This site is intended for health professionals only


Closing the gate before our role has bolted



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