BJGP Interviews

Today, we’re speaking to Dr Jasjot Saund, a public health registrar based in London. Title of paper: Association of the NHS Health Check with all-cause mortality: a longitudinal cohort study in primary care Available at: https://doi.org/10.3399/BJGP.2025.0451 The NHS Health Check (NHS-HC) has been shown to improve detection and management of surrogate markers of health, such as blood pressure and cholesterol. The long-term impact, however, is less evidenced, with mortality reductions seen in a UK Biobank cohort and no mortality reduction seen in a Cochrane review of general health checks, including those outside the UK. The current study added real-world evidence from a diverse UK urban population, and a 15-year study period. Survival analysis of GP electronic health record data shows reduced mortality in those who attended an NHS-HC compared with those who did not. These findings should be interpreted cautiously given the observational nature of the study design. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:01.440 - 00:00:58.570 Hi and welcome to BJGP Interviews. I'm Nada Khan and I'm the senior research editor of the Journal. Thanks for taking the time today to listen to this podcast. In today's episode, we're talking to Dr. Jazjot Sound, a public health registrar based in London. We're here to discuss the paper she's recently published here in the BJGP titled Association of the NHS Health Check with All Cause Mortality, A Longitudinal Cohort Study in Primary Care. So thanks very much for joining us here today, Jazja. It's really great to talk about this work and I think just before we get into the study itself, we know that NHS health checks are something that most GPs will probably be very familiar with, but maybe we don't always stop and think about the evidence behind them. So, just to start off, I wonder if you can explain to us a little bit about, about what the NHS Health Check program is actually designed to do. Speaker B 00:00:59.050 - 00:02:16.370 Yeah, absolutely. So the NHS Health Check program was rolled out in 2009 and it's essentially a population level preventative initiative, focusing particularly on cardiovascular disease, but potentially wider as well. And so it's specifically targeted at people who are between the ages of 40 and 75 and who don't already have a, a cardiovascular disease or a known cardiovascular disease. And I think that's really important because it's targeting people who are potentially at risk or have undetected disease. And what this means is, so ultimately the health check itself, it consists of a check that's usually undertaken by primary care, so looking at lifestyle factors, modifiable risk factors, biochemical tests, as well as sort of just other general checks. And importantly, this is embedded into primary care pathways. So essentially it's ensuring that these patients are followed up if they are determined to be high risk and potentially put on prescriptions or followed up with lifestyle modifications. So that's generally what the health check is at the moment. Speaker A 00:02:16.690 - 00:02:31.070 Brilliant. Yeah. And I guess the big question behind this paper is, do they actually make a difference? And I wonder what did we actually know about the impact of NHS health checks before you started this work? So what was out there in the literature already? Speaker B 00:02:31.550 - 00:04:07.320 Yeah, so there is a, a huge amount of evidence in different parts of the health check. So you might be aware already that it's a multifaceted intervention. So there's, there's the process bits like uptake and invitation. So there's a big amount of evidence that's been telling us that it's really important that we even just the method of invitation can be really influential on who takes up the health check. But then there's also the specific parts of the check itself. So how we communicate risk to patients, for example, can have an impact on how people go home and take on lifestyle advice. And then there's the body of evidence that's closer to where this paper sits, which is looking at clinical outcomes. And there is a whole body of evidence looking at surrogate markers, so things like does it shift the marker on blood pressure or bmi. And then there's the evidence on mortality, for example, or clinical endpoints such as stroke. And so far the evidence is predominantly positive to say we do see a change in clinical outcomes. And more recently, there was a paper in 2024 which was using a UK Biobank cohort and shows that there was an impact, a positive impact on disease, end stage disease, as well as mortality. But as the paper sort of addresses, there's some gaps in this evidence, which is what we. What we hoped to fill. Speaker A 00:04:07.560 - 00:04:25.280 Yeah. And I guess I wondered if you could just talk us through the data used for this study, because this was a really large real world cohort from an inner city London population, wasn't it? So very different than the kind of population that might, for instance, have taken part in UK Biobank? Speaker B 00:04:26.240 - 00:05:17.420 Yeah, absolutely. So we thought it was really important to look at whether or not the health check was having an impact as it was being delivered in a real world population. And so we were lucky enough to look at a cohort going all the way back to when the health check was implemented in 2009 in Lambeth, which is a really ethnically diverse and socioeconomically diverse cohort. So, for example, we have a population in lambeth that is 40% non white, as opposed to, I think the UK Biobank participants were 96% white. So there's a real difference. And so we wanted to ensure that the population we looked at was representative of some of the inner city boroughs that have particular challenges around NHS health check uptake. Speaker A 00:05:17.660 - 00:05:27.330 Okay, so let's get into what you found. And what was the headline result when you compared people who attended at least one NHS health check with those who didn't? Speaker B 00:05:28.120 - 00:05:53.320 Yeah, so the headline result actually showed that there was a 32% relative risk reduction associated with the health checks on all cause mortality. So that's looking at any cause of death, but shows quite an impressive risk reduction. So that is a relative risk reduction as opposed to absolute. So it's important to note that overall the absolute rate of survival was high,. Speaker A 00:05:53.750 - 00:06:03.670 And that's pretty Striking, actually. So that substantially lower risk of all cause mortality, were you surprised by the size of that association? So 32% is quite big, isn't it? Speaker B 00:06:03.750 - 00:06:33.490 I think initially I was surprised, but then looking back at the evidence and the data that's already out there, it does fall in line with kind of what we were seeing, particularly in the UK Biobank cohort as well. I think there is sort of evidence that potentially looks at general health checks, which has shown a converse picture. But as we discussed in the paper, it's really different to how the NHS health check is delivered here. So that's definitely something to bear in mind. Speaker A 00:06:33.810 - 00:06:45.250 And you also looked at absolute mortality risk over 10 years and the difference seemed to be really pronounced with increasing age. So could you talk us a little bit through what you found there? Speaker B 00:06:45.650 - 00:07:39.440 Yeah, so we found that although the older population had a. A higher absolute risk reduction, they also had a higher absolute baseline risk of death as well. So it's really difficult to distinguish whether or not that finding was related to the health check being more beneficial in older patients or whether or not actually we see a bigger absolute reduction, because in our over 65 population there is a higher baseline risk of, of death. I think we, like, when looking back at the data population who was enrolled in 2009 at the youngest possible age were 40. And even though we had 14 years of follow up, they would only be 57 years old at this point now. So their absolute risk of death is still very low, which might be more difficult to pick up in a study like this. Speaker A 00:07:39.760 - 00:08:10.860 Yeah, fair enough. And I guess, you know, whenever we look at observational research, I suppose the question is whether people who attend an NHS health check are somehow different than people who don't. And that's, you know, in parallel to the studies. For instance, you know, just focusing on UK Biobank, it's sort of a different population really. And I guess people who attend a health check could potentially be more health conscious or more likely to engage with healthcare. Anyway. How did you try to account for that in this work? Speaker B 00:08:11.100 - 00:09:45.530 Yeah, and that's a really important point to pick up and something that's really challenging in observational data in general. But so, yeah, we really wanted to make sure we tried to adjust or account for this. And so, as you said, some. The healthy attender bias is something that can come up when people are more likely to attend a health check if they're more health conscious. So we used a method called propensity weighting, which is similar to propensity matching in that we look at the probability that somebody attends a health check based on their characteristics and use that probability to weight the groups to ensure that the characteristics are balanced between those who attend and those who don't attend. So that was one method, but we also saw in our descriptive analyses that actually it wasn't a uniformly healthy group of attendees. There was a higher rate of overweight and obesity in the people who attended health checks and there was a higher rate of a family history of coronary heart disease as well. To be extra sure. We also did some statistical analyses which tried to measure the level of unmeasured confounding. So obviously we can only adjust for what we can measure. So we wanted to understand how big is the unmeasured confounding, and we found that actually it would need to be twice as big as the things that we had already adjusted for to account for the full picture. So that's quite, quite large. Speaker A 00:09:45.770 - 00:10:15.510 And I was also, as you were describing, interested in the fact that the NHS health check isn't just a single intervention. So it's a check, but then there's all that stuff that happens afterwards. So identifying the risk factors, how you communicate that to people and how that impacts things, then they might have follow up or start medication or get referred onwards. And do you think that that's one of the reasons it's difficult to really pin down what part of the program is actually making a difference? Speaker B 00:10:15.830 - 00:11:04.610 Yeah, I think it's a really complex public health intervention and it does require each aspect to have its own rigorous evaluation as well as the whole picture as a whole, which is where our study sits. But that is on top of evidence behind each facet. But it does then make it quite difficult to understand which is the biggest lever. But I think far what we're seeing is definitely ensuring uptake in underserved populations, as our study also highlighted that there is a benefit across all ethnicities and imd, like deprivation quintiles as well. But also the follow up is important as well, ensuring that these health checks are embedded in clinical processes also been shown. Speaker A 00:11:04.850 - 00:11:10.050 Yeah. And I wonder if there are any other main findings from this work that you wanted to highlight. Speaker B 00:11:10.470 - 00:11:46.530 Yeah, I think I sort of touched on it just briefly. But interestingly, we ran the analysis on premature mortality as well and found that the benefit still held. And we also ran the analysis on different deprivation quintiles as well as multiple ethnicities and found that the direction of the evidence is the same, showing that health checks do improve mortality, although some of the smaller subgroups didn't reach statistical signals significance. But we think this is likely just because we're looking at small groups and those with the biggest groups did reach significance. Speaker A 00:11:47.090 - 00:12:13.160 Really interesting. And I guess overall, I wonder what your feelings are about what the implications are for general practice, because I guess sometimes it can feel like one more thing that has to be fitted into an already pretty busy system. And it's really interesting to get your perspective as a public health doctor as well. Do you think that this study should change the way that we think about the value of the health track? Speaker B 00:12:14.440 - 00:13:29.500 So definitely, potentially, yes. I think some of the wheels are already in motion as well. So this will have implications as a full body of evidence, not just this paper in isolation, at local and hopefully at national level as well. And we're starting to see changes already. So there's been rollouts of digital pilots as well as workplace based health checks as well. And so I think the evaluation of those are going to be really telling and important to see whether we're still reaching or we can reach the intended outcomes of the health check. But it also means that potentially these are pulling on those levers, such as increasing uptake and reducing those traditional barriers and ensuring that, yeah, health checks are equitable. But also I think we're seeing signs in the recently published Cardiovascular Disease Modern Service Framework, which talks about potentially expanding the scope of health checks, so looking at a more cardiovascular, renal, metabolic focus rather than just cardiovascular disease. And this is because these conditions can co occur and particularly in more underserved populations as well as, and you've mentioned. Speaker A 00:13:29.500 - 00:13:43.020 Equitable access in some underserved communities. Was there anything that you felt needed to be highlighted in terms of how health checks need to be more equitable or anything, especially given the population that you included here in this study? Speaker B 00:13:43.820 - 00:14:28.680 Yeah, so interestingly, Lambeth is obviously a very diverse population and interestingly, the uptake was pretty high in our minority ethnic groups and underserved populations. So that was really positive in knowing that, okay, it is potentially reaching the right people, but there will still be a group of populations of people that will be struggling to access these. So I think definitely this paper highlighting the fact that the mortality benefit is held across diverse populations is really important to ensure that within the borough and across other boroughs that we do continue to reach those underserved populations. Speaker A 00:14:28.840 - 00:14:40.440 And I guess finally, for gps listening to this, who might be trying to think about how to take the findings back to their own work, what's the one thing that you want them to take away from this study about NHS health checks? Speaker B 00:14:40.520 - 00:15:14.260 Yeah, I think. Well, I'm hoping it's reassuring. So I hope that. I know that there might be some people on the fence about whether or not health checks are beneficial. So I hope that this can add to the body of evidence that provides reassurance to gps that although it's very difficult to see such a complex public health intervention moving the needle on, you know, small parts of the population, that actually at the overall population level, it is making a difference or there is an association with a reduced mortality. Speaker A 00:15:14.740 - 00:15:24.440 Yeah. And it's so brilliant to see this work done, as you say, in a real world sample. And I think the findings are really striking, actually. So it's great to, to hear more about this work. Speaker B 00:15:24.600 - 00:15:25.240 Thank you. Speaker A 00:15:25.560 - 00:15:30.760 Yeah. So brilliant. I think that's a great place to wrap things up. But I just wanted to say thanks very much for joining us here today.

Today, we’re speaking to Dr Emma Ladds, a GP partner and DPhil candidate at the Nuffield Department of Primary Care Health Sciences at the University of Oxford. We’re here today to discuss the recent article she and her colleagues have written for the journal, titled, ‘Ambient scribes in general practice — help or hindrance?’ Title of paper: Ambient scribes in general practice — help or hindrance? Available at: https://doi.org/10.3399/BJGP.2026.0097 Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.320 - 00:01:15.600 Hi and welcome back to BJGP interviews after our summer off. I'm Nada Khan and I'm one of the Associate editors of the Journal. Thanks for listening to this podcast today. In today's episode, we're talking to Dr. Emma lads. Emma is a GP partner and a DPHIL candidate at the Nuffield Department of Primary Care Health Sciences at the University of Oxford. We're here today to talk about the recent article that she and her colleagues have written for the analysis section of the Journal. And the article is titled Ambient Scribes in General Practice. Help or Hindrance? So, hi again, Emma. It's lovely to speak to you about this work. And I think one of the reasons we were interested in picking up this article is that it's really highly topical and it's in an area that I think a lot of people are wondering what to do in their day to day practice. And I think that some of the issues that you've highlighted in the article do speak to some of the concerns that people are raising, but also some of the challenges with the implementation in practice. But I guess before we get onto some of the issues that you raise in the paper, can you just explain what we mean by an AI or ambient scribe? Speaker B 00:01:16.160 - 00:01:45.660 Well, it's the technologies based on artificial intelligence that detects conversations, so between the patient and gp, or between GP and other colleagues. And in consultations, it then generates a summary of what's been discussed, but also does some other things as well. So, for example, it might add some coding labels for specific things that are mentioned, and then all of that goes into the patient's electronic health record. Speaker A 00:01:45.980 - 00:02:15.130 And I think that these tools are often presented, at least to some of the GP colleagues that I know and work with, as almost like an obvious win for general practice. So less documentation, more efficiency, and maybe more time with patients. But what made you want to just take a pause and think about some of the assumptions behind some of those quick wins that people might be thinking about, thinking about. Speaker B 00:02:15.450 - 00:03:31.980 And I mean, I think it's interesting, isn't it, because ever since we started to introduce different technologies into the consultations, there's often been an assumption that every new thing would be a quick win. And even since the introduction of the computer, you make for greater efficiency and it will be easier to store data, to retrieve data, to share data, et cetera. And of course, a lot of the time what those technologies do is they drive particular activities. I think it's been interesting just to think about how introduction of different technologies and platforms and digital approaches has driven a much more transactional, quantifiable way of working. And those things that can be recorded and can be captured in technologies or enabled by technologies have been promoted, perhaps at the expense of some of the less quantifiable, more nuanced activity. So suppose it was looking at that journey of technologies and just trying to think about what this next step might also add to that picture. Speaker A 00:03:32.220 - 00:03:41.820 And one of the things you talk about in the article is that AI scribes could create what you call false efficiencies. But can you unpick what you mean by that? Speaker B 00:03:42.300 - 00:04:53.150 I think there's this assumption that actually the summaries and the codes that AI scribes will generate will be very time saving for gps. And no GP ever has enough time. So everybody's looking for, as you put it, the quick wins. And some of the challenges with the outputs from AI inscribes are that they often produce very long transcripts because they're trying to capture a summary of everything that was discussed and that gets entered into the record. And obviously it takes time for subsequent clinicians to look through those kind of summaries. So that could be a fold sufficiency. But also, I mean, it can add false labels or generate errors and that requires checking as well. So it's not that it just produces an accurate summary and then that's out there. Actually, the clinician still has to go back and double check that everything's been done correctly. So even though they don't have to do the actual typing, there's still a level of processing that they have to do of that summary. So it's not necessarily a time saving tool, really. Speaker A 00:04:53.630 - 00:05:15.390 And I think that's one of the interesting things about it because, yeah, there's that interesting point that, you know, GPS might be getting that time back in some other way, but I guess that's highlighting that that might not actually be quite that simple, that the time that you might get back from not having to type out the notes from a consultation is actually being used elsewhere. Speaker B 00:05:15.390 - 00:06:20.920 Actually, I think that's very true. And I think the other thing that's worth thinking about is what's in the notes, the actual information that's there. Yes, it's a summary of the consultation, but actually generating that summary when the clinician does it, there's a level of processing, there's a level of sort of cognitive thinking, of reflection, of thinking about what it was that was happening during the encounter between patient and gp, what was actually being said, or a lot of the time, what was not being said, and the AI scribe won't detect that. And a lot of clinical reasoning sometimes happens for gps, sometimes happens behind the scenes when they're doing that retrospective processing. And as one of my colleagues said, you know, she often thinks about other investigations she'd like to add or things that she might not have made overt to the patient, which perhaps need to be made over to the. So it's those sorts of subtleties that aren't captured in just a very superficial representation of a consultation. That's the content of a consultation. Speaker A 00:06:21.720 - 00:06:53.030 And I think that struck me that taking notes isn't simply an administrative task, it's actually part of clinical thinking. And I certainly, I've tried AI scribes, but how I do my consultations is I write on a piece of paper because I think that's how I process it, and then I move from the paper to the notes and that's part of how I work through the problem. And I guess that's what you're getting at here just in terms of sort of the clinical thinking about actually putting the notes onto the record. Is that what you're saying? Speaker B 00:06:53.350 - 00:08:00.370 Yeah, I think that's right. And I think it's a reflection about how we all develop as individual practitioners as well. I mean, the way you do your consultations may be slightly different to the way that I do my consultations, and the way that you write your notes may be slightly different to the way that I write my notes. But I think often when you've worked together with people for quite a long time, you learn hidden meanings and you pick up that they may phrase things in very particular ways and that conveys a deeper level of meaning to you because of that kind of relational knowledge that you have of your colleagues. So for example, if I write one consultation in my note, my partners know that it was an extremely long consultation that was probably quite circular. We probably didn't come to a very conclusive outcome and probably the patient is going to want to come back and see me again rather than one of them. You know, there are these subtleties in communication that actually at the moment the AI scribes aren't good enough or nuanced enough to be able to detect. And I don't know if they'll ever get to that kind of level of something. Speaker A 00:08:01.130 - 00:08:28.010 But I suppose an AI scribe is never going to really capture clinicians voice, is it? And I think that's what I see when I see some colleagues who are using AI scribes that the. There seems to be quite a lot of detail there which is great, but it doesn't have that clinician's voice in it. So it's hard to really unpick some of the hidden meaning behind sort of what's going on there. And I think that's why I don't use it, because I don't feel it reflects my thought process when I'm going back to look at notes. Speaker B 00:08:28.150 - 00:09:41.210 Yeah, yeah, no, I think that's exactly right. And I think it's extremely good at trans. At sort of capturing transactional interactions and transactional material. And I think that during my detail, I was observing a GP using one of the AI scribes, and we. I watched a series of consultations and in one, which was a very transactional discussion phone call with a patient where he was just adjusting her medication doses, he said, oh, yes, the scribe will be very good in this one. I'll just use the scribe. And it was. It was very accurate. It captured exactly what they. What they discussed. And then he had a consultation with a very complex patient with a number of comorbidities and lots of psychosocial difficulties in the background. And he actually turned the scribe off before the consultation because he just said, it won't capture this. This not the sort of thing it will be any good at. And I just thought that was very interesting, that whilst it is very good at capturing that more not simple is the wrong word, but you know, that. That much more transactional encounter, it just can't quite cope with the relational stuff that often, I think, is GP says now our bread and butter. Speaker A 00:09:41.370 - 00:09:56.020 And I think you make that point in the paper, that a consultation is sometimes much more than just the word, words that are spoken. So looking at those examples, what do you think that an AI scribe might struggle to capture in that sort of more complex or relational type of care? Speaker B 00:09:56.820 - 00:10:51.900 I mean, I think that kind of complex care, there are so many uncertainties, aren't there, ranging from sort of diagnostic uncertainty to prognostic uncertainty. There's often uncertainty, I find, in thinking about what my patient is doing, feeling about me, you know, that level of kind of psychodynamic uncertainty. And I think all of that sort of stuff is likely to be overlooked by the AI scribe. And if you take a very simple example, I mean, often in general practice we're going through a sort of process of diagnostic reasoning where we're weeding out diagnoses, or you'll do a particular investigation thinking, well, that will exclude X, but sometimes the AI scribe might actually put X into the coding as a diagnosis. There isn't that well, this is possible to be captured. So I think that can be another sort of potentially problem as well. Speaker A 00:10:52.140 - 00:11:25.470 Yeah, you talk about that quite nicely in the paper that, about this uncertainty because general practice is often about symptoms that don't fit neatly into a diagnostic category or you're wondering about a diagnosis so you're querying it as you continue with investigations and more consultations and things. And I guess that does create a challenge for AI tools that sometimes seem more designed to classify and summarize and structure information a bit differently. So I thought the example that you gave in the paper was actually very nicely done. Speaker B 00:11:25.950 - 00:12:55.130 There's a lot of talk, or there has been over the years and increasingly still in general practice about the cohort of patients who present to us for whom there is no formal diagnostic label that can be applied. And, and that doesn't mean they're not suffering and they don't have trouble and that they shouldn't be worthy of an appointment. It just means that you can't give them a hard diagnosis at the end and say, well this is X and take Y and it will get better. Actually your, your therapeutic input is through the witnessing of their distress and that kind of human connection. And I guess one of my biggest worries with AI scribes, or not of them per se, but the sort of devoted promotion of them without considering the, than the potential negatives, is that actually because they learn on the kind of data that they're designed to collect, you'll end up with a self perpetuating model where AI scribes will get much better at facilitating transactional consultations and then actually they will just be used within transactional consultations and people will get more and more and more likely to do much, much more transactional consultations in order to use the technologies. And so you'll have technologies driving our values rather than a sort of consideration of what we're actually what we want to promote in general practice, which for me is still about human connection and relationships and I guess sort of bearing witness to the human condition. Speaker A 00:12:55.610 - 00:13:07.300 And having thought about all this, I wonder if you are against the use of AI scribes or is it really about being more thoughtful about how and when we use them. What are your thoughts about that? Speaker B 00:13:07.700 - 00:13:56.690 I think it's that I'm not brilliant with technology, but I'm definitely not somebody who wants to stand in the way of this. I think technology can facilitate our sort of behaviors and our efficiencies enormously. What I don't want it to do is to drive everything. And I think My concern, for example, if you take the executive summary of the table 10 year plan, for example, the word care is used 78 times, but only one of them is as the verb to care. And I just think there's this idea that actually technologies are going to drive models of care or enable faster care, but nobody is actually thinking about what it means to care and how technologies can stand in the way of that sometimes. Speaker A 00:13:56.770 - 00:14:26.270 And I think the way that some people are using AI scribes and how it's being rolled out is a bit patchy. So I know in some practices, for instance mine, There are some GPs who are using it and I know of some practices where it's almost a requirement to use it and that's kind of the, the, the way that they've decided to go forwards. But I think we probably. AI scrubs are likely to become increasingly common. But do you have any thoughts about what good implementation would look like or what would you like to see happen in that? Speaker B 00:14:26.270 - 00:15:57.850 I think I'd like GPC been more involved in the conversations around the development of them and particularly thinking about whether it's possible to enable the technology to capture some of these nuances and subtleties that I've sort of talked about. But I think it's also important for us just to think about what the commercial models and the background is that's driving some of the development of the scribes themselves and what the different agendas might be underlying some of that development. So, for example, you have to think about what the value of data is. I mean, why are people developing such ambient scribes? Actually, it's not for the good of mankind. It's because there's a commercial interest in doing so, and that commercial interest is tied up in data. And so it's in the interests of AI scribe developers often to produce more and more and more data. And so you're looking at more and more and more content. But that might not be the most helpful thing for a practicing gp. You know, actually what we might need is for our ambient stripes to generate a very succinct portrayal of what went on that could be easily skimmed. If you look back at some of the old Lloyd George records, for example, you know, there will be chest infection, amoxicillin, and that's the extent of a consultation. And now think about how lengthy our health records are. And I sometimes wonder how much added value some of that information has brought to things. Speaker A 00:15:58.650 - 00:16:16.570 And I guess in this space, I wonder if you have any thoughts about what you would like GPS to think about before they switch on an AI scribe in their consultation room. So what could be going through someone's mind about the use or good use of it, really, before they think about using it? Speaker B 00:16:17.300 - 00:17:16.280 I think they need to think about what their consultations are for, what are the core activities that they're still trying to enable in their consultation and not to let the AI strive come in the way of them doing that. And so if it is all just about transactions or if it is just about the titration of blood pressure, I kind of argue no consultation is ever just a transaction.

In this episode, we look back at the last season of the BJGP podcast and reflect on some of the work we’ve discussed. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.560 - 00:11:08.620 Hi, and welcome to the BJGP podcast. I'm Nada Khan, one of the associate editors of the Journal. And we've reached the end of another podcast season, and before we take a short break for the summer, we thought we'd look back at some of the papers we've covered and pick out a few highlights and common threads between them. And looking back at the different podcasts over this this past season, it seemed that although each conversation started with a completely different research question, by the end we all seemed to be talking about the same thing, and that was, how can general practice work better for patients in today's increasingly complex healthcare system? And although we talked about a wide range of different topics, we covered cancer diagnosis, dementia, women's health, medical education, and we even talked to Garth Funston about artificial intelligence. They all came back to this same underlying challenge. And we know that general practice has always dealt with complexity, and that's not really anything new, but the kind of complexity we're dealing with now feels different. Patients are living longer with multiple conditions. Care is spread even more so across increasing numbers of services than ever before. Technology is changing the way that we work, and somehow, amongst all that, we're still trying to preserve those relationships that have always sat at the heart of general practice. And I think another thing that really struck me was that very few of the papers and researchers were talking about making dramatic changes. And instead we had a lot of discussions about how we could make systems we already have, just work a little bit better. So making it easier to navigate, getting people more connected, more equitable, and more human as well. So one of the first interviews we recorded was with Katharina Savolkul about why medical students choose or don't choose a career in general practice. And on the surface, it's comes across a bit like workforce paper. We know that we need more gps, and understanding career choice is clearly important, but I think we talked about something a little bit bigger, which is, what kind of profession are we asking people to join? And this review highlighted positive GP placements, so good role models and the hidden curriculum as well. And although we often focus on recruitment targets, Katharina reminded us that students choose career because of the experiences they have and the values that they see lived out. And interestingly, continuity of care remains one of the biggest reasons people are still drawn towards becoming GPs, even though many of us worry that that's becoming harder to achieve in practice. And I think that continuity became one of those defining threads that ran through a lot of the interviews that followed. And we had Ewan Lawson join the podcast to speak to Charlotte Morris about dementia care. And what they talked about was that participants weren't really asking for more investigations or different medications. What they wanted to feel was to be known and to have someone who understood who they were before their diagnosis recognize those changes over time and stayed alongside them as their condition progressed. And I guess listening to that interview made me realize that it's not just about seeing the same gp, but it's about patients feeling that someone is carrying the thread of their story over time. And I had a really similar feeling talking to Dr. Tory Ford about recurrent vulvovaginal thrush. And these were two qualitative papers about diagnosis and healthcare experiences. But I think by the end of the interview, we were talking about something much broader. And as clinicians, we think sometimes about those bite sized consultations, but patients don't at all. At least this was the experience that I think that we drew out from Tori's work. And in this work, I think Tori highlighted that people experience illness as a continuous journey. And although in a system where continuity of care might be challenged, clinicians might see episodes of care, but patients live their whole story. And I think that's why sometimes recurrent conditions can feel so frustrating for patients, not because, particularly those individual episodes of care consultations are poor, but because if there's discontinuity, no one's joining those consultations together. And I think the more interviews we recorded, I pulled out another pattern, and that's that whether we're talking about dementia, recurrent thrush, pediatric safety or postnatal care, patients and families were doing a lot of work. So an extraordinary amount of invisible work, they were chasing referrals, following up on test results, explaining the same story repeatedly to different professionals. And although these papers weren't a criticism of general practice, and oftentimes many of the patients talked about how much they valued their GP teams. But I think that it almost made it feel as though patients and families were bridging these gaps together between increasingly fragmented services. And I think that Tom Purchase's work on pediatric patient safety really captured this beautifully. So rather than seeing patients just as recipients of health care, his study showed that they're active contributors to safer care. So they're already preventing harm. Patients and their families are identifying problems and improving systems. And I think he challenged us to think about patients as partners in care, rather than just recipients of care. Another theme that kept surfacing was inequality. And I spoke to Eliza Hutchinson about her work in inflammatory skin disease in People with skin of color. And her participants talked about delayed diagnosis, underrepresentation in medical education, and that impact of dyspigmentation as well in practice. And I think, again, what stayed with me wasn't just the clinical message, which was really helpful, and I'd encourage gps to go back to listen to that, but it's how often people really just wanted their experiences to be recognized. And similarly, I think that Claire MacDonald's work on postnatal care reminded us that women with the greatest social needs are often face the biggest barriers to access and care after birth. And ironically or sadly, this is just as services begin to step back. And I guess these two papers were asking a much broader question was how do we design healthcare systems that work equally well for everyone? And I think one of the papers that I really enjoyed, or one of the people I really enjoyed talking to, was Garth Funston and his work using large language models to analyze free text consultation records, aiming to pick up earlier signals for ovarian cancer. And I think that, you know, we. We talk a lot about artificial intelligence, but actually what we ended up talking about was how we record things in consultations. And as gps, we write huge amounts that really never get coded as read codes in the system or snowbed codes, you know, symptoms, concerns, uncertainty, those details that really make up the richness of a consultation. And I think that what Garth's work showed us was that AI might help us make better use of the information we've already recorded. But I think that actually, you know, it's worth thinking about how we're actually using technology to help recover the stories we've already written in the free text as well. And the last thing that we talked about in this season was something that probably every GP understands instinctively, but few of us have actually been explicitly taught, and that's prioritisation. And we spoke to Andrew McClary about the rapid decisions we make every day. So which patient do we call first? What referral can wait? And crucially, what do we do first? Do we tackle the difficult task or go for the quick wins? And I think that I liked the title of his work, because I suspect every GP probably immediately recognized them themselves somewhere between these two approaches. And I think we also touched upon that prioritisation isn't simply about managing workload, but it's also about managing uncertainty. And I think that if there's one thing I'll take away from this entire season and the different people that we've talked to and the great work that we've listened to, I think it's that general practice has always been about managing complexity. But these conversations reminded me that complexity isn't something we can just eliminate or fix. It's something that it's worth delving into to try to understand a little bit better. And I think, you know, whether we're talking about continuity, inequalities, patient safety, or the workforce force, another common thread I thought that ran through these, these conversations was that connection. So connecting services together, connecting research with everyday practice, and staying connected to patients and the stories that they bring with them through time, really. And I guess for me, really, every interview this season left me thinking a little bit differently about how I, how I consult and practice and about that patient that's going to be sitting in front of me. And I think that's probably a mark of how strong this research was that we covered in this season as well. So I guess on that note, I just want to say a big thank you to all of the authors who joined us this season to share their work and to all of you for listening. We'll be taking a short break for the podcast over the summer, but we'll be back in September with another season of conversations about the latest research published here in the bjgp, and importantly, what it means for everyday general practice. So, yeah, until then, thanks again for listening and we'll see you in September.

Today, we’re speaking to Andrew McClarey, who works as a GP and Education co-ordinator Lead for General Practice in the Scottish Centre for Simulation and Clinical Human Factors. Title of paper: “Quick wins” vs “eating the frog”: Exploring general practitioners’ prioritisation dilemmas Available at: https://doi.org/10.3399/BJGP.2025.0628 Link to tactical decision making games: https://archive.johs.org.uk/article/doi/10.54531/svvw4195 This is the first study to look at the factors which experienced GPs consider when prioritising their acute workload. Several themes have emerged which highlight the importance of prioritisation training in General Practice. These themes could be used to teach prioritisation decision making to GP registrars or in the creation of continuing professional development resources for experienced GPs. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A 00:00:00.400 - 00:00:56.560 Hi and welcome to BJ GP Interviews. I'm Nada Khan and I'm one of the Associate editors of the Journal. Thanks for listening to this podcast today. In today's episode, we're speaking to Dr. Andrew McClary. Andrew is a GP partner and he also works as Education Coordinator, Lead for General Practice in the Scottish Centre for Simulation and Clinical Human Factors. We're here today to discuss the paper that he's recently published in the bjjp. And the paper is titled Quick Wins versus Eating the Frog, Exploring general practitioners Prioritization dilemmas. So, hi, Andrew, it's really nice to meet you. And this paper really stood out to us, I think, because prioritisation is something that gps do every day, but it's not really something that we discuss explicitly. I'm just interested in what made you do this work and made you interested in studying it. Speaker B 00:00:57.200 - 00:02:00.600 It's interesting, I think, that for me, I finished my GP training just after the pandemic and therefore I did a lot of my training during the COVID pandemic. And around then the face of general practice, like most things in life, changed completely overnight. We moved on to telephone consulting and being encouraged to have empty waiting rooms. And I think around the same time we realized that we probably couldn't continue doing what we had been doing, which was being everything to everyone, which brought us on to prioritizing our workload. We have to decide who needs seen, who does not, and when are they seen. And that was a real gap for me in the training that I was provided. And I found myself going into working as a fully qualified GP without really an awareness of how to prioritise in a, in a sensible way. And I think that's where this interest was born out of. Speaker A 00:02:00.760 - 00:02:42.050 And before we get into what you found, it's probably worth saying a little bit about how you approach the study. So this was a qualitative interview study involving gps from a range of practices and career stages. And what you did was you really explored how they prioritized work during the course of a typical surgery. And then I guess through those interviews you looked at sort of the strategies and influences and trade offs that shaped those decisions in everyday general practice. But one of the things I found really interesting was that prioritization wasn't just about clinical urgency. And I wonder if you could talk through some of the other factors that GPs are weighing up quickly, I suppose, when they're deciding what to tackle first. Speaker B 00:02:42.690 - 00:06:17.800 Absolutely. It was very interesting, the themes that emerged from the data and also actually how much agreement There was amongst the gps in the focus groups, as we're not traditionally a group of people who agree about very much. So one thing that GP is particularly interested in, there's five main themes. One is about the system awareness. So we're aware about our own surgeries and where the pressure points are. For example, we're low on particular acute slots today, or there's a certain type of patient that is coming in more frequently at the moment, so we're aware of that. But it's not just having that awareness, it's also being able to adjust how we consult based on the pressures that the system are under. For example, if there are a lot of children or fevers coming in, we want to see them all face to face. We ask the admin team, just bring them all in face to face and we'll see them that way, rather than setting everything up over the phone. So it's not just an awareness of the system, but actually adjusting ourselves to that demand. Another one is the time management. What's the most efficient use of my time? How am I going to get out on time this evening for nursery pickup or whatever else I have to do in the evening? But it's not just our time, it's also the system's time. So what I mean by that is, I know if I try and refer to a hospital service in the afternoon, they'll probably be at capacity. If I do that in the morning, I am much more or first thing, except an afternoon surgery. I'm much more likely to have my patient accepted and managed in a way that I think is most appropriate for them. Also, third theme, familiarity with our patients. We are more familiar with our patients and therefore we don't have to go trawl through their histories. We know, right? I know that patient, I know what that's about. I spoke to them about it last week. Let's just phone them first and move on. That's an easy thing for me to do. Then relationships. Fourth theme, relationships with patients, in that we develop a trusting relationship, particularly if you've been working in a practice for a long period of time. For example, we might be able to have a conversation on the phone saying, well, are you as bad as you were the last time, for example, when you went to hospital with your copd? Is it as bad as that? Well, no, no, Doctor, not as bad as that. And you know these patients and you trust them to tell you the story like it is. But we also not only prioritise relationships with our patients, but also with other staff members. For example, if you're interrupted during a duty doctor session and it's the practice nurse who is needing help with something, that person is there in front of you. They're a valued member of your team and you want to be able to provide input for them in a timely way. And I guess that takes us back to system awareness. We know that that nurse has also got lots of patients to see, and if there's a delay in that, then the whole system is suffering from it. And then lastly, fifth is this idea of personal preferences. Some of us like doing hard things first, so that's eating the frog. Some of us like the quick wins and the endorphin release, of actually seeing all of the columns or all of the slots in the IT system changing a different color, we get a bit of a rush from that. There's no right or wrong answer with this, but actually a lot of it does come down to that. But it's also about looking after ourselves, but also balancing that against good patient care and what needs to be done first from a clinical urgency perspective. Speaker A 00:06:18.360 - 00:06:45.170 And the title of the paper is Quick Wins versus Eating the Frog. And I find that really interesting because from my own clinical practice, sometimes I feel like I'm telling myself off if I'm only taking off the easy tasks, because I know then at the end of the day I'm going to have all the long referral letters, the things that I've really been putting off. And I think, gosh, why did I leave it to this point, really? But I wonder if you can explain what that means a bit more generally, and why it captured something important about GP decision making. Speaker B 00:06:45.570 - 00:08:12.210 I think ultimately, for me, it's about when we are at the trainee stage. We are actually honest about how we approach prioritizing our workload. And I think ultimately that comes down to personality. Some of us like doing the more difficult things first, and then we feel that we've got the wind at our back and we're able to go on about our afternoon knowing that the most difficult thing in that list is done. In fact, the quote goes, eat a live frog first thing in the morning and nothing worse will happen you for the rest of the day. And I think that's probably paraphrasing a little bit, but I think that's the thing. If the worst thing is out of the way, the afternoon suddenly seems much better versus actually some of us need that endorphin release. And the highs, I guess, of actually seeing, feeling that we're going through our afternoon at a Good rate. And we are managing things well and some of us like that. But I think ultimately, if we can have that conversation at the trainee stage to say, look, you're either a frog eater or you're a quick winner and you have to decide which you are. And maybe actually you're at the point in your career where you have the opportunity to actually try these out. Say, right, we'll do the hardest thing first, how does that feel? Versus, you know, take off a few easy things, how does that feel? And you'll get an idea of what you're like as a person. So I think that's where that comes. Speaker A 00:08:12.210 - 00:08:35.850 In for me and I just wanted to go back to unpick some of the themes that you're talking about and I wonder what your thoughts are about sort of this role of familiarity with patients. How do you think that knowing your patients really influences prioritization decisions? You took an example of knowing whether you can trust a patient, for instance. And for me that also links in a bit with continuity of care, I think. Speaker B 00:08:37.420 - 00:10:02.500 Yeah, absolutely. I think working in the same place for a more prolonged period of time allows us to develop this familiarity with patients that's impossible to have even if you're just as a trainee in a practice or new there. There's probably a few avenues we could explore here. So one is about I see your name on the list, I see what the problem is, I know what that's about and I can tick that off very easily. I can see that as a quick win almost because I'm so familiar with your story and your situation. Perhaps only me, perhaps only I can sort that out. Let's do that because I'm the best person to do that and let's do that now because I'll feel that I've achieved something, but it's a double edged sword because actually seeing the same person over and over with shortness of breath, who is copd, your bias will push you towards yes, this is copd, and you're missing something else that's perhaps serious because you're so keen to make the presentation fit into the last five times that you've saw that person. So you have to be aware of your own biases. Even though the familiarity allows you to be very quick, perhaps in your decision making, you also have to have a little bit of having the brakes on to ensure that you're not missing things. Speaker A 00:10:03.060 - 00:10:13.060 And there definitely is that tension, as you say, about experience helping GPs make rapid decisions, but also that experience can introduce bias. So I think that's a really interesting tension. Speaker B 00:10:13.540 - 00:10:14.260 Absolutely. Speaker A 00:10:15.540 - 00:10:23.300 How much of prioritisation do you think is about managing risk? And do you think some of it is just about managing workload as well? Speaker B 00:10:23.970 - 00:10:47.570 I remember actually during one of the focus groups, one of the participants said, well, yeah, if this was to be a game, it would be called risk, because actually when we are dealing with our duty, doctor There is risk everywhere. And I think that it would be impossible to actually tease apart managing risk, because it's all risk versus anything else that might come up. Speaker A 00:10:47.730 - 00:11:04.830 You've touched on this and I think that one of the most striking points in the paper is that prioritisation is a core skill that we're all doing all the time, but it often isn't formally taught. Do you have any ideas about why that is and how do you think we should teach this to our GP registrars? Speaker B 00:11:04.910 - 00:12:01.130 I think perhaps it hasn't been traditionally taught because it wasn't necessarily part of our roles. And now as time has gone on, we have to. In fact, it's one of the biggest parts of the day. And it was interesting because There was about 39 participants in the focus groups and there was a tremendous amount of agreement on how we did it, but no one had particularly received any prioritization training and it was all left on the job. And if they had done any, it was ad hoc. It was never a fixed part of the curriculum for us. We have developed a tool called a tactical decision game. A tactical decision game is a tabletop simulation exercise whereby the participants are forced to make prioritization decisions on imperfect information. Speaker A 00:12:02.250 - 00:12:03.930 Sounds like life in general practice. Speaker B 00:12:04.090 - 00:13:11.410 Absolutely. It's a duty doctor session and it lends itself beautifully to training prioritization skills to registrars. It works best as a group of seven, eight registrars with one facilitator. The participants initially prioritize as individuals the list of 12 or 13 presentations, and then actually what happens is they move into the group and ultimately it's a group decision as to which presentation is being dealt with first versus last. And it means that it's all about learning from each other and learning where their own tolerances of risk are. And it can be a really rewarding and useful session to deliver. And it's something that the registrars in particular have found useful. But actually, in my now role as the education coordinator lead, I'm now running this to fully qualified GPs in general practices. And it's amazing the amount of conversation that can be generated by playing this game together. Speaker A 00:13:11.570 - 00:13:17.360 Yeah, I'll definitely be taking that back to my Own practice. Is there a link available for that or is it widely available? Speaker B 00:13:18.160 - 00:13:26.720 Yes, it's. The game is. Yes, it's available in ijos. It was published in IJOS a few years ago. Speaker A 00:13:27.200 - 00:13:39.840 Great. We'll link to that in the show notes. That's perfect. Great. And I guess just having done this work, was there anything in the findings that changed the way that you think about your own prioritization decisions when you're at work? Speaker B 00:13:40.140 - 00:15:27.870 I think that I came at this research as a relatively junior GP who had only begun to develop my own prioritization strategies. And it was incredibly interesting to learn from those who had been doing this for years. I think a key one for me was about time management and the recognition that everything that we do in that four hour session will chip away at the time that we have available to carry out the work. So, for example, you see a set of notes and you see a slot or so you see a patient's name and a slot note and you think, oh, I wonder what that's about. And you click into a set of notes, there's a minute gone. And I know a minute is a small amount of time, but actually over an entire session, that can really add up.

Today, we’re speaking to Dr Tom Purchase, a GP and Health and Care Research Wales NIHR doctoral fellow. Title of paper: Co-generating ideas for safer paediatric care in general practice with parents and stakeholders Available at: https://doi.org/10.3399/BJGP.2025.0690 Research has highlighted the important role parents play in in paediatric patient safety, for example, through mitigating safety incidents in general practice, yet their perspectives have rarely shaped system-level improvements. This study co-generated and prioritised ideas for change with parents and key stakeholders, identifying feasible and impactful strategies to improve paediatric safety in primary care. These strategies centred around practice communication, accessing care records and results, and fostering a culture of shared learning and development. Parents are willing and able to contribute meaningfully to safety improvement efforts, and their insights align with national patient safety priorities. Clinicians and policy makers can use these findings to strengthen collaboration with families, tailor safety interventions to local needs, and embed parent voices into the design of safer care systems. Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions. Speaker A 00:00:00.480 - 00:00:49.500 Hello and welcome today to BJGP Interviews. I'm Nada Khan and I'm one of the Associate editors of the Journal. Thanks for listening again to this podcast. In today's episode, we're talking to Dr. Tom Purchase. Tom is a GP and a health and Care Research Wales NIHR Doctoral Fellow. We're here today to talk about the paper he's just published in the bjgp and the paper is titled Co Generating Ideas for Safer Pediatric Care in General Practice with Parents and Stakeholders. So, hi, Tom, it's really great to meet you and to talk about your work, but before we talk about the study itself, I'm interested to know what first got you interested in pediatric patient safety in general practice. Speaker B 00:00:50.060 - 00:02:26.850 Thanks. It's born, I think, out of an extension of the work that we've been doing within the patient safety team within Cardiff University. So a lot of what we do is looking at incident reports, safety incident reports, and trying to pick out what are the, you know, high level key learning points and takeaway messages from those. And then within the team, we started to think about, as well as the types of incidents and the types of harms that are occurring within pediatric incidents. For example, how are parents involved? And it was a bit of a novel approach to what we normally do, trying to have that extra aspect within the incidents and figuring out how parents were either helping to contribute or to mitigate against the incidents, not just looking at the incidents themselves. So that was the starting point, really. And then once we'd started digging into that data and identifying that, actually the majority of the time, which is in one of the papers that was published last year in BJGP, 77% of the reports we were looking at specifically around general practice showed that parents were taking these mitigatory actions that, you know, positive actions that were able to prevent harm or further harm from occurring to their child, for example, chasing results or chasing referrals or importantly, being able to speak up. And then that highlighted, I think, the importance of parents being able to have a voice and advocating on behalf of their child. And that really sparked, I think, the interest, and therefore this part of the. Speaker A 00:02:26.850 - 00:02:46.490 Project, and I think that's a really interesting thing about this paper, is that it focuses on parents and parents not just as observers of care, but as active contributors to safety. And I wonder what your thoughts are about why that's an important shift in how we think about these things. I think you've touched on it a bit, but yeah, I'm interested to know a bit more about that. Speaker B 00:02:46.810 - 00:03:55.980 I think it is a really important aspect of care, but also particularly safety, which maybe is untapped in terms of parents as a resource as to how we can keep children safe. We know that children on the whole are more, maybe not more vulnerable, but certainly are a vulnerable group when it comes to patient care in general and patient safety. And that's because they're so heavily reliant on others to speak on their behalf, to make sure somebody else is looking out for their healthcare needs. And therefore they are probably playing a part within the world of patient safety. And there are good studies from hospital relating to incident reports that show that parents are capable of picking up issues early on. They're able to detect issues that maybe other parts or people within the system aren't detecting. And as I mentioned, our paper from last year specifically looking at general practice showed that parents are able to prevent harms from reaching their children. So they're playing a substantial part already. And from a systems perspective, that is mainly parents figuring out workarounds within a system that really isn't, I don't think, designed to support them as well as it could be. Speaker A 00:03:56.460 - 00:04:33.810 And I guess that's kind of the crux of what you were doing here. So I guess before we get into findings, just, you know, a quick word about the methods because you worked here with groups of parents to develop ideas for improving pediatric patient safety in, in general practice, in primary care, and then you explored those ideas with a wider group of stakeholders and that included clinicians, managers and policymakers, and then brought them all together to co generate ideas for safer care. And it was really interesting because the parents generated 16 different ideas for improving safety. And were there any that particularly surprised you and jumped out at you? Speaker B 00:04:34.450 - 00:05:33.980 I don't think necessarily any were too surprising on the basis that we. I don't think I really had any thoughts going into it as to what they might say. But I guess what did surprise me more was that some of the ideas that we then took forward to the stakeholder group kind of highlighted some disparities or some clear disagreements between the parents who were accessing our services and the people who work within the services. And how we viewed, I suppose, viewed what's actually happening, that kind of work is imagined and how we think things are going and the work is done. I guess what the parents were trying to do to come up with the idea is to bridge that gap unknowingly. I suppose maybe what's surprising is that none of them, I didn't think any of the ideas were necessarily too resource intensive. You know, I think what was quite reassuring is that lots of what the parents were saying were actually relatively simple things that we might be able to enact or at least adopt or adapt, you know, to our own environments. Speaker A 00:05:34.540 - 00:05:47.730 And a lot of the ideas seem to center, I think, around communication, access to records and test results, and actually just helping parents to speak up. And why do you think those themes emerge so strongly? Speaker B 00:05:48.450 - 00:07:24.990 I think that comes back to maybe that difference between how we like to think the system's functioning and how parents think the system's functioning as healthcare professionals and parents. Because we know from a thematic analysis we did, which is also going to be published in bjgp, from these discussions we've had with the parents, that a lot of them said they felt the need to fight in order to be heard. So although within, say, pediatrics and GP training programmes and CBDs and everything we have to do for revalidation, taking ideas, concerns, expectations, collateral histories, making sure we're really considering that the holistic approach is all considered clinically, what you're then getting, I suppose, from the parents is that maybe we're not doing it as well as we could be. And one parent within the workshop said, I know as a parent you are expected to advocate for your child, but what it surprises me is how regularly you have to do it and sometimes it feels like a full time job. And I think that one really struck a chord in terms of really emphasizing how much extra effort and how much work parents are feeling they need to put in. And I think that also implies that the system isn't making it as easy as possible for them to be able to do the right thing. So I can't necessarily explain unfortunately why they feel that those areas needed to be targeted. I guess it's because there are barriers that we are not tackling correctly in order to help parents to speak up more efficiently and certainly to be listened to. Speaker A 00:07:26.840 - 00:07:35.160 And one of the stakeholder priorities was this idea of a designated parent advocate. Can you tell us a bit more about that idea and why it resonated? Speaker B 00:07:35.640 - 00:09:21.810 Yeah, sure. I really liked that one and I thought it was an interesting one because again, it highlighted, I think, a number of issues that we could discuss in a lot more detail. I know this podcast isn't ours. I think we could talk about it for a long time. So that one, I think came out of the need that parents were identifying to sometimes just want to clarify something if they weren't quite sure how to access something or they didn't really know how something worked. We know that our systems are complicated and one of the issues we found was parents found that just navigating that system was an issue. So it's one way of trying to work around that. If there's someone that you can speak to who understands the system, maybe working within the practice or even as a third party, you know, you could go to them and get some advice. But they also specifically said it's not just kind of system advice, it's also advocacy, help, well being. If they wanted to give feedback or raise a concern. It's someone who is very importantly separate from that complaints process. Because I know I keep talking about the system and how it's designed, but the complaints process, for example, is very specific. And what we found talking to the stakeholders is that they, they felt that what the parents were asking for here kind of already existed, but in the form of maybe the complaint system, which obviously has a particular purpose, isn't always easy to use. You know, if you've got to email the practice manager, that might not be something that you want to do. And parents worried about coming across as a nuisance or having some negative repercussions on them. So it was an idea of here is someone who's maybe a bit more independent, they know how things work. I'll be able to get some sound advice from them and that might be able to help me progress or to get my voice heard in a way that wouldn't have a negative repercussion on me. Speaker A 00:09:21.890 - 00:09:38.050 And I think a lot of GPS listening will be thinking about what this work might mean for their own practice. And which of the proposed changes do you think are most achievable at practice level? Is it that about a parent advocate or are there any other ideas that you thought could be achievable? Speaker B 00:09:40.360 - 00:11:56.550 Thankfully, that was one of the questions that we were asking the stakeholders. So when we took all of these, the 16 ideas to the stakeholders you mentioned, we specifically said of these ones, which do you think are the most doable and which ones will be the most impactful? And then we went through each one in turn and plotted them on a matrix to say, you know, to try and come up with an arbitrary way of saying, well, which ones do we think are the most impactful and most doable that we could then suggest to, as you say, practices or readers in a meaningful way. Where there was most agreement between the parents and the stakeholders, as well as being positioned as the most doable and the most impactful, was asking parents for solutions and feedback. So parents felt that they weren't being asked enough for their opinions and their experiences when it comes to, well, lots of parts of the process, but obviously in relation to safety. And then the stakeholders also strongly agreed that actually, if we're going to improve our way of working and integrate the parent voice more, we obviously need to be asking them. And in lots of other industries, we're obviously asking for feedback all the time, and we don't necessarily do it very well in the NHS or within general practice specifically. So I think it reflects maybe, you know, a broader issue about patient and public involvement that in. Specifically in the context of parents, because child safety is so important to them, I think their involvement is therefore seen as a really important role that maybe they're not currently being given the opportunity to fulfill the disagreement or not disagreement. But the discussions that happened in the stakeholder meeting around this, everyone agreed that it was a good idea, but it was. How it was then implemented was maybe going to be obviously based on where you are and your population, but also what you were actually asking the parents for. So whether it's a case of doing something similar to us, where you maybe have a focus group or workshop, or whether you just send out a survey with some specific questions, or if you speak to some individuals with one stakeholder, highlighting that if you do have a significant event or some safety incidents that you've been looking at, are you then talking to the people who've been involved, those parents, and trying to identify the gems that sometimes come out of that in order to identify where you can make improvements that could lead to a meaningful change? Speaker A 00:11:57.330 - 00:12:08.290 Yeah, I like that idea of involving parents in significant event meetings, or at least taking the results of those two parents, because often I feel like those meetings are kind of closed within the practice, aren't they? They're not. Speaker B 00:12:08.770 - 00:12:30.960 Yeah, absolutely. And there's no reason necessarily that we couldn't. I think it's just maybe we haven't thought about whether we could or we should. And then once you start to have those ideas, you know, you can then start thinking about, well, how feasible is it? How could I manage this? Or even quality improvement projects or any kind of safety activities, you know, probably could have parent involvement as well. We're just not necessarily thinking about it in those terms. Speaker A 00:12:31.440 - 00:12:39.440 One thing I thought was really interesting is that the paper talks about parents as a source of resilience within the healthcare system. What did you mean by that? Speaker B 00:12:39.920 - 00:14:07.020 So what we mean by system resilience normally is how adaptable is that system to any change or unpredictability which within all of healthcare, being the complex socio technical system that it is, we are constantly facing unpredictable scenarios. And you know, those, those interactions between us, the parents, the children, all the other staff, our technologies are always changing, the organizational structures are always changing. You never quite know how the interactions between all those elements are going to come to fruition or what's going to emerge as a result. So resilience is facing all of those changes. If something was to happen, how well can you know you bounce back as a practice or how well are you going to be able to cope with an issue or an event? And parents being an important part of that system. Resilience is because not just as a safety net, but also as an information source and somewhere to go or someone to talk to who would be able to, as we mentioned earlier, pick up on when something isn't quite going right, or if they want to challenge a decision. And from a human factors and ergonomics point of view, we know that when someone is able to advocate or speak up or challenge or help to correct something that supports resilience. So it's giving the systems all of the opportunities to continue to function safely and correctly that it can. Speaker A 00:14:07.180 - 00:14:15.340 And I guess having done this work, what do you think is the one thing you'd most like gps to take away about working with parents to improve safety? Speaker B 00:14:15.730 - 00:15:03.200 If I had to choose one, I think it would be encouraging parents to speak up. Lots of things we've talked about obviously in this podcast around how we could incorporate them in other ways, but just the simplicity of validating their concerns and considering their concerns as clinically meaningful. But then creating a culture within the practice where a parent speaking up or asking a question isn't viewed as a criticism, which I think is often the case, or a hindrance and welcoming and proactively seeking out parents insights. So trying to shift the thought process from parents being passive participants within our system to actively trying to incorporate their voices into what we're doing on a daily basis. Speaker A 00:15:03.520 - 00:15:15.510 And I'm going to ask sort of a similar question but in a slightly different way. But if you could implement just one of the ideas from the workshop in your own practice, which one would it be do you think? And why? Speaker B 00:15:15.830 - 00:16:23.070 It's tricky because what we say in the paper is that I think choosing a selection of them would be the most beneficial on the basis that you'd be able to target different areas. I think personally, what I would be interested to see, whether it makes a difference or not, would be some sort of just simple display or poster to Kind of encourage parents to speak up as part of fostering that culture of saying it's okay to voice your opinion and to share any thoughts or concerns that you have with us. So within the stakeholder event, one of the stakeholders described it as being a useful idea because it almost gives parents that permission to be able to speak up if they need to. And I think that's a very good starting point to then build upon.