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At the heart of general practice since 1960

Do we need gatekeepers for the gatekeepers?

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I encourage all of you to read the seminal article by Mathers and Hodgkin in the BMJ published back in 1989. In ‘Gatekeeper and the wizard’, they look at GPs as the sentry within a well-funded, robust primary care system, preventing the collapse of secondary care.

Times have moved on. Consultation rates in primary care have become unsustainable as our funding is still based on capitation rather than activity. GPs are an extremely precious resource so is it any wonder we question the wisdom of being used to rubber-stamp a sick note for flu or write a letter for AN Other?

The truth is, we need gatekeepers for the gatekeepers if we are to continue functioning in the current funding model. And there’s the rub.

We will become a cross between a community geriatrician and a medical ethics adviser

In order to remain sustainable in the NHS, the entire model of general practice as we know it has to be turned on its head. No longer can this model be delivered in independent practice units that engender ownership and continuity of care. Instead, the direction of travel is for GPs to work in large integrated care organisations as ‘primary care consultants’.

Patients will not be able to see us until they pass through several layers of telephone and clinical triage from other healthcare professionals. All the back pains and joint problems will be managed by an orthopaedic physiotherapist. All the mental health problems will be seen by a community psychiatric nurse or psychologist. All the minor illness will be treated by a nurse practitioner or pharmacist.

Patients will be navigating their way through the system like a Monopoly board. They may land on ‘go to jail’ and start again if they are triaged to the wrong health professional. Or they may get a ‘chance’ card and advance directly to ‘go’ because they have a red flag symptom.

And what will become of our role? We will become a cross between a community geriatrician and a medical ethics adviser. We will be left to see the patients with complex physical and psychiatric co-morbidities but without the historical knowledge that continuity of care provides. We will not have seen them for their coughs, colds and hip pain so we will not have built up the kind of relationship that is required to manage risk and uncertainty.

By having our own gatekeepers, we will become less effective gatekeepers for secondary care, and admissions and referrals will escalate. The NHS will crumble and the Tories will tell us the whole system is unsustainable.

There are simple solutions to this mess. Ensure general practice returns to at least 11% of NHS funding; protect the quality and continuity of care found in small partnerships; and reduce patient demand. Selling the despicable lie of a seven-day service will not do any of this.

We are catapulting towards a very different type of general practice, and I am not sure patients will like it.

Dr Shaba Nabi is a GP trainer in Bristol

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Readers' comments (15)

  • They definitely will not like it,and it will not be a role that any of us signed up for at the beginning of our careers.Maybe it is time to be a locum .Damn that lease!

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  • General Practice is a very damaged listed building of the highest order. Nothing short of a natural disaster will bring it down to force a rebuild. I can hear a hurricane building up.

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  • Harry Longman

    I've always felt that "gatekeeper" is a very poor label for GPs. The fact that over 95% of patient demand is dealt with by GPs says it all. These are not patients desperate to waste secondary care money, they just want help, and they trust their GPs. Right with you Shaba that gatekeepers to the gatekeepers is a disastrous direction, and all the evidence is against it. The thinking is wrong: industrialise, cheapen, reduce to transaction. The result is NHS111, demands on ambulances, A&E etc going up not down.
    Right now we have choices. Don't let go of continuity of care. Don't see scale as inevitable - there is no evidence for it. See http://gpaccess.uk/evidence/efpc-2015-how-does-practice-list-size-affect-secondary-care-demand/

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  • Azeem Majeed

    It's a good article Shaba. Sadly, I don't see any easy way out of our current predicament.

    http://www.tandfonline.com/doi/full/10.1080/17571472.2015.1082343

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  • @ Harry Longman

    May I ask where you buy your lovely cardigans from?

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  • @ Harry Longman
    Long time no see, welcome back!
    For once I totally agree with you.

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  • I would argue that we already have outstanding gatekeepers in front of the GP - called receptionists. Their role in filtering out what is obviously administrative, nursing or plain bonkers should not be underestimated.

    GPs as the expert generalists should triage, but they need a team of various skills behind them to pass on to. This is where the scale adds value - as it means you can have a broader range of skills to utilise. The other key area is purchasing power - which is certainly correlated against scale. So whilst I agree with Harry from the clinical side, the commercial side still says you can't make a profit on the small business model anymore - and no dollar - no service.

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  • Drachula

    Telephone triage has something to be said for it, but it is it a panacea.

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  • We are not gatekeepers any more. The nhs constituation gives patients the right to demand and get a referral. All patients who ask for a referral are referred. All patients who have any vague unexplained symptoms now fit into some 2ww criteria or other. We can not take clinical risk for fear of the GMC, CQC, ombudsman, patient complaints. Doctors are not going to jail if patients die, even if no fault of their own. Practice very defensively, refer a lot and appropriately, don't take any risk which - this will only help patient care. Secondary care lack of ability to cope is definitely not primary care's problems. Think about yourself (no one else does...no one) and your family and ensure your are able to look after them at all times. Spend as much time with them rather than be stuck to work. your family will look after you, your work will not when you are sick. Pay of your mortgage and if young enough emigrate, find alternative careers or retire if old enough.

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  • The solution is not to get here in the first place.'First and foremost = DO NOT take up medicine a career. In no other profession do you have the funnel web spider [GMC] lurking in the toilet seat to pounce on you at your most vulnerable.
    You are clever do computers or Engineering = you are needed there and they look after you.
    If you become a doctor in the UK by mistake, DO NOT become a GP.
    Think of leaving the UK as soon as you can.

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