Complexity, demand, and those little white spots

Ben Hoban is a GP in Exeter.

As memories of summer fade and general practice settles into another season of acute respiratory infections, I find myself wondering how we will manage this year. Depending on how your surgery works, some patients suffering from the current bug du jour may be able to make a GP appointment, while others are fitted in as extras around the edges of booked surgeries, as remote consultations, or with duty doctors and non-medical clinicians. They may have straightforward expectations, such as a prescription for antibiotics, and there is a general feeling that their needs are best met by systems addressing acuity rather than complexity, and prioritising access over continuity of care.¹ Astute patients even recognise that there is a code to use: It’s been over a week… My phlegm is green… I’ve got little white spots in my throat…

Tonsillar and pharyngeal exudates are associated with a variety of infections, although the Centor and FeverPAIN scoring systems treat them as a marker of invasive Streptococcal disease. It is worth noting the following caveat, which is included in the NICE guidance that promotes their use: There is no evidence that sore throats caused by bacterial infection are more severe than those caused by viral infection, or that the duration of the illness is significantly different in either case.²

In trying to avoid prescribing antibiotics for self-limiting infections, we have inadvertently created a closed semantic loop in which we define bacteria as an indication for antibiotics, antibiotics by their effectiveness in treating bacteria, and viruses as being neither bacteria nor requiring antibiotics. This means that we instinctively dichotomise acute infections, when the reality is less clear-cut. Swabbing anyone’s throat will show up plenty of different bugs, whether they are ill or not,³ and 80% of throat infections get better without treatment after a week anyway, regardless of which germs you find.⁴ Trying to distinguish “viral” from “bacterial” infections is therefore not usually meaningful in practice.

Patients presenting with severe infections will be treated with antibiotics in any case, and those with mild disease will not. The real challenge lies in spotting someone in between who is likely to become more unwell, and the evidence is that clinical scoring systems function poorly here⁵ and point-of-care tests may act as traps rather than tools.⁶ All things being equal, a higher clinical score or C-reactive protein level may well be significant, but variations in individual risk due to age, frailty, and comorbidity are likely to count for more, as is the local prevalence of a given pathogen. If you want to know whether to treat someone, don’t just look in their throat or their blood; look at the whole person, and then look in your waiting room.

Even taking these things into consideration, it is possible to get caught out. Any system for managing seasonal illness necessarily makes certain assumptions, primarily that we are dealing with a seasonal illness rather than something superficially similar but more serious, such as coughing due to a pulmonary embolism, persistent fever as a sign of Kawasaki Disease, or a sore throat caused by leukaemia. What are we to do, then, in the face of such prognostic and diagnostic uncertainty, especially when general practice is already so thinly spread?

Our natural reaction is to push back, to contain the uncertainty within structures that force upon it the appearance of clarity and separate people into those who need to see a doctor and those who don’t, those who score highly enough to get an antibiotic and those who are not yet sick enough. As the days become shorter and our hours longer, we respond by building rigid and increasingly complicated systems whose primary function is to protect us from being overwhelmed. Inevitably, these lead to arbitrariness, gaming, and a paradoxical increase in demand arising from their failure to meet people’s underlying needs.⁷ We aspire to provide continuous, whole-person, generalist care, but end up with something that feels very different.

If our first mistake when faced with unmanageable demand is to think that we can manage it, our second is to assume that we need to. The key to dealing with uncertainty is not in the end control, but trust; to tolerate and hold ambiguity safely with our patients rather than trying too hard to resolve it for them. Most people with an acute illness will get better without medical help, and our primary role is to give them both the confidence to look after themselves while they can and the means to ask for help when they need to. A demand-led system offering large numbers of “minor illness” appointments may result in impressive levels of activity, but also makes it harder to distinguish the signal from the noise.⁸ If we start instead by building effective relationships with our patients and removing barriers to access rather than building them, people will still get ill, but it will be easier to care for those who actually need our help with a smaller number of more meaningful consultations.

Some patients will undoubtedly benefit from antibiotics, and it may be appropriate to prescribe them after only limited contact with a non-medical clinician, but in this case, the prescription should still be a reflection of proper care rather than a substitute for it. This is perhaps what it comes down to in the end: not whether someone has little white spots in their throat, or indeed gets antibiotics, but whether they have been adequately cared for. Whatever expectations patients bring to the medical encounter, they are not usually wedded to them, provided that their concerns have been properly addressed, and just as likely to feel fobbed off by being given a prescription as being refused one.⁹

Ultimately, a limited number of doctors cannot take responsibility for dealing with unlimited demand. It is tempting to look for short-cuts that offer certainty without the need for care, but they are a dangerous illusion. Turning our back on what makes us distinctive as GPs will never make us better doctors, just as splitting patients into two groups based on what might be wrong with them simply replicates the false dichotomy between bacterial and viral infections. There are no simple cases; complexity gets everywhere. We are more likely to make it through the winter if we accept this and work together with our patients to promote effective self-care as a platform for appropriate health-care. So yes, I’m happy to hear about someone’s throat and how they’re managing, but let’s not worry too much about those little white spots.

References

1. Aboulghate A, Abel G, Elliott MN, Parker RA, Campbell J, Lyratzopoulos G, Roland M. Do English patients want continuity of care, and do they receive it? Br J Gen Pract. 2012 Aug;62(601):e567-75. doi: 10.3399/bjgp12X653624. PMID: 22867681; PMCID: PMC3404335.
2. National Institute for Health and Care Excellence, How do I diagnose the cause of a sore throat? cks.nice.org.uk/topics/sore-throat-acute/diagnosis/diagnosing-the-cause/ accessed 31/08/2025
3. Bosch AA, Biesbroek G, Trzcinski K, Sanders EA, Bogaert D. Viral and bacterial interactions in the upper respiratory tract. PLoS Pathog. 2013 Jan;9(1):e1003057. doi: 10.1371/journal.ppat.1003057. Epub 2013 Jan 10. PMID: 23326226; PMCID: PMC3542149
4. Spinks A, Glasziou PP, Del Mar CB. Antibiotics for treatment of sore throat in children and adults. Cochrane Database of Systematic Reviews 2021, Issue 12. Art. No.: CD000023. DOI: 10.1002/14651858.CD000023.pub5. Accessed 31 August 2025.
5. Seeley A, Fanshawe T, Voysey M, Hay A, Moore M, Hayward G. Diagnostic accuracy of Fever-PAIN and Centor criteria for bacterial throat infection in adults with sore throat: a secondary analysis of a randomised controlled trial. BJGP Open. 2021 Dec 14;5(6):BJGPO.2021.0122. doi: 10.3399/BJGPO.2021.0122. PMID: 34551959; PMCID: PMC9447300.
6. Rebecca Payne, Sarah Mills, Clare Wilkinson, Malene Plejdrup Hansen, Point-of-care C-reactive protein testing in general practice out-of-hours services: tool or trap? British Journal of General Practice 2025; 75 (758): 388-389. DOI:3399/BJGP.2025.0302
7. Jennifer Voorhees, Simon Bailey, Heather Waterman, Kath Checkland, A paradox of problems in accessing general practice: a qualitative participatory case study, British Journal of General Practice 2024; 74 (739): e104-112. DOI: 10.3399/BJGP.2023.0276
8. Nassim Nicholas Taleb, Antifragile: Things that Gain from Disorder, Penguin, 2013
9. Christopher R Wilcox, Michael Moore, Paul Little, Use of antibiotics for acute sore throat and tonsillitis in primary care, British Journal of General Practice 2022; 72 (716): 136-137. DOI: 10.3399/bjgp22X718793

Featured photo by Brittany Colette on Unsplash