Annabelle Rose Machin is a GP, WiseGP Fellow, RCGP Curriculum Editor and CPCS Clinical Facilitator. She is on Twitter: @drannabellerose
Recent political debates have centred on radical ideas to overhaul general practice. One proposal is to stop GPs being ‘The sole Gatekeeper’ to the NHS, allowing patients to self-refer to secondary care services.1,2 This proposal illustrates a lack of understanding of the complexity of everyday general practice and the nature of the ‘gatekeeper’ role that we play.
Approximately 33 million appointments take place in general practice every month.3 Many consultations involve discussion of minor illnesses, where reassurance and safety netting, without escalation of care, help to prevent secondary care from being overwhelmed. Up to 45% of patients consulting GPs have persistent physical symptoms or distress, where no biomedical explanation can be identified.4 Untangling these complex problems and avoiding harm through over-investigation and treatment is where the distinct expertise of a GP lies.5
I would see GPs as more than a wizard in the consultation, ‘curing’ people with magic potions.
So, is the description of the GP as a ‘gatekeeper’ outdated? I would argue it is. GPs are not trying to block access to specialists. Rather, through their distinct expertise, they provide a safety net for patients who could risk further harm by stepping through the gate.
In 1989, Nigel Mathers published his story of the Gatekeeper and the Wizard in the British Medical Journal.6 In this tale, the Wizard (specialist) resided in a castle (hospital) where magic potions would allow him to heal the sickest of people. By the castle entrance resided the Gatekeeper (GP), who saw the poorly people first. The Gatekeeper healed the majority, only sending the sickest people to the castle, to be treated by the Wizard.
So how does this tale apply now to the 21st century NHS? I’d certainly consider GPs to deserve equal status to specialists, since we have our distinct expertise in generalism, though I would see GPs as more than a wizard in the consultation, ‘curing’ people with magic potions. Rather, I see GPs in the guise of Gandalf from the world of Tolkien, sharing wisdom, interpreting the ‘foreign’ language of specialists, guiding people through uncertain terrain and illuminating the overall picture.
A GPs decision to medicalise – test, diagnose, treat or refer – is based on providing a patient with the best tailored care to support their individual needs at a particular time. Everyday decisions which may appear simple on the surface, like whether to refer a patient with back pain to a hospital specialist (or open the gateway), can be far more complicated. In these situations, GPs use complex problem-solving skills (knowledge work) to explore a problem, create an explanation to guide action and evaluate the impact.7-9 They apply their knowledge to individuals, considering their preferences, social context and community. Beyond scientific facts, a GPs knowledge encompasses a ‘tacit dimension’- knowledge shaped by their experiences, beliefs and ideas- which informs their professional judgement and expertise in providing whole-person centred care.10
So that seemingly straightforward decision about whether to refer a person to a hospital specialist, now considers a huge number of factors, including our gut feelings (or inner knowledge work), the patient’s preferences and how evidence from the guidelines would apply to them, the opinions of their relatives and carers and our past experiences. GPs integrate this evidence through knowledge work to create a new understanding of such complex situations. First and foremost, they consider the right action to take for an individual. As expert generalists, GPs support people to stay in the community who do not require specialist care and help to prevent iatrogenic harm.
So, considering the wizard in the GP consultation- could technology replicate this magic and help prevent the NHS from becoming overwhelmed? Well computers already play an important role in our everyday consultations, providing a 3rd voice that often competes for attention,11 though they can’t replace the complex decision-making skills of an expert generalist. With investment, technology could assist in triaging patients, but would risk widening health inequalities, by isolating people without access to, or the skills to use digital technology. Increased reliance on technology could also disadvantage people with poor health literacy and reduce opportunities to build on crucial relationships in general practice. For instance, some patients may only disclose embarrassing symptoms to a clinician that they know and trust.
A GPs decision to medicalise – test, diagnose, treat or refer – is based on providing a patient with the best tailored care to support their individual needs at a particular time.
So, what would happen if patients could self-refer to a specialist? Well, beyond NHS being overwhelmed,2,12 it is likely that inappropriate self-referrals, potentially to the wrong specialist, would delay access for those in most urgent need of care. There is also the question of who would identify the self-referrer who deserves to see a specialist? Sometimes a GPs knowledge of a patient and their individual context is needed to recognise the potential harms of specialist input. Some self-referral pathways already exist and work effectively (eg. talking therapies). However, added complexity comes with referrals to hospital specialists.
GPs are far more than gatekeepers. We are a safety net protecting the NHS from being overwhelmed and patients from the harms of too much medicine. The daily work of a GP is not defined by guidelines, or contracts, but by our ability to work beyond those boundaries to manage undifferentiated and complex needs. This is the distinct knowledge work of advanced generalist practice.13 As demonstrated by recent political debates,1,2,12 these skills are not adequately understood, valued or supported in the way that the NHS is run. WiseGP has been established to change that.9 Do you recognise the wizard in the GP consultation? Then follow WiseGP and join us in reclaiming professional control of front-line patient care!
1. Streeting W. We must think radically- I want to phase out the existing GP system. The Times. 2023. Available from: https://www.thetimes.co.uk/article/wes-streeting-we-must-think-radically-i-want-to-phase-out-the-existing-gp-system-tmpb0wqt6
2. Philpotts E. GPs hit out at misguided labour plans for self-referral and practice reform. GP Online. 2023. Available from: https://www.gponline.com/gps-hit-misguided-labour-plans-self-referral-practice-reform/article/1810279
3. NHS Digital. Appointments in general practice. 2022. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice
4. Chew-Graham CA, Heyland S, Kingstone T, Shepherd T, Buszewicz M, Burroughs H, Sumathipala A. Medically unexplained symptoms: continuing challenges for primary care. Br J Gen Pract. 2017 Mar;67(656):106-107. DOI: 10.3399/bjgp17X689473
5. Van Dijk W, Faber MJ, Tanke MAC, Jeurissen PPT, Westert GP. Medicalisation and Overdiagnosis: What Society Does to Medicine. IJHPM. 2016; 5(11), 619–622. DOI: https://doi.org/10.15171/ijhpm.2016.121
6. Mathers N, Hodgkin P. The Gatekeeper and the Wizard: a fairy tale. BMJ. 1989; 298. DOI: https://doi.org/10.1136/bmj.298.6667.172
7. Drucker, P. The Landmarks of Tomorrow. Harper: University of Virginia; 1959.
8. Reeve J. Rethinking generalist healthcare: opportunities from challenges. BJGP. 2002; 72 (720): 338-339. DOI: https://bjgp.org/content/72/720/338
9. Reeve J. Rethinking generalist healthcare: opportunities from challenges. BJGP Life. 2022. DOI: https://bjgplife.com/rethinking-generalist-healthcare-opportunities-from-challenges/
10. Ray T. Rethinking Polanyi’s Concept of Tacit Knowledge: From Personal Knowing to Imagined Institutions. Minerva. 2009; 47(1), 75–92. DOI: https://doi.org/10.1007/s11024-009-9119-1
11. Swinglehurst D. Displays of authority in the clinical consultation: A linguistic ethnographic study of the electronic patient record. Social Science & Medicine. 2014; 118:17-26. DOI: https://doi.org/10.1016/j.socscimed.2014.07.045
12. Knowles M. If patients could bypass GPs to see specialists the NHS would grind to a halt. The Guardian. 2023. Available from: https://www.theguardian.com/society/2023/jan/16/if-patients-could-bypass-gps-to-see-specialists-the-nhs-would-grind-to-a-halt
13. Reeve J, Machin A. Puzzled by knowledge work? WiseGP Blog. Available from: https://www.wisegp.co.uk/post/puzzled-by-knowledge-work