The paper by Vedsted and Olesen1 raises serious questions about GPs and their gatekeeper role. Clearly, if the gatekeeper function is acting simply as a delaying tactic then it is difficult to justify its presence. If the delay leads to harm, such as delayed diagnosis and increased mortality, then it is an example of a medical system causing harm, and that would need to be reviewed, and maybe removed.
The data that Vedsted and Olesen use are from some time ago, reflecting practice conditions and outcomes in the 1990s. Is no more recent data available to see what is happening currently?
In the UK, GPs now have access to the 2-week rule system for urgent referrals and growing access to detailed diagnostic scans and tests. Our means to diagnosis are improving, but we do not yet know if we use them well.
Perhaps the key need now for primary care in the UK, and the world, is to focus its effort more clearly on the diagnostic activity, and its accuracy of problem definition. The current short, crowded primary care consultation in the UK is an obstacle to allowing doctors sufficient thinking time to assess symptoms and their significance, both to the patient and in terms of likely pathology.2,3The problem of delayed diagnoses may not be gatekeeping, but rushing, and thereby failing to define the problem properly. Perversely, we seem to have built a UK medical system based on rushing rather than thinking and in doing so achieved a reduction in both our sensitivity for and specificity of diagnosis. This may appear cheap, but it may actually be costing more to run, as referrals may become a displacement mechanism for time stressed doctors, rather than a carefully formulated question to ask a specialist.
Have we overvalued speed and quantity in medicine thereby actually reducing our quality and effectiveness?
- © British Journal of General Practice 2011