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 cheaper health outcomes, and gatekeeping was a part of that ‘strength’. In the NHS the gatekeeping function was decidedly uneven, with wide and often inexplicable variations in referral behaviour among different GPs and different practices, but it was still the right thing to do.
Across the water things were less straightforward. In the US, gatekeeping was seen as anything but a benign cost-containment function and was criticised because it prevented people getting to the best (that is to say, specialist) care quickly enough. And in continental Europe, where primary care was ‘weaker’, and patients were able to access investigations and specialists directly and rapidly, the disturbing news began to emerge that population health outcomes were at least as good as ours and the amount of gross domestic product spent on health care wasn't very different from the UK. What price gatekeeping now? Concerns also began to emerge that the NHS had little about which to be complacent in a number of areas of avoidable mortality, including cardiovascular disease, maternity outcomes, and cancer survival — indeed much of the evidence adduced by the coalition government for the need for NHS reform related to the need to improve the UK's health outcomes, as well as to make high quality health care affordable.
The primary:secondary care divide and the referral system has had a further unwanted effect, this time on research into diagnosis and referral. Rather than adopting a more collaborative generalist/specialist approach, researchers seem to have remained bunkered, so that the primary care ‘early diagnosis’ paradigm is in danger of having more to do with identifying thresholds for referral than with making the diagnosis as quickly as possible, and much hospital research has entailed an examination of the ‘appropriateness’ of GP referrals under different referral protocols.
Now we are faced with a further challenge — Vedsted and Olesen, from Aarhus, Denmark, quite reasonably ask ‘Are the serious problems in cancer survival partly rooted in gatekeeper principles?’ And their answer is ‘Yes’. In a study involving 19 countries, to each of which they allocated a 1-year cancer survival score, they have found that countries with gatekeeping systems, registered list systems for patients, and those in which primary care is the first point of patient contact, have consistently worse cancer survival than those without these features. The authors acknowledge the limitations of their ecological study but assert, and it is hard to demur, that their findings are themselves a potential ‘red flag’ for cancer care.
Delays all along the way are recognised for many serious diseases and patient delay in presentation can be the hardest to modify. Delays at the treatment end are a supply-side problem, but we must be sure that the primary-secondary structure of patient care in the NHS doesn't become dangerously fossilized. Collaborative work arising, for example, from Quality, Innovation, Productivity, and Prevention initiatives emphasises the impact that a multidisciplinary effort can have on costs and outcomes. Direct access, intermediate triage, and joint evaluations may all play their part in speeding up accurate assessment and earlier intervention, and we would be wrong to disregard warnings about the gatekeeper role, no matter how cherished a concept it has been.
- © British Journal of General Practice 2011