BJGP Interviews

Today, we’re speaking to Cate McCarter and Amanda Williams. We’re here to discuss the research they’ve recently published here in the BJGP titled, ‘Understanding chronic pelvic pain in women survivors of sexual violence: a qualitative study’.
Title of paper: Understanding chronic pelvic pain in women survivors of sexual violence: a qualitative study
Available at: https://doi.org/10.3399/BJGP.2026.0057
Chronic pelvic pain (CPP) is common and can be difficult to treat. Some women with CPP are survivors of sexual violence. How such women understood their pain was strongly influenced by feeling ignored by doctors and shamed by both CPP and sexual violence. According to women in our study, a ‘good enough’ response from GPs involved being seen as a whole person, being asked about sexual violence, pain being adequately investigated, and the GP acknowledging what is not understood about CPP and sexual violence. This allowed the negotiation of a pain explanation that validated the woman’s experience and integrated her social context with medical results, delivered with empathy and understanding.
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
00:00:00.240 - 00:00:56.560
Hi, and welcome to BJGP Interviews.

I'm Nada Khan and I'm the senior research editor here at the bjgp.

Thanks for listening to this podcast today.

In today's episode, we're Speaking to Kate McCarter, a clinical psychologist and Professor Amanda Williams.

Amanda is emeritus professor of Clinical Health psychology based at ucl, and we're here to discuss the paper that they've recently published here in the bjgp, which is titled Understanding Chronic Pelvic Pain in Women Survivors of Sexual Violence A Qualitative Study.

So, Kate, I think I'll start with you.

And we were talking just about, you know, how important this work is, and perhaps we could just start by talking about why you wanted to explore the experiences of women with chronic pelvic pain who have also experienced sexual violence.

What did you feel was missing from what we already know in this area?

Speaker B
00:00:57.650 - 00:02:15.360
Yeah, I suppose the.

I approached this research topic with anecdotal evidence, having worked with survivors of nursing and sexual violence for about 10 years before I started researching this.

Just anecdotal evidence that lots of women also lived with chronic pelvic pain.

And I didn't, you know, I hadn't any thoughts about the association really, or whether it was causal or what, but I just noticed that the women I was supporting before training as a psychologist, they were living with chronic pelvic pain, and a lot of them had found it very difficult to seek health care and to receive health care for that.

So I just started speaking to Amanda about that, and from our conversations, we started thinking about the meaning of pain and how there's an established association within the literature about chronic pain, chronic pelvic pain after sexual violence.

But what's the meaning of that for the women who live with it?

That felt missing.

And because meaning, personal meaning, is so key to understanding a personal lived experience of pain, it felt like a gap that we could begin to address by asking women, how do you make sense of the pain that you're living with?

Came from there, really.

Speaker A
00:02:15.440 - 00:02:24.400
And your background is as a clinical psychologist.

So interpreting what pain means is quite a personal thing for a lot of women, isn't it?

I guess.

Speaker B
00:02:24.480 - 00:03:23.180
Yeah, absolutely.

Yeah.

Is very personal and.

And complex as well.

The.

The attempts to understand exactly what pain means to a woman is, you know, you take into account those experiences of trauma very often, but not always, and you take into account the social context and what's going on around them, how sort of how they've come to be in the situation they're in.

So, yeah, it is Highly personal and effective treatment can't really start until that's understood because the way that a woman will approach her attempts to seek health care is very much led by how she makes sense of it.

So if she's.

Some of the women in the study linked it to surviving sexual violence, then the meaning is wrapped up in that.

Has she disclosed that to her healthcare provider?

Does she feel able to.

It's an incredibly difficult thing to talk about.

Has she been asked?

So, so yeah, very personal, absolutely.

Speaker C
00:03:23.820 - 00:04:12.840
And I think often sort of co created in the encounter with healthcare professionals and that can go either way and in the paper are examples of both.

But women are looking for information and understanding to incorporate into the meanings of pain and that doesn't always happen.

Or they get multiple different accounts which are incompatible.

People really struggle.

I mean, I've worked in pain for 35 years and I hear this in all sorts of pain, but I think particularly where there isn't anything very definite, no tissue damage to identify, nothing to show for it, as it were.

Speaker A
00:04:12.920 - 00:04:36.579
And this is a really sensitive area.

And you interviewed 10 women about both their pain and their experiences of sex, sexual violence.

I just wanted to touch on how you approached these conversations and how you learned from listening to women in this way, sort of taking both of these things into account.

And we'll go a little bit more in depth into the themes that you discovered.

But yeah, just as a sort of overview.

I wonder if you wanted to comment on that.

Speaker B
00:04:36.739 - 00:05:54.960
I suppose it started with I believe that you've been sexually assaulted.

There was no question about that.

And I think the reason I say that is because that's.

That's often disbelieved or dismissed or minimized by anyone.

It's not specific to healthcare at.

By anyone that a woman tells about her experience.

So I think it started from that even before we had a conversation.

The advertisement, the information sheet about consenting into the study was.

I tried to make it as validating as possible.

It was an opportunity to talk in depth about a topic, topics that are taboo, that are not spoken about, that are shamefully hidden.

And I think giving women the opportunity in a space where they felt believed meant that women perhaps relaxed into the conversation as we got talking.

I think also it helped that it was a semi structured interview so I was very much able to follow where that woman was going.

But I think also the women were so motivated to talk to me, they really encouraged me to publish.

I wasn't.

I don't love writing.

Amanda's very good at writing.

I don't love it, but I really wanted to do it for them.

I said I would and therefore I did.

Speaker A
00:05:55.360 - 00:06:05.120
And one of your main themes was attempts at silencing women.

What did women mean by that and what were they experiencing when they tried to get healthcare for their pain?

Speaker B
00:06:05.600 - 00:07:28.130
So this, this was a finding that really fitted with both experiences of pain and of surviving sexual violence.

And women were talking about being actively told not to talk about those things.

So sometimes they're disclosed to a family member and they'd been told, I don't believe you, or don't talk about that.

That's just something that women have to go through.

But also, unfortunately, some encounters with health care professionals as well.

So not being believed, not being asked as well.

That was a really significant part of some of the women's narratives, that if you don't ask, then I won't tell you.

And that's, that's not a new finding that's fairly established within primary care.

The women in this study really just backed up that finding that women want to be asked that it's, it facilitates disclosure of difficult experiences, sexual violence being one of those.

So if they'd, if they'd been asked, then they were more likely to disclose.

But, yeah, it's the responses to that disclosure that were, that was silencing and that fitting within a societal context of minimizing sexual violence, of minimizing particularly women's pain, particularly in the pelvic area.

And the message of just get on with it, really.

Speaker A
00:07:28.850 - 00:07:44.440
And I wonder just a little bit, I mean, that comes through quite strongly, that experience of not being believed or of having pain attributed to mental health problems.

But why do you have any thoughts, either of you, about why that happens, particularly with chronic pelvic pain in women?

Speaker B
00:07:44.840 -...

Today, we’re speaking to Dr Rupinder Bajwa, a Research Fellow based in the centre for Academic Primary Care at the University of Nottingham.
Title of paper: Unpacking barriers to and facilitators for research leadership for Black primary care researchers: a qualitative study
Available at: https://doi.org/10.3399/BJGP.2026.0175
Researchers of Black heritage are underrepresented in primary care research leadership, and there is limited evidence on their lived experiences of why this underrepresentation exists. This study addresses this evidence gap and highlights how systemic inequities, racism, and inequitable academic practices contribute to this lack of representation. This study also presents practical enablers to improve progression and retention, such as proactive leadership, tailored career support, and increasing visibility of Black role models in academic primary care. These findings emphasise the need to foster inclusive research environments that strengthen the diversity and relevance of primary care evidence.
Transcript
This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.
Speaker A
00:00:01.120 - 00:00:54.620
Hi and welcome to BJGP Interviews.

I'm Nada Khan, I'm the Senior Research editor at the BJ gp.

And thanks very much for joining me here to listen to this podcast.

In today's episode, we're speaking to Dr. Rupinder Bajwa.

Rupinder is a research fellow based in the Centre for Academic Primary Care at the University of Nottingham.

We're here to talk about the paper she's recently published in the BJGP titled Unpacking Barriers to and Facilitators for Research Leadership for Black Primary Care A Qualitative Study.

So, hi, Rupinder, it's really great to meet to talk about this work and I wonder if we could just start by talking through what prompted you and your team to look at the experiences of black researchers in academic primary care.

And I'm wondering what we already knew in this area and what you felt was missing from the picture.

Speaker B
00:00:55.260 - 00:01:34.840
Firstly, thank you so much for having me on to talk about the work that we did so the way this sort of came about.

So primary care serves some of the most diverse communities in the uk, but what we realised is, when you look at primary care, researchers of black heritage remain largely underrepresented, especially in more senior academic and leadership roles.

And so because of that, we wanted to understand, well, why does this gap exist and, you know, what can we do to improve representation but also improve retention of researchers of black heritage and their career progression as well?

Speaker A
00:01:34.920 - 00:01:43.320
And you spoke to people from a black background, is that right?

So talk us through just who you discussed this project with and how you got those.

Speaker B
00:01:43.640 - 00:03:01.100
Yeah.

So to start with the project team itself, there's myself, I'm a researcher of South Asian heritage.

We had Adwa and Ralph, who are researchers of black heritage.

Manpreet Rains is a researcher of South Asian heritage.

We have Professor Joe Kai on the team, who is also of Asian Heritage.

And we had Professor Christian Mallon on the team as well, who is a senior leader at the School for primary Care research.

And so we had sort of that diversity within the study team.

We predominantly wanted to speak to researchers of black heritage who are working in academic primary care across all levels, so from junior up to senior.

And we also spoke to leaders of departments where, you know, they're leading academic primary care departments as well.

And we, you know, really wanted to explore what, especially with the researchers, you know, barriers that they've experienced or barriers that they know of as well as what's gone well for them as well, you know, for their progression opportunities that they've had, but also, you know, what their thoughts and feelings were around the current level of representation and what could be done and with leaders as well.

We sort of spoke about some of the barriers, but also some of the work that might be going on on to address some of these barriers as well.

Speaker A
00:03:01.340 - 00:03:25.340
Just the introduction to your paper and work that's been done more widely in this area.

We do know that the underrepresentation of researchers of black heritage drops off, particularly as sort of more senior levels of academia.

And I wonder what you heard from the experiences of researchers as they move through their careers and why does that progression seem to become more difficult?

Speaker B
00:03:26.280 - 00:04:51.480
Yes.

So a lot of what we found in the project isn't just an academic primary care problem.

I'll start with that.

It does speak to wider challenges across academia.

So when you look at academia as a whole, I think it's around 1% of professors are of black heritage.

So that's quite a small number.

Speaking to researchers around their progression.

We wanted to understand what some of those challenges are.

And what came through was there are a lot of structural and systemic barriers that continue.

So structural and systemic racism is one key challenge.

And when we were speaking to researchers, what this looked like.

You know, it was more, it could be subtle microaggressions being passed up for opportunities, stereotypes, but also sometimes the academic culture could be quite exclusionary and researchers found that it was sometimes difficult to find opportunities.

There was limited access to some development opportunities as well.

And especially for a junior level, sort of the short term contracts and the funding insecurity made that progression difficult.

And for those who were sort of mid career researchers and thinking about the next steps, it was, you know, well, what does that look like?

What support is available?

Is there any support available?

And there was challenges around that is finding adequate support, adequate mentorship and sponsorship as well.

Speaker A
00:04:51.810 - 00:05:10.690
And you know, you're talking about these structural and interpersonal barriers as well.

But I wonder how that impacts things like academic funding or recognition and how that's distributed.

Did they talk about barriers to getting funding or grants and recognition for the work they were doing?

Speaker B
00:05:10.770 - 00:06:02.430
Yeah, so this was a, this was a concern as well that came up and researchers were keen to highlight that, you know, this is a challenge across the board in terms of research funding.

A lot has changed in the last few years.

Pools of funding have got smaller, but it seems to be there's additional challenges involved for minoritised researchers in terms of how to get that funding, how to apply for that funding, you know, how to position yourself for that Funding, unless you know it, you don't know it.

And it can be even more challenging if you're a minoritised researcher where you may be starting off on a slightly different footing, coming into the space.

And that can make it really difficult for funding.

But more recently, I know NIHR and funding bodies are now looking at this and making proactive steps to address that, which is really positive.

Speaker A
00:06:02.910 - 00:06:18.030
And one thing that really struck me was the difficulty that some people felt in speaking up about discrimination.

So what did the people that you spoke to tell you about raising concerns?

And I wonder whether that says something about sort of the culture within academic institutions as well.

Speaker B
00:06:18.400 - 00:07:15.700
Yeah, this came up across levels as well.

So it wasn't just junior researchers, but senior researchers reflected on their experiences as junior researchers as well.

And there was a concern around the impact that raising issues could have on their careers, but also concerns around actually, will anything be done about it?

If I raise it, what's going to come out of this?

And so people might not report it then if they a, feel it will impact their career and impact their trajectory.

But then also if they feel that actually, you know, I don't really have faith that the system will address this or anything will change that then will leave them feeling like actually it's not worth reporting it.

And that in itself is challenging because if you've been, you know, if you've experienced that, you should be able to go somewhere that's impartial and that will take your experiences seriously and look into it and address that.

Speaker A
00:07:16.190 - 00:07:31.070
And you mentioned that when you conducted this study, you also wanted to look at things that helped people to stay and progress.

So I wonder if you could talk through just some of these different areas because there...

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...