BJGP Interviews

Today, we’re speaking to Professor Miriam Santer, a GP in Dorset and Professor of Primary Care Research based at the University of Southampton.
Title of paper: Non-antibiotic interventions to prevent recurrent urinary tract infections in women: overview of systematic reviews of randomised controlled trials

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

Recurrent urinary tract infection (UTI) is very common and defined as two or more UTIs in the last six months or three or more UTIs in the last 12 months. Long-term antibiotic prophylaxis is widely used but other preventative strategies have been suggested. This overview of systematic reviews found good evidence for some treatments but identified unresolved questions such as treatment adherence for vaginal oestrogen, questions about long-term use for methenamine hippurate and optimal dosage for cranberry. Increased fluid intake has been shown to be of benefit for women drinking less than 1.5 litres at baseline but is without robust evidence in other groups. The evidence base is still developing for other treatments, such as vaccines.
Transcript
This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.
Speaker A
00:00:00.560 - 00:00:55.830
Hi and welcome today to BJJP interviews.

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

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

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

An Overview of Systematic Reviews of Randomized Controlled Trials.

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

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

Speaker B
00:00:56.520 - 00:02:38.580
Well, it was exactly that, that I had a colleague, a non clinical colleague who had recurrent UTI and I guess I hadn't really appreciated the massive impact that they had in terms of, you know, keeping, being ill, keeping missing work, everything else.

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

So it made me think about my own practice.

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

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

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

So it was interesting.

Speaker A
00:02:38.900 - 00:03:04.080
Yeah.

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

But let's just talk through what.

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

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

Speaker B
00:03:04.480 - 00:04:07.360
So there were seven systematic reviews covering vaginal estrogen and they were pretty positive and especially the most recent one.

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

So it's a slightly confusing message.

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

But the evidence is pretty strong.

It's been amassing over a number of years.

Seven systematic reviews have been positive about it.

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

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

Speaker A
00:04:07.520 - 00:04:21.750
And one thing I found really interesting was that there was particularly low uptake of vaginal estrogen in more deprived areas.

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

Speaker B
00:04:21.990 - 00:05:59.500
And it's tempting to say more research needed.

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

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

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

There's.

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

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

It's a number of other things.

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

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

I mean, of course HRT is Pretty safe.

Vaginal estrogen is even safer.

But that message doesn't always get across.

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

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

So more research needed.

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

Speaker A
00:05:59.500 - 00:06:22.180
I can think of a lot of conversations I've had with women with recurrent UTIs and suggesting vaginal estrogen and often they're quite surprised but quite happy that I'm suggesting something that could work.

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

Speaker B
00:06:22.340 - 00:06:41.460
And I've also certainly met a few women who said, oh, was I meant to keep using that?

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

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

Speaker A
00:06:41.790 - 00:06:52.350
And I guess one other thing that you also found really good evidence for was methanomine.

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

Speaker B
00:06:52.670 - 00:07:29.200
So methenamine has also made it into the nice guideline on preventing recurrent uti.

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

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

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

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

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

Speaker A
00:07:29.760 - 00:07:39.680
Interesting.

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

Speaker B
00:07:40.310 -...

Today, we’re speaking to Matt Conroy. Matt is a PhD fellow at the University of Manchester and also works for NHS Greater Manchester (ICB) as the Head of Primary Care Intelligence.
Title of paper: Impact of local enhanced incentive schemes on the performance of general practices within the United Kingdom: a systematic review
Available at: https://doi.org/10.3399/BJGP.2025.0377
Most local commissioning bodies in England, known as Integrated Care Boards (ICBs), have developed their own additional local pay-for-performance (P4P) incentive schemes alongside the Quality and Outcomes Framework (QOF). To our knowledge this is the first review to date to summarise existing evidence on the scope and effectiveness of local incentive schemes implemented in general practice in the UK with a focus on the indicators and their alignment with national schemes.
Transcript
This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.
Speaker A
00:00:00.480 - 00:01:01.140
Hi and welcome to BJGP Interviews.

I'm Nada Khan and I'm the Senior Research Editor here at the bjgp.

Thanks for taking the time today to listen to this podcast.

Today we're talking to Matt Conroy.

Matt is a PhD fellow based at the University of Manchester and he also works for NHS Greater Manchester ICB as the Head of Primary Care Intelligence.

We're here to talk about the paper he's recently published in the bjgp, which is titled the Impact of Local Enhanced Incentive Schemes on the Performance of General Practices within the United A Systematic Review.

So, hi, Matt, it's really nice to meet you and to talk about this work and I wonder if, just to start with, if you could explain a bit about what we mean by local incentive schemes in general practice and why you wanted to look at them, and I wonder if you wanted to draw a little bit on your additional role working for the Greater Manchester ICB as well here.

Speaker B
00:01:01.220 - 00:01:54.400
Thanks.

I guess by a local deep incentive scheme, we mean something that's kind of locally designed or locally commissioned within a ICB footprint to try and address any particular population health challenges or local nuances that go over and above national policy, things like the Quality and Outcomes Framework.

I guess what was really insightful for us through doing this piece of work was actually through an FOI that we undertook.

Like 90, 98% of ICBs actually have their own local gene for incentive schemes, but we only identified 17 schemes through the published literature, the last one being from 2018.

So getting on for 10 years ago, and the fact that we know that so many ICVs are doing these things, but there's not the evidence body there, there's not the learning and sharing of best practice to really inform policy and help ICVs all try and address their local challenges.

Speaker A
00:01:55.210 - 00:02:10.650
Yeah.

And you've mentioned qof and I guess a lot of people are really familiar with qof, and as you mentioned, there are lots of local schemes sitting alongside it.

And I wonder if you have an idea of just what sort of things they're trying to incentivize, just from sort of the background to your work.

Speaker B
00:02:11.210 - 00:04:48.850
Yes.

So, as part of my day job, I help design and deliver the local GP incentive scheme in Greater Manchester.

It's roughly valued about £17 million for this year.

And I think what we try to do is use QOF as a bit of a body of evidence, but also look at a lot of our local and national data to really highlight where we think we can make a difference with these local incentive schemes.

So, for the 26, 27 financial year, we've done a piece of work to really home in on CBD and diabetes as one area, respiratory as another area, elective care.

So we can get the interface between primary and secondary care and also antimicrobial stewardship.

I think one of the things that's really fleshed out from that is the impact of non attenders on things like qof.

So through qaff, if patients have two or one invites seven days apart, they automatically get exception reported if they don't necessarily attend.

But what we found through our local data is actually there's a really strong link between those people and actually poorer CBD control and wide use of healthcare systems.

So.

So through our local GP insentive scheme, we've really designed almost a narrow cohort that looks at people's individual disease control, looking at things like blood pressure, HbA1c, but also where people haven't attended a review in more than 18 months.

So really trying to hone in on specific cohort, acknowledging that those people are really difficult to engage with by proxy.

The fact that they've had two invites and not responded.

But actually through having a local GP incentive scheme that really highlights these as a specific target cohort group and having dedicated funding alongside it, we can see that from our QOF data, we've had a reduction in exception reporting and actually it's led to these people being targeted and then we can see slow improvements in overall disease control.

So whilst it's being funneled through the local GP incentive scheme, there's this wider spillover effect in things like QOF as well.

I think that's something that we're looking to evaluate in particular and really draw out, actually, not to say that it's easy to do this exceptional reporting and we know that patients are difficult to engage with, but actually by having a really dedicated piece of work, targets these patients with the body of evidence that these are the people who are more likely to not attend their yearly GP review, but are more likely to end up using emergency care services at that point of contact, that if there's dedicated funding and almost a dedicated cohort, to say these are the people that, as an icb, we've agreed on that we really need to focus on that we can see that those improvements are being yielded and that that is actually having a secondary impact of increasing coif achievement as well.

Speaker A
00:04:49.010 - 00:05:03.310
Yeah.

So really important work, I guess, being done in local area and this review tried to bring together all of the existing evidence on this, on these different schemes.

So what did you find overall in your, in your review?

Speaker B
00:05:03.550 - 00:07:48.730
So we found overall that there was 17 schemes that have been reviewed.

Of those there was a range of different indicator types, the most of them aligning to the existing indicator types of quaff where they have a lower and upper threshold and achievement scales based on fixed cohort and payment alongside that, which isn't surprising.

And I think what surprised me is that so many of the schemes almost piggybacked off QUAFF and just gave more money for existing cough indicators, which was quite surprising in a sense of well, if quaff is already there and as well bodied there was almost that assumption, well, if we provide more money that we're going to get greater achievement on the same indicators that's already there.

I think this is the part of the, the push and pull of incentive schemes is that we're all aware that general practice has finite capacity and finite resource and there's almost an assumption that by providing more money you're going to get more outcomes.

And it's a bit crude but the analogies, it's a bit like whack a mole and that if you try and do something over here then implicitly means that something there isn't the time and dedicated effort to do something else around the system.

I think that's the real challenge with designing these schemes is that acknowledging that where there's already work that's gone in, but how do you address your local challenges and populations and that part of this might be the acceptance, that part of the money is just to give practices the time and the headspace and the workforce to deliver some of this.

I think that's one of the things that we've found really locally within our scheme that when we've scaled it up in some areas quite drastically in the first couple of years, you might not see the achievement that you want because there's a lot of time to get around these schemes, to embed them and really employ the workforce to actually start to deliver them.

I think the other thing that surprised me is that how little of them actually had an inequalities focus.

I think that's partly down to the access to data that's available.

I think through undertaking the literature review in a lot of cases people were just using aggregated EMIS extracts that just had a single denominator or numerator for an indicator.

And that's something that I think we're really keen to explore throughout the rest of my PhD and that how can we really apply a, a rigorous inequalities lens to some of this and looking at tools like the index of disparity as a way of helping us understand are we in a position where it might look on the surface like achievements going up?

And that's great, but is that because we sweep in generalization, are we actually targeting the white British affluent worried well and actually

Today, we’re speaking to Dr Megan Foreman, a GP and NIHR Clinical Lecturer based at the University of East Anglia.
Title of paper: Diagnosing in the dark: the childbirth-related post-traumatic stress disorder GP evidence gap
Available at: https://doi.org/10.3399/BJGP.2026.0269
Transcript
This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.
Speaker A
00:00:00.320 - 00:00:58.460
Hi and welcome to BJGP Interviews. I'm Nada Khan and I'm the Senior Research Editor here at the Journal. Thanks for taking the time today to listen to this podcast.

In today's episode, we're speaking to Dr. Megan Forman, who is a GP and NIHR Clinical Lecturer based at the University of East Anglia.

We're here to discuss the recent analysis piece that she and her team have published in the September issue of the Journal and it's titled Diagnosing in the Dark the Childbirth Related Post Traumatic Stress Disorder GP Evidence Gap. So, hi, Megan, it's really nice to meet you and thanks again for joining us here to talk about this article.

I suppose, to start with, could you explain a little bit more about what you mean by birth trauma and childbirth related PTSD? And I suspect that these are probably terms that GPs are not as familiar with that we should be.

Speaker B
00:00:59.310 - 00:01:46.360
Yeah, thank you. So birth trauma is a broader term and that can be.

So we're talking here about psychological birth trauma rather than physical birth trauma in the context that we're using it in. We're talking about people who have had a difficult, potentially a pregnancy experience or a birth experience.

That's not just looking at birth itself. That can cause ongoing mental health issues and psychological concerns when we talk about PTSD after pregnancy and birth.

So what's often referred to as childbirth related ptsd, those are people who meet diagnostic criteria for PTSD as a result of a trauma that was related to their experience from pregnancy or birth. So birth trauma is a broader term and then PTSD is a specific diagnosis.

Speaker A
00:01:46.520 - 00:02:14.480
And we were talking just before we started about the wider reach of this work and how, um, it's been picked up more in the mainstream media. But you've also had people telling you about their stories as well.

And what I find quite sad in a way is that there have been a number of reviews around inadequate care in women's health.

And I'm really struck by some of the poor outcomes that you mentioned in the article, like high suicide rates in women postnatally as well, which is really shocking, actually.

Speaker B
00:02:14.880 - 00:03:14.130
Yeah, I mean, you mentioned the people who I've spoken to.

So I've had a really involved patient participation group with the work that I've been doing, and they've talked about their own experiences, even in situations where they've had really extreme birth complications. So, for example, a neonatal loss or severe physical injury, even in those circumstances, may have struggled to access support.

I've also been contacted by a member of the public since the paper was published and since there was media interest in this, talking about her own experiences of birth almost 30 years ago and difficulty in dealing with that going forward. So it clearly is a big issue.

It's also important to say that even if a birth looks straightforward medically on paper, it's still possible to develop birth trauma symptoms and indeed ptsd. So it doesn't have to be a birth with serious complications or a poor outcome for somebody to develop these symptoms.

Speaker A
00:03:14.620 - 00:03:37.180
Yeah, and I think that's one of the things that really struck me in the article, is that birth trauma is very subjective and that these issues can happen like, just like you're saying, just after what might appear to have been or appears to be a medically uncomplicated birth. And I think that's probably really important for GPs to understand in terms of what this will look like when women present to their gps as well.

Speaker B
00:03:37.260 - 00:04:27.610
Yes.

And I think an important consideration is that when women keep referring to women, but I include in that people with other gender identities who have a baby, but when women go into pregnancy, they come to pregnancy with all of their past experiences.

And we know that people who have had difficult previous experiences, so for example, intimate partner violence, previous adverse childhood experiences, substance abuse or pre existing mental health problems, these people are particularly at risk of developing PTSD after birth. And it can be something that develops after what looks like a normal birth on paper.

So it's really important that we consider birth trauma and PTSD in people, even when it appears that the birth is straightforward and that we still are inquiring about these symptoms to make sure that they're identified.

Speaker A
00:04:27.850 - 00:04:40.970
And we'll come back onto sort of inquiring about symptoms. But what might a woman with childbirth related PTSD look like when she presents to her gp?

Are there any clues that we should be looking out for, aside from asking questions about it?

Speaker B
00:04:40.970 - 00:06:08.320
Well, one of the issues with PTSD is that one of the symptoms that women often experience is avoidance.

So people can find that either talking about their birth experience or visiting a healthcare setting can retrigger their symptoms and can be really distressing.

So a particular issue with PTSD that isn't necessarily an issue with other perinatal mental health problems is that people can be incredibly reluctant to talk about their experience and that can be with both with family members, friends and healthcare professionals. So it's something that we really need to be vigilant for.

But in terms of the symptoms that people describe, essentially there are four symptom clusters. So the first would be hypervigilance so feeling constantly on edge, a constant fear that something bad is going to happen to themselves or the baby.

I mentioned the avoidance, avoidance of anything that reminds them of the birth, because it can bring back very extreme, intense physical symptoms. Reliving the birth is another symptom that, that often differentiates it from anxiety and depression.

So that can be symptoms like flashbacks and nightmares. And again, the flashbacks can be triggered by reminders of the birth experience. And then the last thing is alterations in mood.

So that can be low mood, but it can also be things like disproportionate feelings of guilt. And so mood disturbance is a feature as well.

But really, for a diagnosis of ptsd, a person would have to have symptoms from all of those symptom groups.

Speaker A
00:06:08.720 - 00:06:35.280
And I suppose in primary care, GPs sometimes can be in a bit of a practice gap. So primary care really has a role in assessing and coordinating this care.

But I think that sometimes we're not really sure how to do that, especially when there are other people involved, like the health visitor or the midwives and things. So what do you think that looks like in practice at the moment?

So I think probably what you're going to describe is that there's a sense of fragmented care in this area.

Speaker B
00:06:35.750 - 00:07:56.120
Yeah, I completely agree. And I mean the guidance.

So, for example, the nice guidance on antenatal and postnatal mental health, it suggests that if, if another healthcare professional is concerned about mental health symptoms, that they should be sending people to see their gp. And obviously there's. There's perhaps this expectation that women will also be offered a six to eight week postnatal appointment.

So GPs will be seeing women at these points. But absolutely. Care can be fragmented. Sometimes concerns either aren't picked up or aren't passed on. Communication between services can be limited.

I know certainly from my own experience, often the information we get in a discharge summary, for example, can be very cursory, which can also make it difficult then to really to preempt you maybe having more problems. Another issue. So we know from research evidence that GPs often mistake postnatal PTSD for depression.

So there have been research studies that have demonstrated that this is a common problem. Part of the issue is the overlap with depressive symptoms.

So, for example, if you look at the Edinburgh Postnatal Depression Score, it does include symptoms of hypervigilance and mood, so it can easily be mistaken for other conditions. And this can be really problematic because the guidance on the treatment of PTSD and depression are quite different.

Speaker A
00:07:56.470 - 00:08:24.550
And I guess just thinking about treatment, so one of the Issues I wondered about was the access to secondary care services, and this isn't always straightforward.

And talking about sort of gaps in care, I wonder if some women are falling through a gap here in terms of not potentially fitting criteria for NHS talking therapies because of their symptoms, but not quite at the stage where...

Today, we’re speaking to Dr Ben Walker, a post-doctoral associate based at the University of Calgary, who conducted this work while working at the University of Manchester.
Title of paper: Relationships of actual and expected levels of income with GP job satisfaction: repeated cross-sectional study
Available at: https://doi.org/10.3399/BJGP.2025.0683
Recruitment and retention of GPs remains an issue for general practice in England. This work examined the relationship between actual income and income expectations with job satisfaction and intentions to quit. Higher actual income was found to be associated with job satisfaction, but there was little evidence to show that it was associated with intentions to quit. A key and novel finding was that higher income expectations were associated with both lower job satisfaction and higher intentions to quit. The findings suggest that policies that help GPs build accurate income expectations, such as increased transparency for incomes for different GP job roles, may be a means of addressing job dissatisfaction caused by discrepancies between expected and actual income for GPs.

Transcript
This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.
Speaker A
00:00:01.040 - 00:00:58.350
Hello and welcome to BJJP Interviews. I'm Nada Khan and I'm the Senior Research editor at the bjjp. Thanks for taking the time today to listen to this podcast.

In today's episode we're talking to Dr. Ben Walker.

Ben used to be based as a research fellow at the University of Manchester, but is now working as a postdoctoral associate at the University of Calgary in Canada.

We here to talk about the paper he's just published in the BJ GP that's titled Relationships of Actual and Expected Levels of Income with GP Job Satisfaction. A Repeated Cross Sectional Study.

So, hi Ben, it's really nice to meet you and to talk about this work and I guess to start us off, I just wanted to talk a little bit about the background to this paper and it's about GP income and job satisfaction, which is clearly a topic that people have plenty of opinions about. But what made you want to look at this question in a bit more detail?

Speaker B
00:00:58.590 - 00:02:08.930
So, yeah, it's something we had been discussing internally as a team for a while, obviously, I mean, working in a primary care group, a lot of the driving motivation for a lot of our work is the GP recruitment and retention crisis. And we've always had, we've had this data for a while on GP income from us via our surveys.

We've also had this data on GP income expectations and this has been in the survey forever and we've never, we hadn't used anything with it and basically because a lot of us are economists as well as this concept in economics of the Easterland Paradox or the idea that relative income matters more than actual income for happiness.

And so we decided that, well, it would be like, like because we are interested in the GP recruitment and retention crisis, it would be interesting to look at the extent to which relative income matters for GP recruitment and retention. So job satisfaction and intentions to quit being two components of recruitment and retention.

Speaker A
00:02:09.330 - 00:02:14.290
So you mentioned about a survey. So are you talking about the GP Work Life Survey that was done through Manchester?

Speaker B
00:02:14.370 - 00:02:17.130
We are indeed, yeah. So the GP Work Life Survey.

Speaker A
00:02:17.130 - 00:02:28.110
Yeah, yeah. So talk us through that just briefly. So what was that all about? I think, I mean there have been a few publications in the BJGP about it, but what.

Who are you surveying through that?

Speaker B
00:02:28.590 - 00:03:18.400
So the GP Work Life Survey has been going since I believe, 1998.

It's been run by Manchester for I believe, all of its history and it's a government funded survey and when we do it we are attempting to a sample of the general GP population to basically ask about various things to do with their work life, including more sort of like formal things like their income and how many hours they're working, but also just how satisfied they are with their jobs, different aspects of their jobs. Yeah, so we collect lots of data on the GP to respond, and, yeah, we aim to get as general a sample of a population as we can.

Speaker A
00:03:18.800 - 00:03:40.000
And I think one of the really interesting things about this study is that you're not just asking how much GPs actually earn, but how much they think they should earn.

And you mentioned about this paradox that you're interested in in terms of health economics, and I wonder why you think that distinction is important between actual earnings and sort of relative earnings or how much people think they should earn.

Speaker B
00:03:40.990 - 00:04:21.630
So I guess with a lot of things in life, and obviously from this economics paradox, a lot of things are not. It's not necessarily what you have. Absolutely.

A lot of it is driven by things like peer comparison, or if you're seeing that someone else is getting paid more for doing what you believe is like, similar amount of work or similar quality work to you.

So the idea of pure comparison's always just been like, important and there's lots of data out there and lots of studies looking at sort of the effect of absolute income. And this just felt like another relevant dimension to explore, basically.

Speaker A
00:04:22.190 - 00:04:33.710
So I guess if we just come on to sort of the big finding. And what did you find when you looked at actual income and GP job satisfaction? What was sort of the main headline here?

Speaker B
00:04:34.220 - 00:05:21.850
So, for job satisfaction, we, like, we find absolute income matters quite a lot and it has higher absolute income lead generally associated with higher job satisfaction across most, if not all domains.

And for job satisfaction, absolute income matters a lot, but we found that absolute income didn't seem to have any statistically significant association with intentions to quit. So we asked them whether or not they want to leave direct patient care within five years or leave medical work entirely in five years.

And we found that absolute income didn't have enough, didn't have a statistically significant association with that.

Speaker A
00:05:22.170 - 00:05:41.410
So that's quite interesting, I guess, and it's a bit surprising, really.

So higher actual income wasn't really associated with intentions to quit, but paying gps might make them more satisfied, but doesn't make them necessarily mean they'll stay. What do you make of that? It's kind of an interesting finding with.

Speaker B
00:05:41.410 - 00:06:00.300
Job satisfaction that's obviously kind of in line with what we would expect. Intentions to quit, maybe it's just. It's a surprising finding.

We would have expected it to have an effect on intention to quit, especially given that job satisfaction, intention to quit, go together. So it's a little contrary to what we might expect.

Speaker A
00:06:00.940 - 00:06:17.100
I think it's quite an interesting distinction, I guess, because I guess sometimes in workforce discussions, we sometimes think about pay as one answer to recruitment and retention problems. And I think what this work is showing that maybe the picture is a little bit more complicated than that, actually.

Speaker B
00:06:17.420 - 00:06:18.540
Yeah, I completely agree.

Speaker A
00:06:19.100 - 00:06:27.420
So I wanted just to move on to some of your other findings. So you found something interesting when you looked at expected income. So can you talk us through that as well?

Speaker B
00:06:27.920 - 00:07:00.990
So we find that higher expected income is associated with lower job satisfaction, and we actually find that has a small but positive effect on intentions to quit. So higher expected income has a small association with higher intentions to quit. I think there's obviously rationale for this.

Obviously it kind of goes along with the economic theory and what studies have found in other domains with things like worse mental health, with higher gaps between actual and expected income.

Speaker A
00:07:01.070 - 00:07:15.230
Yeah. So if I'm understanding that.

Right, it's not simply that earning less makes you unhappy, it's about the gap between what you earn and what you feel someone else with your experience and career stage ought to be earning. So do you think that's a fair way of thinking about it?

Speaker B
00:07:15.230 - 00:07:57.860
I think that's a very fair way of characterizing it, yeah.

Basically, if you feel that you should be earning more, even if you're on, like a salary that, say, is pretty good, or they do things like pay the bills, if you feel that you should be earning more for the stage of your career, you're at the training you've had. I mean, gps are, obviously, they have to go through a lot of training through med school, and GP training itself is quite intense.

And there's a lot of hours they have to work. So all of this builds into income...

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...