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Do we need gatekeepers for the gatekeepers?



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