The Gatekeeper's Dilemma: Unpacking the Complexity of Low-Value Care in General Practice

Low-value care (LVC) is increasingly the focus of debates on how to reduce the use of healthcare resources while maintaining quality care. General practitioners (GPs) are often considered central to this aim. Although GPs facilitate early disease detection, disease prevention and coordinated medical care, they must do so while aiming to protect both patients and the healthcare system from the harmful effects of medical overactivity. Public healthcare systems with gatekeeping practices, such as Denmark, lack many of the identified economic and structural incentives for LVC. Why then does LVC persist? Drawing on ethnographic observations and interviews with practising GPs, we explore how Danish GPs handle the difficult task of drawing a line between what requires medical attention and what should be left untreated or monitored. Our findings suggest that LVC literature may overlook the value of some interventions when used by GPs to improve patient trajectories over a longer term, maintain the relationship between patient and practitioner or balance the use of time and resources across the healthcare system. We clarify this point by unpacking the relational and context-dependent work of GPs, which is central to their capacity to serve as trusted gatekeepers.