Gatekeeping: Is It a GP Thing?

There’s this fascinating tension I didn’t notice much when I was a specialty registrar — the constant low-level turf war over what is, and isn’t, “a GP thing.”

It’s a common trope: GPs are expected to know everything and yet are often treated like they know nothing. On one side, specialists get flimsy referrals and mutter about incompetence. On the other, GPs get frustrated at specialists gatekeeping basic care, hoarding diagnostics, or sneering at primary care’s “vague” concerns. This dynamic isn’t just anecdotal — evidence shows that gatekeeping systems, while efficient, also create bottlenecks and resentment when coordination is poor.

When you’re in hospital, overwhelmed and firefighting, it’s hard to see the GP on the other end as anything but the person throwing you more work. You don’t stop and think, Why now? Why this referral? You don’t consider the workload, the time pressure, the patient who refused to leave the room until a referral was made. You just see another GP dumping another mystery meat problem.

But I’ve worn both hats. And because I’m either insatiably curious or just an overenthusiastic arse, I’ve started pre-empting referrals by doing what specialists do — or at least what I see them doing in triage. Dermatology? I’ve learned to check the photos over time, do some routine bloods, screen for allergies, start a basic emollient. Psych cases? I’ll throw in a PDQ or CTQ if I’m sniffing out complexity, but I explain clearly: This isn’t diagnostic. It’s context. It’s data.

Sometimes that lands. Sometimes it doesn’t. I’ve had psych colleagues push back with: “You’re setting an expectation of treatment.” Which… fair. But if we can’t investigate for fear of implication, we’re already screwed. Studies have shown that GPs often walk a line between advocating for their patient and anticipating defensive reactions from specialists — a relational dance that has little to do with clinical content and everything to do with trust.

Even now, some blood tests require specialist sign-off — not because of risk, but because they belong to someone else’s budget. You want a full autoantibody screen? Better get your gastro pal to nod along. This kind of test-access disparity has been documented across systems as a form of “diagnostic turfing” — a known inefficiency in gatekeeper-led health models.

So we end up with these weird gaps. GPs are held back from screening while still expected to “just know” when something serious is going on. So yes, sometimes I’ll shotgun a screen on the TATT brigade — tired all the time — knowing full well what I’m really treating is depression or burnout or divorce. But the bloods buy me time, space, rapport. They’re not diagnostic. They’re diplomatic.

Here’s the kicker: on both sides, we forget the value of context. You can’t know what’s reasonable for a GP to do unless you’ve done the job. Likewise, GPs need to own when a referral’s a bit wobbly. If you’re not sure, say so. Ask for advice. Say: “This one’s odd. Something’s not right. I just don’t know what.” That honesty goes further than you think — especially in interprofessional settings where siloed expectations compound miscommunication.

I’ve made ropey referrals. I’ve faked confidence to get someone seen. I’ve chucked my toys to get a scan. It doesn’t always end well — but carelessness and courtesy both matter. And sometimes, even just a simple, “I know this is vague, but I’m worried,” opens the door to something useful. Sometimes it opens a wider dialogue.

I’m not saying GPs should become mini-specialists. But if we see patterns, if we’re managing work that’s not being picked up elsewhere, maybe we should be able to act on it — or at least talk about why we can’t. Literature shows that what patients value most is coordination and continuity — not ownership of knowledge, but the confidence that someone is navigating the mess.

So yeah, ask questions. Push gently. Own your choices. And remember: pattern recognition isn’t just a hospital thing. We do it every day. We’re trained for it. We just don’t always get the credit.

Stay Positive

DW