Networks, nodes, and equilibrium

Ben Hoban is a GP in Exeter.

On any given day, GPs diagnose and treat, listen, validate, interpret, advise, support, and advocate. A large part of what we do, though, is indirect, by linking patients with various other parts of the healthcare system. When we prescribe, investigate, or refer, we are asking a pharmacist, laboratory technician, radiographer, or fellow clinician to act on a patient’s behalf, albeit in more or less specific ways. We function as a node connecting patients to a wider network.

If we think a bit more about what this network looks like, it makes sense to start with another node representing the patient, connected to ours, but also to others: informal health advisers including friends and family; non-healthcare professionals like teachers, social workers, and probation officers; and directly accessible healthcare professionals such as pharmacists, nurses, midwives, and paramedics. All of these may effectively refer a patient to their GP, just as their GP may refer them to another professional with a more specialised role.

We can picture a model, then: on the left side are the patient and their connections, and on the right, the GP and theirs; the two halves are linked to each other through a single connection, that between patient and GP. There is a flow from left to right, as, for example, when a grandparent’s concern about a child prompts their parent to arrange a consultation at the surgery and agree on referral to a paediatrician, who might in turn arrange a dietetic assessment, and so on.

This is a reasonable model of the NHS a generation ago, with the relationship between a patient and their GP at the centre of the network. The ability to hold uncertainty and make shared decisions at this point moderates flow from left to right by preventing inappropriate medicalisation, holding back the worried well and letting through the vulnerable. Since then, however, the number of GPs has fallen,¹ and the expectations of policymakers have shifted. In particular, the drive to diagnose cancer earlier has to some extent made primary care a clearing house for patients with non-specific symptoms waiting to be investigated.

Between 2009/2010 and 2019/2020, GP referrals for suspected cancers increased by 163%, driving down the rate of positive diagnosis from 10.8% to 6.6%.² The recommended threshold for referral is a nominal 3% risk of having cancer,³ however, implying that despite the huge increase in referrals, we should still be sending far more patients to secondary care than we are. Deliberately increasing traffic within the system and directing it through a narrowing channel seems a little like closing your eyes and putting your foot down when you see the lights change.

This has no doubt contributed to our current professional malaise, as well as causing a proliferation of actual and proposed work-arounds, secondary care services directly accessible by patients that create new connections between the two halves of the network, bypassing general practice. In theory, these allow patients to arrange their own care without needing to see a doctor, but in practice they also transfer the control in the system from the doctor–patient relationship to the various protocols that govern these new pathways. If you know how to access a service, you can self-refer, but you may just get a letter advising you that you don’t meet the threshold to be taken on; those less able to negotiate this increasingly complex and rigid system inevitably lose out.

The management of uncertainty is likewise changing: rather than being buffered in general practice it is now more likely to be cryogenically preserved in secondary care through the prolonged follow-up of patients with incidental findings like lung nodules and mildly raised prostate-specific antigen levels.

At a time when the benefits arising from continuity of care in general practice have been well established,⁴ demonstrating clearly the importance of the relationship between patients and their doctor, the network within which this relationship plays such a significant role is on the brink of being reconfigured to make it redundant. This may eventually result in a new equilibrium, in which GPs no longer regulate the wider network but become one node among many, and patients see us not because they have to in order to get what they have been told they need, but because they believe that we have something of value to offer them. I hope I get to see it!

References

1. British Medical Association. Pressures in general practice data analysis. 2023. https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice-data-analysis (accessed 17 Apr 2023).
2. Cancer Research UK. Early diagnosis data hub. https://crukcancerintelligence.shinyapps.io/EarlyDiagnosis (accessed 17 Apr 2023).
3. National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. NG12. 2021. https://www.nice.org.uk/guidance/ng12/chapter/Context (accessed 17 Apr 2023).
4. Pereira-Grey D, Sidaway-Lee K, White E, et al. Improving continuity: THE clinical challenge. InnovAiT 2016; 9(10): 635–645.

Featured photo by Clint Adair on Unsplash.