Healthcare at street level

Ben Hoban is a GP in Exeter.

It is easy in general practice to feel stuck in the middle, pulled in too many different directions at once without moving one way or another, just becoming more stretched. The forces acting on us are not in themselves harmful, but they often pull in opposite directions. On the one hand, for example, it matters that we diagnose serious conditions promptly. This is a business routinely complicated by ambiguity, complexity, and misunderstandings, and therefore ideally addressed through face-to-face contact between a patient and their usual GP. On the other hand, demand often feels too high to be safe, let alone ideal. Many problems are straightforward, and what good is it knowing your doctor for twenty years if you can never get an appointment with them? In an effort to resolve this tension between access and effectiveness, many practices have adopted systems in which contact is remote by default and with any qualified practitioner, even though this can create its own problems.¹ This is more than just  a matter of supply and demand, though. As medicine becomes more technologically sophisticated, healthcare is pulled towards the proactive diagnosis and treatment of diseases by technicians and specialists, and away from holistic, person-centred care by generalists. We can fix many more things than before, but we pay for it with the bitter disappointment felt by those left behind, whose problems cannot be fixed at public expense, or at all, and whose need to live with and make sense of their suffering exerts its own opposing pull. We feel stretched, then, not simply because there are too few of us, but because of the position we occupy in the middle-ground of healthcare.²

We may feel aggrieved at being caught up in this tug of war and prevented from getting on with the job of doctoring, but the feeling is misplaced. Our job is certainly clinical, although in terms of the skills that make it distinctive, it perhaps resembles more those of teachers, social workers, and police officers than others in healthcare. Michael Lipsky refers to these as examples of street-level bureaucracies, services defined at their point of origin by clear frameworks, rules, and procedures, but also at their point of use by the infinitely varied requirements of the public.³ The role of the practitioner is to bridge the gap between the committee and the street, using their discretion to adapt services to a local context and interpret the needs of prospective service users to render them eligible for help. In this sense, they do not merely implement policy, but decide what policy looks like in practice. Street-level bureaucrats therefore occupy a position of some influence; the reason they rarely feel it is that the systems in which they work are all characterised by effectively unlimited demand. They are therefore responsible for resolving the mismatch not just between the available services and people’s needs, but also between the competing needs of different people trying to access those services, and the competing priorities of the system, including their own survival. As GPs, we are sometimes in the position of applying a given rule to the patient in front of us, resulting in the correct treatment, investigation, or referral. More often, we must use our discretion in deciding which rule is most appropriate, whether and how best to apply it, and whose needs to prioritise.

The rule book is becoming weightier, though. The unavoidable corollary of having plentiful expert opinion to inform our practice is that we feel uneasy about deviating from it. Despite their stated intention, guidelines readily become a standard against which we are judged, and against which we come to judge ourselves.⁴ Referral pathways aim to regulate our practice more explicitly, and prescribing is constantly tweaked to keep down costs. It is becoming more difficult to use our discretion, and yet it is the discretionary aspect of the street-level bureaucrat’s role that sets it apart, and on which services rely to keep functioning. A rigid and under-resourced system cannot deal with demand that is fluid and unlimited.

As street-level doctors, then, we are in the middle of things, not by accident, but because it is intrinsic to our role. When we feel pulled in different directions, it is not because we are in the wrong place or doing things wrong, but because we are holding together a service that would otherwise tear itself apart. In theory, this tension represents a stable dynamic equilibrium in which the system provides resources within certain broad constraints, and we allocate them based on our more granular understanding of people’s needs. In practice, it is a balance that is being upset by the growing inflexibility of the system and the attrition of the discretionary role of GPs. The result is an increase in clinical risk and frustration because services are less well aligned to people’s needs. This is mirrored by an increase in risk-averse practice because healthy decision-making requires a degree of confidence in the responsiveness of the system which would currently be unjustified. GPs are routinely expected to walk patients across the street without any real understanding  that the traffic will slow down for them.

Street-level bureaucracy, which includes general practice, is fundamentally about using professional discretion to connect people in difficulty with services under pressure. In the face of systemic changes that make this model less and less tenable, it is tempting to quit the middle ground and allow ourselves to be absorbed by the healthcare machine, becoming nothing more than its public face. We should be clear though: the system cannot relate directly to the people without either distorting their needs to fit what it can offer or becoming totally overwhelmed. The alternative is for us to push back against protocol where it interferes with patient care and to make appropriate use of our discretion in the consultation. We cannot provide an unlimited number of appointments, but we can seek to understand our patients’ stories, concerns, and needs in ways that the system cannot, and to offer care that is less medicalised, less risk-averse, and ultimately more efficient.

References

1. 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-e112. DOI: 10.3399/BJGP.2023.0276
2. Rupal Shah and Jens Foell, Fighting for the Soul of General Practice: The Algorithm Will See You Now, Intellect Books, 2023
3. Michael Lipsky, Street-Level Bureaucracy: Dilemmas of the Individual in Public Services, Russell Sage Foundation, 2010 (30^th anniversary expanded edition)
4. Wessely B, Gerada C. You are being watched: panopticons in healthcare BMJ 2016; 352 :h6777 doi: https://doi.org/10.1136/bmj.h6777

Featured Photo by Marc-Olivier Jodoin on Unsplash