BJGP Interviews

Today, we’re speaking to Dr Luisa Pettigrew, a GP and Research Fellow at the London School of Hygiene and Tropical Medicine and Senior Policy Fellow at the Health Foundation.

Title of paper: Counting GPs: A comparative repeat cross-sectional analysis of NHS general practitioners

Available at: https://doi.org/10.3399/BJGP.2024.0833

There have been successive Government promises to increase GP numbers. However, the numbers of GPs in NHS general practice depend upon how GPs are defined and how data are analysed. This paper provides a comprehensive picture of trends in GP capacity in English NHS general practice between 2015 and 2024. It shows that the number of fully qualified GPs working in NHS general practice is not keeping pace with population growth and there is increasing variation in the number of patients per GP between practices. We offer research and policy recommendations to improve the consistency and clarity of reporting GP workforce statistics.

Transcript

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

Speaker A

00:00:01.040 - 00:01:04.810

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. Louisa Pettigrew, who is a GP and research fellow at the London School of Hygiene and Tropical Medicine.

Louisa is also a Senior Policy Fellow at the Health foundation and we're here today to talk about the paper that she's recently published here in the bjgp. The paper is titled Counting A Comparative Repeat Cross Sectional analysis of NHS GPs.

So, hi, Louisa, and thanks for joining me here today to talk about your work. And I guess just to set things out, it is really important to know how many gps there are working.

But I wonder if you could just talk us through what we already know about this. We know that there have been successive government policies and promises to increase the number of gps.

There are, as we know, different ways that gps could be counted.

Speaker B

00:01:05.530 - 00:02:37.470

So, yeah, as you rightly point out, there's been recurrent governance promises to increase GP numbers.

Not just our current Labour government, but the previous Conservative government too, and previous governments too, because they realize that, you know, having access to GP is important for the public and there's a shortage, a perceived shortage of them.

So the issue that we notice that there's different ways to count GPs who are working NHS General practice, and therefore depending on how you choose to count them, then that affects the trends and it affects your numbers.

So you can count a GP by headcount, whether they're working in NHS general practice or not, and you can count them by full time equivalent, so the actual reported numbers of working hours. You can also consider GPs to be fully qualified GPs alone, or you could include GPs who are fully qualified, plus what is categorized as GP trainees.

Now, that category includes GP trainees, but it also includes foundation year one and two doctors and any other sort of junior doctor that might be in general practice. And the other dimension to how you count gps is whether you take population growth into population size.

So in the UK, over the past, sort of between 2015 and 2024, which was a period of analysis of our study, there was about 12% increase in population size in England. So once you take population growth into account, that again, changes your trends and your current figures.

Speaker A

00:02:38.510 - 00:02:46.830

And in this paper you used a few different ways to calculate the number of gps. But just talk us through briefly the data sets that you used here to look at that.

Speaker B

00:02:46.990 - 00:03:45.590

So we use the nhs, England's GP workforce data set that provides both national figures and practice level figures.

So we use the national figures to look at the overall trends and then we looked at practice level figures to disaggregate and look at sort of the range, the median and the 95th and 5th percentile of patients per GP across practices in England. We also used the number of patients registered at jail practice to get our total number of patients, your denominator from the nhs.

But we also compared this to Office of National Statistics, Office for national statistics ONS figures of mid year population estimates between 2017 and 2023 to again compare how you know what your population is changes the number of patients per GP or gps per capita. You can calculate it both ways and.

Speaker A

00:03:45.590 - 00:03:57.920

I think just setting that out shows us why this is actually a really complicated area.

So there's lots of different ways to define a GP and how they're working, but there's also lots of different sources you can look to to count a GP as well.

Speaker B

00:03:58.880 - 00:04:21.140

Correct. And, you know, there's, there's nuance to this.

And the risk is that if we don't consistently count them and report them in the same way, then you end up having different figures and people end up speaking at cross purposes and people can pick and choose which figures to use depending on what's more convenient in terms of the story that one wants to tell.

Speaker A

00:04:21.940 - 00:04:27.980

Fair enough. Okay, so let's move on to what you found. So what were the numbers of total GPS if we were just doing a.

Speaker B

00:04:27.980 - 00:06:05.730

Headcount between 2015 and 2024? So we took quarterly data over that period and we saw that there was.

If you take headcount, so this is the absolute best case scenario, you take headcount and you include trainees, there was an 18% increase, so it rose from 41,193 to 48,758. That's raw number of GPs in NHS general practice. A separate question is GP's not in NHS general practice? But that's a different study, not this one.

But then if you consider working hours so full time equivalent and you exclude GP trainees on the basis that they are not equivalent to a GP because they might not be delivering the same amount of care, foundation union doctors may not choose to specialise in general practice. So therefore, arguably shouldn't be included in the overall numbers. So full time equivalent and no trainee, what we found is actually a 5% reduction.

So from 29,364 down to 27,966 between September 2015 and September 2024.

If then you take into account population growth and using NHS registered patients rather than ONS figures, what we actually see is only a 6% rise in the headcount plus trainees. So that's 6% rise versus an 18% rise. That's once you've taken population growth into account.

And when you actually take in population growth into account and consider true sort of working figures, which are full time equivalents without trainees, there's actually a 5% reduction in the number of GPS per capita. Yeah.

Speaker A

00:06:05.730 - 00:06:16.030

And I also wanted to touch about the range of patient to GP ratios across the country, because what you found here suggested that there's actually a big range between these ratios across England as well.

Speaker B

00:06:16.510 - 00:06:55.010

Yeah, that's right. So that was the next part of the analysis where we looked at practice level data.

So what we saw is that between the period of September 15 and September 2024, the gap, or the difference between, say, the 5% practice of the least number of patients per GP and the 95th percentile, practices with the greatest number of patients per GP, that increased. So there's a big difference.

So, and that's principally driven because the gap has increased, because those at higher end, those with more patients per capita, has increased that faster rate than those with less patients per capita.

Speaker A

00:06:55.490 - 00:07:01.250

And what does that mean on the ground for these practices in terms of the ratio of patients to GPs?

Speaker B

00:07:01.970 - 00:07:49.290

Well, the thing is, I guess we don't. We don't know the reason for this. So our study didn't examine the reasons for this. You might speculate there might be a variety of reasons.

So practices may have employment shortages, they might be in areas that are struggling to recruit, they may have made active decisions not to recruit for financial reasons, they may have less gps, but actually may have many other additional roles.

So other direct patient care roles, pharmacists, social prescribers, physios and so on, and therefore compensating their GP shortage, the relative GP shortage with other roles. But again, that was beyond the study and that's only, you know, what we can infer based on what's going on in just now.

Speaker A

00:07:49.930 - 00:08:10.920

Yeah, and I think this study is really interesting because it's kind of based around how all these things are defined. And you point out in the paper that depending on how you define a GP, there could have been a rise of 18% of GP numbers or a 5% reduction.

And what do you think this means about how we look at the data or talk about the number of gps in practice?

Speaker B

00:08:11.960 - 00:09:43.860

Yeah, I think.

And what we recommend in the paper is that we ought to, we ought to report both headcount and full time equivalent because it's important for policy decisions to understand whether it's a complete headcount shortage or whether it's about people reducing their work hours. And obviously it's important to know the number of retainees and report them as well. So it's important to understand with and without trainees.

But when you're looking at capacity, I think it's important to report full time equivalent and it's important to capture the figures or report the figures without trainees to actually try and capture what actual GP capacity there is in general practice at that moment in time. There's some other nuances. So for example, ad hoc locums are not captured in the same place in the workforce statistics.

And also the new ARS funded GP roles are also captured in a slightly different place in the data sets. So bringing them all in to the data set is important because then once you bring them in, you can see the overall net increase or decrease.

Because for example, the government has been reporting the rises in additional roles reimbursement employed GPs because the practices get funded to employ these roles, but they're presenting them in a way that doesn't let you capture either the full time clue figures or the net overall increase or decrease in gps, because obviously at the same time as they're joining the workforce, other GPs are leaving or reducing their hours.

Speaker A

00:09:45.060 - 00:10:01.840

This all sounds quite complex in some way, even discussing it on a methodological level, but I guess getting this message out to the public is another thing because you kind of have to explain around how things have been counted to make the data meaningful. Really?

Speaker B

00:10:02.080 - 00:11:09.970

Absolutely.

And I think one of the things that's probably important to highlight as well, around the full time equivalent hours, there are limitations to the study and the statum, and I think probably one of the more important limitations is that there is evidence from elsewhere, colleagues in Manchester have looked at this, that actually full time equivalent reported hours are likely to be underestimating the actual hours worked by GPs. They estimate that GPs are working around 50% extra than their full time equivalent reported hours.

So that is an important limitation in this, in this process. But it doesn't mean that we shouldn't do it. It means that we need to work better at capturing those full time equivalent hours.

So currently it's subject to a practice manager submitting the hours on an online portal. So, you know, you need to be checked whether they've submitted it, submitted it correctly.

The GPs whose hours are reporting are usually not involved in that process. So you could for example, ask the gps to sign off or cross check whether those hours correct.

And once those systems were in place, then you probably improve the collection collection of this data.

Speaker A

00:11:10.130 - 00:11:22.930

And another interesting point you touch upon in the paper is that we kind of need to know what GPs are really doing in that time as well. So whether it is direct patient contact, whether it's supervision or other activities as well. So talk us through that.

Speaker B

00:11:24.050 - 00:12:31.010

Yes, I guess these figures only give us the number of hours worked or the headcounts in practice.

It doesn't tell us whether they're seeing patients face to face or what the other responsibilities that might be involved with being a GP might be, which are very broad and may be different, for example for a partner than a salaried doctor.

So for a partner it might be interesting to understand how much of their time is spent on practice management and things related to the running of the practice.

And for a salary gp, it might be interesting to understand actually how much back office work they're doing with admin and so on, which also applies for partners. But actually understanding these issues are important because I think in general there is a retention issue in general practice.

So it's not just about the overall figures, it's understanding the pressures of what GPs are doing with their time.

So therefore we can design policies and understand how to improve or make it a more attractive job and address some of the challenges that the workforce currently facing that leads to. To attrition.

Speaker A

00:12:32.210 - 00:12:58.270

Yeah, and I think there's a couple of ongoing projects. The RCGP is doing one and where the projects are essentially counting what gps are doing in their time.

So asking gps to time code each activity to find out actually what's happening in that time and maybe that might capture some of that so called hidden work or that extra work that gps are doing on top of their full time hours. Really. So that's interesting to think about as well.

Speaker B

00:12:58.670 - 00:13:17.710

Yeah.

And knowing that would be helpful as well because then you can understand for example better what activities might could be automated or technology could help with or which activities need additional or could be done by additional different roles to make the job more effective and more attractive for the gps that we do have.

Speaker A

00:13:17.710 - 00:13:20.430

Any other findings that you wanted to pull out from this paper?

Speaker B

00:13:20.830 - 00:14:12.270

I think if you look at the overall difference difference. So to sort of to present to you, the difference in this is like if you count by headcount and trainees.

So again, the best case scenario per thousand patients versus full time equivalent without trainees, it's 40% higher in 2015 and then in 2024 it's 74% higher. Now, there's two things that have been driving that. One, there's more trainees, which is a great thing, but we also need to think about retention.

And two, GPs are being reported to working at less full time equivalent hours in NHS general practice.

So the importance of measuring the gps in a consistent way is getting even more important because the gap is widening because of other things that are going on, which are more trainees and more full time equivalent hours. So less full time equivalent hours, more part time working.

Speaker A

00:14:12.430 - 00:14:29.260

And often I ask people coming on the podcast what they'd want to sort of tell gps working in practice, but I think for this paper it's more important to ask, what would you tell people wanting to use figures about gps, or how is this important for policy? And where do you want this work to go next, really?

Speaker B

00:14:29.580 - 00:15:13.600

So I think there's multiple ways to report NHS general practice workforce statistics. This can end up with contradictory discussions about trends and current figures.

So what we'd suggest is you report headcounts, including Trinis, and ignoring population growth will overestimate GP capacity and will harm the interpretation of workforce trends. So using fully qualified full time equivalent gps per capita will capture the current downwards trend in GP capacity.

But there are limitations to current NHS data, so that needs to be worked on.

And reporting the extent of variation across practices in England is necessary to capture widening variation and differences in GP provision within practices in England.

Speaker A

00:15:13.760 - 00:15:21.360

And I think that's probably a great place to wrap things up. But yeah, I just wanted to say congratulations that you're on the paper and thanks for talking to me today.

Speaker B

00:15:22.000 - 00:15:24.200

Thanks very much for the opportunity and.

Speaker A

00:15:24.200 - 00:15:39.770

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

Louisa's original research article can be [email protected] and the show notes and podcast audio can be found@bg bjjp life.com thanks again for your time here, and by.

Today, we’re speaking to Jadine Scragg, a researcher based at the University of Oxford, and Sabrina Keating about their recent paper published here in the BJGP.

Title of paper: GPs’ perspectives on GLP-1RAs for obesity management: a qualitative study in England

Available at: https://doi.org/10.3399/BJGP.2025.0065

General practitioners (GPs) play a central role in managing obesity yet face significant challenges due to limited treatment options and resource constraints. GLP-1RAs are emerging as a promising treatment for obesity but access in primary care is limited. This study provides new insights into GPs’ perspectives on the integration of GLP-1RAs into primary care, highlighting concerns around resource limitations, health equity, and misuse of the medications.

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 - 00:01:00.730

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

Today we're speaking to Judine Scragg, a researcher based at the University Oxford, and Sabrina Keating, a DPHIL student who's also based at the University of Oxford within the Nuffield Department of Primary Care Health Sciences.

We're here to talk about their recent paper, published here in the BJJP, titled GP's Perspectives on GLP1 Receptor Agonists for Obesity Management A Qualitative Study in England. So, hi, Judine and Sabrina, it's great to meet you both for this chat.

I guess the first thing to say is that this work is really topical at the moment, especially given current plans to increase the rollout of GLP1 receptor agonists into the community. But, Judine, I'll come to you first and I wonder if you could just tell us a bit more about what you wanted to do in this research and why.

Speaker B

00:01:01.510 - 00:02:25.330

Yeah, absolutely. So, for a long time, as you've said, the GLP1s have been very topical, both in clinical groups and with patients as well.

So I'm first and foremost, I'm a weight management researcher and I've done work in populations with people living with type 2 diabetes and polycystic ovary syndrome. And within those populations, one of the things they've constantly asked about is about GLP1s, when do I qualify? When do I get it around?

And similarly with the gps GP groups as well, there's been a lot of questions, there's lots of media about, you know, both good and bad about GLPs and outlining different people's thought processes and are they good? Are they bad?

So what we sought to do with this was to sort of more robustly work out what it is GPs actually feel about the perceived integration of the GLP1s into primary care to very kind of firmly focus on GP specifically.

And this ended up coming at a really timely point, as midway through the study, the NICE guidance was brought out on outlining the plans for how tirepatide would be rolled out. So it was a really timely piece to find out exactly what they were thinking and feeling about how this may impact them and their patients.

So that's really what we set out to do.

Speaker A

00:02:26.200 - 00:02:55.660

Great.

And this was a qualitative interview study of 25 GPs across England working across different roles, and they all had different experience in weight management services. But I really Just wanted to come on to what you found here.

And let's start with an area that's quite a common issue right now, and I certainly don't seem to go a day without a patient asking me about whether they can get a weight loss injection. But what did gps think about navigating these patient requests when they. When they get them?

Speaker C

00:02:56.140 - 00:03:56.260

Yeah. So at kind of the moment we were conducting interviews, that was definitely a real source of sort of frustration and difficulty.

There were quite a few patients presenting, asking for GLP1s, the majority of whom were ineligible often, or would only be eligible through kind of this longer, more drawn out process of accessing specialist care, which in many of the regions just did not exist or was going to take kind of years and years. So it was not necessarily an amazing option.

This kind of left the gps we spoke to in quite an uncomfortable position where they kind of had to play the role of gatekeeper, really manage those expectations and potentially kind of have that compromising sort of interaction with their patients. So certainly the gps that we spoke to had some frustrations associated with that.

Speaker A

00:03:56.820 - 00:04:03.620

Yeah, absolutely. And I suppose it's a little bit about how to manage those requests. So did the gps talk about that at all?

Speaker C

00:04:04.100 - 00:04:31.440

Yeah, there were some different strategies that we heard about. I would say the primary one was just around identifying other options that would be available.

That was more difficult in some cases where patients had already exhausted those options and were feeling quite frustrated.

One of the other strategies that we heard about was testing patients for type 2 diabetes to try to identify whether maybe there was another avenue that they could kind of come in through.

Speaker A

00:04:31.840 - 00:04:47.040

And did they talk at all about private prescribing or. We might come on to this a bit later. But did any of the gps talk about suggesting or dealing with patient requests for private prescriptions?

Because I think that's quite a big industry and a growing industry at the moment as well.

Speaker C

00:04:47.360 - 00:05:42.850

Yes, certainly our sample were very much aware of this going on and it had been kind of entering the remit of their practice, specifically kind of asking for prescriptions to be carried over into NHS care, which most of the time the answer was a pretty concrete and clear no on.

So that could also be quite disappointing, particularly for patients who had come in through other international health systems who are then like, oh, I thought I would surely be able to get this on the nhs. And, yeah, a lot of the services didn't have, like, a great answer or kind of protocol to responding to those requests for private prescription.

So there was also kind of the frustration of okay.

This is taking up quite a lot of our time, quite a lot of our effort that could be put towards other things, especially at a time when we're so overstretched.

Speaker A

00:05:43.810 - 00:06:08.040

And I think that leads on to the next thing I wanted to talk about.

And I think that, as you say, one of the big concerns for GPs, especially given the increasing effort to provide GLP1 agonists to a wider community population, is how we're going to fit this in alongside all the other things that we're doing. So what else did the GP say about this and about the different resource limitations in general practice?

Speaker B

00:06:08.760 - 00:06:09.320

Yeah.

Speaker C

00:06:09.400 - 00:07:15.450

So I think many had an awareness that in kind of an ideal world, this made a lot of sense to be carrying out in primary care.

A GP has that kind of connection, ideally to their patients, and is able to see kind of the broader context of where and how they live, who they are as an individual. But within that, there was an awareness that that was going to be exceedingly difficult given the resource limitations of the time.

So a few of the gps we spoke to were essentially just like, we don't know how this is going to happen. This needs to stay in secondary care. It's just not kind of a viable model.

Others were really worried that some of the components that should be integral to GLP1 delivery, like wraparound care, behavioral and psychological support, were certainly not going to be easy to provide within primary care. And there was a real discomfort of this is just simply not how the medications are or should be used.

Speaker A

00:07:16.570 - 00:07:48.870

Yeah, I guess that goes back to How Current Tier 3 weight management services are provided or were provided, perhaps, in the nhs.

And the fact that you're right, there's a bit of a wraparound system around it, and certainly GLP1 agonists would only have typically been prescribed in those services alongside, as you say, all of the different weight management services. So that's quite a hefty burden for a GP or practice to pick up.

Judine, I don't know if you wanted to comment on that, given your background in weight management research as well.

Speaker B

00:07:49.590 - 00:09:14.320

Yeah, I mean, I think, as Sabrina said, there's definitely concerns, but I think as well, there's definitely some very strong themes of these GLP1 drugs coming in as a very helpful tool as well, in a few different ways.

So, for example, I think one of the gps that we spoke to voiced concerns about how sometimes it's quite tricky for people to navigate the best way to support themselves, to lose weight and to navigate that wraparound care, and they perceived that GLP1 is a really helpful tool to help, particularly some people will find it a bit more tricky to navigate.

You know, all the different referral systems that exist within wraparound care, such as try this dietary program, you might be eligible for this program. And they saw that as a helpful tool to do that. Yeah.

Thinking about some of the other patient groups that we've spoken with, so particularly I'm thinking patients here with type 2 diabetes or with polycystic ovary syndrome. They have often told us when they've tried to access care and they ended up managing to get in through Tier 3 services.

And I used the word managing because obviously that is quite tricky to access. And there are, as we know, very long wait lists across huge areas of the country.

They felt like they really had to advocate for themselves to get to those and have not necessarily found it the easiest setting to navigate from a patient perspective.

Speaker A

00:09:14.800 - 00:09:39.260

Another aspect your participants talked about was health equity, and this is certainly an area we've covered elsewhere in BJJP life. I wrote an about this titled how to drug your way out of an obesity crisis.

And we know that there are other environmental and social determinants of obesity that really need to be a focus here. And Sabrina, I'll come back to you. What did the GP say here about that?

Speaker C

00:09:39.579 - 00:10:32.900

Yeah, I would say that was definitely front and center in many of the conversations that we had. We did also kind of actively sample for general practices and general practitioners within kind of more deprived settings.

There certainly a discomfort of, okay, if these medications are becoming our first line treatment for obesity at kind of like an individual level, a political level, a medical level, does this become our sole solution to obesity and, you know, a real awareness of the consequences that that could have when obesity is a much more embedded issue and the kind of social factors that contributed to people being in these situations in the first place were not going to go. And in that case, some of the momentum to actually addressing them may just be sort of smoothed over.

Speaker A

00:10:34.580 - 00:10:37.940

I guess those things don't really have an easy fix, do they really?

Speaker C

00:10:39.540 - 00:10:54.180

Yeah, which is why there was also that counterbalance. Awareness of these things take time. There might not be that political motivation to solve them in the short term. We do need something immediate.

We just can't let that be everything.

Speaker A

00:10:55.470 - 00:11:02.430

Fair enough. And I think finally some GPs were concerned about the misuse of these injections. So can you talk us through that as well?

Speaker C

00:11:02.750 - 00:12:14.870

Yes. Some of that concern about misuse, was it becoming this overriding treatment for everyone?

I think especially with everything going on in media and patient demand, it's easy to have kind of that kickback response of, oh, gosh, everyone wants these, everyone wants to be slimmer. So that was a source of kind of discomfort, especially when social inequality might be taking the backseat.

There was also just awareness that these medications could cause some really uncomfortable dynamics in consultation, be that around requests or prescribing or discontinuation of the medications. So there was kind of a view that in the future there might be problems to do with the appropriateness of prescribing.

And since patients are coming in and applying potentially actually significant pressure for the medications to be prescribed, GPs are in quite a difficult position to say no to that. One of our participants referred to it as being called in as the policeman to kind of keep an eye on patients and be the one making those calls.

Speaker B

00:12:15.350 - 00:13:03.340

I think one thing that cropped up was sort of that concern there, that if they said no, that ultimately patients would seek to obtain these medications through other avenues, be it private use.

And then there was obviously that very real concern about how do GPs within an NHS setting look after patients who are obtaining these medicines through private resources?

I think some of the participants mentioned that sort of factoring into those dynamics where they couldn't provide the patients with what the patients were explicitly asking for, that there's this sort of sense that the patient will, you know, if they are able to financially, they'll. They'll just simply try get it elsewhere.

And I think that was a source of anxiety for some of our participants about how do they best make sure that these patients are being looked after appropriately.

Speaker A

00:13:03.820 - 00:13:27.600

Yeah, and there's certainly no shortage of different quality of clinics that are providing these different injections as well.

And I guess this is sort of happening now and many local ICBs and PCNs are trying to figure out how to roll out GLP1 agonists and who should be eligible. I just wonder, after doing this research, what you would say to them about the GP perspective here, given your research.

Speaker B

00:13:28.240 - 00:16:02.500

One thing that we are very looking forward to is getting the data on how many patients actually end up taking these, particularly in the first phase of the rollout, because it is quite a small group of people in primary care who are in the first phase. So I think that's going to be really interesting to see, actually. How many people are we talking in primary care? How many people choose to do it?

We talk a lot about how patients really want this, but there are definitely groups of patients that don't want this. We know, for example, when we think about diabetes One of the key drivers of often weight loss and remission is to take themselves off medicines.

So this might not be a thing that's of interest to everybody.

So in terms of advice, I think maybe it's not so much advice as in we are going to be learning a lot over the next few years about how patients actually feel about these. Now they're on offer potentially to them.

And in terms of advice to gps, I think a lot of that is just keeping themselves as, I guess, kind of up to date with other things that they can offer patients in the meantime. As Sabrina said, there's always going to be an influx of patients wanting these and they might not be eligible just yet.

So being able to offer patients something in the meantime is probably something that certainly patients have said to us in the past about. The main thing they feel downhearted with is when they feel like they get nothing at all. So, you know, something is better than nothing.

I mean, a lot of ICBs as well, I think are doing a really good job of putting on their social media or their websites kind of about some information. So I've seen quite a lot of different ICPs put together.

Really lovely patient facing documents to advise them that, you know, when these drugs might make their way to the patients and to sort of help their patients advocate the system a little bit. For example, you know, helpful tips and tricks.

If they're already in specialist weight management, they'll probably contact us about it very shortly and try.

I can see that ICPs are already making really, really helpful patient facing documentation, which I think is a really, of course, really useful trick to manage that patient demand. I can see why that, you know, doing that potentially to stop, you know, dozens and dozens and dozens of patients coming to their doors every day.

But I think there's definitely something to be said for kind of reassuring the patients about when they may be eligible, what they can do in the meantime and that, you know, not to worry, you've not been forgotten. We can't give it just yet, but no, it's happening soon.

Speaker A

00:16:04.250 - 00:16:54.390

And as you say, it's very interesting times around this and things are a bit in flux as different ICBs work out the best way to provide these services to the right patients. So as I said before, I think this is really timely research.

So great to chat to you about it, but I think that's a great place to just wrap things up. So I just really wanted to say thank you both for your time here.

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

Sabrina and Judine's original research article can be found on bjgp.org and the show notes and podcast audio can be [email protected] and I just wanted to say a special thanks to Sabrina who is on the west coast of the US and had to wake up at 5am for this podcast. So thanks again for joining us here today and thanks to you all again. Bye.

Today, we’re speaking to Dr Steph Stockwell, a senior analyst based at RAND Europe.

Title of paper: Evolution of the general practice receptionist role and online services: a qualitative study

Available at: https://doi.org/10.3399/BJGP.2024.0677

The introduction of online systems and services into general practice and the impact on general practice staff has been considered from a clinician perspective, but comparatively little is known about how these introductions have affected the receptionist role. This study highlights that the use of online services is leading to an evolution of the general practice receptionist role. The role is becoming increasingly complex as practices use multiple online systems, which impacts demand management and navigation aspects of the role. Online systems have variable consequences on workload for receptionists, which has potential implications for workflow, consistency of task completion, job satisfaction, and retention and recruitment of these key staff members.

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 - 00:00:53.350

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

In today's episode, we're speaking to Dr. Steph Stockwell, a senior analyst based at RAND Europe.

We're here to discuss the paper she's published here in the BJGP titled Evolution of the General Practice Receptionist Role and Online Services A Qualitative Study.

So, hi, Steph, it's great to meet and talk about this work and one of the reasons I really wanted to talk about this is that I think it's timely work, given that we know there's an increasing emphasis just in general practice on triage and also the multidisciplinary team. You talk in the introduction of this paper just about the role of receptionists, which has been evolving and changing in recent years.

So just talk us through that a bit.

Speaker B

00:00:53.720 - 00:02:09.550

Yeah. So this work came about because we were doing some work for the wider de facto study, which was a.

An observational, mixed methods study that involved delete reviews, some surveys, ethnographic case studies and some interviews.

And it was whilst I was doing some of the ethnographic case study work that we spent a lot of time around reception staff because they were the ones who were doing most of the digital facilitation, which is the phenomena that we were. Were looking at. It was whilst doing these observations that the idea for this, this paper came to me, as, you know, often the.

The first point of call for, for patients making contact with general practice and they're really crucial for helping to manage that demand and facilitating patient access to care.

But during these observations, I noticed how the perception of what a receptionist did, particularly among patients and the public, was a little bit outdated and the array of technologies and platforms that they were having to manage and, and help patients use as well, was really sort of the stereotype of answering telephone calls.

So, yeah, the rationale for this work sort of came about on the back of that and it made me want to look back at some of the work that we did for the De facto study and to see what sort of impact the online services had on the role of GP receptionists.

Speaker A

00:02:10.030 - 00:02:50.390

Yeah. So you wanted to look, as you mentioned, just at the impact of online services on sort of the evolving role of receptionists.

And as you mentioned, you took quite an interesting and varied approach here.

So you did the ethnographic work that you mentioned, but you also did interviews with patients and staff and practices and the ethnographic work was really interesting. So you were actually sitting in eight different practices and observing what receptionists were doing.

But I want to really focus on what you found here and I think the first thing to talk about is that the receptionists had a really different and varied role between those different practices and even within the practice itself. So talk us through that.

Speaker B

00:02:51.170 - 00:03:43.630

Yeah.

So speaking to a couple of receptionists who'd been in the role sort of a longer time, they were reflecting in their interviews about how the role itself, from their point of view, having been in it for such a long period of time, has changed. Previously they would do sort of fewer and more repetitive type jobs, but now it's just so much more varied.

That's just one person within their role over a period of time.

But then we were noticing that receptionists within one practice and between the different practices, we went into what was conceptualised as a receptionist.

What the receptionist role looks like was very different and it was impacted by whether the practices had specific administrators, so people like reception clerks or IT officers, the number of different receptionists that were available and working on. On shift, and also the confidence and competence of each specific receptionist themselves.

Speaker A

00:03:43.950 - 00:04:02.830

Yeah, it's interesting you talk about experience and I think that probably a lot of people who work in general practice might reflect on that.

But talk us through what you found in terms of the differing experience that receptionists had, just in terms of how comfortable they felt with the varied role or changing role. Really.

Speaker B

00:04:03.310 - 00:04:55.060

Yeah. So some staff who were sort of newer to the role, it's all. They're sort of known. We had some cases of.

Because there was sort of a lack of training and support around some of these newer bits of the role in a formal sense. There was a lot of support happening from receptionist to receptionists and sort of learning on the job types of things.

But it would mean that for newer members of staff who are learning on the job, they might be shown something by one person and then shown how to do the same task, but in a slightly different way by another person.

And then for that new member of staff, that could be quite disorientating, quite nerve wracking, because then they didn't really know which was the right way to do it and which way they should be doing it. So, yeah, because of that lack of more formalized training there for newer members of staff, that was. That was quite tricky.

Speaker A

00:04:55.300 - 00:05:24.370

Yeah, fair enough. So maybe a nod there to the need for more formal training rather than the ad hoc kind of training that people get on the job, potentially.

Yeah, fair enough.

And I think that one thing that a lot of people working in general practice and probably patients really can empathize with is how people get through to practices, you know, by phone or by E consults. It's quite complicated, actually, at the moment. And you talk about this in terms of demand management in this work.

How did this impact on the receptionists?

Speaker B

00:05:24.850 - 00:06:20.400

Yeah, so it's, as you say, it's not just them seeing people as they walk in face to face and letters and telephones, which was, you know, how things happen traditionally, but all of these different online ways to access practice, which is great for patients, but, you know, can be a bit of a nightmare to manage. So you've got things like email, you've got online triage tools, you've got practice websites, you've got different apps.

And then, you know, during the pandemic, the NHS app came in, so sometimes practices were running, you know, a more local app with the NHS app with the practice website and all of these things. So there were lots of modalities for patients to contact the practice via, which in. In some ways can be a good thing. You know, it's.

It's just the reception staff were saying, it's.

It's not actually reducing demand, it's just the same level split across multiple different things, which adds complexity to what they're having to manage through those different channels.

Speaker A

00:06:20.640 - 00:06:25.120

And did they have clear pathways on how to manage that? How did they deal with that?

Speaker B

00:06:25.360 - 00:07:06.750

Yeah, so, I mean, every practice was kind of worked it through differently.

So they might have some members of staff who would monitor emails, they might have some members of staff who would look at econsults or something like that. So they split it up that way. And other people might say they split it up by the individual person was responsible for the different way in.

Others split it up by a bit more of a rota to try and make it a bit more varied for staff so they didn't get bored doing the same thing every day.

So they might have a morning being responsible for whatever E consults were coming in, and then the afternoon they might be doing something else and someone else would take over that role. So, yeah, each practice was sort of.

Speaker A

00:07:06.750 - 00:07:18.320

Different, increasingly, and sometimes referring to receptionists more as care navigators. How did reception staff that you talked to or observed look at this? And what was their perception about that?

Speaker B

00:07:18.800 - 00:08:20.840

Yeah, so the navigation of patients has always been sort of a key part of the receptionist role. But, you know, with the increasing skill mix within general practice, where they route people to is is changing and become more Complex.

But the addition of the online services adds another level of complexity because.

So, for instance, when patients were phoning up and there were no appointments left, receptionists were sort of navigating patients through the find routes, because that way they could offer people an appointment because there had been slots saved for econsult appointments or something like that. So there was just an extra level of something that they could help patients navigate to try and get access to an appointment.

And receptionist themselves said, you know what, that is actually quite helpful, implicating some patients. You've got someone on the phone who is looking for some help, there are no appointments left.

And so actually being able to say, well, if you go through this route, actually I can. Can offer you something. And that made things a little bit less stressful for the receptionists.

Speaker A

00:08:21.080 - 00:08:45.000

I think that really speaks to the perception of receptionists being seen in the public as these sort of dragons at the front door of general practice, where actually we all know that they're really just trying to help the patients rather than block patient access. And it's a shame that that perception is still really persisting because they are kind of that front door to overstretched services. Really.

Speaker B

00:08:45.380 - 00:09:00.180

Yeah, no, absolutely. And there were.

There were lots of cases that we saw where receptionists were really trying to help patients through that digital facilitation, you know, helping them to use the online services to try and help them get the. The care that they. That they needed.

Speaker A

00:09:00.420 - 00:09:10.420

You were embedded in these practices. Did you get a sense from sitting and observing what was going on, what worked and what didn't work in terms of the reception role?

Speaker B

00:09:11.070 - 00:10:04.210

Yeah, I think when receptionists were tasked with something quite specific for a short period of time, that they could then dedicate their focus and their attention to that thing. And they did it really, really well.

Other instances where maybe there weren't as many receptionists to kind of balance that demand coming in, it felt a little bit more. From my perspective, it may not have been the experience of.

But from my perspective, it looked a little bit more chaotic because there was a lot of task switching and trying to balance things.

Whereas where you had, this receptionist is going to be on telephone calls, this receptionist is going to be on E consults, this one is going to be doing X, Y, Z.

That seemed to really use the skills of the people and keep them focused on a task, which meant that things were, I don't know, a little bit more calm, potentially from the outside looking in, at least.

Speaker A

00:10:05.010 - 00:10:17.790

Yeah.

And I think we all know that things can sometimes get a little Bit chaotic in general practice or anything to sort of ease that sounds like a good shout. Wonder if there's any other key findings that you want to pull out from the paper at all.

Speaker B

00:10:18.030 - 00:12:20.790

One thing that was really interesting was that a lot of the online services are sort of badged as a great way to kind of reduce workload and, you know, help staff and help patients and all that kind of thing.

And in some ways they do because, you know, if patients can self serve via online routes, that can kind of sometimes help reduce some of the workload for reception staff because of the links that are available to people they can book into appointment slots and things. But that requires the patients to actually be able to do it themselves.

And you know, when patients aren't able to do that themselves, it's often the receptionist that they call upon to help them. So that doesn't actually reduce any, anything for the receptionist themselves.

There are also cases where patients were using the online systems incorrectly.

So either because they didn't really have a, an understanding of how to use them properly or how they were intended to be used, or actually where patients were trying to work around the system to try and get what they really wanted. And that involved the reception staff having to kind of reconcile things behind the scenes.

For instance, people might be booking into inappropriate appointment slots because they don't understand that actually you don't need a 20 minute appointment with this particular practitioner for a blood test or something. And so that would require the receptionist to go in and rebook it and move things around.

Or they might fill in a form, an inquiry form online, but it's the wrong form because those forms go to this particular team and those forms go to that particular team, but the patient doesn't really know that. They just see, you know, it's on the website, so it just goes to the, the practice. And.

But if they, if those forms do go to the different teams, then it's normally the receptionist or the administration team, depending on which practice, that has to do all of that work behind the scenes to then redirect it to the right people, the right teams.

So that was, that was quite an interesting thing that I hadn't really thought about in terms of that sort of hidden work that the receptionists are doing behind the scenes.

Speaker A

00:12:21.430 - 00:12:42.940

It sort of sounds like, you know, that kind of calm duck above the water and then the sort of legs are really going underneath. Just a lot of work going on really to help manage that.

And I think it's an important point to make, especially with an increasing emphasis on Online services in policy, really in terms of how people want general practice to work?

Speaker B

00:12:43.340 - 00:12:44.380

Yeah, absolutely.

Speaker A

00:12:44.540 - 00:12:56.540

I wonder, just given the findings from this work, what do you think it's important for practices to know here to help support their reception staff during this period of flux and change? Any tips for practices?

Speaker B

00:12:56.940 - 00:14:37.070

Yeah, I mean, for me this work really is important for the consideration.

When you're thinking about recruitment and retention of GP receptionists, we can see that the role has definitely evolved and become more complex since the introduction of these online services services and that should really be reflected in job descriptions and skills requirements.

Maybe having that digital element in there, the digital competencies in there for those who are newly recruited or already in post, maybe some more formal training or support for those reception staff might be helpful.

As I said earlier, even if it's just here's how we're going to do it in this practice to standardise the messaging and practices within a single surgery, that could be potentially helpful. But I also think it's not just on the GP practice to make changes.

I think a lot of these online systems are developed by tech companies and if for instance, the systems were really simple and really easy for patients to use and to use them correctly as they're intended, then that would actually reduce the workload for the receptionist trying to rectify things behind the scenes.

So it's also on the developers of these technologies to co design those from the patient facing side of things so that patients can understand and easily use them and to make them very intuitive.

Then also the behind the scenes version that you see, that the receptionist staff see and other members of staff see it in the practice, they're also co designed so that they are useful to those people in those roles and they can be used in a way that, you know, isn't going to overburden them, it isn't going to create more workload and actually makes things easier for them.

Speaker A

00:14:38.200 - 00:14:59.880

Brilliant. Yeah, really helpful advice, I think, for practices and as you say, also for people designing these different systems too.

You know, we do it in research to co design systems with patients and with the people who are going to be using it. Wise words, great. But yeah, I think that's probably a great place to wrap up. But I just want to say thanks very much for speaking about it.

Speaker B

00:15:00.200 - 00:15:02.920

Thank you so much and thank you.

Speaker A

00:15:02.920 - 00:15:06.455

All very much for your time here and for listening to this BJGP podcast.

Speaker B

00:15:06.455 - 00:15:06.550

Thank you.

Speaker A

00:15:07.500 - 00:15:32.220

Steph's original research article can be found on bjgp.org and the show notes and podcast audio can...

Today, we’re speaking to Dr Sophie McGrath, Consultant Medical Oncologist based at the Royal Marsden NHS Foundation Trust and at Kingston Hospital in London.

Title of paper: Management of menopausal symptoms following treatment for hormone receptor positive breast cancer

Available at: https://doi.org/10.3399/BJGP.2025.0264

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 - 00:01:11.660

Hello and welcome to BJJP Interviews. My name is Nada Khan and I'm one of the associate editors of the bjgp. Thanks for joining us today to listen to this podcast.

In today's episode, we're speaking to Dr. Sophie McGrath, who is a consultant medical oncologist based at the Royal Morrison NHS Trust and at Kingston Hospital in London.

We're here to talk about the recent analysis article that she and her colleagues have published here in the BJDP titled Management of Menopausal Symptoms Following Treatment for Hormone Receptor Positive Breast Cancer.

And just to point out that these colleagues included not just medical oncologists, but also GPs and patients, which I think has really shaped this article and is one of the reasons why we wanted to highlight it here in the podcast. So, hi Sophie, thanks for meeting me to talk about this article, which I think touches on a really important topic in practice.

But talk us through some of the initial side effects that you discuss in the introduction here. Just in terms of hormone positive breast cancer, what kind of symptoms do women experience generally as a result of endocrine therapy?

Speaker B

00:01:12.220 - 00:02:32.900

So, yeah, thanks very much for asking. And it's a bit of a broad answer that I would give.

I mean, I've focused on, or we have focused on three main symptoms within the article which relate to hot flushes or vasomotor symptoms, also to joint stiffness and pain and swelling, arthralgia, and also to vulvovaginal symptoms, otherwise known as genitourinary syndrome of menopause.

But I think what we've tried to include within the article as well is a table that certainly acknowledges that there are unfortunately many other symptoms that women can get as a result of these medications, essentially mimicking menopausal side effects.

And of course, you know, these might be symptoms that women having already gone through the menopause may have suffered or experienced at some point already.

But actually for a population of premenopausal women, these will be symptoms that they haven't had any experience of yet and can often be quite intense and develop quite suddenly. Whereas often our post menopausal women have had some sort of lead up to this, they've had some experience.

Speaker A

00:02:34.710 - 00:02:44.710

And you work as a medical oncologist. But just talk me through your own experience of working with women who are going through the sort of sudden menopause as you describe as well.

Speaker B

00:02:45.350 - 00:05:50.240

So obviously the focus of the article here is on menopausal side effects in general from the treatments that we use. And we've talked a lot about using our endocrine treatments such as tamoxifen, letrozole.

But actually many of our women also experience menopausal type side effect secondary to the chemotherapies we give them. So I think, you know, there's sort of two groups you often have, particularly premenopausal women who stop their periods whilst on chemotherapy.

That may happen several weeks into their chemotherapy treatment and it can be quite sudden.

You know, they're already dealing with the numerous side effects attributed to the chemotherapy itself, but then they're also having to tackle these hot flushes, insomnia, potentially arthralgia. Obviously the vaginal symptoms may be more medium to longer term impact.

So you've got that group of women who are sort of thrust into menopausal symptoms very quickly and then you have the other group who perhaps have already gone through their menopause.

So they're not necessarily getting those symptoms alongside chemotherapy, but, but then after that we are introducing letrozole, which by removing even that last little bit of oestrogen production in the system is giving them enhanced menopausal side effects yet again. So I think that's sort of psychologically a big thing for the patients to deal with as well.

Whether they're sort of having all of that thrust upon them in one go or whether it's more gradual and they're almost waiting for it to occur. So I think for us, us there's a lot we've got to get through in our consultations.

Obviously if it happens alongside chemotherapy, then we're seeing them regularly anyway. We've got our nurses to support them in the clinics too.

But I think the challenge arises more when our ladies are moving on to their endocrine therapy and moving away from regular consultations in our clinics and having more contact again with primary care. They're wanting to get on with their lives. They're wanting to not be coming up to the hospital quite so often.

And so that was a real focus of this article, wanting to reach out to primary care, but also perhaps non oncology based secondary or tertiary care practitioners.

So maybe gynecologists or people that work very closely within menopausal clinics, not necessarily just within primary care and try and work out how can we support these ladies with symptoms that may take several months to declare themselves and may even be once they've been discharged to our stratified follow up programs, but not necessarily seeing us regularly in, in the clinic.

Speaker A

00:05:51.120 - 00:06:13.110

And I think one thing that I'm always struck by, especially with Women going through the perimenopause and the menopause is that this is a busy time in women's lives. So they might be juggling younger children, a career, caring for, you know, older parents.

So there's a lot going on in these women's lives that things like arthralgia, vasomotor symptoms are going to have a big impact on. Really?

Speaker B

00:06:13.910 - 00:07:33.180

Absolutely. And I think it's really important that we let these ladies know that we're there to try and help and support them.

We're not going to have a one size fits all approach for everybody. But also we do try and not paint a doom and gloom picture from the outset.

Not all women suffer these symptoms to the same degree, of course, so it's sort of in making them aware that they could happen, but then arming all of those medical professionals that they may come into contact with, with the tools to work through and try and help and support. I think, you know, one, one thing that often vasomotor symptoms really impact, for instance, is sleep.

And so, you know, insomnia can be a really big problem for our ladies.

But actually, if you dig into it, you often find that it's because they're having their mainstay of their vasomotor symptoms in the night and they're being woken up by them and then they're struggling to get back to sleep.

So, you know, yes, I agree it's a really challenging time, both in terms of what we might be contributing to in terms of their symptoms, but also them wanting to get on with their lives after this diagnosis.

Speaker A

00:07:33.820 - 00:07:52.690

Yeah, fair enough. And you touch on the fact that systemic hormone replacement therapy is avoided in people with a history of breast cancer due to the increase in risk.

But I wonder if you could talk us through some of the alternative options here that you mentioned in the paper. And let's start with the vasomotor symptoms because you just touched on that as well.

Speaker B

00:07:53.170 - 00:12:56.770

So I suppose just to clarify, obviously the focus of this paper is in hormone receptor positive breast cancer because it is the majority subtype that we see in our women.

It's not a blanket rule, but we are less concerned usually about the use of hormone replacement therapy in our ladies with the hormone negative subtypes. Of course, the primary care practitioners always very happy for you to contact us oncologists if you want to clarify anything there.

But, you know, the focus of this article is about the hormone positive space.

And so certainly within those early years after a diagnosis, our mainstay is trying to minimize that Circulating level of oestrogen as much as possible.

Obviously that may be suppressing ovarian function with GnRH analogues but even on top of that, you know, if that were all that were required, then why do women, postmenopausal women develop hormone sensitive breast cancer? We know it's because of these, this production of estrogen elsewhere in the system.

So then you've got your aromatase inhibitor medications, they're trying to eradicate even those small amounts.

So it, it does, it's very counterintuitive for us to be able to support the use of even topical estrogen based treatments when we're in this sort of early stage after a diagnosis.

That said, of course, and it's sort of outside the scope of this discussion, but of course, you know, we will consider the particular risk of that individual patient. We'll have to consider, you know, their age, the quality of life etc.

So by no means is it a blanket rule but I think, you know, what we're hoping to gain from this article is to highlight what other possibilities are out there that we could look to try.

First of all, so in terms of the vasomotor symptoms, as you say, there are some of the sort of lifestyle changes which to be perfectly honest, I imagine most of our patients are well read.

You know, they will have already looked to methods that they can help themselves with such as portable fans, layered clothing, but it is important to bear those things in mind trying to use lighter fabrics where possible. There is some data to suggest that reducing or removing alcohol and caffeine can help with such symptoms.

And then there is, you know, the exercise in its own right, we know that's very helpful for the arthralgia but actually there is suggestion that that can help with the individual vasomotor symptoms as well.

But what we'll often then talk about with our ladies is say, right, well the next sort of group of potential strategies is around non pharmacological interventions but things that do have now a good database behind them. So actually there's qu a lot of growing evidence for cognitive behavioral therapy which I'm quite excited about.

You know we've had various trials including a major UK led trial, Menos 4 which really did show significant benefit for management of the vasomotor symptoms and many of the patients that I speak to are really open to this concept. The British Menopausal Society has great links.

Our local Maggie Centre, and I'm sure this is the case elsewhere around the country, is starting to offer on site or online CBT as well to try and help with such symptoms. But certainly there are self directed programs as well, which I would highly recommend patients to explore.

But the other thing from a non pharmacological perspective is acupuncture. And again we're fortunate where I work that we do have on site acupuncture services.

The wait is fairly long unfortunately, but at least we can offer that.

And many of our women have really noticed a significant improvement in the intensity and the frequency of their hot flushes from, from a course of acupuncture.

And sometimes ladies can be taught to self needle as well, which can be quite useful if they do find months down the line that they get a slight flare in the symptoms and then they can get that control back using the technique themselves. And then I suppose the final group is the pharmacological interventions.

Speaker A

00:12:57.250 - 00:13:00.690

And you mentioned tibalone in the paper as well, don't you? As well?

Speaker B

00:13:00.690 - 00:14:46.130

Yeah.

So in terms of data support supporting tibalone, I mean at the moment, just to clarify, I'm not recommending that within the paper as a well researched safe intervention within these patient group.

Unfortunately, you know, we know that it's got oestrogenic progestogenic properties, but unfortunately the main trial looking at this was actually stopped prematurely because there was a suggestion of increased recurrence rates of breast cancer. So at the moment that's certainly not something that we would advocate.

We weren't able to go into great amount of detail in the article, but I think a really interesting watch this space area is going to be these novel neurokinin 3 receptor antagonists.

So fezzalinitant is the one that probably most people will have heard of, but there are others and certainly in the non breast cancer space, I know that many women have gained significant improvement in menopausal symptoms from these medications, but we're just a little nervous reticent at the moment in the hormone positive breast cancer population, mainly because we just don't have the data in that group specifically.

But the trials are running at the moment and hopefully we'll have that data soon and have such medication available to our ladies if those other non pharmacological methods aren't working well for them.

Speaker A

00:14:46.210 - 00:15:02.050

And in terms of joint issues in arthralgia, you point out the lifestyle modifications that people can make, many of them quite similar to what you've described for the vasomotor symptoms alongside acupuncture as well, which you've mentioned. But you also touch on the use of duloxetine as well.

Speaker B

00:15:03.170 - 00:15:19.080

Yes. So it's there as an option. It has been looked at in trials.

There was some benefit noted, but I think it's a really tricky drug from a toxicity profile.

Speaker A

00:15:19.160 - 00:15:19.720

Yeah.

Speaker B

00:15:20.440 - 00:17:05.040

And also I think it's the same for the vasomotor symptoms.

When you start mentioning to patients about taking another medication to solve the side effects of the medication you're giving them, people do start getting a little bit nervous about that, that prospect. And duloxetine is one of those personally that I haven't seen a great deal of good benefit from in my own patient cohort.

That's not to say, of course, that it doesn't work for ladies out there.

Again, I was interested in producing this article that there was very little objective evidence supporting things like the omega 3 fish oils, glucosamine. Actually, in practice, many of my ladies are taking that not just for their joints, but for cardiovascular and brain health.

And they will say, look, actually when I'm not on it, I notice the difference. So I do find that generally in my ladies to be helpful and trying where possible, to keep regular movement and exercise. But it is a challenge.

And that is where, you know, by all means, sometimes we do end up having to change the endocrine therapy. It's much less prevalent, of course, with tamoxifen versus the aromatase inhibitors.

In practice, it can be less with exomestane versus some of the other aromatase inhibitors.

So I think it's really important that we try and work with our ladies as closely as possible and get these symptoms ironed out as much as we can in those early months.

Speaker A

00:17:05.840 - 00:17:40.750

Yeah, fair enough. And I think a common thing that we see a lot in practice and deal with as gps are the genitourinary symptoms of the menopause.

And I think there is some confusion about what kind of topical treatments we can use safely for this and whether oestrogen containing pessaries are safe in women with a history of a hormone receptor positive breast cancer. And I think I've even had, had, you know, conflicting advice given to me from colleagues or from hospital specialists as well.

Do you think gps are safe to start this in practice in this group of women?

Speaker B

00:17:41.790 - 00:22:01.630

So I suppose if we go to the guidelines now, whether that's UK based or American guidelines, they will mostly still say in the case of a hormone sensitive breast cancer patient that it is advisable to avoid even topical containing oestrogen containing products. There is a mixed data set from the trials as to whether there really is an increased rate of recurrence with the use of such medications.

But we do know that you definitely can detect increased rates of circulating oestrogen or estradiol in ladies that use such products. Whether that of course results in a recurrence is, you know, yet to be fully elucidated.

So I suppose, you know that judging by the guidelines that we have available to us, what we tend to say in the first instance is let's try and see if all non hormonal containing products have been utilized to the fore in the first instance. And I think what's often missed is the importance of saying with these non hormonal containing products.

So actually, you know, the lubricants are very useful around the time of intercourse, but it's actually the moisturizers that are going to provide the longer term benefit. And actually they need to be used regularly.

So the suggestion is at least two to three times per week applied and that on average, you know, it may take 30 plus days for a lady using that regular regime to really notice a significant difference. So I sort of say to my women, right, this becomes part of your skincare routine, okay?

It, you know, might not be what you would normally associate with your skincare routine, but you, you add this into, you know, your, your regular routine.

And by all means, if you have young sexually active ladies who are religiously applying these products, they've, they've done everything you've said and they are still really, really struggling. Even those women who, it may not be around intercourse, it may be recurrent urinary tract or just symptoms of itch or pain in the vaginal area.

If these methods have been tried and are not alleviating the symptoms, then I think we have to be open to the fact of looking at potentially short courses of using things like, I suppose, low dose estriol in the vaginal area.

What the article does talk about though is that it's thought that it's probably safer if you're going to use such products to combine those with tamoxifen based endocrine treatment rather than continuing with an aromatase inhibitor.

So I suppose what my quick answer

Today, we’re speaking to Euan Lawson, the Editor in Chief of the BJGP, about a number of issues around editing, the future of the journal and how you can get involved with the BJGP.

Here's a link to the BJGP Research and Publishing Conference: https://bjgp.org/conference

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

Speaker A

00:00:00.400 - 00:00:55.980

Hello and welcome to BJJP Interviews. I'm Nada Khan and I'm one of the associate editors of the bjjp. Thanks for taking the time today to listen to this podcast.

In today's episode, we're speaking to Euan Lawson, who is the editor in chief of the bjjp.

We're going to have a chat about a number of issues around the future of the Journal, around editorial issues and how you can get involved with the BJJP as well. So, hi, Ewan. Yeah, nice to see you. And just wanted to really start by saying thanks for joining me here today for this podcast.

But yeah, thanks for joining me here today, Ewan, just to have a general chat about things going on with BJGP and your role as editor.

And yeah, just a chance to catch up about some of your thoughts about issues around academic publishing and then just have a chat generally about other things that you've been thinking about as editor. So how's your week been?

Speaker B

00:00:57.420 - 00:02:13.730

We've already had that conversation before we got here. Now we won't go there again. As you know, it's not been perhaps my ideal week.

But as I'm delighted to be here and talking a little bit about what's going on with the Journal and just give a little bit of insight into how things are going, perhaps the biggest thing that we're I've recently written about the impact factor at the Journal, and perhaps the most important thing I need to say is that we don't worry too much about the impact factor.

I know we do quite well on the impact factor, but I wrote an editorial which really pointed out that we are much more interested in the real world influence of the journal rather than what is quite a narrow metric about citations. We're more interested in how it affects clinical, how the journal articles affect clinical practice, how they affect policy.

And we're really pushing, trying to push in that direction.

And once we get into worrying about the impact factor and there are a lot of perverse kind of incentives in academia and it can sometimes result in what's known as questionable research practices and things can just slide away from the ideal a little bit.

So that's perhaps one of the things that we're trying to concentrate on most in this coming months and years is just making sure that we keep our impact all about real world rather than anything else.

Speaker A

00:02:14.130 - 00:02:26.230

Yeah, you mentioned questionable research practices and you did talk about this in your editorial or your editor's briefing, but how do you think the Journal can tackle that head on?

Speaker B

00:02:27.750 - 00:04:23.309

I mean, it is challenging because it's.

The thing about QRP questionable research practices is that there's like they're a spectrum and they go from really very minor stuff, which is like, you know, giving you, a professor in your department authorship on a paper where they really didn't do anything, to a kind of a. The far end of the spectrum where you start to creep into outright research fraud.

And most researchers, and I think particularly in the primary care field though, you know, we'd always got to be. You always. One has to be careful about making assumptions, you know, are.

Have bags of integrity and do the best they can, but they're working in pressurized systems. And sometimes the QRPs are just things like that can be about the authorship or it can be about declarations of conflicts of interest.

It's how we go about doing our work in terms of how we quote other papers. Or sometimes it can be a little bit about how we tweak results to try to get positive results out because they're more likely to be published.

And those are perhaps the areas where as a journal we can be a little bit more helpful in that, you know, making sure we are quite happy to publish negative findings. We don't overstate results.

It's very easy as a journal to take a paper and there's a, you know, you want a brief summary of it to explain it to people. But it's important that we don't overstate and overinflate results that result in inaccurate messages going out about those papers.

So they're the kind of areas we can help. But let's not be under any illusions. It's a systems kind of problem.

Academic departments and the culture they have and the whole system of getting grants, publishing how those then get disseminated in the media as well. So it's a big old complex beast. And I think we just try and look at the areas journals may have the.

May have an impact, and we're trying to push things in the right direction.

Speaker A

00:04:23.789 - 00:04:40.109

Fair enough. And you mentioned impact and I just wanted to touch here on the BJJP research conference next year, which is going to have a focus on impact.

So talk us through what we're doing there and sort of what your aim is really to get that focus for the conference next year.

Speaker B

00:04:40.269 - 00:06:24.960

Yeah, I think one of the things I've always been keen on, the BJJP Research and Publishing Conference is that it's very much just, you know, it's a little bit something that we want to offer more for the Community, particularly early career researchers and academics.

But any GP that's got a scholar or primary care person, clinician, that's got an interest in sort of the scholarly aspects of work and understanding a little bit more about that. So we're a small, friendly conference. I certainly had some feedback recently that they were.

Someone was happy that they had had a really great experience and found it very welcoming. And I was really. I mean, that was that. I felt really pleased about that because that's certainly what we're aiming at.

And this year the theme is a little bit around impact and influence. We're very lucky to have a couple of speakers who really know about that.

We're going to have Rebecca Payne, who's the gp, former chair of RCGP Wales, and also we're going to have Prof. Martin Marshall, who was former chair of the college, of course, during COVID and is now over at the Nuffield Trust.

And I think that's a really interesting perspective because the think tanks like the Nuffield or the King's or, you know, Health foundation, others that are around, have an enormous understanding of how to influence policy through research and we're hoping that'll be really useful for people and give them an understanding. What we see a lot of is that people are.

People do the research, but often everybody knows you have to do something to try to make your research get your. Everyone wants to get the research out in the world, but far too often, and again, this is part of the way the system is set up.

People just stop at that point and nothing further happens beyond that. And there's so many opportunities in so many ways that you can actually develop that. So we want to try and help people a little bit with that.

Speaker A

00:06:25.200 - 00:06:38.160

Yeah, and we've talked a bit about that just in terms of actually the impact of research and disseminating the results, that actually makes an impact. And I think that's going to be an interesting angle to get from Martin, especially from his perspective as well.

Speaker B

00:06:38.240 - 00:07:46.020

Yeah, it'd be good to see. I want to. We should point out the last few years, all of the research in the journal is open access, so it's not paywalled at all.

And we're having conversations about reducing paywalls across the journal as well. So there. That's in development, but, you know, yeah, we're. We're keen to make sure that we can do. We're trying to do our bit.

It's important that stuff just doesn't disappear into the journal. There's a slight risk of that.

Perhaps some of my favorite moments as editor in the past couple of year, few years have been when I've heard about papers that have changed practice and policy. The very obvious one being the Sandvik paper about continuity, which has been really picked up in government level particularly.

I know in Scotland they're pushing hard on that.

But also when we hear from people like NB Medical or Red Whale or the other RCGP Essential Updates, when they take our papers and they're part of the look obviously across all journals, but when I hear about our papers that are then really being translated into actionable clinical findings, they're perhaps some of my best. That's why I really love seeing that. That's. I think that's really where we want to be and what we want to be doing.

Speaker A

00:07:46.580 - 00:08:02.740

Yeah.

And we've been talking about the clinical practice and analysis papers in the BJGP and we've often reflected on the fact that some of those papers are some of the most read papers across the journal as well. I'm remembering the one about Earwax from a couple of years ago.

Speaker B

00:08:03.860 - 00:08:05.540

I was thinking earwax as you were speaking.

Speaker A

00:08:05.540 - 00:08:22.290

Yeah, fair enough. But I think it's important to think about how we can promote other writers and clinicians, primary care academics to submit those articles to us.

And I don't know if you just want to give a plug for those articles and how we use them.

Speaker B

00:08:22.450 - 00:09:57.910

Yeah, so absolutely. I'd be delighted to receive many more submissions around clinical practice. I think the key thing about this is you don't.

You know, almost all the academics who do anything related to clinical could write a clinical practice article almost next week because they're, they're subject area experts. But There are many GPs out there who've got a special interest.

Well, not just GPs, but any clinicians who've got a special interest in an area could write a really could write incredibly valuable articles that would change people's practice. I think the thing about clinical practice is they're relatively short, sharp articles.

But what we're really what think the ones that have worked really well are, you know the earwax one. Yeah, we saw incredible number of downloads for that.

I mean, I think there are some niche areas where people just don't get their education anywhere else. So they're incredibly useful.

We tend to try to tilt clinical practice and I'm not sure this is written down in the author guidance, but it's worth flagging it towards kind of when we have the ideal reader in mind, we perhaps think of the more experienced GP mid career Onwards, who knows their way.

It doesn't need the basics explaining to them, but has got some quite deep, challenging questions when you get the more complex patients or you've got a little niche area and that's like the perfect zone for us. And the perfect zone is not a great big topic like all of you know how to manage, you know, menopause.

It has to be a niche within that and then those kind of those because mostly because of the allowances of space, but like a niche in that targeted, that kind of gp, that kind of clinician who's got that level of knowledge. Where would. I would love to hear from you, you know, people who've got those, they should get in touch.

Speaker A

00:09:58.150 - 00:09:59.270

Yeah, send us an email.

Speaker B

00:09:59.270 - 00:10:00.230

We're happy to guide.

Speaker A

00:10:00.470 - 00:10:14.060

Fair enough. And what about the analysis papers?

Because often they're quite interesting in terms of critical look at a specific aspect of general practice policy or research and I know that you're interested to get more submissions on, on that angle as well.

Speaker B

00:10:14.060 - 00:12:01.900

Yeah, Again, my personal view is, again, if you're involved in any kind of research or writing articles or you're working in these areas, you could almost, you should almost always be able to write an analysis article that we could publish and I hope you will, people will consider doing it because, you know, whether it's two page version or a four page version, the. You've got that, people have got that expertise, they've got that understanding and they could, they should be able to really. We, we.

I know we've got some academics who are very good at it and understand that process and we often get submissions from them and. But I think so many more people could be doing it to improve their impact and influence of the work they do.

One thing I should mention about analysis, and this is kind of like a heads up, it's in the pipeline and one of the things that we've struggled with over the years with the BJGP is to publish service evaluations and sometimes Innovations in Practice.

We're working quite hard at the moment to create a new section which will be very analysis like and it's probably going to be called something like Innovations in Practice and it's going to be an opportunity to publish things that do that. People that.

Some of the radical, not necessarily radical, but some of the innovations that are going on, developments in general practice, particularly when we consider the ten Year Plan at the moment, it's an opportunity to publish those.

There might be some audit data, some service evaluation data as part of that and share good practice, good policy and so we're creating a section of the journal where those can go in. We've got a little bit of work, so we're not quite there yet.

But if you're doing something novel, important, you think valuable in your area of primary care, we will very soon be.

We're hoping to get that launched early part of next year, to give people an opportunity to bring forward again very much about influence, so that we can actually do a real world influence rather than just. It's not about pushing our impact factor up.

Speaker A

00:12:02.220 - 00:12:16.080

Yeah, fair enough.

And I think that kind of section would really support gps who might not be linked to an academic department, but, as you say, are doing something innovative in practice. Might not have a lot of experience of publishing research, but, yeah, we're certainly.

Speaker B

00:12:16.080 - 00:12:42.530

Going to create it so that it's relatively templated up so you don't have to just know, you don't have to understand all the kind of the nuances and wrinkles of how to write an academic paper. We're going to try and make that as straightforward as possible. And I think that's right.

It's examined exactly that kind of scholarly gp, doing good work, who thinks what they're doing could be valuable to let other GPs and other primary care systems so people know about. And that's probably been a slight gap in our offering over in past years and we're trying to fix it.

Speaker A

00:12:42.770 - 00:13:03.490

Yeah, fair enough.

So I wanted to take a bit more of a philosophical slant here and just get some of your reflections on general practice and primary care research as a whole. And how do you think this role that you've taken on as BJGP editor has shaped your view of research or your clinical practice?

How is it making an impact in other areas?

Speaker B

00:13:06.330 - 00:15:13.420

I think it's. It's hard to say. My reflections on general practice in general are kind of.

I mean, I come from a particular perspective, I guess, and it's hard not to have it in mind when I'm working clinically.

One of the things that's probably my about myself is I've never been a GP partner and that's probably an important declaration because I do have some comments about GP partnership at times that I can, you know, I'm broadly a supporter, but I can see some serious flaws in the model at points that worry me that we are kind of wedded to it in a way that is a barrier to future change.

And I think there was an article, in fact, from the RCGP saying, you know, recently from Camilla Hawthorne, the chair, saying that how important the partnership model is, but we've got to be able to develop it for the future.

I've never been a partner and I've tended to work on the fringes a little bit, you know, out of Arrows Care, drug and alcohol services, prison medicine. I was in the army in the past, so I've worked in a lot of kind of more fringy areas rather than.

Of course I've done mainstream general practice as a salary GP as well. And so I'm not sure I can. That perhaps has been.

That's perhaps more important in terms of what I have brought as BJ GP editor rather than the other way around.

And so it's influenced me in terms of trying to work hard as an editor to cover bits of general practice that don't otherwise get seen and particularly related to inequalities as well. But it's just trying to find the bits of general practice that don't get good coverage. And sometimes, you know, I.

And I can think of numerous examples over the past few years where we've just not had a single article about sex. There was a.

There was one, I think we had an editorial on sex work like a year or two ago and I looked back and really couldn't find an article on that at all in the journals archives going back what, 60, 70 years, whatever it's been. So I really think that's kind of. In terms of my role as editor, I'm really very keen not to kind of ensure we cover those.

So I guess that's a plea as well if you're working in an area of general practice and you think it's had very poor coverage, it's not visible. Get in touch again. I'm really. I love having these conversations and hearing about them.

Speaker A

00:15:13.740 - 00:15:28.630

Yeah. And we often have issues focusing on inclusion, health and we had that focus on missingness from Andrew Williamson's team up in Scotland as well.

So I think that's been really great to highlight and I know that's influenced a lot of people who are thinking about that space as well.

Speaker B

00:15:28.630 - 00:15:51.930

Yeah, that's exactly a good example. And I think we cover tons of the mainstream stuff as well. Of course, all the regular practice.

Yeah, I'm keen to shine a light, try to...

Today, we’re speaking to Dr Jo Burgin, a GP and a researcher based at the University of Bristol.

Title of paper: Mental health consultations during the perimenopausal age range – Are GPs and patients on the same page?: A qualitative study

Available at: https://doi.org/10.3399/BJGP.2025.0069

Mood changes are a recognised symptom of perimenopause, for which Hormone Replacement Therapy is considered a first line treatment. Recent studies have found mental health symptoms are overlooked in menopause care, which is mostly delivered in primary care. This study identifies some key barriers to identifying perimenopause in women presenting with mental health symptoms and suggests important changes clinicians could make to their consultations to address this.

In this episode, we speak to Dr Diarmuid Quinlan, a GP and MD candidate based at the Department of General Practice at University College Cork.

Title of paper: Competencies and clinical guidelines for managing acne with isotretinoin in general practice: a scoping review

Available at: https://doi.org/10.3399/BJGP.2025.0135

There is evidence of inequitable access to the most effective treatment for severe acne, isotretinoin. This scoping review identified the clinical competencies to safely manage acne using isotretinoin. No global consensus exists among clinical practice guidelines (CGPs) on whether GPs are appropriate prescribers of isotretinoin. Appropriately resourced and CPG-guided patient access to isotretinoin in primary care may promote safe, timely, and equitable acne management for patients and improve antimicrobial stewardship.

Transcript:

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

Speaker A

00:00:01.440 - 00:01:07.850

Hello and welcome to BJGP Interviews. My name is Nada Khan and I'm one of the associate editors of the bjgp. And welcome to our autumn edition of the BJGP podcast.

We're kicking off with a new set of interviews for the next few months. So thanks again for joining us.

Today we're speaking to Dr. Dermod Quinlan, who is a practicing GP in Cork and is also an MD candidate at University College Cork in Ireland.

We're here today to discuss his paper, recently published in the BJGP titled Competency and Clinical Guidelines for Managing Acne with Isotretinoin in General Practice. A Scoping Review. So thanks very much, Dermid, for joining me here today to talk about this paper.

But yeah, I guess I just wanted to start by saying that this is a really interesting paper and I think it covers a very common condition that we see in general practice and covers treatment, which can be quite difficult as well for acne.

But I wonder if you could just start by telling us a little bit about why you wanted to do this research and just a bit about the treatment of it and why you focused down on this topic, really.

Speaker B

00:01:09.610 - 00:02:59.510

So lovely to meet you, Nada. I'm first and foremost a GP and I see patients three days a week, 20 hours a week.

And I did a diploma in dermatology over a decade ago and I still do some online tutoring. So I have a long standing interest in dermatology and have an extended role in dermatology.

I work in an urban practice with lots of young teenagers and young people in it.

Acne is a common chronic disorder and I would see a lot of young people with acne of all grades of severity, mild, moderate and severe, and very severe. And as a clinician, very clearly recognize that behind acne is a patient very commonly suffering profound distress.

And we know that the morbidity associated with acne and particularly severe acne, is very extensive.

There's the emotional morbidity, there's psychological morbidity, it impacts people's employment opportunities, their education achievements, and then more widely, because treating acne is resource intensive, it has an impact on the healthcare workforce. And then there are concerns about the very prolonged use of antibiotics in acne, raising real antimicrobial stewardship concerns.

So I have an interest in this. And then we decided that we would do research into it because we don't know the clinical competencies for safe use of isotretinoin.

So I was particularly interested in severe acne and the management of severe acne, and also it didn't clearly identify which were the clinicians that could be safely tasked with managing acne using isotretinoin. So they were the two research questions that we set out to look at.

Speaker A

00:02:59.750 - 00:03:27.250

The first thing is I just wonder if you could talk us through, because typically in general practice, at least in the places where I've practiced, we wouldn't, as gps typically, be expected to start isotretinoids in practice. And I wonder if that was part of your reasoning for doing this research.

So did you go into it trying to establish whether GPs could be clinically competent to prescribe these medications?

Speaker B

00:03:27.650 - 00:04:48.480

For many years, I transcribed prescriptions initiated by dermatologists and then increasingly found that patients faced challenges in access to dermatologists and waiting to see a dermatologist. The research clearly shows there are issues with timely and equitable access to isotretinoin.

And in terms of equity, the inequity particularly affects ethnic minorities, people from lower social classes and women. So there are very real issues for patients accessing isotretinoin.

One of the concerns about isotretinoin is that it is a very potent teratogen, causing severe fetal abnormalities. GPs are competent in managing many other teratogenic medicines, lithium, methotrexate, sodium valproate, ACEs and ARBs, to name a few.

And GPS can are good at providing contraceptive advice and pregnancy prevention. So I felt that as a gp, that I had a lot of the skill set but didn't know what the guidelines say.

So that that was what led us and led me like it was the equity piece, it was a timely access and also it was the skill set required with clinical competencies to safely manage acne using isotretinoin hadn't been defined in.

Speaker A

00:04:48.480 - 00:05:34.780

The literature, so all really topical issues in terms of access and equity.

And as you say, this research aimed to look at clinical practice guidelines and consensus statement recommendations to look to see what should be the clinical competencies for prescribing oral isotretinoids in practice. And you did a scoping review? And we won't go too much into the methods because it followed sort of established methods for doing a scoping review.

And I really just wanted to focus on the results, really. So what did you find? So you found eight clinical practice guidelines, is that right?

And talk us through those and just how you looked at those and what you found really, in terms of what should be the clinical competencies and how you think that applies to general practice.

Speaker B

00:05:35.180 - 00:08:18.270

So we identified eight clinical practice guidelines, five of which originated from Europe, one each, then from America, Canada, and Malaysia. The Clinical Practice guidelines identified four clinical competencies for doctors to safely manage isotretinoin.

And these are dermatology, blood testing, mental health, and a pregnancy prevention program. And to take these one by one, the dermatology piece.

Obviously, doctors, GPs need to be able to diagnose acne and more especially need to be able to identify those patients with acne which should perhaps be treated with isotretinoin.

And they are, you know, people with severe acne, acne resistant to treatment, acne causing scarring, or acne which is having a severe psychological impact on patients.

The blood testing has reduced very substantially in recent years because the evidence for undertaking blood tests in otherwise fit largely young people indicates that the benefit is relatively modest. There is some heterogeneity among the guidelines as to what tests should be done and when they should be done and how often they should be done.

But largely there is an agreement that some blood tests are prudent, but not excessive blood testing. The two big pieces really are around mental health and pregnancy prevention.

Mental health is a concern with isotretinoin, and isotretinoin has been on the mark now since licensed in 1982 by the FDA. So it's around a very long time. And there have been concerns expressed continually about mental health and isotretinoin.

It's very reassuring that the evidence also identifies that at a population level, there isn't an increase in suicide. But case reports continue about raising concerns about mental health.

So the guidelines all recommend that people should have regular mental health assessments.

And while we can look at the potential adverse side effects of using isotretinoin to treat acne, we must also be very cognizant of the other side of the equation, where young people and people in general with severe acne can suffer very substantial emotional and psychological harms and burdens by virtue of their severe acne. And parents and doctors will be very familiar with the adverse psychological, emotional, social issues that arise with severe acne.

So, as in everything else in medicine, it's balancing the risks and the harms.

Speaker A

00:08:19.230 - 00:08:26.350

And then the final thing was around contraception, is that right? But again, here the guidelines diverged in some areas, didn't they, on their recommendations?

Speaker B

00:08:26.830 - 00:09:34.750

Absolutely, yeah.

So again, and pregnancy prevention and isotretinoin and all teratogenic medicines like, it's a really important piece that we can safely manage acne using isotretinoin. And pregnancy prevention is more than simply contraception. It is contraception, it's emergency contraception and it's termination of pregnancy.

And that really speaks to the complexity of sexual health medicine in the current world. The guidelines are on contraception. There is some divergence, but most guidelines recommend dual contraception.

The key piece from it, from a clinician's perspective, is about how to manage pregnancy prevention in women who are not sexually active. And most of the current guidelines recommend that women who are not sexually active, that the use of hormonal contraception is not mandatory.

And that's an important clinical piece because often young women in the our women are not sexually active. And there is an ethical issue of coercing women to take hormonal contraception, which brings its own litany of side effects.

Speaker A

00:09:35.230 - 00:10:00.330

So I guess one of my questions to you is what do you think about the divergence in the different guidelines?

Do you think that these are divergent enough that we might not be able to find a consensus about what we should be doing, for instance, in general practice around blood tests?

Or do you think that we should be developing new guidelines in terms of potentially how general practice could take prescribing of isotretinoids forward?

Speaker B

00:10:00.730 - 00:12:16.270

I was involved in a paper published with the BMJ in January of 2025 which looked at the New Zealand experience of GPS prescribing isotretinoid from 2008 onwards.

And a single policy change in New Zealand to enable GPs to issue isotretinoin had a seismic effect on the subsequent access to isotretinoin since 2008. Back in 2008, almost all isotretinoin in New Zealand was prescribed by dermatologists.

In 2023, 80% of isotretinoin is prescribed by GPs in New Zealand and there's a very substantial enhanced access to ethnic minorities, particularly Maoris, Asians and Pacific people, less so with socially deprived people, but certainly an increased access.

So enabling, Supporting and resourcing GPs in New Zealand to take on this work has certainly helped overcome the access barriers that people have described and the inequity I think we can learn from the New Zealand experience. And the two big pieces that they found with gps in New Zealand required were education supports and resources.

And we are, the research team are currently looking at the education resources that are required for GPs to safely prescribe isotretinoin. And then the final piece is the resourcing, because prescribing isotretinoin is resource intensive.

Patients are seen usually once a month, possibly for six months or so. So it is resource intensive. There is a global shortage of GPs. There is a shortage of GPs in most Western countries.

The UK, Ireland, Canada all describe severe GP workforce shortages. So GPs, if they are to take on this work and the clinical competencies, suggest that we may be able to.

But there is a resourcing issue which needs to be addressed at policy level, at national level, so that gps can incrementally take on this work and support our patients with safe, timely, equitable access to isotretinoin.

Speaker A

00:12:17.060 - 00:12:34.580

And that touches on a point that I wanted to pick up on, really was about the perspective of GPs and dermatologists and patients. And I think you touch on this in the discussion. And do we know from the New Zealand model what is coming out from those perspectives?

And could that help inform what happens in the future?

Speaker B

00:12:34.900 - 00:13:18.010

Elsewhere, the New Zealand model has found that the GPs have embraced access to isotretinoin. And incrementally, the number of patients prescribed isotretinoin has grown year on year.

In 2008, it was just under 8000 patients a year in New Zealand, and in 2023 it was almost 24,000.

So the number of patients accessing isotretinoin in New Zealand has almost trebled in that time, showing that there is a very significant unmet need and also that the gps, with appropriate resources and education supports, can incrementally deliver that service in a safe, timely and equitable fashion for patients.

Speaker A

00:13:18.090 - 00:13:54.100

And I suppose one thing really to touch upon is that, as you say, this would be an equitable way of accessing these treatments for a range of patients that may not necessarily get to have these due to long wait times from dermatology or a fear of coming in to speak to a dermatologist or a specialist.

And I just wonder if from your own practice you have any thoughts about how potentially being able to prescribe these medications might impact on patients and their use of these medications and their perspectives as well.

Speaker B

00:13:54.420 - 00:14:39.090

Certainly I have found it very positive in my practice. I've been prescribing isotretinoin for in excess of a decade at this stage. I take referrals from other GPs in the area.

The patient experience is very positive. I have young people coming in and initially, often when they come in, they're very downcast, they're.

Their mood is quite low, they avoid eye contact, and then they're back a month later and they're feeling much better. So the psychological impact of acne on our young people is enormous. We have described the clinical competencies that are required.

GPs meet these clinical competencies, but we do require education and resources to incrementally adopt this work.

Speaker A

00:14:39.970 - 00:14:53.790

And I think one word that you're using repeatedly is incrementally and I think that's a really important word to keep in mind as well as we try to learn more about what's actually needed in terms of resourcing and workload implications as well?

Speaker B

00:14:54.110 - 00:15:30.099

So there are very significant workload and resourcing implications.

It is a resource intensive piece and we know that young people like the New Zealand experience shows that there is an incremental expansion in people using isotretinoin. So there is definitely an unmet need, there is an equity barrier.

Working with our patients and our dermatology colleagues, we can safely and equitably address this education gap, this resource gap, this service provision gap, and improve the, you know, the well being of our patients with acne.

Speaker A

00:15:30.099 - 00:15:54.270

I think a lot of the findings from your paper have implications at a policy level, at a broader system level. But do you have any thing that you want to say to gps practicing who are managing patients with acne?

Do you have any take home messages for them in terms of what they can be doing now in terms of the results of this scoping review?

Speaker B

00:15:54.750 - 00:16:48.140

I think that gps are already managing this very well. Many of them are already managing the mental health assessments, they're managing the ongoing pregnancy prevention contraception piece of it.

Many of them are doing the blood testing. They're also looking after the mild and moderate acne. It's a small additional increment of clinical expertise required.

We know that in the UK, many GPs already working within dermatology departments are actually doing this work under dermatologist governance. So there is very substantial expertise already within the UK GP community.

And we would encourage GPs to consider, albeit the workforce challenges and workload challenges that we all are very familiar with, whether this is a role that might, in time, migrate increasingly into general practice and into our surgeries.

Speaker A

00:16:49.100 - 00:17:03.000

Thank you for that.

It's very thoughtful words and I think it's very wise of you to think about the clinical benefits, but also consider very carefully the system changes that may need to be be allowed to support this as well in the future.

Speaker B

00:17:04.040 - 00:17:30.729

And we know that if GPs take this work, you know, there are opportunity costs that if GPs are seeing patients with acne, then they may not be available to see other patients.

So we need to consider the implications of any evolution of access to isotretinoin and balance that against the current inequitable access which adversely affects women, ethnic minorities and people from socioeconomic economically deprived Macrons.

Speaker A

00:17:31.209 - 00:17:38.729

Great. Thank you, Dermod. That's been a really great chat around this paper and I just wanted to say thank you again for joining us to talk about it today.

Speaker B

00:17:39.449 - 00:17:40.649

My pleasure, Nada.

Speaker A

00:17:41.289 - 00:18:03.530

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

Dermid's original research article can be found on bjgp.org and the show notes and podcast audio can be [email protected] it's been great to chat to Dermot about a very clinically relevant topic, and I hope you all have a chance to go back and read the paper. Thanks again for listening. Bye.

Today, we’re speaking to Professor Helen Atherton. Helen is Professor of Primary Care Research based at the University of Southampton.

Title of paper: What do patients want from access to UK general practice?

Available at: https://doi.org/10.3399/BJGP.2024.0582

Widely accepted as perpetuated by the media is that patients are unhappy with access to general practice and desire faster access to a general practitioner. This review sought to summarise the research evidence about reported patient wants from access to general practice. Patients wanted to easily make an appointment in a timely fashion, to have a positive relationship with the practice, to see a specific clinician and choose consultation modality according to individual circumstance. Communication and being kept informed about access throughout the process of making and having an appointment, was something patients wanted, and this could be addressed by 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

00:00:00.480 - 00:01:00.150

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

In today's episode, we're speaking to Professor Helen Atherton.

Helen is professor of Primary Care Research based at the University of Southampton, and we've only just speaking to her recently on this podcast about the increasing digitalization of general practice. This time we're speaking to her about her recent paper here in the BJDP titled what Do Patients Want from Access to UK General Practice?

So, hi, Helen.

It's really nice to speak again about this area of research and I guess I just wanted to start by saying that access is such a loaded word and really, when it comes to general practice, it's part of a fairly negative media campaign against general practice. But it seems that this negative narrative just keeps getting pushed, despite lots of attempts to fix it.

So I just wonder if you could reflect on that.

Speaker B

00:01:00.470 - 00:01:51.950

Yeah, absolutely. So that the negative media coverage was one of the reasons that I wanted to do this review.

So this review was a bit of a labour of love because I had a feeling from the work that I was doing on digital access and other research that actually the reality was probably quite different, what we were seeing in the headlines and having looked into it, although there's lots of research out there on patient experience and satisfaction, we have a national survey that looks at that. There wasn't anything about what patients actually want. And so that kind of.

I thought, actually, wouldn't it be really interesting to find out from the evidence what they actually want and see if it does fit with the narrative we see in the papers and on social media. So, yes. So completely agree. And that was kind of where the idea came from, really.

Speaker A

00:01:52.420 - 00:02:08.180

Yeah.

And I just want to unpick what you really mean by access in this paper, because I think for some people it means, you know, just getting an appointment to see their GP within a day, but it can mean lots of different things to other people. So what did you conceptualize that as?

Speaker B

00:02:08.740 - 00:02:49.840

Well, it was difficult.

And you're right, there are lots of different definitions of access, and particularly in the research context, for us, we were interested in access to an appointment, so we were very focused on the processes that patient would go through in order to get the appointment, go to the appointment.

And we did go back and forth several times with this review because it was so difficult to define and there will be other researchers who use different definition, but because we were so interested in a lot of the kind of media narrative. It just felt like the best fit to look at access to an appointment with a gp.

Speaker A

00:02:50.000 - 00:03:04.540

So this paper was a systematic review and you looked at papers which explored different aspects of access. And I guess the big question here is, what did patients want in terms of access?

I wonder if you could just give sort of a headline summary and then we can talk a bit more in depth about it.

Speaker B

00:03:04.780 - 00:03:56.070

Sure. So what was interesting is I don't think their wants were particularly surprising or out of line with what general practice wants to deliver.

That's the first thing to say. And it was things like wanting to choose a clinician that they've seen before, if they.

If they've seen a clinician before, wanting to have choice around the skill mix. So which healthcare professional. They saw the consultation modality wanting to have a good relationship with the practice.

They wanted ease of booking and relatively speedy access. But not. There wasn't any evidence that people all wanted to be seen on the same day, which is maybe how the media narrative goes.

And there were also some things around wanting it to be easy to get to and having a nice waiting room. So really quite simple things as well.

Speaker A

00:03:56.230 - 00:04:19.350

I think choice is a really interesting area to explore.

So some people might not feel they have the right access if they get booked in, like you say with the gp, they don't know, or if they get booked in to see someone working in another clinical role in the practice.

But I wonder what you thought about the implications, given the increasing lack of continuity of care and this widening multidisciplinary team in practice.

Speaker B

00:04:19.870 - 00:05:16.510

Yeah. So it didn't escape our notice that a lot of what we were seeing was probably at odds with current policy around general practice.

The fact that patients fully understand that continuity of care is important at times, and there's lots of evidence that that is the case. And general practice, as a rule, tends to encourage that, I would say. And then also with the skill mix at odds with the idea that you.

You can kind of sub in other healthcare professionals as a way to tackle lack of capacity. Whereas I think patients are smarter than that and realise that sometimes it's appropriate, but other times it's not. Yeah.

And then also with the digital as well.

So, again, people wanting the choice, understanding that sometimes it's better to do things that way or more convenient, but not wanting to be forced down that route, which is kind of the way that we're going, really, in terms of policy for digital access.

Speaker A

00:05:16.990 - 00:05:24.830

And. Yeah, talk us through that.

What people thought about access in terms of the kind of consultation they got like a telephone or a face to face appointment.

Speaker B

00:05:24.830 - 00:06:12.650

Yeah. So patients were happy to have those types of consultation.

So when it came to use of remote consultations, patients were happy to do that where it met a need. So if they didn't want to come to the practice, they weren't able to.

Perhaps if they had a sensory disability, lots of reasons why they wanted to do it, but wanting to have the choice about how that happened, which was interesting. So people would say they didn't want to have to travel to the practice because it wasn't convenient.

This could be around work or childcare, or it might be that they had mobility issues, but there was generally a reason why they didn't want to be in the proximity of the general practice. And that's when remote consultations were what patients wanted.

Speaker A

00:06:13.450 - 00:06:35.840

Yeah, fair enough.

So it seems a lot of the time people just want a choice and I think it's interesting, particularly given the increase in a triage first approach in many practices.

But there was something you mentioned in the article that I thought was quite interesting, which was about co production with patients to solve access problems. Just tell us what you think this should look like.

Speaker B

00:06:36.160 - 00:08:01.890

So as well as doing this review, I'm involved in other research around access to general practice. And a big thing that we see happening is almost like a. Not a lack of communication, but a miscommunication between patients and practices.

You know, not intentional, nobody's trying to confuse the other, but patients perhaps not really understanding the access systems in place, not understanding what is available to them. If they don't have a choice, why they don't have a choice.

And so I think there's a lot of room for more kind of working together in terms of what that looks like. I think we have to be brave and ask patients what they want.

This is a systematic review, so it looks at existing evidence and most of those studies were not focused on looking at just what patients wanted, they were looking at other things as well. I think if we were to ask them what they wanted, we might get a bit more insight into how things can be tweaked or changed.

I think the problem is probably that that's quite a scary thing to say, what do you want? Because what if patients say a load of things that, you know, can't happen?

But I think this review does quite a good job of showing that actually what patients want is quite simple and straightforward and those conversations together would perhaps generate some realistic solutions. Better communication outwards to patients in a way that they understand.

Speaker A

00:08:02.610 - 00:08:24.430

That's really Interesting that you mentioned this mismatch because sometimes when I speak to patients, they say something to me like, oh, it's impossible to get through, impossible to get an appointment. And I'm looking on our appointment screens and seeing lots of empty slots in this week and next week. And I think our practice is doing really well.

But obviously there's a mismatch in how we're perceiving access, I suppose.

Speaker B

00:08:24.750 - 00:08:36.830

Yeah, that's.

I think that's right and I think that's something that's been shown in research that I've been involved in, but also others working in academic primary care and it's how we tackle that mismatch, I think that is really important.

Speaker A

00:08:38.209 - 00:08:44.209

Yeah. So you touched on your other research around access. What are the other things that you're looking at in terms of access to primary care?

Speaker B

00:08:44.529 - 00:10:16.670

So I have co led a study with Professor Catherine Pope at the University of Oxford, where we looked at long term sustainability of access approaches in general practice and that study finished quite recently.

So we're trying to disseminate some of those findings as well and seeing very similar results around this mismatch between the patient view and the practice view. But also other interesting observations like the changes to the role of the receptionist.

So increasingly colleagues in academic primary care have been writing about this, but it's definitely the case that the introduction of digital services and triage and it's really the triage type approaches, has really changed the role of the receptionist.

But there's not necessarily been any space or time for general practice to reflect on that, to understand whether that role needs to be developed or even professionalised. And it's perhaps something that we, you know, could consider looking at in more depth.

Other things arising have been around the sheer amount of work that general practice is doing to manage access.

So making tweaks and changes all the time to how access systems operate, which is almost a form of invisible work really, because it's not accounted for, but it's happening all the time. And I think probably really important to acknowledge if we're thinking about how we set up long term sustainable approaches to access.

Speaker A

00:10:17.230 - 00:10:27.770

And if you could step into a practice where people felt dissatisfied with their access, what would you tell the practice team in terms how they could improve things or manage things better?

Speaker B

00:10:28.010 - 00:12:00.890

Well, I think I'd probably start by assuring them that it wasn't a criticism of necessarily of how they were doing things, because that is absolutely not the case and that is certainly not what our research demonstrates.

I would say that it's probably really important to open that dialogue and find out some more about what the specific issues are that patients are facing and perhaps have a look at where the kind of pinch points are in terms of patient dissatisfaction. The other thing is it's very difficult.

I think when you're managing a huge amount of demand and having to kind of manage their capacity, it can be quite easy.

And again, this is something that we saw, we've seen in some of the research I've done in general practices, to really focus on this kind of amorphous demand and not necessarily remember to think that for a patient, their individual encounter is what matters to them. There's probably some work to be done.

I'm not quite sure what it would look like around examining what a patient journey looks like in that particular practice. So what happens to patients who call the practice and where do they end up? It's difficult.

I don't know that I do have answers, but I think it's really great that we can shed some light on exactly what is happening and perhaps also shed some light on the fact that some of the policies that are meant to be helping probably are not helping when it comes to how patients experience and perceive general practice.

Speaker A

00:12:01.930 - 00:12:23.280

Yeah. I don't know if you want to touch on that a bit more, because it does seem like the policy focus has been on faster access.

But some of the results from this work, and I think your previous work as well, suggests that actually quick access isn't necessarily the main goal for some patients when they want access to their general practice.

Speaker B

00:12:23.750 - 00:13:04.290

Yeah, absolutely. And it's much, much more complex than that. And you're absolutely right.

We've seen an announcement in the last few weeks about the expansion of the NHS app and how patients will be able to do more on the app. But that completely ignores the fact that lots of people don't use the app. Even when they do use can be quite sporadic.

It doesn't always match up with the systems that are in place in general practice for people to access care. So it doesn't always link up very well with messaging. There's an awful lot of work to be done.

But if you read the headlines, it would appear that this is going to save time and improve patient experience as well.

Speaker A

00:13:04.690 - 00:13:19.170

Yeah, it's going to be interesting to see what comes out of the upcoming long term plan, especially since the expansion of digital services and the NHS app seems to be such a critical part of that sort of three pronged approach to saving the nhs. Really.

Speaker B

00:13:19.490 - 00:13:53.710

Yeah. And there's also a wider question, I think around what we want general practice to look like.

So it seems that patients are saying they want it to keep looking like it's always looked, and be somewhere that they can see a clinician that they may know already in somewhere that is close to home and that they have a good relationship with, which is kind of at odds with some of the policies which, as you say, are pushing for fast access and high volumes of access, perhaps in a short space of time.

Speaker A

00:13:53.950 - 00:14:10.010

So what would you say that this paper really brings to the table in terms of those negative media, media portrayals that we started this conversation about? Do you think it sort of reinforces them or does it suggest that actually those portrayals aren't completely capturing the patient experience?

Speaker B

00:14:10.410 - 00:14:58.710

Yeah, I would say that they're not completely capturing the patient experience. And I think hopefully this review shows that what patients want isn't a million miles away from what general practice wants.

And that yes, there are always going to be some things that are a compromise, but it's, it's not necessarily a deal breaker for patients because there are so many factors that are important to them. But I also hope that it shows that this is an area that we should be focusing more on.

So it would be really great, for example, if the general practice patient survey, as well as asking people about their experience, perhaps ask people about what they wanted.

I don't know how easy that would be to do, but it could be really useful in actually getting the perspective of the people who are using general practice on what they would like to see.

Speaker A

00:14:58.950 - 00:15:12.470

Yeah, really fascinating work, Helen. And I know that you're doing a lot of work in this area, so, yeah, really look forward to seeing your other outputs in this area.

But it's been great to have a chat about this paper. So I just wanted to say thanks again for joining me.

Speaker B

00:15:12.710 - 00:15:15.830

Thanks for having me, and thank you.

Speaker A

00:15:15.830 - 00:15:50.880

All very much for your time here and for listening to this BJGP podcast.

Helen's research article can be found on bjgp.org and the show notes and podcast audio can be [email protected] and just to say, this is the end of this season of the BJGP podcast and we're going to take a bit of an extended summer break. We'll be back on the 9th of September with a new season of podcasts talking about recent research and clinical practice articles in the the BJGP.

So look forward to then. But until then, thanks again. And bye.

Today, we’re speaking to Dr Sara Noden, a GP with an extended role in ADHD, and Dr Nishi Yarger, Consultant Psychiatrist in adult ADHD services.

Title of paper: A guide for primary care clinicians managing ADHD medication side effects

Available at: https://doi.org/10.3399/bjgp25X742653

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 - 00:00:55.720

Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the associate editors at the bjgp. Thanks for listening to this podcast today. In today's episode, we're speaking to Dr.

Sara Noden, a GP with an extended role in ADHD, and Dr. Nishi Yarger, consultant psychiatrist in Adult ADHD Services.

We're talking about the recent Clinical Practice article here in the BJGP titled A Guide for Primary Care Clinicians Managing ADHD Medication Side Effects. So, thanks. It's great to meet you both Sara and Nishi.

This is a really topical area to highlight in the journal, and not least because it seems that every week there seems to be a new article in the media about the increasing diagnosis of adhd. So it's a really topical area to look at, but I guess, Sar, I just really wanted to start with what prompted you to write this article and why now?

Speaker B

00:00:56.620 - 00:01:39.320

Yeah, so I think coming from a GP perspective, before I specialized in adhd, I think these medications did create a bit of anxiety, especially as they're controlled drugs, their stimulants, their specialist medications, and there was a lot that I didn't know about them as I since developed a special interest and it sort of demystified some of these medications. And I just.

I think we wanted to pass on to primary care clinicians some of that knowledge that we've learned, some really basic things that they can look out for that may or may not be related to medications and some common things that they can advise and to know when to escalate secondary care and how to manage these patients, essentially.

Speaker A

00:01:39.560 - 00:01:54.040

Yeah. And Saura, I wonder if you could just tell us a bit more about your role as a GP with an extended role in adhd.

So you must be very much in demand at the moment, but talk us through what led you to sort of take that role and what your typical week is like.

Speaker B

00:01:54.320 - 00:02:58.810

Yeah, So I think my interest in ADHD stemmed during my training years and I currently am working as a salary GP, but also working at CNWL under Dr. Jaga. I'm doing diagnosis and medication titrations. And I think my interest stemmed because of how prevalent ADHD is becoming.

I was seeing such an increase in patients presenting to gp, suspecting they have ADHD and requesting referral, and reading about this treatment and what we can offer, I was really taken aback by not only how ADHD can impact a patient in terms of their symptoms and concentration of focus, but also the lifelong issues that can arise sometimes with adhd, like all the Research showing that it increases rates of depression, underachievement at school, even early death and accidental injuries. So I feel it's a really important, important condition for us to be able to pick up, to be able to refer promptly and start treatment.

And that's where the interest started.

Speaker A

00:02:59.050 - 00:03:14.570

And, Nishi, from your perspective, what's it like having a GP working with your team?

And from a secondary care perspective, I wonder if you could just tell us a bit more about your impression on how secondary care and general practice communicate around ADHD and people living with it.

Speaker C

00:03:14.650 - 00:04:27.649

It's been great having Sara in the team for many reasons. So I guess primarily we're very aware that we need to work more closely with primary care.

There's so much back and forth with emails and us trying to be helpful to primary care primary care, having concerns and needing our input, that the idea of actually training primary care keeps coming up for us as a service, like, how much can we involve them, how much can we train them? It's such a huge area of work. We know more and more patients are coming forward and we know very much that it can't just stay a specialist service.

So as a service, we're very keen to have involvement from primary care. So we have Sara and we also have a GP trainee, which is great from more selfish point of view.

It's been great to have a GP in the team because ADHD patients often have a lot of medical comorbidity and it's been great for us to be able to discuss that with a GP instead of needing to contact a cardiologist or go to another specialist. We know that probably this is, you know, within the remit of a gp, so it works well both ways.

Speaker A

00:04:27.969 - 00:05:05.980

Great.

And I think, as you mentioned, you know, I don't think any specialty or general practice practitioner would feel that less collaboration is a good thing. So I think the more the better. And I guess I'd recommend people listening to go and read the full article here and take a close look at it.

But I wanted to specifically focus on Table 1, which lists some common ADHD medication and then some key practical advice around prescribing it.

But I wonder if you could just summarize some of the common areas we should be considering in general practice amongst patients who are being prescribed ADHD medication. What are your top tips?

Speaker B

00:05:06.300 - 00:06:14.360

I think some of the most common symptoms and side effects that we see with patients taking medications are things like appetite suppression and weight loss.

And there are some basic advice that can be offered to a patient who might be Experiencing these, such as having a big breakfast, taking the medication with or just before. Sorry, just after food. And if this is still a persistent issue, then we would encourage the GP to refer back to secondary care.

Another common issue is sleep disturbance. And again, some advice the GP can give can be taking medication. Medication at different times of the day, such as taking it earlier.

Often a lot of these things would have been worked out with the specialist when they're being titrated, and often by the time the patient gets to the gp, these symptoms would be stabilised and the patient would be stable.

However, things can change and I think what the GP needs to look out for is any new symptoms or any new side effects that weren't present before and be able to identify what's normal, what's acceptable, what would be sufficient for simple advice and what needs to be flagged back up to the psychiatrist.

Speaker A

00:06:14.840 - 00:06:26.840

And I guess that touches on the next thing, which is shared care agreements in ADHD prescribing. And I guess, where do you think the GP role lies here in terms of monitoring and assessing side effects of treatment for adhd?

Speaker B

00:06:27.880 - 00:07:16.120

I think it's a really complex question, actually, and quite controversial because the NICE guidelines do say that the annual review should be done by someone with expertise in adhd, but often we know that that can fall on the gp.

And I know there are lots of discussions in various areas across the country of how to best manage this and create a more uniform shared care agreement, which is really clear on who's doing the reviews.

And I think essentially, if the GP is feeling confident and competent to do the reviews and they have a good pathway back to secondary care and a good support system to raise any red flags to, then that could be something that gps might be comfortable and can consider. But there are funding implications for that and I think that it's probably a wider issue that needs to be addressed. Absolutely.

Speaker A

00:07:16.280 - 00:07:18.520

Nishi, do you have any thoughts about that at all?

Speaker C

00:07:18.680 - 00:09:38.930

It's a very hot topic, really, because of the number of patients that are being diagnosed and that are taking treatment. For any service to manage annual reviews for thousands of people is not feasible.

So I think, and I agree with Sara, that you know, where there is a level of confidence, and I think our hope with this article was to give gps confidence and to enable them to almost realize that they probably are able to do this. They. They manage such severe illness, they manage all kinds of medications, they. They do have the knowledge.

So I guess we wanted to share that it's not that specialist an area for most patients can be managed. But we do appreciate that there are the more complex patients, there are the ones that do need to be seen in secondary care.

And we would just really like a much smoother collaborative working where it's easy for the GP to ask and it's easy for us to see the person that would be the ideal.

With shared care, the GP always knows I have someone I can speak to, I can send a quick email, I can get a response without the really hard kind of boundary of you have to do this and you have to do that.

And I think within shared care, the fact that the GP is prescribing every month, there is a level of, you know, that's a huge responsibility to actually, you know, prescribe something and to know what you're prescribing and what the problems may be.

And I guess there'll be situations where a patient might have been seen by someone in the GP practice saying, you know, I'm worried, I'm losing weight, and then the next prescription is due and the GP prescribes, but just knowing that, ah, that came up. Let me just think about that. Is that a problem here? And be able to respond confidently Or I need to speak to someone, I need to ask a question.

So I think shared care is a big. Is kind of a big topic. But as Sara and I have discussed, GPs are, you know, are really top of their game and we think it is.

I feel very much that the shared knowledge and the reassurance and the being this kind of incredibly supportive backup service would really help if we could. If we could achieve that.

Speaker A

00:09:39.970 - 00:09:53.070

And the kind of systems that you're putting in place, having GPs with extended roles and trainees in your service, I think will only help upskill people going forward. So that might be a nice template for other, other areas to take on as well.

Speaker C

00:09:53.310 - 00:09:55.710

Let's hope. Yeah.

Speaker A

00:09:55.790 - 00:10:32.730

Yeah, brilliant. And it's really useful in the article as well.

You have a list of typical medications and their typical and common side effects and some key practical advice around it. So I think that's really helpful for people to go back and take a look at as well.

So for anyone listening, again, if you've got people on these medications and you're wondering about what the common side effects are and practical advice, I think that's a really helpful place to look for that. And I guess really my next question is about.

Sorry, you touched on this and do you have any advice on when people should be referred back to secondary care for review? What are your thoughts on this?

Speaker B

00:10:33.050 - 00:11:23.100

Yeah, it's A good question.

So I think from the GP perspective, things to look out for, the red flags that would definitely prompt you to want secondary care input would be any patient presenting with manic or psychotic symptoms would absolutely need immediate psychiatry input and advice relating to their medication. And secondly, any time you're suspecting misuse or diversion that would prompt a secondary care referral.

Any patient who's got new cardiac symptoms or high blood pressure and you need advice regarding the medication, whether stop or start, that would be a good time to get secondary care input.

Any patient who's had weight loss, especially more than 5% weight loss, and you've excluded any of the physical health conditions you'd normally exclude with weight loss. These are the ones that come to mind. Nishi, do you have any other.

Speaker C

00:11:24.300 - 00:12:08.910

I guess the only other ones are, and we do get this quite often is the patients that don't sleep, but partly, maybe linked to their medication, but often part of their ADHD or neurodiversity that often comes back to us as something to think about. And when the medications don't seem to work anymore, I guess that's the only other time.

And again, there's a, often there's a very simple reason for it and hopefully gps can think about that. But it happens, you know, not, not often, but it does happen.

Someone's life situation changes and actually their ADHD is more of a problem, the demands on them are greater and the medication doesn't seem as effective and that would be a very reasonable time to send someone back.

Speaker A

00:12:09.150 - 00:12:30.040

And Sara, I know that you've really upskilled in this area and have got a lot of specialist knowledge about ADHD medication and management, but do you have any tips or advice just for regular jobbing GPs who might not have that expertise? Do you have anything that you want to tell them about, sort of maybe to boost their confidence or any tips that you want to sort of pass on to them?

Speaker B

00:12:30.120 - 00:13:18.790

I think I've learned that it's not as complicated as it looks on the outside. I think, like I said at the beginning, a lot of gps feel a lot of anxiety about ADHD medications and I don't think they need to.

There's not many ADHD medications and they all have very similar side effect profiles and things to look out for. So it's not like, like antipsychotics where there's lots of different things to think about for every individual medication.

I think if I could give a take home message for gps, it's really to know what is normal with these medications and what needs escalating. And there are a lot of side effects that are normal and not to worry about immediately with these medications.

So I'm hoping that in the Table 1, GPS can refer to that and feel more comfortable knowing, okay, this is something that we can expect and know when to escalate.

Speaker A

00:13:19.030 - 00:13:33.110

And I guess from a general practice perspective, knowing our patients quite well over a long period of time helps us to sort of work out what's new or what's different and what may be down to the ADHD and what we need to be concerned about, really.

Speaker B

00:13:33.350 - 00:13:57.530

Yeah, absolutely. I think in gp, we're in a unique position where we really know our patients. And like Nishi said, life circumstances do change.

And although patients tend to be discharged when they're stabilized, anything in a patient's life can cause their medication to not work quite the same or a new side effect. And as gps, we're in a really good position to know what's normal for our patients and what's beyond our remit.

Speaker A

00:13:58.090 - 00:14:00.570

Great. Anything that either of you want to add?

Speaker C

00:14:01.690 - 00:16:17.600

I wanted to add something in terms of kind of simple things to reassure gps. I think the risk of misuse and diversion is a real fear for gps, understandably.

But I think it would be good for them to know that the only medication out of the ones that we prescribe that really can be misused is dexamphetamine, and we don't prescribe it very much. So the other medications have been formulated such that they can't really be misused, they don't give that hit.

And the rush that, you know, amphetamines would. Would give for people that do misuse them. So, you know, we tend to avoid prescribing dexamphetamine.

We would only prescribe as someone who is a very low risk of misuse, you know, who does not have a history or very low risk. And the one that we prescribe more is lisdexamphetamine. So the kind of modified release formulation which can't be misused. So, you know, it's.

It's formulated in that way. So I think this. This fear of diversion is. Is not as great as it needs to be.

It did become a little bit of an issue when we had supply problems with lisdexamphetamine.

We were needing to prescribe more dexamphetamine, but we were very aware that we don't want loads of dexamphetamine out there in the community, and it was only really prescribed when it should be, when it needed to be. So I think this idea of Lots of people misusing their medication isn't quite the case.

And we know that people with ADHD are at greater risk of developing a substance misuse problem. We know that if their ADHD is treated, that risk is hugely reduced. They're a lot less likely to misuse drugs if they have ADHD treatment.

They don't have the desire or the need to do that. So. And that often becomes a problem. Like someone say, oh, this person has misused in the past, they've had substance use problems in the past.

We shouldn't be prescribing this. These medications for them. It's quite the opposite. Prescribe these medications for them and help them not fall back into that problem.

So I think that should be. I hope it's reassuring.

Speaker A

00:16:18.240 - 00:16:21.040

Thank you. Anything that you want to add, Sara?

Speaker B

00:16:21.760 - 00:16:48.500

No, just for really gps to be aware of ADHD and feel a bit more comfortable with adhd, both in terms of picking up patients who are undiagnosed historically under diagnosed cohorts like women who have more internalized symptoms and to be comfortable referring and to be more comfortable in the shared care agreements and familiar with these medications that I think will be more commonly prescribed in the future.

Speaker A

00:16:49.110 - 00:17:12.470

Thank you. Yeah. And as you point out, yes.

As these medications and the prevalence of people taking them or increasing, it is an important area that we need to consider in general practice, especially as we take on prescribing.

So thanks very much and I think that's been a really interesting chat around this area and a very topical and very practical article that you've both written. So thanks very much for your time. Thank you.

Speaker C

00:17:12.470 - 00:17:13.030

Thank you.

Speaker A

00:17:14.400 -...

Today, we’re speaking to Dr Cini Bhanu, GP and Academic Clinical Lecturer in the Primary Care and Population Health Department at University College London. 

Title of paper: Antidepressants and risk of postural hypotension: a self-controlled case series study in UK primary care

Available at: https://doi.org/10.3399/BJGP.2024.0429

Antidepressants are associated with postural hypotension (PH). This is not widely recognised in general practice, where antihypertensives are considered the worst culprits. The present study examined >21 000 older adults and found a striking increased risk of PH with use of all antidepressants (over a four- fold risk with SSRIs) in the first 28 days of initiation. 

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 - 00:00:56.990

Hello and welcome to BJGP Interviews. My name is Nada Khan and I'm one of the associate editors of the bjgp. Thanks for listening to this podcast today.

In today's episode, we're speaking to Dr. Cini Banu, who is a GP in an academic clinical lecturer based in the Department of Primary Care and Population Health at University College London.

We're here to talk about her recent paper in the BJGP titled Antidepressants and Risk of Postural Hypertension, A Self Controlled Case Series Study in UK Primary Care. So, hi Cinny, it's really nice to meet you today.

I guess this is an interesting area to cover, especially as the prescribing rates for some antidepressant medications are increasing.

But I don't know what your feeling is, but I'm not sure if many GPs would actually know that antidepressants are associated with poison postural hypertension. So, yeah, talk us through that.

Speaker B

00:00:57.310 - 00:01:18.350

Yeah, so I think that's one of the reasons this study is so important.

So definitely from conversations that I've had with gps that I work with and it's not commonly recognized that postural hypotension is associated with antidepressants, though it is by geriatricians, for example, where it's very.

Speaker A

00:01:18.350 - 00:01:41.850

Well recognized and in this study used a big database to look at the risk of new postural hypertension associated with the use of antidepressants in people aged over 60.

I guess there's quite a lot of in depth stuff in the methods, but I guess just for a summary for people who are interested in what you did, do you mind just sort of going over it at sort of like a high level?

Speaker B

00:01:41.850 - 00:02:54.200

Yeah, yeah. So we looked at a big database, what we call a routine primary care database called imrd.

And essentially this captures data from software that gps use like EMIS and Vision System and captures a whole load of information like problems, symptoms and prescriptions. So we went into this database and identified everyone over the age of 60 that might be eligible during our study period.

And for this we looked at people that were contributing at least one full year of data between 2010 and 2018. And then within that we identified people with a first diagnosis of postural hypotension.

And then again we made subgroups according to people who had this diagnosis but also had a first prescription of a new antidepressant during that time.

And what we were interested in, and the methodology is called a self controlled case series, we weren't interested in who got postural Hypotension, because everyone was a case, but rather when that diagnosis happened in relation to antidepressant exposure.

Speaker A

00:02:55.230 - 00:03:07.310

And we'll talk about those different time points in a bit, but I wonder if you could just talk us through why that focus on people aged over 60 and why this is so important, especially in that age group.

Speaker B

00:03:07.710 - 00:04:22.710

Yes, so two big reasons.

So, postural hypotension is very, very common in people aged over 60 and we know that it affects around a third of people living out in the community. It's largely under recognized and under detected by gps and in prim care.

And postural hypotension in older adults has significant risk of adverse complications and long term effects, including risk of being admitted to hospital, falls, fractures, but also later down the line it increases your risk of stroke and cognitive decline. So it's a really important common diagnosis. We're probably not managing as well as we can in primary care.

Second is that antidepressants are actually used quite commonly in this group of patients.

So we know that for people with late life depression, they're more likely to be given an antidepressant treatment for their depression rather than another therapy. So over 80% of people with depression in this age group are given an anti, are prescribed an antidepressant.

So there's very high risk with both the exposure and the outcome.

Speaker A

00:04:23.510 - 00:04:50.610

And I guess this comes back to the fact that, yes, a lot of GPs might not know about this as a risk. So it's really important that you've done this research.

And so you looked at these different time points of people after starting their antidepressants and risk of postural hypertension. But talk us through what you found here.

So in people who were taking one of the most commonly prescribed antidepressant classes, SSRIs, what did you find here about the risks?

Speaker B

00:04:50.770 - 00:06:05.480

Yeah, so we actually found some really interesting time variable trends with the risk of postural hypotension associated with ssri. So we looked at two specific time periods.

And that was initiating the drug, which was between a short period, days 1 to 28, and then days 29 to 56, which we treated as initiation, and then a continuation period, day 57 onwards.

And what we've seen in SSRIs, but also all of the antidepressant drugs, is this peak in your risk of developing a new diagnosis of postural hypotension within that acute day 1 to 28 period.

And so that was mimicked across SSRIs, tricyclic antidepressants and the other antidepressant group for SSRIs in particular, we noticed a fourfold increase in that day 1 to 28 peak that gradually declined as time went on.

And tricyclic antidepressants and other antidepressants had a similarly increased peak, not to the same extent, but about twofold that declined with time.

Speaker A

00:06:05.960 - 00:06:17.240

And we know that tricyclic drugs are often prescribed for other things as well, like pain. So do we need to be careful when prescribing it at lower doses for things like neuropathic pain?

Speaker B

00:06:17.240 - 00:06:51.460

We didn't look into dosing, but it's certainly likely that the majority of these prescriptions were prescribed in low doses for other indications, like neuropathic pain, as you. You've said, and insomnia. And we've already seen a twofold increased risk in that acute initiation period, likely for low doses.

So there is certainly a risk to be aware of in older patients that we're prescribing tricyclic antidepressants to. And it's likely that as the dose increases, that this risk increases.

Speaker A

00:06:51.620 - 00:07:04.400

And I think one thing that's really important here is that the effect sizes are actually pretty significant. So this could represent a fairly significant risk for patients, especially in that initial peak time that you mentioned.

Speaker B

00:07:04.960 - 00:07:38.380

Absolutely, yes.

And I think there's certainly a striking risk associated with SSRIs in this group, and a lot of it depends on the context of the person you're prescribing this medication to.

So whilst we know there's a fourfold increased risk in this study, you may be more cautious with someone who is at greater risk of postural hypotension at their baseline anyway, either related to advancing age or other chronic conditions like diabetes or Parkinson's, for example.

Speaker A

00:07:38.700 - 00:07:53.740

And I think what's really interesting is you point out in the paper that actually postural hypertension isn't highlighted as a common side effect in the BNF for these drugs. So it seems with such a significant effect that probably that's something that should be highlighted.

Speaker B

00:07:54.300 - 00:08:19.640

Yes, that's something I think is really, really important.

So you'll often see hypotension cited as a side, but they are quite different and the assessment is different and how you might manage it would be different too. So I think it's definitely really important that that increased risk of postural changes in blood pressure is documented for these medications.

Speaker A

00:08:20.760 - 00:08:46.019

I think it's interesting because often when people start these medications, they might have an early review with a GP about how they're getting on with it. And often that that initial review really focuses on mood and how they're coping and may touch on side effects.

But I'm not sure that at the moment that sort of initial review would include a check for postural hypertension, for instance.

Speaker B

00:08:46.179 - 00:09:28.160

I think it's unlikely.

And whilst many of us may be very good at asking about side effects more broadly, I think one of the barriers here is that a lot of patients may not recognize the symptoms of postural hypotension, or if they experience dizziness on standing and it's transient, they may not think it's important to report to their gp. And that's something that we've gauged from our PPI group that are involved in this study.

So really, it does need for a clinician to ask directly about postural symptoms and maybe even check their lying and standing blood pressure.

Speaker A

00:09:28.320 - 00:09:39.500

I guess that overlaps with what I was going to ask next, really, which was really, what should we be telling people starting these medications? And is there anything that GP should be doing differently in practice as a result?

Speaker B

00:09:40.060 - 00:10:32.290

Yeah.

So I think some really simple things about just warning patients that they might experience these side effects and symptoms to report, like dizziness on standing or other symptoms like blurred vision or feeling light headed on standing upright, are important to make note of and to report to report back in itself will make a huge difference. But just also some general advice around reducing falls risk during this period.

Once you've initiated an antidepressant, which will look different from person to person, things like keeping well hydrated and reducing alcohol intake are all conservative measures that can reduce your risk of postural hypotension and its adverse outcomes.

Speaker A

00:10:32.530 - 00:11:03.330

And we know that for some medications, side effect profiles might only last in that first initial period.

So often for SSRIs, for instance, I might mention to a patient, you may experience some gastrointestinal type symptoms for the first couple of weeks, but they may ease. So do you think your findings would support that of maybe being a bit more cautious in that first month?

But then how would you recommend we monitor that? Or do you think it's really that initial peak that people need to be looking out for?

Speaker B

00:11:03.650 - 00:12:06.680

Yeah, it's an interesting question.

And certainly the results in this study where we looked at the three antidepressants, that's what the consistent trends seem to show, that it's the early acute period that's of greatest risk and your risk subsides over time.

And it probably does align in the way that different adverse effects like you've mentioned GI adverse effects and the pharmacodynamics and pharmacokinetics of a drug lead to this initial period being the highest risk.

So what I would say is I think that period is definitely a key time where it seems that giving this type of preventative advice and potentially even monitoring people who are at high risk is of greatest importance. But whether or not they're completely risk free later down the line, I think that's a difficult question to answer.

And again, it will be different based on who you have in front of you and what their underlying risk of developing postural hypotension is at baseline.

Speaker A

00:12:07.320 - 00:12:30.480

Yeah.

And I think this study is really important in highlighting that risk because I think there are some drug classes where you may be, as you say, quite cautious about prescribing because of a risk of postural hypertension. So you may be very cautious with the beta blocker in an elderly patient.

But it's important, I think, to highlight these other drug classes as potential culprits because we. You don't want people falling over and.

Speaker B

00:12:30.800 - 00:13:00.760

Absolutely, absolutely. Yeah. And I think traditionally we associate these antihypertensive and cardiovascular drugs as the ones to have the greatest effects.

But a lot of studies show that this group of drugs, but also antidepressants and alpha blockers used for urinary symptoms all have very, very high risk of drug induced postural hypotension. So yeah, hopefully it highlights that range of risk.

Speaker A

00:13:01.720 - 00:13:32.300

Yeah.

And as you've mentioned, with some of these other drugs, for instance alpha blockers or antihypertensives, often they will be co prescribed, especially in a more elderly population. So it's really great to highlight the risk of additional drug classes as well.

But yeah, I think that's been a really interesting discussion with a lot of really key take home messages for practitioners to take back to their work and to their patients. So yeah, I just wanted to say thanks very much for joining me to talk about this.

Speaker B

00:13:32.540 - 00:13:36.860

Great. Thank you so much. Thanks for having me and thank you.

Speaker A

00:13:36.860 - 00:14:00.550

All very much for your time and for listening to this BJGP podcast.

Cini's original research article can be found on bjgp.org and the show notes and podcast audio can be [email protected] and Cindy has told me that she will be presenting this work at the Society for Academic Primary Care Conference which is happening in Cardiff this year. Thanks again for listening and bye.