From patient advocate to gatekeeper: understanding the effects of the NHS reforms

Abstract

In her editorial the Chair of the Royal College of General Practitioners describes the role of GPs as gatekeepers in a negative light.1 She asserts that this role has arisen in the past 20 years as a result of GPs being encouraged to take financial, as well as clinical, responsibility for their patients. In fact the role of the GP as a gatekeeper has been recognised for at least the past 100 years.2 There should be nothing demeaning about GPs having a gatekeeper role — it has been associated with the cost-effective delivery of healthcare services the world over.3 The role of advocate, that she proposes, has legal rather than medical roots. The advocate’s only duty is to their client. It presupposes the separate and distinct role of a judge who is responsible for final arbitration. Such separation of advocacy from decision-making is a luxury that does not exist in medicine. In seeking to disengage GPs from the financial concerns of providing health care Dr Gerada is not helping us face reality. It may help us to see financial resources as we do any other finite resource, for example, a blood bank or a doctor’s time. Clinical triage principles would direct a doctor to use the blood supplies on those patients in whom it would gain the greatest benefit and not those for whom its use would be marginal or futile. Similarly, a doctor does not decide how to allocate their time simply on the basis of one patient’s need but has to spend it with regard to all their patients’ needs. In both these cases the doctor does not behave as an advocate for an individual patient but as a steward (a gatekeeper even) of a finite resource who seeks to maximise its effectiveness. It is also important to be clear that the GP would be at fault for closing the gate unnecessarily as well as for opening it irresponsibly. Therein lies the complexity and value of general practice.