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At the heart of general practice since 1960

GPs should give up their gatekeeping role

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In the past week, it has transpired that 100 practices a year are applying to close their lists and 40% of GPs are to quit in the next five years. We all know that the workforce crisis in general practice has now reached tipping point. We know recruitment of new GPs won’t happen in time, even if the current recruitment drive is successful. We know that with pensions being eroded and workload escalating, there’s little to tempt retiring GPs to delay. It’s time for a much more radical look at reducing demand on general practice.

I get frustrated every time I hear the president of the Royal College of Emergency Medicine on the news complaining about how busy their departments are. His comments are newsworthy because he appears when it has been a bad week or month. Maureen Baker would have to be on the news every day if the situation in general practice was to be similarly reported. What irks me most is that the answer to the A&E crises is always ‘GPs should be seeing more patients’. That is not the solution.

Patients with suspected fractures should go to A&E, not their GP. Patients with haematemesis should go to A&E, not their GP. But I think we can extend this principle even further. Yes, I am calling for the (partial) end of the GP’s gatekeeper role.

Giving up the gatekeeping role could be the price which saves general practice

There are clear situations where a GP’s role is simply to redirect an informed patient to the specialty they require. If there is a national screening programme, then adverts should not direct concerned patients to their GP. They should be directed to a national number which will feed them into local screening clinics run by Public Health England. This is currently how the abdominal aortic aneurysm screening programme works – concerned patients ring and book an appointment themselves.

Similarly, diabetic patients should be able to book directly with NHS podiatrists if they have problems with their feet. Postmenopausal women who experience vaginal bleeding should be able to book directly with a gynaecology service. Women over a certain age with a breast lump should be able to book directly with a breast clinic. There are many situations where there is a clear need for a specialist opinion.

Already the technology exists to support this. NHS Choices and 111 could easily be enhanced to link with Choose & Book, local pharmacies, podiatrists, optometrists and physiotherapists. There are increasing numbers of solutions for GP practices to use to signpost their patients rather than book a GP appointment. These should be rolled out and funded nationally.

Ultimately, GPs are best at assessing and managing complex multimorbid patients. No longer can we afford to waste our time redirecting otherwise healthy patients to another professional. Giving up the gatekeeping role could be the price which saves general practice.

Dr Phil Williams is a First5 GP in Lincoln, and former RCGP National Lead for the First5 initiative

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Readers' comments (12)

  • Sound argument.

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  • Azeem Majeed

    It's an argument that needs consideration. There are some NHS services that could be open access.

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  • It is inevitable and probably nearer than we think. We can't afford it - but what the heck.

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  • Beautifully put argument Phil, and I am fully supportive of this approach. The only problem is that when these other services inevitably get overwhelmed you just know that the fall back position will still be 'go and see your GP then'!!

    Disillusioned GP Partner (3.95yrs)

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  • We might be able to cope more if we weren't used as the hospital consultant's SHOs. We all recognise "please would you arrange.....", or "please could you refer the patient to my colleague". As a junior hospital doctor in the 80s we did not let patients go home till all their problems had been addressed. These days it is normally just the issue they came in with with a note to the GP to sort out the rest. Patient's who don't attend hospital appointments, often due to failure of the administrative processes in the hospital, are told they need another referral.

    The internal market has got in the way of joined up healthcare and we are now forced to spend too much time on unnecessary processes which get in the way of our real job - which is to act as the gatekeeper and co-ordinator of care.

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  • I suspect this is going to happen like it or not. Based on what you say there will be no GPs to keep a gate. You make a good cogent argument.

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  • I couldn't agree with you more. Let babies see a paediatrician directly. Let gyne patients see a gynecologist. Let anything that comes under the 2ww (blood from any orafic! lumps and bumps esp breast lumps, haemoptysis, weight loss) be direct dial patient access and the clock starting at phone call. Thats what the rest of the world does, why not UK?

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  • Makes sense really letting people think for themselves.

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  • Taken to the the extreme perhaps we should just get rid of GPs. Let people decide which specially their 'symptom set' needs. Remove GPs from the process entirely.y
    What happens with folk with non specific abdominal pain? Do they book them selves to see a colorectal surgeon, an upper GI specialist or a lower GI one? ... if they are female will they think maybe they might need to see a gynaecologist? What about foot pain? Direct to the orthopaedic surgeon ...a physio...orthotics...or a podiatrist? Which one do you think they will choose? Head ache? Will they need immediate direct access to the best neurosurgeon in the country?..or maybe a neurologist? ..will they think of seeing an ENT specialist? Or maybe they might book themselves to see a spinal surgeon for the referred neck OA they didn't think of..obviously rather than considering physio first ..before getting their eyes checked at specsavers ...perhaps they'll realise they need to stop drinking seven bottles of Coke a day and cut out the codeine, before their self refer to anyone. Rather than wait 10 months to be told by the neurosurgeon they booked with. Perhaps all these difficult decisions could be made by a computer protocol like they use at 111? (Current standard advice - 'go see a GP')
    I can see why people might self refer for a few very limited issues (e.g podiatry, maybe physio, sexual health and screening ) but removing the gate keeper role more generally would mean the end of our publicly funded system. The country couldn't afford it. I guess the reason why it might be suggested is simple exhaustion - because we have been so screwed and underfunded it feels like we should just give up and throw in the towel. Fare enough ..we should all quit then... but I have no doubt getting rid of the general gate keeper role of GPs is a bad idea, will lead to massive over investigation, misdiagnosis and time wasting as specialists investigate conditions which were never in their specialty to start with ..and we'd be left thinking ..if only they'd seen a generalist first...what a radical idea. Much more sensible, but only if the country actually bothers to fund it.

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  • I disagree..giving up the gatekeeping role would tip the NHS into financial oblivion (if it is not already there!)

    The real problem is our contract and the open ended demand for GP services. We should be paid for activity, therefore the busier we are, the more income generated, the more we can employ people to cope with demand. Then if other areas of the NHS wish to dump workload on us ..fine..we will get paid for it. At the moment we are getting massive extra work for basically no funding. This is what the RCGP should be talking about.

    In the example of A&E above, this is how it works.

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