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The unpopularity of the gatekeeper GP

Hard-wired GP

Luke Koupparis

Tuesday, 26 March 2019

GP consulation_AdobeStock_84435010.jpgI have been increasingly analysing what I achieve following a consultation with a patient. In the main, they seem quite happy with the care that I provide, but I have often wondered if they are happier when they are sent on for a scan or to a secondary care “specialist” over being managed by myself. Most patients seem to have a view on what conditions a GP can manage and what might need a referral. They see some symptoms or conditions as the remit of a more specialist doctor. The distinction between primary and secondary care is clearer when it comes to surgery, but much more blurred when considering medical conditions.

Interestingly, the other day I was asked by someone whether I was a GP or had I specialised in something? Usually, I don’t react very much to questions like this, but this time I did. I challenged his assumption that one group were specialist and the other group not, outlining to him that I was a specialist generalist who had an holistic knowledge of the patient and that contrary to his thoughts, I had received a number of years of specialist training to achieve this position.

With this in mind, I was really interested to read recent research from the BJGP that looked at patient care and attitudes to GPs working as gatekeepers for the NHS. The authors found that gatekeeping was associated with lower healthcare use and expenditure, and better quality of care, but with lower patient satisfaction.

It therefore shows that GPs are keeping the costs of healthcare down whilst providing improved quality, but possibly at the expense of the patients wants. The “want” verses “need” question regularly crops up in consultations and perhaps this is part of our role as GPs to manage expectations in a professional way. We all know that allowing patients direct access to their specialist of choice would, on the face of it, be popular with them (although considerably less so with the specialist). However, it is likely that patients haven’t thought through the implications of this change. For example, the abdominal pain that may have a medical cause over a surgical one is a common issue where the patient may end up sitting in a gynaecological clinic with irritable bowel syndrome. Or the presentation of chest pain that is rarely cardiac. Providing direct access to cardiology for these patients would be unwise and would clog up their clinics further increasing waiting times.

So, why should we be worried if the patients are less happy about this situation if the health outcomes are no worse (as the study seems to confirm)? Well, it does continue to empower the misconception of a divide between specialist doctor and (non-specialist) GP. The study talks about having a more integrated approach to the care of a patient without the divides that currently exist. Certainly, in many areas this approach is being developed and strategically the development of Integrated Care Systems are increasingly trying to break down these barriers.

If GPs find themselves increasingly working alongside specialists seeing more complex patients, with allied healthcare professionals seeing the more straightforward and self-limiting cases, then we may start to change the view of our role. However, in doing this we are relinquishing the role of the GP as a specialist generalist providing a holistic understanding of the patient and their family in favour of a more transactional, but increasingly specialist, approach to their specific condition.

I suppose I am concluding that we cannot have it both ways. We either have a more generalist approach, part of that is as a gatekeeper managing expectations, or we join the ranks of specialists and leave the holistic role increasingly to non-doctors. With the unstoppable march towards integrated care, along with the GP recruitment crisis we may find that we have no choice but to accept this new status quo.

Whether patients will be happier with it than they are now will remain to be seen.  I worry that we may find that they will remain less happy with the gatekeeper role, but that in addition the quality of care may reduce. So before we move in this direction perhaps our next job is to try and get patients to understand the complexity of our role as a specialist generalist gatekeeper. 

Author's Image

Luke Koupparis

Luke is a general practitioner in the Bristol area with interests in men's health, child health, minor surgery, online education and medical information technology. He is the IT lead for Bristol clinical commissioning group, LMC representative and chair of the locality provider group. He also works as the medical editor to OnMedica helping to deliver high quality, peer reviewed information to the wider medical community. In his spare time he is a keen road cyclist and likes to ski with his children.
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