Managing demand at the interface between primary and secondary care

This is the fourth of five articles on ways of managing demand for health care

General practitioners have acted as official gatekeepers to the United Kingdom hospital service since the inception of the NHS in 1948, but the roots of the referral system can be traced to the conflict between physicians, surgeons, and apothecaries in the 15th and 16th centuries.1 Specialists and general practitioners had to compete for paying patients until the early 20th century, when the issue was resolved with the establishment of registered general practice lists, a salaried hospital service, and a formal system of referral from one to the other. The gatekeeping role (more recently called filtering) of general practitioners is arguably the most important mechanism for managing demand in the NHS. The British referral system undoubtedly contributes to the low cost of health care relative to other countries. Healthcare systems which allow patients direct access to specialists—America, Germany, France, and Sweden—tend to incur higher costs than those that channel demand via general practitioner referrals, such as Britain, Denmark, Finland, and the Netherlands.2 At its best the referral system ensures that most care is contained within general practice, and when specialist care is needed patients are directed to the most appropriate specialist. However, it is also a restrictive practice, initially introduced to protect the interests of doctors, which gives general practitioners a monopoly over primary medical care and restricts patients' freedom of choice. Despite this the system has survived relatively unscathed by public criticism, a tribute to the widespread public confidence in general practitioners and to the fact that the gatekeepers have been very willing to open the gates to secondary care in response to patient demand.