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The Wizard and the Gatekeeper need to know each other's kingdoms

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Once upon a time, in a green and pleasant land, there lived a Gatekeeper and a Wizard. Their tale has been recounted by many learned scribes in distinguished scrolls over the decades.

For the first time, I felt I'd sat in the moat with a clear view of both sides

The Wizard was highly revered and lived in a splendid white castle on the hill. He possessed a crystal ball that could tell him why the village people fell ill, and had many mystical potions at his fingertips to make them better. At the bottom of the hill lived a Gatekeeper, who would decide which of the many people who came with their illnesses should go on to see the Wizard.

Carrier pigeons flew between the two to convey their messages. But there was a moat around the castle, which the pigeons were prone to dropping their messages in. This sometimes made it hard for the Gatekeeper and the Wizard to understand how each others’ kingdoms were working. From time to time, they each wondered if the other was abdicating responsibility for managing the sick people. When this happened, it would lead to a loss of goodwill in the other. But they carried on as best they could, and the sick people were ferried across the moat as each felt was appropriate.

Wind forward a few centuries.

Recently, a 52-year-old librarian with depression on our psychiatry ward had double incontinence. I wanted some advice from the medics, but was dreading calling the main hospital again.

Fortunately, I'd honed my phone-holding skills in general practice. I knew just where to position the speakerphone so I could eat lunch with one hand whilst sifting through the daily deluge of letters with the other, and tune out the ‘on hold’ music that threatened to bore into my caffeine-soaked brain.

40 minutes of the usual ping-ponging ensued, being passed from one irritated person to the next. I could feel my frustration mounting. But I caught myself, and tried to remember that only a few months ago I was scurrying around the castle cradling a phone, trying to explain to a disgruntled GP in between the piercing tones of my bleep that I couldn’t help.

Soon afterwards, the librarian was being discharged. I decided to update her GP. I fired off an email marked ‘non-urgent’ for the duty doctor, and left my mobile number. By the end of the day, we had formulated a plan together. She also added some useful background about the family dynamic at home which we hadn’t yet unearthed.

I paused for a moment. For the first time, I felt I'd sat in the moat with a clear view of both sides. The resulting plan felt like a sequence from Connect Four, where the coloured pieces had dropped neatly into place. Why was this so unusual?

I realised that I'd  picked up enough in general practice to know the little things that made a difference, like how best to contact the GP in between the surgeries, home visits and, if she was one of the lucky ones, the toilet breaks. I had an idea of how we could support each other to make sure the patient’s transition back across the moat was smooth. But that’s because I’m soon to be in her shoes.

It struck me then that whilst all GP trainees spend around two thirds of their postgraduate training in secondary care, many of my specialty colleagues might never have stepped into a GP surgery as a doctor. Yet for our patients, 90% of their contact is in primary care.

I wonder if that’s where some of the cross-interface lambasting stems from, born out of a somewhat antiquated view of the pressures in GP that result in the torrent of letters stamped with ‘GP to chase’ from secondary care, sliding under window frames and cascading down corridors like Harry Potter’s invitations to Hogwarts.

I can see why the finger is sometimes pointed in our direction too. We might occasionally fire off lukewarm referrals into the ether, as our capacity to manage them in house is constantly chipped away.  And leave out the soft intelligence that’s accumulated from knowing our patients over a lifetime. Our frustration at forever occupying the ‘dumping ground’ niche might leave little room to consider the plight of our secondary care colleagues.

Ultimately, I worry that it’s the patients that feel the biggest impact of any discord at the interface, as they start to resemble problems to be shifted from one discrete four-walled silo to another.

Many of these issues were aired recently in a fascinating piece of qualitative research by Sampson et al. They found similar concerns about issues at the interface emerging from clinicians on both sides. It got me thinking about what we can do about it. And I think they hit on one important answer in their paper: spending time in each others’ kingdoms.

Rotating through paediatrics in St Mary’s Hospital showed me the power of this. I saw paediatric consultants regularly stepping out of the castle to sit alongside GPs, running joint clinics for children that would often otherwise end up in secondary care.  A dedicated email and telephone line also keep the interface porous, instead of flinging discharge summaries or referrals over the moat to faceless recipients. The reductions in A&E attendances and outpatient appointments are impressive. But even more so are the relationships that are cultivated across the fault line.

As we push the centre of gravity away from secondary care, the importance of having strong connections at the interface will only grow. Perhaps apparating over the moat from time to time could lead to a better understanding of each others’ kingdoms.  And understanding breeds respect.

And, after all, when the Wizard and the Gatekeeper are allies, it’s the sick people in the green and pleasant land that stand to win.

Dr Nishma Manek is a GP trainee in London. You can follow her on Twitter @nishmanek

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Readers' comments (8)

  • Excellent article. All speciality doctors should have a rotation in primary care. I was recently working in OOH home visit shift in a very remote area; 30 miles away from the main DGH. I called the Surgical on- call doctor to transfer a patient with obstructed inguinal hernia and fecal impaction.
    The reply I got was;" To put up an IV drip". I almost fainted.
    The reply I got

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  • Brilliant article. Having worked in Canada 30 years ago as a GP where GPs had admitting rights for their patients (covered by junior doctors at night) and hospital doctors frequently worked in the community there was a far closer working relationship between primary and secondary care. I only had 700 patients. So it was possible to be their GP and manage conditions that required admission. This was the most enjoyable job I have ever had.. On first name terms with hospital doctors. Not sure if things are still like that though.

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  • Good article.

    The well-known Wizard and Gatekeeper analogy is actually rubbish, though, because a gatekeeper doesn't actually do anything except operate the gates - he or she has no ability to help anyone in other ways.

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  • Bit of advice to help bypass the switchboard slog - download the 'Induction' app - user populated app used by junior docs in hospitals around the UK - generally has an extensive and quickly navigated directory of direct numbers for wards/secretaries/on call docs etc etc - saves me a huge amount of time calling people directly, and can also help bypass some hospital gatekeeping. Quality of directory varies hospital to hospital, but it's usually v. up to date.

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  • The App is called Dr Toolbox

    Needs NHS email to logon

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  • I've tried both and find Induction quicker, more intuitive and has some of the harder to find phone numbers - each to their own though.

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  • Azeem Majeed

    Thank you for your article Nishma.

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  • Really good article. I think the demise of the clinical assistant/hospital practitioner posts has not helped. When I was in post both I and my consultant found it an invaluable way of learning from each other and understanding our individual challenges and barriers

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