The Backstop Problem

Or: how every pathway somehow ends with “ask your GP”

There’s a particular luxury I didn’t know was a luxury until I became a GP: having a backstop. Someone else to hand the problem to. Someone further up the food chain — with more tests, more toys, more time.

When I was a registrar, I didn’t think about it much. In fact, I used to have that smug, slightly edgelord-y attitude about GPs. What do you even do? Everyone just gets dumped back to you anyway. Funny how regret tastes stronger with age — like that one last whiskey you definitely didn’t need.

Because now I see it. Specialists might be the climax of the story, but GPs are the aftercare. We’re the ones left holding the plot once the credits roll.

You’re fine. Off you go. Back to your GP.

This is the line that echoes through every discharge letter and outpatient outcome. No more treatment options. No diagnosis. Or a diagnosis so complicated or incurable or future-tense that it barely counts as actionable. And still — back to the GP.

That phrase is doing an incredible amount of emotional labour.

Because the patient doesn’t stop being unwell. They just stop being interesting. They stop fitting into boxes that trigger specialist engagement. And suddenly, the person who’s seen their neurologist or their rheumatologist or their pain consultant for months — maybe years — is back with us. In ten minutes. With a folder full of questions and nowhere else to go.

It’s chronic conditions, it’s long-term fallout, it’s functional symptoms, it’s mental health, it’s diagnostic uncertainty. It’s everyone who isn’t about to die, but isn’t getting better either — the very group who fall through the cracks of fragmented care systems.

And it’s always us.

You only get a specialist when you’re special

The word specialist carries this unearned reverence. When I was in renal, I felt it. People stood up straighter when I said I was a registrar. It didn’t matter that I was flailing most days, pretending I understood RRT and tubular acidosis. It mattered that I had a title.

Compare that to being a GP, even one with a specialist interest. You could have a decade of experience, a grip on comorbid complexity that would make a registrar cry — but you’re just a GP. The gatekeeper. The generalist. The bin.

You can smell it in referrals. You see it when someone says, “But I need to see a specialist.” As if you’re just the warm-up act.

Even if you’ve made the same call. Even if you’ve already done everything they’re going to do.

Even if they bounce the patient straight back with a letter that says “reassure and monitor” — AKA, you deal with it now, cheers.

This reflects the ongoing hierarchy of esteem in UK medicine — where specialist care is valorised, and general practice, despite being the linchpin of continuity, is too often dismissed.

Why the fuck does no one plan for the handover?

The most generous specialists — and they do exist — write back with plans. They say things like: “If X happens, do Y. Otherwise, follow this protocol.” They think about what it means to discharge someone. They prepare us.

But more often than not, it’s just: discharged back to GP care.

No roadmap. No clarity. No real acknowledgement that the patient’s still in the middle of their story, and we’re just being given the book with ten pages ripped out and told to write the sequel.

Shared care planning remains inconsistent across secondary-to-primary care transitions, with GPs often left to manage ambiguity, risk, and the emotional fallout alone.

If specialists are our backstop, then what happens when they bounce the ball back?

We’re not the backstop anymore. We’re the wall. And walls don’t absorb complexity — they just reflect it.

We need better endings. Not better guidelines.

I’ve had patients burst into tears in my room because they got discharged from clinic and didn’t know what that meant. Sometimes they’ve been told. Sometimes they haven’t. But the feeling is the same: abandoned.

And because there’s no structure to say what happens next, it falls on us. And if we don’t have answers — or worse, if we do but the patient doesn’t trust them because they didn’t come from a “proper” doctor — then we’re just stuck.

Stuck in the loop. Until the next referral. The next rejection. The next moment of “this isn’t our problem anymore.”

This emotional load is a key contributor to GP burnout and moral injury, exacerbated by poor system coordination and unclear role boundaries.

So here’s a radical thought: what if we stopped punting people back and forth like bureaucratic hot potatoes?

What if, when specialists ran out of options, the answer wasn’t back to GP, but let’s plan this together?

What if we named that end-of-line care? What if we treated long-term management as a shared responsibility — and gave it the time, resources and respect it deserves?

Because right now, it’s the GPs who bleed for it

We deal with the panic, the grief, the rage, the symptoms, the side effects, the aftermath. We explain the letters. We answer the Columbo questions. We get blamed when people feel abandoned, even if we were never part of the plan.

And yes, sometimes we send shit referrals because we don’t have a choice. We’ve tried everything. The patient won’t budge. The guidelines say refer. So we refer. And you bounce it back, pissed off. I get it.

But maybe — maybe — pick up the phone. Or write back with kindness. Assume there’s more to the story than a badly-worded summary.

Because we’d do the same for you. Or at least we should.

TL;DR?

Specialists are vital. But they’re not the end of the road.

If GPs are the glue, then we need specialists to be more than scissors.

Be our backstop. But don’t throw the ball back and run. Help us make a plan. Help us hold the line.

And for fuck’s sake, stop writing “GP to follow-up” like it’s an ending. It’s not. It’s where the real work begins.

Stay Special

—DW