Gatekeeping is having a difficult time. Not that long ago it seemed a fairly uncontroversial idea that skilled generalist physicians (in other words, GPs) did their best to manage their patients in the community and reserved hospital referral for investigations or a specialist opinion for problems they were unable to deal with, or when ‘red flag’ presentations mandated urgent action. There was a recognition that this arrangement was an artefact of the original structure of the NHS, in which primary and secondary care have always been sharply divided, and this serendipitous state of affairs was later credited with the cost-effectiveness, or at least the lower costs, of the NHS compared with other health systems. A strong primary care sector seemed, according to the late Barbara Starfield, to be associated with better and …