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BJGP Interviews

The British Journal of General Practice

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

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

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

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

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

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

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  • S4 · E226
    March 3 · 24 min

    Designing neighbourhood urgent care: A general practice perspective

    Today, we’re speaking to Dr Mike Holmes, a GP in Yorkshire and Chair of Nimbuscare, a local GP-led multi-neighbourhood provider. Title of paper: Neighbourhood delivery of urgent care in North Yorkshire, UK Available at: https://bjgp.org/content/76/764/133 Neighbourhood-based urgent care, led by GP Multineighbourhood providers, can reduce reliance on hospitals and NHS 111. Delivering urgent care in community settings is more cost effective than Urgent Treatment Centre and Emergency Departments attendances. Digital integration and shared clinical systems improve safety, responsiveness, and patient experience. Co-locating operational and clinical teams streamlines service delivery and enables operational and quality oversight. Sustained impact requires recurrent funding and performance measures that reflect system-wide improvement rather than single-provider metrics.

    • Transcript
  • S4 · E225
    February 24 · 19 min

    Delayed, declined, or disengaged? Understanding childhood vaccination patterns

    Today, we’re speaking to Dr Karol Basta, a Public Health Registrar based in London. Title of paper: Predictors of Childhood Vaccination Uptake and Timeliness in a Diverse Urban Population Available at: https://doi.org/10.3399/BJGP.2025.0319 Childhood vaccination rates have declined in the UK, with inequalities in urban, deprived, and ethnically diverse populations. Previous studies have lacked individual-level clinical data or did not explore both uptake and timeliness. We analysed 13 years of routinely collected primary care data for over 37,000 children in a diverse London borough to identify predictors of uptake and timeliness. Distinct sociodemographic and clinical factors were associated with incomplete and delayed vaccination, offering timely insights as responsibility for vaccination services shifts closer to local systems and place-based commissioning. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.880 - 00:00:52.000 Hi and welcome to BJJP Interviews. I'm Nada Khan and I'm one of the associate editors of the Journal. Thanks for taking the time to listen to this podcast today. In today's episode, we're speaking to Dr. Carol Basta. Carol is a public health registrar based in London and we're here to talk about the paper she's recently published here in the bjgp, which is titled Predictors of Childhood Vaccination Uptake and Timeliness in a Diverse Urban Population. So, hi, Carol, it's really lovely to meet you and to talk about this work. And I guess just to start, I wanted to put this work into context. We know that in the uk, overall childhood vaccination rates have unfortunately been declining. Could you talk us through some of the current challenges around vaccination, especially in urban and diverse areas? Speaker B 00:00:52.720 - 00:02:06.750 Yep. So we know vaccinations are really powerful and cost effective tools we have in giving children the best start in life life. But unfortunately, in the UK, since 2012, the uptake has been declining and actually since 2021, none of the vaccines in England have reached the 95% target recommended by the WHO to stop communicable disease outbreaks. And the kind of negative consequences of this aren't just sort of future hypothetical risks. We've already been seeing vaccine preventable diseases such as measles and whooping cough resurgences, and this is especially in certain parts of the uk, such as London or the northwest of England. So no uptake of vaccines is decreasing and vaccine preventable diseases are increasing. But that's not the full picture. We also know, for example, following work done by, at the time, Public health England in 2017, there are avoidable inequalities across the childhood vaccination program nationally, for example, linked to deprivation, geography and ethnicity. However, what was missing was really kind of contemporary granular evidence on the social and clinical factors associated with unequal vaccine outcomes, especially in diverse urban environments. Speaker A 00:02:06.990 - 00:02:16.670 And I know this was highlighted as well during COVID but there is a mistrust of health services amongst some communities as well, which might be playing into this. Speaker B 00:02:17.470 - 00:03:11.120 Yeah, exactly. So at the time when I was working in Lamb of Council, we knew qualitatively from talking to our community and talking to our local GP partners, that there was kind of sense of rising mistrust in healthcare services, but also rising difficulties with actually access to services. And that doesn't just affect whether or not people can get the vaccine, for example, it also affects whether they can have conversations about vaccines and the kind of continuity of care and building up those relationships. And so this is what we had kind of on a local level, but we knew that there was also national feelings and sentiments around mistrust, not just national, but actually globally vaccination mistrust from the COVID 19 pandemic. And there were worries that this had run off into the childhood vaccination program as well, that it hadn't just confined itself to Covid vaccines. Speaker A 00:03:11.440 - 00:03:41.490 So this was a study looking at predictors of routine childhood vaccination from 40 general practices in Lambeth and London, which is a pretty ethnically and socioeconomic demographically diverse borough. And you looked here at the vaccination uptake and timeliness and some of the predictors for these. This was a really big sample. But just to underline the population here, tell us more about the demographics in Lambeth as a borough in terms of ethnicity, because that's where you were based when this work was done. Speaker B 00:03:41.890 - 00:04:32.250 Yeah, exactly. So Lambeth is an inner London borough and it is very ethnically diverse, it's very densely populated, but it also has some of the highest levels of deprivation in the country. And part of the strengths of this study is that we were able to use detailed ethnic subgroup breakdowns. So, for example, rather than using the broad category of South Asian, we were able to split this down into Pakistani, Bangladeshi, Indian, et cetera. And this was really important because this aligns with national health equity guidance. We know that health outcomes actually vary between the details, subgroups. There's some evidence to suggest that, but it was also important following local community engagement work, where people repeatedly told us these kind of big, broad groups don't reflect how we self identify. Speaker A 00:04:32.490 - 00:04:39.530 And I wanted to just move on to the results here, so can you start talking us through some of the associations based on deprivation to start with? Speaker B 00:04:39.690 - 00:06:22.410 Yeah, sure. So we looked at two main outcomes. We looked at vaccination uptake, so that's whether children had received their vaccines at any time point during the study. And we also looked at vaccination timeliness. And vaccination timeliness is important because although a child might eventually go on to receive their vaccine, it leaves them. They're late, it leaves them unprotected for at times when they're most potentially likely to get unwell. And what we found with deprivation in uptake, there was really clear patterns associated by deprivation. There was actually children living in more deprived areas were progressively less likely to be vaccinated compared with those living in the least deprived areas. So, for example, children living in the most deprived 20% of our population were about a third less likely to be fully vaccinated compared to those living in the least deprived areas. This kind of wasn't just a straight out deprivation. There was also lower uptake linked to other markers of social vulnerability, such as being born outside of eco, or such as children having safeguarding involvement. And so that was what we found for uptake. But what was interesting is the findings for timeliness didn't mirror this. So whilst those living deprivation were less likely to be vaccinated, if we zoom in on just the population that were vaccinated and think about were they vaccinated on time, we didn't find that children living in deprivation were less likely to be vaccinated on time. We found no difference. And there was a similar pattern for other markers of social vulnerability, such as safeguarding involvement. They have a lower uptake, but it wasn't associated with kind of untimely vaccination. Speaker A 00:06:22.650 - 00:06:31.210 And you've touched upon this, but there was a really striking result here in terms of children who were born outside of the uk. So can you talk us through this? Speaker B 00:06:31.530 - 00:06:59.060 Yeah. So we also found that children born outside of the UK were much less likely to be vaccinated compared to children born inside the uk. However, if again, we zoom in on just those vaccinated and look at timeliness, we actually find the opposite. So if you were born outside of the uk, you were more likely to have your vaccine delivered on time compared to those who were born in the uk? Speaker A 00:06:59.380 - 00:07:03.380 Sure, yeah. So talk us through some of the reasons that you think that this might be happening. Speaker B 00:07:03.380 - 00:08:30.800 Yeah, I think these findings, the difference between uptake and timeliness, not having the same predictors and in some case having the opposite patterns being shown are really quite interesting. And they're kind of a few possible explanations as to why this might be. One is perhaps potentially there's a form of selection going on. So when we look at only children who get vaccinated in groups with lower overall uptake, for example, children of non white British ethnicity, or as we've said, children not born in the uk, the children who do get vaccinated may represent more engaged, health literate or well supported families. And that same engagement may also support timely vaccination. But in groups of higher overall uptake, for example, children of white British ethnicity or children born in the uk, the groups who do get vaccinated may include a kind of broader, more mixed group of families, including some who vaccinate later, which can then reduce their overall level of timeliness. And this raises the possibility that our kind of existing recall and catch up systems may work better for some groups over others and in doing so may actually unintentionally reinforce inequalities rather than reduce them. But there are other alternative explanations and I think what's really key here is future research is really important. Timeliness has generally been less well described and these findings potentially raise important questions. So it's definitely an area where both qualitative work and also future quantitative work I think would be helpful. Speaker A 00:08:31.040 - 00:08:45.360 And you've touched a bit about the deprivation and children born outside of the uk and in this cohort, as you said, you were able to get quite detailed information about ethnicity rather than sort of the broad brush groups. Speaker B 00:08:45.760 - 00:08:46.200 Yeah. Speaker A 00:08:46.200 - 00:08:52.560 What did you find here in terms of ethnicity and uptake? So did it mirror some of the findings around children born outside the uk? Speaker B 00:08:53.530 - 00:11:05.920 Yeah. So compared to children of white British ethnicity, lower uptake was observed with all other ethnic groups. The largest gap was seen among children of black Caribbean ethnicity, whose odds of being fully vaccinated were around 70% lower than those of white British children. But other groups such as Indian, Pakistani, Bangladeshi, Chinese, Arab and several other mixed ethnic groups also had lower uptakes, ranging between 30 to 50% lower than white British children. And so all, although all groups had a lower uptake compared to white British, it suggests that the kind of barriers may not be experienced in the same way or to the same extent and could potentially reflect a combination of different structural, cultural and service related factors. I think with all of these findings, I think it's. I think there's two important things to note, is one, we found all of the inequalities were present for both individual vaccines. And then because we looked at overall patterns across the schedule, they weren't just kind of isolated to one vaccine, they were found for all the vaccines for all different sorts of combinations. And this was important for us to find, as some of our work qualitatively, but also some findings nationally suggested perhaps some communities have lower uptake relating to just the MMR vaccine, for example, but we didn't find that. So this suggests that kind of these inequalities are unlikely to be driven by really specific parental concerns about one vaccine, but it's kind of more wider barriers to accessing vaccination services. So I think that's one important thing to be aware of. And then the second thing is that these inequalities are persisting after adjustment for a wide range of socio, demographic and clinical factors, as well as age as well as GP practice. So that kind of indicates a Certain level of robustness to measured confounding. But however, as of any observational study, there are unmeasured factors that might be influencing things. For example, in this case, things like parental education or family size, which we weren't able to explore but would be interesting to do in further studies. Speaker A 00:11:06.080 - 00:11:25.620 It's interesting. You're talking about access as potentially quite a major contributing factor. And one thing I was wondering was that, is it that there's more outreach needed to certain communities, or do you think it is sort of a matter of access to health care or an understanding about healthcare and what's being offered? Really? Speaker B 00:11:26.500 - 00:12:25.010 Yeah. Research shows that it's often. It's not necessarily just one thing, it's not necessarily just access, but it could be access combined with kind of vaccination misinformation or mistrust in the system. So there's often multiple things going on which can combine to cause vaccination inequalities. I think, though, given the kind of strong findings across the vaccination pathways showing structural and social influences on vaccination inequalities, access is going to be definitely part of the story. And we also know this from qualitative research as well. And so I think there are a number of things, not just general, general practices, but kind of different bodies that support general practice, such as national policy or integrated care boards. I think there are definitely things that can be done in this space. Speaker A 00:12:25.250 - 00:12:45.120 And I think, as you're pointing out, this study has shown some of those persistent inequalities present with vaccination uptake. I think that actually your work as a public health doctor is really important to draw on here. What do you think needs to be done at both the local or national level to start to tackle these inequalities? Speaker B 00:12:46.160 - 00:13:02.720 Yeah, I think it's one of those things that requires a whole range of groups to play their part. So I'd say there are kind of implications for GPs, implications for local teams, local integrated care boards, implications on a national level, and also implications for the research community. Speaker A 00:13:03.040 - 00:13:14.150 It would be great to start with, what do you think that gps should be doing? Because these are people coming in to see us or families that we might know over time. So it would be really interesting to hear your thoughts on that. Speaker B 00:13:14.550 - 00:15:25.730 Yeah, yeah. We've hopefully established that this study has shown a broad range of social and structural determinants of vaccination, and these are across the pathway. So I think practices are likely to have a greater impact by strengthening the overall vaccination pathway to work better for families. Facing those barriers rather than focusing on individual vaccines or short term campaigns. There are a number of ways this can be done. Firstly, it's about making access easier, not more demanding. So people who, families who are under vaccinated aren't necessarily even against vaccination, but they're juggling multiple competing pressures. Life is challenging. So practical changes like flexible appointment times, opportunistic vaccination during other consultations, walk in clinics, simpler booking and recall systems could make a real difference. But it's not just the kind of process booking. I think the experience of the appointment itself also matters, especially if it's kind of one of earlier on ones. Feeling welcome, not rushed and having questions taken seriously makes families more likely to return and stay engaged with a vaccination program. But I think there's kind of secondly work that beyond the practice walls that gps can take. So having stronger links with health visitors, children's centres and safeguarding teams can help reach families who are just going to find it really hard to consistently engage with general practices. And in some cases vaccination outside the surgery, for example, community settings or through health visitors, may be more effective. And I think thirdly for practice, it's about building trust and continuity, which can sound kind of nebulous and difficult, but things like seeing a familiar clinician or having conversations in culturally sensitive ways can support engagement. And I think people who might have concerns about vaccines kind of not to expect that suddenly one consultation is going to solve all their problems. But it's kind of about visit upon visit building that trust and engagement. I've said all of that, but I'm very aware that this is very resource intensive and requires upfront investment, which I think it also needs to be supported by national policy and changing some of the funding mechanisms. Speaker A 00:15:26.130 - 00:15:41.870 I think, I mean, that's really the main point that I wanted to highlight was, you know, you're talking about things like health visitors or children's centers and things like that, and we know that funding for those areas is tight and being cut and I think possibly that this is where the impact is being felt. Speaker B 00:15:42.270 - 00:16:40.150 Yes, yes. And I think even before we get to things like children's centers and health visitors, which definitely their funding is being cut and needs to be, we can talk a lot about vaccination as uptake. We need to use community centres, health visitors, but if the money's not there, it's not going to happen. But I think even for general practice, funding for vaccination is linked to the number of vaccines given. But if you're in a Deprived practice, a very ethnically diverse urban with lots of challenges. You're going to have a harder job trying to vaccinate your population and you're also going...

    • Transcript
  • S4 · E224
    February 17 · 15 min

    From swabs to urine sampling: Rethinking cervical screening in general practice

    Today, we’re speaking to Prof Emma Crosbie, Professor of Gynaecological Oncology based at the University of Manchester. Title of paper: Urine human papillomavirus testing for cervical screening in a UK general screening population: a diagnostic test accuracy study Available at: https://doi.org/10.3399/BJGP.2025.0105 The switch from primary cytology to primary human papillomavirus testing has enabled innovations in self-sampling for cervical screening. This study shows that urine self-collected with a first-void urine collection device has similar diagnostic test accuracy and acceptability to cervical sampling in a general screening population. Urine self-sampling has real-world potential as an alternative cervical screening option. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:01.440 - 00:01:07.140 Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate Editors of the bjgp. Thanks for listening to this podcast today. In today's episode, we're speaking to Professor Emma Crosby, who is professor of Gynecological Oncology based at the University of Manchester. We're here to talk about her really exciting paper that's recently been published in the December 2025 issue of the BJGP. The paper is titled Urine Human Papillovirus Testing for Cervical Screening in UK General Screening Population A Diagnostic Test Accuracy Study. So, hi Emma, it's lovely to meet you and to talk about this paper. I really just wanted to start off talking a bit around cervical screening in the uk, and you mentioned this in the introduction to the paper as well, that cervical screening really does have variable uptake rates and we know that there are some, some barriers to access. But can you talk us through these and tell us a bit about why you decided to do this research? Speaker B 00:01:07.940 - 00:03:41.440 So, as you've just really nicely summarised, cervical screening is really important weapon against cervical cancer. So we know that it prevents cervical cancer and since the introduction of the NHS Cervical Screening program in the UK, we've seen deaths from cervical cancer drop by around 70%. So we know that it's very effective. But in the uk, the number of people attending is declining year on year and currently, currently only around 68% of those people who are eligible for cervical screening actually attend. There are a whole range of different reasons for non attendance. These include things to do with the speculum examination, so having to have an intimate examination to be examined. The anticipated embarrassment or fear of pain related to that procedure, I think are important barriers. But there are also barriers associated with access to reaching screening appointments, taking time off work, having childcare and so on and so forth. So we thought that there was some really important barriers there that could potentially be addressed by self sampling. Now, vaginal self sampling is actually been incorporated in many cervical screening programs around the world. Some cervical screening programs are using it just for people who are non attenders or underscreened by traditional screening routes and other countries are using it as a choice for everybody. Now, in the uk, we haven't yet taken up vaginal self sampling sampling, but it will be introduced this year in 2026, principally for under screened groups. And there is some work looking at whether or not it will be introduced as a choice for everyone in the future. But we know from research that's been done in the UK that only around 12 to 13% of people who are offered vaginal self sampling who are under screened actually return a sample. And therefore it clearly doesn't address all the barriers to cervical screening. And we wondered whether a urine test would have more app. It would have the same benefits of vaginal self sampling in that it can be collected at home and posted to the laboratory. So it removes that need for an intimate examination. It removes the need for, you know, making an appointment at a healthcare facility to have your screen taken, but it perhaps, you know, removes some of the barriers towards putting a swab inside the vagina that might be culturally or religiously unacceptable to some groups. And so we thought that a urine self sample could be another option for people who currently aren't screened. And so we wanted to see how accurate it was in this study. Speaker A 00:03:42.320 - 00:04:03.760 And those issues around access are really important, especially in this population of women who are juggling lots of caring responsibilities with young children or caring for older relatives as well. So sometimes it is just difficult to get to an appointment and, you know, juggling work hours and things which often then coincide with GP opening hours as well. Speaker B 00:04:03.920 - 00:04:41.960 Yeah, absolutely. And we, we have seen a drop in people, you know, in the youngest age group of people who are invited for screening, attending SCRE, their rates of attendance are even lower than the 68% that I quoted. And probably a lot of that is to do with having very busy lives, not seeing this as a priority, imagining that you're not at risk and seeing cervical cancer as something that affects older people, perhaps. So there are additional barriers related to certain age groups. But I definitely think that making time for a screening appointment, juggling all the different millions of things that we have to do every day, is a really important barrier that something like a urine based test could help to overcome. Speaker A 00:04:42.120 - 00:05:10.680 Yeah, fair enough. So this was quite a big prospective study of over 1500 women carried out across the northwest of England. So women provided both regular speculum based cervical samples alongside urine sample too. And the main thing you were looking at here was the accuracy of the urine based HPV testing for cervical cancer. But just in case people aren't completely aware of all this, can you talk us through first why we're now only looking at HPV in these samples? Speaker B 00:05:11.060 - 00:06:30.230 Yeah. So, I mean, in 2019 in the UK, we changed from primary cytology based cervical screening to primary HPV based cervical screening. So that means that the sample taken from your cervix is tested first for hpv and only if that is HPV positive is it then looked at under the microscope. To see if there are changes in the cells. And this was based on a very large study done in the UK that showed that HPV testing is a much more sensitive test than cytology as the primary scre. And by that what we mean is it's much more likely not to miss abnormal cells than cytology, which is very effective when there is a large lesion, if you will, that can be sampled with a cervical swab, but not so good at picking up smaller lesions. And so there is the chance that cytology might miss an abnormality. But HPV is really good at showing that somebody is at risk. So we now do all primary screening by HPV testing. And of course this is what has opened up the opportunity for us to do different sample types. So a vaginal swab tested for HPV or a urine sample tested for hpv, you know, could also be an effective way of screening people to see if they are at high risk of cervical pre cancers. Speaker A 00:06:30.390 - 00:06:37.830 So talk us through the results. So how well did the urine based testing perform? So both in terms of how sensitive and specific the results were? Speaker B 00:06:38.130 - 00:09:24.670 Well, first of all, it's really important to say that this piece of work followed on from another piece of work that looked at a high risk population. And in that other piece of work we were able to show that it's really important how the urine sample is collected. So absolutely must be collected with a colipy device or a similar device that collects the first fraction of urine sampled. And that's important because the HPV isn't in the urine itself. The urine is flushing cervical mucus that is accumulated around the urethra into the sample. And so if you don't collect that very first flush of urine, then you're likely to miss the hpv. So on that background, using the COLIP device in this study and collecting that urine sample prior to the routine clinician obtained cervical sample, we were able to obtain two samples from each person that we were then able to test with the same HPV test. And we were able to compare absolutely how accurate the urine was compared to the matched cervical sample. And because we were using a general population, so this is anybody that's due cervical screening rather than a high risk population, we knew that we weren't going to see very many people who had CIN2 plus, which is the cervical pre cancer that we want to identify and treat. And actually what we were looking for here was to see, you know, what prevalence of HPV infections do we pick up using the two tests, you know, the urine test and the Cervical test and how well matched are they at terms of, you know, telling somebody that they're HPV negative and at low risk of cervical cancer and how well matched out they are picking up HPV positive people who also have cytological abnormalities that need to be referred to colposcopy. So if we take all of that information on board, then the bottom line figure is that urine picked up around 16% of people as having an HPV infection, while a cervical sample picked up around 13.5%. So you can see that we picked up slightly more HPV infections with urine than we did with the matched cervical sample. But when we look at, you know, how many of those had CIN2 plus, it was just a very small number. So only 25 of our 15, 17 people actually had a CIN2 plus lesion, and urine picked up 24 of those. So when we look at the relative specificity, if you like, of urine versus cervical sampling for HPV detection in this population, it was really good. It was 97% relative sensitivity specificity. And when we look at sensitivity, you know, we're a little bit underpowered because, like I said, we only had 25 CIN2 plus lesions, but urine picked up 24 of those 25. So it had really excellent sensitivity as well, even bearing in mind small numbers. Speaker A 00:09:24.830 - 00:09:43.940 And I think one of the main things to look at here and to point out was what the participants felt about the different forms of testing. And you looked and asked them what they thought about the cervical screening using a urine sample instead of the more traditional based speculum based testing. And what did they feel about that in terms of sort of acceptability? Speaker B 00:09:44.740 - 00:10:51.420 Well, I mean, as we might expect, most of them were quite happy with attending for routine cervical screening appointments. This probably is not the population for whom a urine based test is intended. It's probably, at least in the first instance, intended for people that are under screened. But it's perhaps not surprising that people who do go for routine cervical screening are more than happy to continue doing so. So we found that around 42% would prefer to continue to for their screening appointment and to have a sample taken by a healthcare professional. Interestingly, around 30% would prefer to switch to a urine based cervical screening test. And another sort of 30% or so had no particular preference over screening method. And this is quite interesting because it suggests that we probably need to have a menu of choices for people that, you know, one option for everybody is not going to answer the problems of reduced uptake of cervical screening and that if we had a menu of choices whereby people could choose the way that they would be screened in the future, that this might have the best way of increasing the number of people who are screened. Speaker A 00:10:51.500 - 00:10:55.180 Any other key findings from the paper that you want to touch on at all? Speaker B 00:10:55.420 - 00:11:42.680 Well, I think the main thing is that we were really impressed with the performance of urine. This is kind of. We didn't directly compare it to a vaginal swab result, which, as I'd already mentioned, is going to be introduced by the NHS Cervical Screening Program from 2026 for under screened women. But if we compare how urine has performed in study, especially if we look at it in combination with the study that was done in a high risk population, and then compare it with the recently published HP Validate study that compared different vaginal swabs with HPV testing results, we can see that urine performs at least as well as vaginal self sampling, if not slightly better. So we were, we were a little bit surprised that it performs better than vaginal swab, but extremely excited that this paves the way for further research in this area. Speaker A 00:11:43.190 - 00:12:02.710 And based on this study, and you've talked a bit about the introduction of vaginal self sampling this year as well, what do you think is the future for cervical cancer screening in the uk? You've mentioned about having a menu of options, but you've also touched on the fact that there might be some groups for whom this is actually the preferred method of screening. Speaker B 00:12:03.510 - 00:13:54.680 Yes, I mean, I think initially the cervical screening program's decision to offer vaginal self sampling to under screen populations is a really good one because it can't do any harm. These people are not being screened by definition and so offering them another option to help them to be screened is fantastic. From previous research, we might expect only around 8 to 13% of those people to actually take up the offer of vaginal self sampling. So it might be that we actually need to introduce another option for under screened people, such as urine based sampling. So I definitely see it as having a role for people who couldn't be screened in other ways. And there are plenty of people that have been, for example, victims of sexual violence, people for whom putting a swab in the vagina is culturally or religiously taboo, people who have pelvic pain conditions, vaginismus, painful vulval conditions and so on. I can definitely see that urine based sampling, if we can show it's as accurate as vaginal based sampling, has a place. But in terms of whether or not we're going to offer different ways of self sampling, for everybody in the cervical screening program, I think that needs a little bit of a more careful consideration. And the reason that I say that is that if, for example, vaginal self sampling and urine self sampling are even a tiny bit less accurate than cervical self sampling, and what we find is that by introducing these self sampling methods to the general screening population doesn't really increase the number of people being screened, but does substantially influence people to switch from regular screening to urine or vaginal based cell sampling. We might actually see a deterioration in the cervical screening program. We might actually see more cervical cancers and deaths from cervical cancers. So we really need to do more research in this area before we just introduce it as other countries have done. Speaker A 00:13:54.920 - 00:14:05.240 And I guess that's the next thing I want to touch on is what's the next steps for you and your team in this area? Are you planning any further research and looking at urine based HPV testing? Speaker B 00:14:05.560 - 00:15:06.700 Yes. So we have done two other large studies. One is looking at under screened women. So we have randomized women to receive either a vaginal self sampling kit sent to their home address, a urine based self sampling kit sent to the home address, or an offer of the choice between a vaginal or a urine self sampling kit, or an offer of vagina self sampling kit or an offer of a urine self sampling kit. So five different groups basically asking the question of whether we really need the option of vaginal versus urine self sampling or whether, you know, one type of option is going to be effective for everybody. And can urine based self sampling actually help people to to be able who are under screened to turn up for screening? So that's the first study that we've done. And then another study that we have done is looking at the acceptability in a much larger population. So several thousands of people who have tried urine based self sampling, what do they think about it? Compared to vaginal self sampling and compared to routine screening? Speaker A 00:15:07.180 - 00:15:30.040 Brilliant. That sounds like all really exciting work and as you say, it's tackling those challenges around the decrease in people taking up cervical cancer screening. So I think this is really important work and it's been great to hear about it and look forward to hearing about the results from those other studies you're working on. But I just wanted to say that's I think a great place to wrap things up. So thanks very much for your time, Emma. Speaker B 00:15:30.120 - 00:15:30.760 Thank you. Speaker A 00:15:31.240 - 00:15:52.770 And thank you all very much for your time here and for listening to this BJ GP podcast. Emma's original research article can be found on bjgp.org and the show notes and podcast audio are@bjgplife.com it's been great hearing about Emma's research in this area, and I hope you all enjoyed listening as well. Thanks again for your time and bye.

    • Transcript
  • S4 · E223
    February 10 · 17 min

    Trust matters: A practice-level look at patient confidence in health professionals

    Today, we’re speaking to Professor Richard Baker, emeritus Professor at the University of Leicester. Title of paper: Factors influencing confidence and trust in health professionals: a cross-sectional study of English general practices. Available at: https://doi.org/10.3399/BJGP.2025.0154 A transactional model of general practice is being introduced to improve access that involves triage and increasing percentages of appointments with professionals other than GPs or that are not face-to-face. Using summary data about almost all English general practices in 2023-24 with 750 or more patients, the patient-reported levels of confidence and trust from the General Practice Patient Survey were associated with increased percentages of appointments that were with GPs or were face-to-face, and with higher continuity, after adjusting for other practice and patient factors. Confidence and trust was lower in practices with fewer appointments per year per patient, fewer patients having their needs met, greater deprivation, fewer patients of White ethnicity, and in practices located in London, as compared to other regions of England. Access to general practice needs improving, but the findings of this cross-sectional study suggest that preserving features of relationship-based care is also needed to maintain patients’ trust and confidence in health professionals. 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 - 00:00:46.980 Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate editors of the Journal. Thanks for joining us here to listen to this podcast today. In today's episode, we're speaking to Professor Richard Baker, Emeritus professor at the University of Leicester. We're here to talk about the paper that he and his colleagues have recently published here in the bjjp. The paper is titled Factors Influencing Confidence and Trust in Healthcare A Cross Sectional Study of English General Practices. So, hi, Richard, thanks for joining me here today and it's nice to see you again. Just before we talk about this paper, I wonder if you could just talk to me about trust and why you think it's important in general practice interactions. Speaker B 00:00:47.780 - 00:01:32.060 Well, it's difficult to have a consultation with a patient if they don't trust you. I mean, it's just very basic, a very basic level, very simple level. But there's lots of evidence as well that trust is important. People who trust you are more likely to follow your advice. They're more likely to take the medication. They're more likely therefore, to come back and see you again, more likely to use services appropriately in the future. And there's some evidence that the outcomes are better if there's trust there. Trust obviously should be earned. You can't take it for granted, you've got to be trustable. But it's obviously very important for clinical practice and essentially always has been, hasn't it, really? Going back to the. The Greek doctors, trust was important then, just as it is now. Speaker A 00:01:32.460 - 00:01:38.540 And you mentioned about different outcomes. So what sort of outcomes do we know could be associated with trust? Speaker B 00:01:39.180 - 00:02:07.990 Just use of services is one example. So you can get people who, if they don't trust who they see, they go and see someone else and again, and so they overuse services and that waste resources. On the other hand, you may get people who just won't come, so they'll delay presenting with the problems because they don't trust the provider to get it right. Then they risk of poor outcomes as a consequence of that. So it's a whole mixture of things. Speaker A 00:02:09.030 - 00:02:21.190 So what were you trying to do in the study? So you wanted to look at trust and how it impacted on patient outcomes, or was it more about sort of the predictors and associations with trust, isn't it? Speaker B 00:02:21.800 - 00:04:33.330 Yes, I think we were conscious that general practice has gone through a lot of change. The big changes came about during the pandemic as to how general practice is delivered, how people have their appointments and things have sort of Reverted a bit to how they were, but only partially in terms of who you get to see face to face, appointment and so on. And we were asking the question, well, what has been the consequence of this? Should we be thinking about confidence and trust in association with these changes? I mean, the changes may have been absolutely essential because we just don't have the capacity in general practice to do everything that we would like to do for an increasingly multi morbid population. But what are the consequences? How do we need to respond? How do we need to respond? Questions I guess for follow on from Is there a link between confidence and trust and these changes in general practice changes? I think when we looked at this, we've sort of grouped them, we sort of imagined that there are two models of general practice which the relationships based care and the transactional model. Of course there aren't two models, it's all mixed up. But to simplify it, you call it two different things. And we've tried to categorize or explain what relationship based care might be, which has typified by high context continuity, face to face appointments with someone, you know, usually a gp, to get generalist medical care. And then the transactional model where you, you have a problem, you, you phone up or email or whatever it might be online and you get allocated or triaged to a particular professional who deals with that particular problem and then off you go on to something else. And, and it could be face to face, it could be over the phone, it could be all sorts of different health professionals. So there's two different ways, it's all mixed up. And every practice offices offers these two approaches in different degrees. It's just. So this arbitrary division that we've described and we're sort of interested in how we look at that, how is competent trust linked to that? Speaker A 00:04:34.769 - 00:04:56.790 This was a study looking at the general practice patient survey, which includes a question about whether patients felt that they had confidence and trust in their healthcare professionals. And. And then as we were discussing, you looked at some of the factors that might influence this trust. But I wonder if you could talk us through the findings. So in this survey, how many respondents felt that they trusted their healthcare professionals? Speaker B 00:04:57.590 - 00:06:12.790 This was, we were interested and the question was, did you have complete confidence in trust in the professional scene at your last appointment? And around about the figure was 64, 65% on average across all the practices. So this was all general practices, but the vast majority of 99% or something of all general practices in England, 6200 practices were roughly in the study. And this was 20, 23, 24 year. It was a simple cross sectional study for reasons the data weren't available for a longitudinal study, unfortunately. But so there are inevitably limitations on that. But I suppose, yes, you would say two thirds had full confidence in trust and others had partial confidence trust and others had absolutely no competence and trust in the professional they had last seen. Now, this relates to all types of health professionals seen, so it would include gps, but it would include the nurse you saw, the physiotherapist or the pharmacist or whatever. It would be the general practice based pharmacist, the people in the primary care team who, who consult with them see patients. Speaker A 00:06:12.870 - 00:06:38.150 And you talked earlier about these two different models of care, the relationship based model and the transactional model. And you know, you described that some of this might be a bit more mixed in practice, but did you find any associations between those different ways of working and how trust was or how much patients trusted their interactions with their last healthcare professional? Speaker B 00:06:39.610 - 00:07:53.140 There's a tendency among the findings for relationship based care to be associated with higher levels of competence and trust, relationship based care being typified by higher levels of continuity, more face to face appointments, more appointments with gps. And of those three things, continuity is perhaps the most powerful association and then points with GPS the next most powerful. And face to face being the third or least powerful element of that three. When you put all three together, I think it becomes quite a powerful message really saying patients do by and large tend to be more trusting, have more confidence in relationship based care. But that doesn't mean to say there are patients who don't want transactional care and have trust and confidence in it, they get it and when they want it. So it's not a simple either or. The picture at the moment appears to be there are probably more patients who want relationship based care than are able to get it. Speaker A 00:07:53.940 - 00:08:14.000 And I wanted to touch here more on continuity of care and it's an area of research that you've worked in for a while and there have been previous studies. I know Chris Salisbury's team in Bristol did some work around healthcare professionals and trust and continuity. What are your thoughts about this based the results that you've pulled out from this survey as well? Speaker B 00:08:14.800 - 00:10:12.260 Well, it just reinforces my perception of continuity being preferred by patients. Some of the first studies I did way back in the 1980s, 90s, I wasn't investigating continuity, but I was investigating what patients thought about their care and continuity just stood out. It just, it almost, almost slapped me around the face. Come on. Notice this. And it was, it was as a became a to say, look, we need to take this seriously and try and provide what patients want. They prefer, by and large, not all patients, but most patients, especially when they've got a more complex or worrying problem, want to see someone they developed a relationship with, a relationship of trust where they know, where they can understand what the person is telling them. Because if you've seen somebody once and they've got you right that time, then you're going to go back and see them again, aren't you? It's just sort of obvious really, but the continuity has actually, since the 80s and 90s, it's really just steadily declined and that's a sort of frustration as to why that's happened. And keep on providing more evidence about the value of continuity from the patient's perspective, from outcomes perspective, from health professionals perspective. This is just another example of one of those studies I'm totally expecting. In this study we were to find that continuity was a predictor of confidence and trust. What we were looking at was a face to face appointments a predictor as well. And is seeing a GP a predictor as well? And yes, they were. They're all linked parts of relationship based care. And yes, the story of the last two or three decades has been a gradual decline in relationship based care, which I think is a shame. Speaker A 00:10:13.050 - 00:10:36.170 And there is this almost tension between this idea of relationship based care currently and quicker access, more transactional ways of working and fewer appointments between a patient and a GP in practice with an increasing multidisciplinary team. So in some ways it seems like a frustrating system, not just for patients, but for GPs as well. Really? Speaker B 00:10:36.890 - 00:11:38.170 Yeah, absolutely, I'm sure it is. Yeah, absolutely. It must be. Well, it's obvious we all know it's very, very difficult working in practice at the moment, juggling so many things at once. It's really difficult. And the changes that have come about in terms of proportion of appointments with gps proportion that were face to face, it's almost, it's essential, it's necessary to enable the service to continue, isn't it? So it's not a deliberate policy of gps to reduce relationship based care. It's something that had to be done in the face of. I don't know quite where the policies came from, but it feels to me as though there'd been a failure to respond to what we knew was going to happen. An aging population, greater demand for healthcare. We should have got our, rolled our sleeves up and planned to deal with that well in advance. Maybe the NHS workforce plan will start to put right some of those things in the next few years. We'll have to see. Speaker A 00:11:38.490 - 00:11:41.850 Any other key findings that you want to mention from this paper? Speaker B 00:11:43.710 - 00:12:32.610 I think the other one that I picked up on is patients have greater confidence in trust when they report that their needs were met at their last consultation. I think that was another finding using information from the general practice of patient survey data, and I think that was quite an interesting one in ways. It's sort of not unexpected. People who write theories about trust, patient trust in the health professional talk about patients assessment of competence, and it seems to me that's perhaps linked to that. So I think that's another thing that it might be worthwhile just thinking about and knowing more about. And I've sort of written that down as that'd be interesting to do a longitudinal study of that or something maybe in the future to try and get. Speaker A 00:12:32.610 - 00:12:49.520 Further into that and just moving on to think about how we could apply the finding of the findings of this study more widely. Do you have any ideas about how practices could try to increase trust in their patient population? Do you have any ideas for GPs or people working in general practice or policy? Speaker B 00:12:51.040 - 00:15:22.040 I certainly, from a general practitioner's practice point of view, I would say look at the GPPS data and understand what's happening locally, what's happening for our practice, how are we doing? I think these are really goldmines of information and you follow it over a few years, years and you start to see trends and what have you. I think that's really a starting point and every practice is going to be different. It's not. There's not a. I don't think there's a blanket thing general practice must do xyz, it's just not that simple. But understanding your own situation and thinking about how we're doing, some practices will be doing fine and don't need to really worry too much. And some might feel, well, we could perhaps do a little bit better. Maybe we need to when the opportunity presents, or we need to tweak things so we can bump up continuity a little bit. Or maybe we're in the situation of, you know, thinking about our staffing needs for the next year or two. How do we. How do we make sure we've got the right staff in place that are going to help confidence and trust or those. Those sorts of questions, I think, are probably things that questions that practices can ask. It's not going to produce an instant solution, but a little bit tweaking things a little bit each year. Moving in the right direction is better than either standing still or going backwards. And that's really what I would encourage. But I mean, it's very difficult for practices, given this current resourcing situation, to dramatically change things. But over time, we hope the message gets through to policymakers that they do start to, I mean, I want to say invest in general practice, but. And I think that's actually true. But I want to make it simpler for policy makers because things are not necessarily easy for them either, are they really? They've got so many different demands and so we have to present solutions to the problems they're facing. And I think, yes, it is a little bit of resource improvement as well as everything else. And again, a tweaking a bit over time. In a few years time we could make a difference. It's taken 20, 30 years to get to this low in terms of continuity and relationship based care. Let's accept that it's going to take quite a few years to get back up to where we'd like to be. But it's making that the first step is always the important one. Keep making steps after that. Speaker A 00:15:23.000 - 00:15:39.520 And as you mentioned, it's important to note that the general practice patient survey does have this longitudinal data over time, so it is a helpful tool for practices to go back and look at the data over time. And it's obviously publicly available as well for practices to go and look at. Speaker B 00:15:40.160 - 00:16:09.820 Yeah, yes, I think, I think is a. We're very fortunate. We have public data. We use the data from the NHS appointment, general practice appointments data sets as well in this study and that's got lots of material in as well. And there are other sources of data as well about general practice that we can draw on. We didn't look at. Well, we didn't use any quaff variables in this particular project because they weren't helpful to us in this particular project. But there's lots of data and. Speaker A 00:16:12.220 - 00:16:12.460 I. Speaker B 00:16:12.460 - 00:16:22.860 Think that's really, really good that the NHS is collecting, using these data, making them publicly available. I think that's something to celebrate, I think. Speaker A 00:16:23.740 - 00:16:37.180 Well, it's been great hearing about this research, Richard, and it sounds like it's given you lots of ideas for projects in the future as well. So we'll look forward to hearing about those as well. But I just wanted to say thanks very much for taking the time to talk about it today. Speaker B 00:16:37.740 - 00:16:42.700 Okay. No, thank you very much. It's. It's great to talk to you and. Speaker A 00:16:42.700 - 00:16:58.920 Thank you all very much for your time here and for listening to this BJGP podcast. Richard's original research...

    • Transcript
  • S4 · E222
    February 3 · 15 min

    Belonging, autonomy and burnout: Why GPs leave

    Today, we’re speaking to Dr Laura Jefferson, Senior Research Fellow based at the University of Manchester. We’re here to discuss her paper recently published here in the BJGP titled, ‘Understanding persistent GP turnover using work and personal characteristics: a retrospective observational study’. Title of paper: Understanding persistent GP turnover using work and personal characteristics: a retrospective observational study DOI: https://doi.org/10.3399/BJGP.2025.0260 GP turnover rates from national administrative datasets have previously been used to explore practice-level factors associated with turnover and its relationship to patient. outcomes. The individual and work characteristics associated with turnover is less well understood, with much research focusing on intentions to leave or smaller samples of GPs leaving practice. This study sought to fill this research gap, through analysis of a large dataset of GPs working experiences linked to turnover, understanding potential predictors that may offer solutions to the workforce crisis being faced in general practice. We find that GPs’ sense of autonomy, belonging and competence are significantly lower in practices with problems with persistent turnover and demonstrate how satisfaction with work characteristics such as working hours and experiences of strained relationships differs in practices with persistent turnover. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.880 - 00:00:53.050 Hello and welcome to BJGP Interviews. My name is Nada Khan and I'm one of the Associate editors of the bjgp. Thanks for joining us here to listen to this podcast today. In today's episode, we're speaking to Dr. Laura Jefferson, who is a senior research fellow based at the University of Manchester. We're here to discuss her paper, recently published here in the journal, titled Understanding Persistent GP Turnover Using Work and Personal A Retrospective Observational Study. So, hi, Laura, it's really nice to see you again and to talk about this research and I suppose I really just wanted to frame our discussion here today by saying that there's been a lot of talk recently about the retention crisis in UK general practice, but I wonder, could you just talk us through how big is the scale of the problem that we're dealing with here? Speaker B 00:00:53.370 - 00:02:12.110 Yeah, thank you. Yeah, well, thank you for inviting me to talk to you today as well. I think it's interesting, we hear a lot of discussion in the media and in our research evidence as well, recently about an increase in GP turnover. In the past sort of decade, there's been a gradual increase, so that's in terms of GPs leaving medicine, but also moving across practices. And it's good to see a kind of change in policy focus from historically, a lot of policies focused on recruitment of GPS. So, you know, we've had like, pledges to have 6,000 GPS that have not been met and it's often kind of criticized as filling a leaky bucket. So if we try and obviously pay a lot. So I think it's approximately half a million pounds to train a gp, but actually to replace the GP is really expensive as well. So it's about £300,000 to replace the GP. And so, yeah, so there's a positive focus to thinking about retention, but actually it's about how can we do that effectively and understanding that the sort of one size fits all approach doesn't necessarily work and that there's different gps with different needs. Speaker A 00:02:12.590 - 00:02:36.830 And this was a study where you were looking at the association between high practice turnover of GPs and GP job satisfaction. And what you did was you linked data from different general practice practices and GP workforce surveys. But the first thing I wanted to really look into was that you identified these high turnover practices. What exactly did this mean? Speaker B 00:02:37.070 - 00:04:33.190 Yeah, so there's been previous research that's done this before, so it's using. We're really fortunate in the UK that we've got really good workforce data compared to a lot of other countries. So we have longitudinal data going back a long way that we can use for research purposes to try and understand more about these trends. So colleagues of mine at Manchester have previously used this data from NHS Digital, which is now NHS England, linking with data on gps by General Practice, which is has got data on their kind of start and leave dates in a practice. And that allows us to track where gps are moving out of a practice and how long they've stayed there for. So they've previously looked at sort of persistent turnover as being categorized as a practice where they have consistently, for three years running, had a 10% turnover of GPS. So this is where it seems to be a more worrying turnover figure. I think it's expected that there's going to be some level of turnover and some level of turnover that might be a useful thing. But those kind of practices where you think, oh, what's going on there? And particularly then within our research, looking at what are the striking differences in those practices, both in terms of the sort of workplace characteristics that GPs are experiencing? So can we use that data to explore strategies that could be used to actually support gps in those practices? So trying to understand, really, what does it feel like for a GP in these practices with persistent turnover, so that then, hopefully, through this sort of research, is kind of like the first step in a puzzle to try and determine strategies to support them. Speaker A 00:04:33.750 - 00:04:50.310 Yeah, fair enough. And then thinking a bit more about what you found here. So you looked, as you said, at some of the characteristics of the GPs who worked in these high turnover practices, and you found some really interesting differences that related to gender, age and experience. So can you talk us through that? Speaker B 00:04:50.390 - 00:06:45.570 Yeah. So this was the first time that these large data sets have been used to look at GP characteristics that might not necessarily predict turnover, but might be associated with turnover. So difficult to make predictions using the approaches that we've used, but we were able to, within our analysis, adjust for things like age, experience, gender, looking at GP partners and salaried GPs to try and draw out, are there any differences? And we did find a gender difference. So women were more likely to be in practices with persistent high turnover. But because of the analytical approach that we've used, it's really difficult for us to unpick. What does that actually mean? Does that mean that are they driving turnover or do they actually become stuck in these practices? So there's a lot of research literature that suggests that women may be less mobile in the workplace for a number of societal reasons. So it could be that that's a factor explaining the gender difference that we found. But this is a really important first step for us to then develop the strateg thinking about what different groups need. Only included a smaller proportion of salaried GPs, so we weren't able to look so well at partners versus salaried. And also looking at ethnic diversity and variations, particularly important given that there's a large proportion of international medical graduates now as GP registrars. So this is a kind of first step and there's going to be future research, which we've been commissioned now to do this research in a larger sample of gps, looking at a longer time frame as well, which will be really nice to be able to look after. Covid. Speaker A 00:06:45.890 - 00:07:02.130 Brilliant. That sounds really exciting. And I think what's really interesting here is how satisfied GPs were with different aspects of their work. What did the gps rate as low satisfaction in their job role and how did this impact on turnover? Speaker B 00:07:02.550 - 00:09:38.570 Yeah, so what we did is we used a theoretical framework to guide our analysis. So within the Work Life Survey, there's a number of different kind of components that gps can rate in terms of their satisfaction with their working lives. But that would be quite a messy analysis. So to try and break this down, we used the ABC of Doctors Needs, which is a framework which talks about the importance of autonomy, belonging and competence for doctors to feel that they're happy and well within their work and that impacts on retention. So, yeah, so we looked at those components and within each of those we used questions from the survey that spoke to those theoretical domains. So, for example, autonomy looked at sort of, there was an item around freedom to choose the methods that they're working with. Also items around paperwork, variety of work and hours of work, belonging looked at particularly around sort of relationships and feeling connected to and valued in the workplace. There's questions in the survey about strained relationships at work and also about recognition, so feeling like they're valued for delivering a good job. And then the third domain that we created around competence, speaks to gps, sort of perceived ability within their role. So I think gps know how to do their job well, but it's actually like their perception as to how well they're able to do that within the constraints of the working environment. So that related to questions on the survey to do with complaints from patients feeling like they didn't have sufficient time to do a good job and also workload issues. And when we came to do the analysis, we found that in those practices with persistent high turnover across three years, all of those domains were significantly related to turnover. So all of those factors are important and it is very Intuitive really, isn't it? But this is the first kind of step in terms of research evidence in a decent sample to show us that these factors are what we should be prioritising for future intervention development. Speaker A 00:09:39.450 - 00:09:50.490 Sure. And one thing that came out really clearly here was the association between that autonomy domain and turnover. Can you talk us through this and why you think it's so important? Speaker B 00:09:50.730 - 00:11:18.330 Yeah. So there's been previous work looking at retention in other fields where autonomy has been really valued. And so this is about. About sort of having flexibility to work, how it's kind of suitable for them in their sort of work life and balancing work life, but also crafting the job to suit their own interests and needs. And this is really interesting, I think, as well, in terms of thinking about the gender differences, I know you're familiar with the other research that I'm involved in about supporting women GPs to thrive in their roles, and that research has shown that there's differences in terms of how patients are allocated to gps according to gender. And so it's really about prioritising fair distribution of work, but also distribution according to doctors interests. So that, that also then speaks to this feeling of competence and being valued. But one of the areas actually that had the highest difference between persistent high turnover practices and the other practices was around competence. And that was really striking, I thought, in terms of those issues around concerns about complaints not having sufficient time were some of the largest differences in practices with high turnover. Speaker A 00:11:18.570 - 00:11:34.020 And I mean, this work is really important because it has shown that clear link between gps having, for instance, a sense of autonomy and belonging at work. But do you or your team have any ideas about how we could use these findings to improve GP retention and reduce turnover? Speaker B 00:11:34.100 - 00:13:36.000 Yeah, I think, I mean, one of the key findings that would be easily implementable for practices would be about supporting team cultures. So there's been a lot of work that's looked at that, but it's. And I know it's often challenging within the sort of workload environments that gps are working in, particularly across fast teams and other roles in general practice as well. But having a sense of belonging within a team and trying to challenge where there are strained relationships would potentially be a kind of first step. I think I've spoken to a number of GPs in my research and in planning future projects where there's just actually no kind of sense of like line management, particularly if you're a GP partner, the kind of. Of getting on with things and not necessarily having that sort of strategic approach to workload management and allocation of work so perhaps a more supportive hierarchy in terms of line management. I know that's, for example, part of the GP retainer scheme, but that's a end of the line approach, you know, and it's also quite short term, so it doesn't necessarily solve the problems that a number of GPs are experiencing. I think also in terms of potentially making the role more rewarding for gps. So I think that they're feeling more distanced from patients, probably, particularly as there's been movements to online consultations and extensive roles in triaging and moving care to other parts of the team, perhaps not necessarily getting that feedback from patients that they're being valued, valued. And obviously there's quite a negative media narrative which drives that as well. Speaker A 00:13:36.400 - 00:13:52.400 And that's a lot of clear messages for practice based working. So, you know, fostering a team environment and trying to think about how to maintain that doctor patient relationship. But if you had a clear message to send to policymakers, what would that be? Speaker B 00:13:52.400 - 00:14:44.400 I think it needs to be grounded in evidence. So we see a lot of policy changes, particularly, you know, in the past year where we don't have an evidence base to support these decisions. And so the work that I'm doing with colleagues at Manchester is. So we've got six years of funding to look at developing retention strategies for GPs that is going to be grounded within the evidence base and developed with gps so that they can be solutions that can be adapted to suit different workforce needs and not this one size fits all approach. So strategies, women GPs, salary GPs, locum GPs and also different area needs so that hopefully then that can develop policy in future, guided by the evidence base. Speaker A 00:14:44.640 - 00:14:57.280 That sounds really exciting, Laura. So, yeah, we'll look forward to hearing more about that big program of research in this area. So, great, great to hear about that, but I think that's probably a great place to wrap things up. But I just wanted to say thank you very much for your time here. Speaker B 00:14:57.440 - 00:14:58.480 Thanks. Nada. Speaker A 00:14:58.970 - 00:15:11.690 And thank you all very much for your time here and for listening to this BJGP podcast. Laura's original research article can be found on bjgp. Org and the show notes and podcast audio can be found at bjgplife. Speaker B 00:15:11.690 - 00:15:12.090 Com. Speaker A 00:15:12.330 - 00:15:14.090 Thanks again for listening and bye.

    • Transcript
  • S4 · E221
    January 27 · 40 min

    BJGP Top 10 research most read and published in 2025

    This episode, we have a round table discussion with the editorial team of Sam Merriel, Tom Round and Nada Khan. This collection of the BJGP’s top 10 research most read and published in 2025 brings together high-profile primary care research and clinical innovation. And here are the top 10 most read papers of 2025: 10 Adoption of clinical pharmacist roles in primary care: longitudinal evidence from English general practice https://doi.org/10.3399/BJGP.2024.0320 9 Factors affecting prostate cancer detection through asymptomatic prostate-specific antigen testing in primary care in England: evidence from the 2018 National Cancer Diagnosis Audit https://doi.org/10.3399/BJGP.2024.0376 8 Paramedic or GP consultations in primary care: prospective study comparing costs and outcomes https://doi.org/10.3399/BJGP.2024.0469 7 What patients want from access to UK general practice: systematic review https://doi.org/10.3399/BJGP.2024.0582 6 Technostress, technosuffering, and relational strain: a multi-method qualitative study of how remote and digital work affects staff in UK general practice https://doi.org/10.3399/BJGP.2024.0322 5 Antidepressants and risk of postural hypotension: a self-controlled case series study in UK primary care https://doi.org/10.3399/BJGP.2024.0429 4 Challenges to quality in contemporary, hybrid general practice a multi-site longitudinal case study https://doi.org/10.3399/BJGP.2024.0184 3 Low-dose amitriptyline for irritable bowel syndrome: a qualitative study of patients’ and GPs’ views and experiences https://doi.org/10.3399/BJGP.2024.0303 2 Artificial intelligence for early detection of lung cancer in GPs’ clinical notes: a retrospective observational cohort study https://doi.org/10.3399/BJGP.2023.0489 1 Effectiveness of low-dose amitriptyline and mirtazapine in patients with insomnia disorder and sleep maintenance problems: a randomised, double-blind, placebo-controlled trial in general practice (DREAMING) https://doi.org/10.3399/BJGP.2024.0173 Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.480 - 00:01:27.500 Hello and welcome to the BJGP Top 10 podcast. So this is where we take a closer look at the most read research papers in the BJGP in 2025 and just have a discussion about what they mean for day to day general practice. I'm Nada Khan, one of the associate editors of the Journal. And in today's episode we'll be exploring some of the themes that really captured attention with the readership, I suppose. And we'll be talking about things like consultation compl complexity and workload pressures. Some work around diagnostic uncertainty and how to look, look after people with multimorbidity. And I think we're going to have a discussion a bit more, not just about what these papers found, but maybe a bit about why they resonated and maybe give a bit of editorial feedback around that. And because it's a conversation here between three clinicians as well. And I'll go around and introduce everyone in a minute, maybe a bit about what they add to the conversations we're already already having in practice and where the gaps still are. And I guess with that we'll be keeping it grounded in the messy reality of today's general practice as well. So I've introduced myself and I'm joined here by Tom Round and Sam Merrill, who are both also associate editors of the bjgp. But I'll go to Tom first. So, yeah, tell us a bit about who you are and how is your day going? Speaker B 00:01:27.720 - 00:01:59.550 Great, Nada. Thanks for having me. So, Dr. Tom Rand, I'm a GP in northeast London and an academic clinical lecturer at King's College, interested in early disease and cancer detection and also health inequality. So, yeah, pretty good. Like everyone, I've got a mild cold at the moment. I think exactly the same last year when we did this podcast, winter cold season. So I think we're all sort of feeling that a little bit in primary care with flus and other things and staff, you know, so otherwise good. Looking forward to having really interesting discussion about these papers which are really fascinating and give a real broad breadth of what we do in general practice. Speaker A 00:02:00.420 - 00:02:07.940 Great. And Sam, we'll go to you and you have some really exciting news in the background as well. So, yeah, tell us about who you are and what you're up to today. Speaker C 00:02:08.180 - 00:02:31.770 Thanks, Nad. I think, yeah, you're alluding to the fact I'm on Puppy alert because our new addition to the family in the winter is keeping us busy and making remote working a challenge. But we're getting through. But yeah, lovely to be with you guys. And I catch up and BJGP and wider podcast audience. So, yes, I'm a GP working in the Northwest of England and a clinical senior lecture at the University of Manchester. Speaker A 00:02:32.650 - 00:04:28.830 Brilliant. Okay, so let's get into the top 10 most read research and published papers of 2025 and I'm going to kick off with number 10 and number 8, just because they're on a sort of related topic. So number 10 is by Michael Anderson and colleagues. Michael's based in Manchester and at lse. And this paper looks at prescribing, quality in practices and the role of clinical pharmacists as. And I'll just point out that I'll put links to all the papers in the show notes as well. So this paper looks at the adoption of clinical pharmacist roles in English general practice and asks that question of does bringing pharmacists into the primary care workforce actually lead to improvements? Michael looked at this through a longitudinal approach. They used national practice level data from 2015 to 2019 and just looked at practices that didn't, didn't have a clinical pharmacist role. And it's really interesting, the results actually. So, not surprisingly, the proportion of practices with a clinical pharmacist increased from about 3% to over 20% over the course of the study. And the, the team found some really significant improvements across several prescribing indicators. So things like reductions in total medication costs, better opioid prescribing and prescribing for anxiety meds after pharmacists were implemented in pract, I guess, really it would be interesting to hear your thoughts, Sam and Tom, about what do you think really are the outcomes we want most from clinical pharmacists? And how do you think we should interpret these modest changes at scale? Because there's a lot else going on in terms of workforce that we need to think about in general practice, like access and continuity and not just meds optimization. Speaker C 00:04:29.310 - 00:05:41.170 I can talk from practice experience because our clinical pharmacist just left for Canada just in the last month or so. But yeah, it was really interesting, like having him part of the team. I think in a lot of ways he took a lot of burden off the gps in terms of meds monitoring, meds management, medication reviews. He builds a lot of continuity with a lot of patients because he was doing a lot of checking in. So in a lot of ways he was quite invaluable member of the team and we have sought a replacement since. At the same time, you know, there was some, some extra challenges in terms of workload and stuff, because obviously pharmacists have different training and the role of a clinical pharmacist in general practice is relatively new. So, you know, their approaches to prescribing and, you know, how close you stick to guidelines and how much you adapt for individual patient situations is slightly different. So. Yeah, but I think that was part of sort of feeling a way out with the role. But it's really noticeable when he's not around because it does affect how the workload flows and how the practice runs and how the patients, you know, interact with the practice. So, yeah, it's been really interesting at the local level. But, yeah, Michael's study also very interesting to look at the wider picture about how it's affecting quality of care. Speaker A 00:05:41.730 - 00:05:45.970 And I'll just jump now to number eight, unless, Tom, you want to add. Speaker B 00:05:45.970 - 00:06:10.770 No, just to say, obviously this, this paper is looking at the macro level up to 2019, so it'd be really interesting what happened since, because we only started having a pharmacist after that point with the induction of ARS roles. So I think, yeah, further, you know, this is giving a signal, we think that some indices are improving, but also I think it's important to be aligned with our own subjective experience, maybe qualitative and other implementation type research. But overall, I think this trend is a good thing, I think, from my own experience. Speaker A 00:06:11.570 - 00:07:55.630 Yeah, absolutely. And then I guess jumping to paper number eight, which was written by William Hollingsworth and his team from Bristol, and this is looking at comparing paramedics in general practice with gps. And the paper is asking a really practical workforce question, which is, is what happens to patient experience, safety and NHS costs when patients are seen by a paramedic in general practice rather than a gp. And this team looked at this, they used a prospective cohort study across sites in England and they looked at patients who had an urgent or same day consultation with either a paramedic or a GP and then looked at their outcomes over the next 30 days. And I guess the headline finding is that really there wasn't a clear difference in patient reported health and well being over 30 days, but there were some differences in that experience right after the consultation. So patients who saw a paramedic said that they were. Well, they reported lower confidence in their health provision, they felt there are more communication problems and maybe a lower perception of how the practice promotes safety. And there were fewer subsequent GP appointments in the paramedic group, but there weren't really any GP savings as such that were offset by higher use of other health care professionals. So I guess that you could sort of summarize that by seeing. Seeing a paramedic might lower GP pressure, but it doesn't necessarily reduce overall NHS costs. So I wonder, yeah, Tom, coming to you, what do you think should really matter when we diversify the workforce? Do you think it should be workload, cost? Yeah. Speaker B 00:07:55.710 - 00:09:28.360 Really interesting discussion, isn't it? And we talk about testification, isn't it? Sort of, you know, how do we, you know, how do we help GPs with workload? Workload, sorry. Fundamentally we need more GPs, don't we? We need to have, you know, we've got high 2,300 to 2,500 patients, sometimes even higher deprived areas. So fundamentally, I think the workforce, we do need more gps. This also debate, also, you know, obviously there's a slightly toxic now debate about physicians, associates. You know, from my own viewpoint, you know, undifferentiated initial consultations in primary care are high risk. We know that from all the evidence and the research. So you've got to be very careful about patient select selection and triage for this. And you can see, I think also this links to. We've got this big increase in the ARS roles, but then we haven't seen that increase in primary care satisfaction. So I think this comes down to people probably still want to see a GP for certain conditions. How do we get to that right model of MDT working? And I think we do need robust safety evidence. So this obviously is, you know, it's good study, but it's fairly small scale, probably need larger scale and systematic review evidence about this replacement. You know, what's the safe role? What are the guidelines? What sort of cases should these people, should other allied healthcare professionals be seeing, particularly for undifferentiated illness? And going back to the, obviously, the PA debate, we've obviously got the college position that probably PAs should not be seeing undifferentiated illness in primary care. So I think it's a nuanced discussion, but we need better, we need further studies like this to help us decide what we're doing. Speaker A 00:09:28.760 - 00:09:54.380 Absolutely. And I think that's really important as the workforce in general practice increases to diversify and policy shifts towards an increasing multidisciplinary team as well. So, yeah, be interesting to see what happens in the future. Really great. So I'm going to go over to Sam and Sam, you're talking about paper number nine, but, yeah, talk us through this. This is a bit a paper that, you know well, so tell us a. Speaker B 00:09:54.380 - 00:09:55.820 Bit more about it and your involvement. Speaker C 00:09:55.820 - 00:09:59.700 In it, first author on a BJGP top 10 paper. I'm very honored. Speaker B 00:09:59.700 - 00:10:00.460 Congratulations. Speaker C 00:10:01.020 - 00:13:14.370 Humble to all the readers out there who had looked at it. So this was a study of asymptomatic prostate cancer detection using PSA in primary care in England. And we used data from what's called the National Cancer Diagnosis Audit. This was the 2018 version. So we had about a quarter of practices in England participate in the ncda and data was gathered using a sort of standardized template on all the new cancer diagnoses in a practice in 2018. So practices participate were given that list and a template to complete and looking at the record in detail. So what happened to these patients in the lead up to their diagnosis? Were they seen in general practice? What happened? Were they investigated? Were they referred to? And it was not screen detected cases for any of these were specifically cases coming through primary care. And the strength of this data set is that we have access to both coded and free text data in the record. So a lot of large primary care research data sets like CPRD don't have free text data. So it's relying on GP coding, which we know varies between practices. So the big things that this study found we looked at. So There were nearly 10,000 prostate cancer cases in the entity. Overall, when we filtered out all the patients who had symptoms recorded at the time of presentation of primary care and the time of diagnosis, we were only left with about 1900. So the vast majority of men with prostate cancer symptoms were present at the time of diagnosis, which conflicts somewhat with existing literature out there, the quality of which is pretty variable and often not great. So that was one interesting finding. In terms of the differences between practices for asymptomatic prostate cancer detection and PSA testing, there's huge variation, something like 14 fold difference between the practices picking up the most men through asymptomatic PSA testing and the practice picking up the least. And we didn't see any obvious GP practice level factors, so it didn't matter about geography, list size, number of GPs, cough outcomes, none of that seemed to make any difference. There were patient level factors, so older men less likely picked up through that route, which kind of makes sense because symptoms are much more common in men as they get older. And PSA testing, the benefit is less generally depending on their general health, so it might be done less often. So that makes sense. Men from deprived areas were less likely to be diagnosed through this route, which we know there are significant inequalities for men deprived regions in terms of prostate cancer outcomes. Not Just PSA testing, but stage of diagnosis, treatment outcomes, we need to do better with that group. And interestingly, white men were less likely to be diagnosed through this route. Even though the sort of stereotypical person being, coming in, asking for a PSA test when there are no symptoms and maybe a low risk is a. Is an older, wealthy white male, they were less likely to diagnose through this route, which. That was an interesting finding. Yeah. So really interesting study. Obviously grabbed some interest and is a very, very, very topical issue at the moment with the NSCS recommendation that's out for consultation. And I think, you know, we still got to watch this space because I think there's going to be more coming in the year's ed. Speaker A 00:13:15.170 - 00:13:42.330 Yeah, really super topical, Sam. And just to point out, we did record a podcast talking about this paper in more detail, if anyone wants to listen to that. Tom, you work a lot in cancer diagnosis in that sort of world. I mean, obviously brilliant work from Sam and his colleagues, but I just wanted to know what your thoughts were. Just reflecting on this paper in terms of sort of the wider policy discussions and discussions around the future of prostate cancer screening. Speaker B 00:13:42.330 - 00:14:36.520 Yeah, yeah. So I think it's very topical, isn't it? There's lots of. In the press around, you know, should we be doing PSA testing? So we currently got a slightly...

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  • S4 · E220
    January 20 · 21 min

    Safety incidents in prison healthcare: Lessons from critical illness

    Today, we’re speaking to Dr Joy McFadzean,a GP in Swansea and Clinical Lecturer of Patient Safety based at Cardiff University. We’re here to talk about the paper she’s recently published here in the BJGP alongside her colleagues titled, ‘Critical illness in prisons: a multi-method analysis of reported healthcare safety incidents in England’. Title of paper: Critical illness in prisons: a multi-method analysis of reported healthcare safety incidents in England Available at: https://doi.org/10.3399/BJGP.2025.0239 Using a mixed-methods descriptive and framework analysis, this paper provides new insights into the complexity of care delivery in prisons. Results resonate with and strengthen the recommendations from recent investigations into prison healthcare by further developing an understanding of the complex intersecting factors contributing to safety incidents and quality issues in care delivery. The fundamental importance of good quality and adequately resourced primary care delivery in prisons has been highlighted. It also identifies system-wide interventions that are needed to improve care delivery, and which are likely to interest policy-makers and scrutiny bodies, commissioners and teams working in prisons to inform developments in strategic health needs assessments, workforce profiling, and training requirements for healthcare and prison teams. Funding This study/project is funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme (PR-R20-0318-21001). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders of the study had no role in study design, data collection, data analysis, data interpretation, writing of the manuscript or the decision to submit. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.560 - 00:01:10.200 Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the associate editors of the bjgp. Welcome back to the first season of the BJGP podcast here in 2026. And we're starting off this season of the podcast with a chat with Dr. Joy McFadyn. Joy is a GP based in Swansea and clinical lecturer of Patient safety based at Cardiff University. We're here to talk about the paper she's recently published here in the BJGP alongside her colleagues. The paper is titled Critical Illness in Prisons A Multi Method Analysis of Reported Healthcare Safety Incidents in England. So, hi, Joy, it's really lovely to meet you and to talk about this research, but yeah, just taking a step back, I think it's fair to say that the prison population is an underserved and probably fairly under researched population as well. But you point out here in the paper that it's not only this, but that the prison population is actually at a much higher risk of early mortality as well. So can you talk us through this at all? Speaker B 00:01:10.680 - 00:02:31.010 Yeah, that's a really good point. So we know that people who reside in prison, known as prisoners, will have very high rates of physical and mental health needs. And as you say, there are concerns that they have rates of premature mortality, so they may die up to 20 years earlier than the rest of the population. But they are a population which isn't necessarily the area of focus. So even though we know the importance of supporting their healthcare as a public health concern, they are often underserved, they're quite vulnerable, and yet there hasn't been enough research to support them to have what we call equivalent health outcomes. So there are lots of definitions of what is considered to be equivalence of care for people in prisons. So the Royal College of General Practitioners Secure Environments Group, they have defined what equivalence of care is for people in prisons, thinking that they should have the same quality of care, the same level of staffing, the same resources as anyone who is residing in the community in order to get the same health outcome. And currently that is not being realised. Speaker A 00:02:31.330 - 00:02:38.210 And just as a background to all this work, how many of these early deaths do you think are preventable? Speaker B 00:02:38.930 - 00:03:39.270 So we carried out a study which was called the Avoidable Harm in Prison Study. So it was focusing very much on healthcare events where people were harmed or could have been harmed whilst they reside in prisons. So our focus is very much on these patient safety incidents, reports and incidents themselves, and ultimately the findings of the other space of the study. We haven't released yet they're still embargoed. But we were seeing within our sample of patient safety incident reports, events where prisoners were undertaking significant harm. So within our paper, we haven't seen any evidence of the deaths which could be considered to be avoidable. But our focus was very much on events where without urgent treatment, there was a high risk of death. And we considered many of those events to be avoidable. Speaker A 00:03:39.590 - 00:04:10.690 And I guess all this is tied into what you're aiming to do here in this research, which was to look at and characterize patient safety incidents in the prison population and find opportunities to improve care. So you used a really detailed approach here and looked at patient safety incidents reported in England and carefully examined and coded all of the incidents here. But I really want us to talk through what you found, what were the main sorts of incident type. And what I'm trying to get at is what really happened in these reports. Speaker B 00:04:11.410 - 00:07:08.750 Yeah, thank you. So we reviewed Originally up to 4,000 of those patient safety incident reports. And then when we focused specifically on those events where someone was at very high risk of death if they hadn't received treatment, we were looking at conditions suggestive of heart attacks, strokes, status epilepticus, diabetic ketoacidosis, for example. And what we saw is that most of the reports that were included for analysis, so about 100 of those reports, people in prison were not being able to access healthcare professionals when they needed to. So in prisons, people will have an assessment when they arrive to the prison, which is an assessment of their healthcare needs. They should also have access to nursing staff, GPS and allied healthcare professionals, as well as referrals to secondary care as needed. And what we were seeing is that when there are events where someone was critically unwell, they couldn't access the staffing when they required. So it's very much a nurse led service in the prisons. And even when there were prisoners who had collapsed, nursing staff could not access the prisoners. And that was for lots of different reasons. Some of it was related to poor communication, that there's quite a reliance on the use of radios in our reports. And so if people were trying to radio from one area of the prison to the healthcare teams, then there was too much radio traffic that their messages weren't getting through or they were using the wrong emergency codes. So actually the nursing staff weren't aware of the urgency of when they needed to get there. So there were lots of delays in actually having the healthcare teams arrive and assess the patients themselves. But also when a decision was made that someone needed to be conveyed to an emergency department, for example, due to difficulties with staffing levels, there weren't sufficient prison officer numbers to escort them from the prison to hospital. So there was significant delays. So what we could see in some of the events is that someone had collapsed. There was concern that this was suggestive of a stroke, they were dysphasic, they had facial palsy, they had tinnitus, headaches, et cetera. And nursing staff had assessed, said, no, they're unwell. Gps had said they need to be conveyed to the hospital and they weren't transferred until the following day. So those types of delays were very evident as well. So difficulty accessing the healthcare professionals in the first place and then a delay getting the correct treatment or management, even with conditions which are time critical. Speaker A 00:07:09.630 - 00:07:29.500 That all sounds really shocking, actually. But I wonder if we could just take a step back and, and could you describe to us what healthcare provision is like generally in prisons? You mentioned about a nurse led care system, but how easy is it to access other healthcare professionals like GPs in prisons generally? Speaker B 00:07:30.700 - 00:11:02.620 So I think there are two very different opinions in this. So we have the access to the patient safety incident reports, which is telling us that it's very difficult for them to access healthcare professionals as needed within the prisons that we looked at for the avoidable harm in prison study, for example, we were only focusing on prisons where health care was delivered on site and the provision is very variable. So different prisons may have NHS provision, but the majority is probably private provision as well. So it's a commission service, there's a lot of competitive tendering and there are concerns by some that a focus may be more on cost saving than it is on quality provision. So what we saw within our patient safety incident reports was evidence that it was very difficult to access the healthcare teams. So even though healthcare provision should be delivered and there are nurses, you know, round the clock, they were having lots of difficulties accessing any types of healthcare provision out of hours. Our instant reports was an overreliance often on some of the electronic E consulting systems. So the use of System 1, for example, in prisons in England, and what we could see is that people were presenting with quite significant symptoms and instead of what we would have thought would happen is someone was picking up the phone and referring them in. Lots of electronic tasks were being sent around teams without necessarily an overview as to who was completing those tasks or an overview of what that meant. So our focus is very much on these critical conditions, but some of it was related to the management of long term conditions. In the first place that if someone's diabetes was being managed appropriately, that they were having annual blood tests or having their blood pressure checked, they were making sure that they had sufficient insulin, for example, then there shouldn't have been an occasion where they were experiencing diabetic ketoacidosis and needed to be admitted. Making sure that there's appropriate management of care, but also then that organisational factors. Are there sufficient staffing numbers or are there not? And part of the concern that we could see in our incident reports was the role of locums and agency staff who perhaps were not as familiar with prisons and prison health care systems. And they would often forget their passes to even log into the system, so they couldn't see a patient's medical records. They were not familiar with the need to actually call for help, how they called for help. They didn't know that if an emergency code is coming through the radio, that meant they needed to grab the healthcare bag with all the emergency equipment and run towards a specific wing or whatever is needed. But focusing very much on these emergency conditions, there was a concern that the locum staff were not familiar with the protocols, the policies of the prison. They were not carrying out observations, they were not documenting efficiently what they had actually carried out with the person residing in the prisons and that was delaying care that was stopping them from being transferred to emergency departments when they needed to be. Yeah. Speaker A 00:11:02.620 - 00:11:15.860 And what's interesting here is that in this paper you looked at some major themes here around these different incidents. Can you talk us through this and what were the main findings here? Speaker B 00:11:16.740 - 00:17:45.240 So we were thinking about the different aspects and cogs within the healthcare system in the prison and how they all interact with each other. And we use the CEAPS model, which is the systems engineering initiative for patient safety, and it has six main domains that we were trying to understand if thinking about our patient safety incident reports and the themes within it, as well as the contributory factors, so why these events were taking place. We tried to then map them to the domains of the Systems engineering and initiatives patient safety model, which is ceps. And what we could see were the different domains were prevalent throughout the reports. So there is a concern about tools and technology. For example, so I've mentioned about the emergency radios, but also the lack of certain tools. So there wasn't a provision of life saving equipment in prisons. So there were often reports from paramedics as well as people who reside in prison to advise that when there were events where a patient may have harmed themselves or there'd been an assault and an injury. There wasn't life saving equipment within the prison, so no cannulas, no IV fluids. Obviously there was going to be no consideration. There would be blood products or anything of the like, but there was nothing that they thought would, would support major blood loss and hemorrhage. There were also, in many of the prisons, no AEDs. So if someone had collapsed, potentially having a heart attack, for example, and their heart had stopped, we know the evidence that they need to get the paddles on their chest, we need to restart their heart if it's in an appropriate rhythm. But there was nothing of that, like in many of these prisons, to actually support that. So if there is any type of delay in calling for an ambulance, an ambulance should be adhering to the same national guidance of the emerg response times. That should still be actualized within a prison too. But what was happening is that an ambulance was being called. There was some confusion as to where in the prison the prisoner actually was, which wing of the prison, which area of the prison. Once the ambulance was arriving at a gate, they couldn't actually come straight through because of security concerns that the ambulance might need to be stopped and searched to ensure that nothing was entering the prison that shouldn't be. And that was, you know, causing significant delays. And then when they were getting to patients who'd collapsed, for example, there were delays for them even conveying them out of the prison. So there was a concern that the healthcare professionals were not saying to them, you just need to convey them now they need to go to an emergency department. We do not have sufficient care for them here. So that was the concerns about tools and technology, for example, and then thinking about the organisational aspects. So that would be within a healthcare system, things like staff rotors. You know, I've mentioned already that there were some concerns with sufficient staffing levels. So there are concerns by people who work in prison. There can be quite a high turnover, perhaps an over reliance on locum and agency staff. People may become quite burnt out in the system and therefore they may leave the prison. And for some GPs who work in prisons, it may not be there full time physician. They may work elsewhere and then they may do a couple of shifts in the prison. So there isn't necessarily that continuity of care and how that might impact on prisoner healthcare. Then within the CEIBS model there's concerns about personal factors or person factors. So these are the people working in the system as well as the patients themselves. So one of our recommendations after reading all of the reports, is that perhaps they require more focused training for how to deal with emergency conditions and the response. So what we saw is that people weren't prepared to have multiple emergencies happening at the same time, which unfortunately does happen in the prison. So there were lots of reports in which there were concerns with substance use in parts of the wing, perhaps using the substance spice, for example. And then there was a report that three, four, five prisoners were all unconscious at the same time. They therefore all required set of observations, need to check their oxygen levels, probably be placed in the recovery position and observed carefully until they came round, or if they weren't coming round, they need to be conveyed to an emergency department. And then thinking about the context of the prison, we think about the internal environment. So knowing that within the prison, security constraints will often outweigh concerns with healthcare. And that is an important balance that both the prison teams, the prison officers, the governors, need to balance alongside the healthcare professionals. And so what we were seeing, for example, is that during any type of lockdown in the prison, so security concern, a wing needs to be locked down. That means the prisoners need to return to their cells. They cannot le. If something happens where someone is considered to be critically unwell, they collapse, they are complaining of chest pain, they have symptoms suggestive of a stroke, for example, they haven't got access to their insulin, so their sugars are rising, they become unwell, etc. What we could see is that the healthcare teams could not access the prisoners, they couldn't get to them. So that's the constraints of the internal environment. And then the external environment is like I was mentioning, about those commissioning gaps. So concerns where care is not being funded appropriately, if that emphasis is on the cost of a service rather than the quality and the outcomes for patients, then perhaps they're not getting appropriate care when they should be. Speaker A 00:17:45.480 - 00:18:04.580 And I think I'd suggest to anyone listening who's interested in this area, I'd suggest they go back to the paper and take a close look at box two, where you talk about the main recommendations for prisoner health as a result of this work. But what do you think are the most important...

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Showing 21–27 of 27 episodes