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Gatekeeping is the term used to describe the role of primary care physicians or general practitioners (GPs) in authorising access to specialty care, hospital care, and diagnostic tests. 1 Gatekeeping has crucial influences on service utilisation, health outcomes, healthcare costs, and patient satisfaction.
In the UK access to NHS and private specialists is generally possible only after a referral from a GP. Gatekeeping was developed as a response to a shortage of specialists and a desire to control healthcare spending 2 and has been an accepted practice in the UK for over 100 years. 3 The NHS is under considerable pressure to use its resources efficiently, and primary care has helped the NHS to achieve this goal through its gatekeeping function. 4 Yet direct access could help reduce GP workload and facilitate greater patient choice. We look at the pros and cons of gatekeeping, describe gatekeeping policies in various countries, and highlight the need for more evidence to devise policy.
Controversy around gatekeeping
While GPs in the UK are the gatekeepers to most medical services, their role in controlling referrals to specialists is the most controversial aspect of gatekeeping, 2 and there is an ongoing debate about the clinical, economic, and ethical implications of gatekeeping. 1 5 6 There are valid arguments for and against gatekeeping (table 1 ).
For | Against |
Leads to lower use of health services and lower expenditures 7 - 11 | Increases costs due to delayed diagnosis. Money saved on access to specialists is spent elsewhere in the system (eg, increased use of emergency departments) 12 |
Reduces waiting times to specialists | Hinders patients from seeing a specialist when they sense their case is not resolved by the GP |
System cannot sustain everything patients want and needs to have referral mechanisms | Negates the ethos of patient choice, empowerment, and shared decision making |
Ensures that specialists see more complex cases, hence building expertise | GPs treat only simple and general cases, which hinders clinical knowledge |
Increases patient safety and protects patients from adverse effects of overtreatment 1 13 | May impair clinical outcomes because of delayed diagnosis 14 - 17 |
Reduces inequalities 18 - 20 | Increases inequalities 18 21 22 |
Referral system increases the flow of information and mutual communication between general practitioners and specialists | Preserves... |