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At the heart of general practice since 1960

Closing the gate before our role has bolted

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I know it’s deeply unfashionable to defend our gatekeeper role – so that’s exactly what I’m going to do.

An over-supply of medical care leaves us GPs deskilled and lazy

I won’t waste words explaining how it works, because if you don’t know, you’re in the wrong column. Try ‘Fencing and Landscaping News’. Suffice to say the key job of the gatekeeper – diagnosing and managing normality – is probably the most difficult and undervalued job in medicine. And doing it properly is what keeps the NHS, and patients, afloat.

True, various pressures have conspired to make it tricky to keep that gate. The gonad-grind of workload, guidelines, complaints culture and general pissed-offness means we’re opening it wider, and with less resistance. But, to be honest, if gatekeeping isn’t working as well as it should, then we gatekeepers are partly to blame. And that’s because we’re asleep on the job.

Take three patients I saw yesterday.

Patient 1. ‘I’m feeling a bit down, doctor, I don’t want pills, I think I just need someone to talk to…’ Can I just stop you right there? Here’s the number of our local open-access psychology service. They deal with all that emotional, sniffly stuff.

Patient 2. ‘My back’s still sore, doc, I wondered if…’ No need to explain, I’ll send you to the musculoskeletal triage service, where they’ll sort out that physio and scan you were about to ask for. Next patient.

Patient 3. ‘It’s about my 13-year-old son, he’s unhappy at school and he’s started to…’ Say no more. Give the child and adolescent mental health services a ring, they’re awfully good at that sort of thing.

Given how I sleepwalk through these consultations, it seems incredible that I once practised with no access to counselling services, with minimal provision of child psychological help and with a physiotherapy wait so long as to render referral pointless. Yet the world didn’t come crashing down around our ears. We sorted the patients out as best we could. Number 3 would have received a dose of sympathy and common sense, Number 2 some simple advice about painkillers and exercise and Number 1 the explanation that, by the time we figured out she needed counselling, she’d had 10 minutes’ worth already, so job done.

I’m not voting to increase our ridiculous workload and stress levels by dumping these services, of course. I’m not a complete tool. But the fact is that an over-supply of medical care not only fuels demand – something we’ve known for ages – it also leaves us GPs deskilled and lazy – something I don’t think we’ve realised or are prepared to admit. In other words, becoming a ‘signposter’, to use the de-rigeur, God-awful vernacular, lowers our referral threshold for rubbish that didn’t need referral at all.

The result is we’re nodding off at the gate, drowzily waving people through. When we wake up, we’ll realise we’re standing by a massive flashing neon arrow that says, ‘All-u-can-eat NHS services this way’, and that the gate has been nicked. So we’re actually leaning on thin air and, like the whole healthcare system, about to topple over.

Dr Tony Copperfield is a GP in Essex. You can follow him on Twitter @DocCopperfield

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Readers' comments (12)

  • I remember a car mechanic of old lamenting about how the repair of engines nowadays is about connecting the car to a computer to diagnose the problem, which is not always correct. Then bolting off a damaged part and bolting on a new or reconditioned one. No self diagnosis through experience and no repair of the damaged parts. He retired shortly after.

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  • The Gate is soon to be replaced by a revolving door with more traffic coming out of secondary care into "hospital at home" . The electricity generated by the door turbine will supply electric shocks to the doorman's genitalia to give the impression that there is still some vitality in the role.

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  • A virtual nobody

    This is a serious issue. I'm not convinced GPs will still exist in ten years. In fact I think we'll end up disappearing far faster than any of us currently imagine possible. Every day people come to see me convinced they know what treatment they require and/or what specialist they need me to refer them to...all courtesy of google. They genuinely believe a GP is an irrelevant irritation simply getting in the way of the care they know they need. Many of them are entirely well but absolutely dead set on spending their fellow tax payers cash on unnecessary and pointless investigations and treatments. The customer is, however, king and it's increasingly difficult to contradict the entitled ignoramus with access to the internet. I really think in the long term it's curtains.

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  • And the customer will then need to be paying the market rate for what they want ,which will them come a bit of a shock to them as they dont pay upfront at the moment.

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  • TBH things have got so bad of late, I long for simple transactional medicine where people pay for what they want. Then everybody will be happy won't they...?

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  • The major problems are:
    1.) Patients often demand referral, especially without personal lists as patients do not learn to trust their own GP's advice.
    2.) The possibility of complaints from patients over GPs not referring when they request it also encourages referral by a GP.
    3.) GPs feel time pressure and it is often easier to refer rather than sort out problems themselves.
    4.) More patients come from abroad, where GPs have not had such a gatekeeper role, so they are not happy with the family doctor sorting out patient problems.
    5.) Other types of medical professionals such as paramedics are working instead of GPs, and they might be more likely to refer, as they do not have the breadth of knowledge of a GP.
    GPs should persevere with the gatekeeper role and of course the treatment role. I for one feel bullied by patients. Why should patients control the outcome of a GP consultation? 'The client is always right' scenario is frustrating. Without GPs, the NHS would be far worse off financially and the medical system would be in turmoil. We need more education of patients (and some of our hospital colleagues) about how GPs can sort out problems themselves.

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  • I think Copperfield has expressed an incredibly astute but unpopular opinion (amongst GPs)when describing them as deskilled and lazy. The tragedy of this, IMHO, is that this feeds into and invigorates the opinion held by secondary care of the general ineptitude of GPs and when those of us who ,despite finishing later than our colleagues, strive to the full extent of their abilities to elucidate the patients problem through a proper history, full exam and meeting up several times as investigations proceed to pin down the cause find that an incredibly comprehensive evaluation with a firm rationale for seeking the specialists input becomes rejected and dismissed as GP waffle. This is the best disincentive I have had this week for doing the job well and makes me feel that this dog will henceforth live up to the name its been given.

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  • I think Dr Copperfield has eruditely set out the current dilemma....
    In my view it is not quite that simple...
    Whilst agreeing wholeheartedly with the sentiment expressed , I would add that this is also exacerbated by the fact that within the 10 min consultation , when we could , in the past have easily dealt with examples 1,2 & 3 above without the need for referral anywhere else ....we are now also expected to deal with problems 2, 3 , & 4 that the patient has brought with them, as well as problems 5 ,6 , 7 & 8 that comprises the Qof , the Quip , meds management software, etc , AND problems 9,10 & 11 relating to issues from secondary care ... appointment not received / good enough , my CT scan result the hospital did please Dr , and "GP to chase results"
    Is it really any wonder the default option is "refer" .. .next problem please

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  • Having met our fantastic Chair Lady yesterday at the RCGP, I whole heartedly support your cap doffing. She has her finger on the pulse and a clear knowledge of what is happening in General Practice across the country. A great representative for us as a profession.

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  • @12.04 - there has definitely been a tonal shift in the press releases and communications with the media since she's taken over - talks with a welcome candor that's been sorely lacking.

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From: Copperfield

Dr Tony Copperfield is a jobbing GP in Essex with more than a few chips on his shoulder