GPs are much more than gatekeepers

The language of medicine

How should we think about GPs? For one thing, we are medical interpreters, steeped in the biomedical model, yet equally fluent in the ways patients communicate about, and understand, their health. People come with stories involving symptoms and experiences, psychology and emotion, social context and relationships, their hopes and fears. We sift and sort and synthesise this undifferentiated material, making sense of it for our patients and for the healthcare system. Sometimes this results in a diagnosis, sometimes not, but the result is a plan—ideally one in which we’ve empowered the patient to participate in what should be done.

This interpreter role is crucial to both the quality of care and its cost effectiveness. With accurate diagnosis (and non-diagnosis), NHS resources are better targeted and waste is constrained. Furthermore, a patient who is understood as a whole person experiences holistic care. It’s one thing to know what could be done about a given problem; it’s quite another to incorporate a person’s individual perspectives, values, and circumstances to decide what should be done.

To be an effective medical interpreter requires sound knowledge of the whole breadth of medicine, excellent consultation skills, and understanding of the psychosocial aspects of illness, as well as the experience, confidence, and pragmatism to handle and explain uncertainty and risk. A longstanding, trust based relationship between doctor and patient can augment these attributes further. Ladies and gentlemen, I give you: the NHS GP.

Necessary investigations

It gets better. As well as being interpreters, GPs are medical generalists, managing vast swathes of illness cost effectively. Those patients who do need a referral are a highly selected population, strongly likely to benefit from specialist input. Without this selection, secondary care would become swamped and less efficient. The opinions, tests, and procedures in secondary care depend on a high prior probability of organic disease in the patient population—something that GPs ensure.

Without this, unnecessary investigations and interventions increase, as does overall cost. Patient experience correspondingly declines, and we see greater fragmentation, less holism, and more iatrogenic harm. With so many modern medical interventions, guarding against overdiagnosis and overtreatment is another important facet of our generalist’s role.

Strategy and tactics

Not all aspects of primary care need a GP’s direct input, and some require very different professionals. Our practice nurses undertake straightforward chronic disease management, family planning, and minor illness triage, alongside more traditional nursing duties. We work with an array of allied health professionals, all with distinct roles.

But none is equipped to case manage the whole person. The GP is akin to a football player-manager: we’re out on the pitch, making our unique contribution, but we also set strategy and tactics to ensure that the team achieves each patient’s goals.

Interpreter, medical generalist, player-manager . . . on top of these, the GP is an expert friend. Illness and its treatment can be a frightening and bewildering experience, and we all deserve a knowledgeable guide for our journey—someone to make sense of it, explain it, and support us through it. If you ask patients, you’ll find that this is what many value most in their GP.