study and the results of our study, and we sit that alongside the work of a paper published by Carol Sinot and colleagues recently, we can see that there's real questions about whether the kind of model of care we have is delivering the types of appointments many patients want and need.

Speaker A

00:09:56.240 - 00:10:18.680

And I think Richard Baker talked about this in terms of two kind of different models of care almost.

So this sort of access, dependent, transactional kind of care model on one side, where there are lots of different people working in practice and access, quick access is prioritized, and then the more traditional sort of relationship based care that you're describing as well, that appears to be in decline.

Speaker B

00:10:18.680 - 00:10:52.380

Sadly, the evidence does show that we've seen a significant decline in continuity of care in general practice in the last five, six, seven years.

And that is really challenging for patients as well as for health professionals, because there's good evidence that relationship based care adds to meaning and work. Joy at work, satisfaction in your job.

It also makes it time efficient to be able to speak and meet with patients whom you already know, particularly if those patients with complex care.

Speaker A

00:10:52.700 - 00:10:57.020

Were there any results from your work here that surprised you when you looked at the data?

Speaker B

00:10:57.260 - 00:12:58.379

That's a really good question. Nada.

And I think while we understood that there had been so much change in general practice in recent years, trying to map out what that means for patients using evidence. If I'm honest, I don't think we expected to see the magnitude of the effects.

We saw the likelihood of reporting trust and confidence decreasing by 80%.

When you have an appointment where the patient's not sure who they've seen, they're confused about that and it's a remote appointment, that's a big effect size. And if I'm honest, that did surprise me.

I think there's things from here that I possibly worried were real and the results confirmed that, so they weren't so much surprising. But that doesn't take away at all from the level of concern about those.

So one of the things that has concerned me from here, from the results of our study, is that we know that almost 1 in 10 patients said their needs were not at all met in their last general practice appointment. That's really worrying.

And it's worrying mostly because, well, even more worrying because those living in deprived areas and those with a chronic illness were more likely to report that their needs weren't met. So that suggests that some of the shifts we've seen in the way that care is organised and delivered may be contributing to the inverse care law.

And that raises some really deep questions about what is the purpose of general practice and how do we ensure that we orientate service delivery models to provide care for patients not only who might prefer or need rapid access for a more transactional type of problem, at the same time as ensuring there's continuity of care and relationship based care for patients who need and will benefit from that model of care. So these are difficult but important questions for general practice.

Speaker A

00:12:58.860 - 00:13:06.620

And I wonder what your thoughts are about how much of this issue is about communication and expectations rather than the roles themselves.

Speaker B

00:13:07.020 - 00:15:03.940

I think there's a very important element that you're picking up on there. Nada. And I do think that communication is a hugely important part of embedding skill mix change successfully into general practice.

So I think it's a complex picture here.

What we can see is that it's really important that GP practices have good systems in place so that when a health professional introduces himself to a new patient, it's expected that they can say, you know, my name is X and I'm a physiotherapist working in this practice, or I'm a physician's associate working in this practice so patients can be clear.

We need clarity on that at both local practice level and also support for that at a national level in terms of successfully implementing some of these changes. I also think that it's not just about communicating roles.

Well, although that's a very important part of what needs to happen here, we also need to recognise that it's more difficult to establish trust and build rapport in situations where care is delivered remotely.

So thinking about practical strategies to support that sort of building of trust and confidence and knowing who it is that you're seeing when the appointment might be remote. I think we also need to recognise that the public really worry about not knowing who they're seeing.

And there's a element of social media in contributing to this.

We've seen some high profile cases leading up to a patient's death where the family and the patient have been confused about who it was the patient saw. And that's hugely upsetting. It's a significant issue of real public concern.

And I think we need to address those worries and communicate and provide assurance and reassurance for patients, both when they come into practice, but also thinking through how changes are implemented at a national level and whether there's things to learn from some of those experiences.

Speaker A

00:15:04.580 - 00:15:23.540

Yeah, and I just wanted to pick up on that, especially going back to your role and experiences working at the Nuffield Trust. And we know that national policy is strongly encouraging multi professional teams in general practice.

And do you have any thoughts about what your findings suggest policymakers should think about as these teams expand?

Speaker B

00:15:24.100 - 00:17:48.710

That's a great question, Nana.

I think what we can see is that multidisciplinary team working in primary care is not new, and we do know that it can offer a mix of potential benefits for staff and patients. But we also know that desired outcomes are not always delivered and we can see that implementation has been really challenging.

So I think there's important reflections there and lessons to be learned about, for example, the importance of building trust and clearly communicating new roles to patients, but also supporting staff and embedding new roles into practice and thinking about the cost of supervisory time to support new roles, to coordinate care, to ensure and avoid fragmenting care. When you have different members of a team working together to support an individual patient.

Today, we’re speaking to Marta Berglund, a Research Assistant and PhD candidate at University College London.

Title of paper: Pre-diagnostic primary care consultations and imaging in emergency-diagnosed vs referred lung cancer patients

Available at: https://doi.org/10.3399/BJGP.2025.0369

It has been postulated that emergency diagnoses of cancer (which occurs frequently and confers a poorer prognosis) may relate to suboptimal diagnostic management in primary care, but evidence to support or refute this hypothesis is sparse. We found that emergency-diagnosed patients with lung cancer were less likely to present with relevant respiratory symptoms and had fewer chest imaging investigations before diagnosis compared to patients diagnosed via referred routes, indicating an important role of disease factors in emergency diagnosis.

Transcript

This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A

00:00:01.200 - 00:01:06.690

Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate editors of the Journal. Thanks for listening to this podcast today.

In today's episode, we're speaking to Marta Bergland. Marta is a research assistant and PhD candidate at university College London.

She's recently published a paper here in the BJGP titled Pre Diagnostic Primary Care Consultations and Imaging in Emergency Diagnosed versus Referred Lung Cancer Patients.

So, hi, Marta, it's really lovely to meet you and it's great to talk to you about cancer diagnosis, which is a really important area for general practice and also a topic we publish on quite a lot here in the bjgp. It's been fascinating reading this paper and it tackles a cancer that we really don't do well with here in the UK in terms of early diagnosis.

But I wonder if you could just start off by telling us a little bit more about lung cancer and how it's actually often diagnosed, which can sometimes lead to some of those poor outcomes.

Speaker B

00:01:07.010 - 00:02:26.970

So, as you said, lung cancer is one of the cancer sites in the UK where the majority or a large proportion of patients are diagnosed through the emergency route, also known as emergency presentations, which is when a patient is diagnosed after they present through an urgent hospital admission or an A and E attendance in the 30 days before diagnosis.

And that could look like someone who has had a persistent cough for, say, two weeks, but didn't actually go to their gp, and then suddenly they have a more severe onset of symptoms like shortness of breath, and then they go to A and E and are referred to a chest X ray and then get diagnosed, which is a pathway that is associated with worse prognosis and worse outcomes after diagnosis. And the more preferred route, if you will, in England to diagnose patients is through primary care.

So through the GP routine referral or the urgent suspected referral route.

And that could look like someone who presents to primary care with cough or dyspneasia again, but then their GP refers them to a chest X ray and then they're diagnosed with lung cancer.

Speaker A

00:02:27.130 - 00:02:45.290

And I guess I wanted to just before we talk about what you found, I wanted to just cover here again, what you mean by this term, that's diagnostic window, because you mentioned that a few times in the paper. But what does this actually mean?

And it relates a bit back to some of what you're talking about, about people presenting with symptoms, isn't that right?

Speaker B

00:02:45.530 - 00:03:09.880

So, for us, it's a measure of healthcare use before diagnosis, and it could be any healthcare use Measure like consultations, symptoms, blood test use, anything like that.

And it's measuring when that changes compared to baseline before diagnosis, which can signal increased healthcare use associated with the subsequent diagnosis.

Speaker A

00:03:10.040 - 00:03:16.840

Okay, so it just, I guess it's what it says on the tin. It's just that window, isn't it, of potentially being able to pick up a change.

Speaker B

00:03:17.490 - 00:03:25.970

Exactly. So the idea is that if there is an increase long before diagnosis, then possibly there is an opportunity to diagnose these patients earlier.

Speaker A

00:03:26.450 - 00:04:09.190

So this was a really big study using the CPRD and this is a database that a lot of the listeners will be familiar with.

And you had a sample of a million patients registered with UK General Practice and then you looked at people diagnosed with cancer and their pre diagnosis rates of consultation like you were talking about, and also chest imaging by the different possible diagnosis routes. So either as an emergency, a routine or an urgent referral. But I really want to move straight to what you found here.

Can you give us just an overview of how the different people in this analysis were eventually diagnosed with lung cancer? So were there a lot of emergency diagnoses here?

Speaker B

00:04:09.350 - 00:05:46.240

Yes, I believe we had around 30% of patients who were diagnosed through the emergency route, compared to 20 something percent in the urgent referral route and the GP routine referral route. That aligns with the national data in NCRAS and also the Rapid Cancer Registry data. I guess that's what we expected to see.

We found that the majority of patients do present to primary care, which then disproves this hypothesis that has been presented in the literature that patients who are diagnosed through the emergency pathway don't present to primary care at all and therefore there wouldn't really be a chance to intervene and improve these patients diagnostic pathway. I think that is one of the key findings, although it is a simple finding.

Then we also found that there are short term similar diagnostic windows across these routes.

Patients who are diagnosed as emergencies had similar opportunity to intervene earlier as patients from the other routes, just because of the timing at which things changed.

However, we also looked at the rates and those were consistently lower for emergency diagnosed patients, even though the timing at which things change at the lower rates mean that these patients present less frequently. And so because they present less frequently, there are simpler, fewer chances in primary care to also like see warning signs earlier.

Speaker A

00:05:46.480 - 00:05:56.480

Yeah, so you looked at those consultations rates. So is that what you're describing here? So is that what those findings show in terms of potential opportunities for earlier diagnosis?

Speaker B

00:05:57.280 - 00:06:17.190

Yeah, so what I had in mind was mostly the consultations and the consultations with symptoms, but then acknowledging that we measured two different things.

So the timing at which things change, the diagnostic windows as well as the rates of these consultations, how frequently they were occurring for patients by route.

Speaker A

00:06:17.430 - 00:06:27.510

And what you're suggesting is that people who were diagnosed via emergency had lower rates. So that sort of is a bit counterintuitive. So can you talk us through that again a bit?

Speaker B

00:06:27.590 - 00:07:06.880

It's a bit contradicting.

Well, it would seem that it is because these patients do present to primary care and then when things start going wrong, let's say they happen around a similar time as for patients who are diagnosed through the other routes. But what sets the emergency diagnosed patients apart is that they present less frequently.

So they may still have cough and may still go to their gp, but they may not do so as often as someone who's referred on a two week wait, for example, or now urgent suspected referral, which then means that there are fewer chances for gps to pick up on persistent symptoms and then refer those patients.

Speaker A

00:07:07.200 - 00:07:19.780

And I guess just.

Were there any other main findings that you found in terms of sort of the diagnostic window or sort of consultations before diagnosis via the different routes?

Speaker B

00:07:19.940 - 00:09:14.860

Yeah, so I think one of the most interesting ones as well to the overall finding of patients presenting to primary care is that patients presented with non specific symptoms around 10 to five months before diagnosis across the routes, which is still quite a while before they're diagnosed.

So potentially this could mean that something could have been done differently to, for example, refer these patients earlier in like say month nine before diagnosis rather than nine months later. But again, as you said, this is also in lung cancer patients, which is a very difficult cancer site to diagnose early.

And part of that reason is because the symptoms that patients present with are non specific symptoms.

So it's also understandable that it is difficult to make that call based on someone presenting with cough in primary care, which is why there's more like work to be done and we need to better understand where the thresholds are for referral, like how many times someone comes in with the same symptoms, something like that.

But the work does show that that is like a common characteristic that is shared among, like across lung cancer patients, even diagnosed by the different routes.

And then another finding was also similar to the non specific symptoms, was that patients had chest imaging, so chest X rays around six to four months before diagnosis, which again is still a while before they're diagnosed.

And because these are chest X rays, then it could mean that they have negative chest X rays before diagnosis and then are again perhaps referred back to primary care with symptoms or they have an another chest X ray within those months where things are increasing, like month four to zero before diagnosis. Maybe there's a learning to be found from that.

Speaker A

00:09:15.100 - 00:09:32.620

Yeah, absolutely. And I wanted to just touch on those findings around imaging.

And I wonder what thoughts you had about the role of access to chest CTs for GPs, just given what you've described here about chest X rays and potential potentially negative chest X rays as well in this cohort.

Speaker B

00:09:33.180 - 00:10:02.380

Well, I do think that it's also pretty well documented in the literature that chest X rays aren't necessarily the best and most accurate diagnostic test for lung cancer and that improving access to low dose CT in England has helped diagnose lung cancer patients. So I think improving access to chest imaging and CT scans specifically could also present an opportunity to diagnose patients earlier.

Speaker A

00:10:02.830 - 00:10:16.990

And I wonder, just given all this information, what you found in this study, what do you think are the main implications for potentially opportunities to diagnose lung cancer earlier and not via emergency routes for these patients?

Speaker B

00:10:17.390 - 00:11:07.090

Again, I think the picture is complex because as you've also mentioned, the paper doesn't have kind of like a clear finding of something that was very different in the emergency diagnosed route. But actually patients who are diagnosed through the emergency route look quite similar to the, the primary care referred routes.

Then I think what we can do is focus on the things that were similar for all patients, meaning that there's also a similar opportunity to diagnose patients earlier across all routes.

Those things include being more vigilant about the non specific symptoms that patients present with and perhaps having a lower threshold for referral or more thorough follow up. And then I also think improving access to chest CTs could also help diagnose

Speaker A

00:11:07.090 - 00:11:22.290

patients earlier in the paper you touch very briefly on screening.

Is there anything that you want to mention here about sort of potentials for lung cancer screening or what might already be in play in terms of potential policy for screening for lung cancer?

Speaker B

00:11:22.850 - 00:12:16.370

Yeah, I mean, I think lung cancer screening is very important and it's definitely going to change the way things look in terms of how patients are diagnosed. And I think we're already seeing that since I think around like 2022 when the program started being rolled out.

There's around 7% of patients who are diagnosed through screening now, which we can see in the Rapid Cancer Registry data set that's actually publicly available as well.

So with that being said, it is still a bit difficult to know what that means because we need to let it play out for a few more years until we know what that means for diagnoses through the other routes. Hopefully it will mean that some patients who would be diagnosed through an emergency route won't be.

But of course we also don't know to what extent emergency diagnoses are completely avoidable.

Speaker A

00:12:16.610 - 00:12:23.280

And I think it's important to point out probably that the lung cancer screening programs are really targeted at the moment as well, aren't they?

Speaker B

00:12:23.360 - 00:12:50.190

Yeah, exactly. I believe there were patients who are eligible are those aged 55 to 74 and who have a history of smoking.

So for example, in our study that was 38% of patients who are diagnosed as emergency patients. So there's still 62% of emergency diagnosed patients who would not have been eligible for the screening pathway regardless.

Speaker A

00:12:50.910 - 00:13:11.950

And I think what you say here about actually not just focusing on what you found amongst the patients who were diagnosed with lung cancer via the emergency routes, but actually looking at everyone who's diagnosed with lung cancer and trying to improve care for all is really important in terms of extrapolating the findings here. It's been really great talking to you about this work. So thanks to again for joining me.

Speaker B

00:13:11.950 - 00:13:12.590

Thank you.

Speaker A

00:13:13.390 - 00:13:29.310

And thank you all very much for your time here and for listening to this BJGP podcast.

Marta's original research article can be found on bjgp.org and the show notes and podcast audio can be [email protected] thanks again for listening and bye.