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The primary-secondary care divide fails older patients

BMJ 2012; 344 doi: (Published 14 June 2012) Cite this as: BMJ 2012;344:e4009
  1. John Hughes, group medical director, Sue Ryder, London WC1H 0AF, UK

Since the United Kingdom’s NHS formed in 1948, general practice has assumed the role of gatekeeper so that only patients in need of secondary care have access to it. This system has, arguably, worked well for elective care, although varying referral practices has led to the development of triages and intermediate tier services. For unscheduled care, general practice’s gatekeeper role has changed over the years, without any accompanying full scale reorganisation.

Gone are the days when general practitioners were responsible for their patients’ care 24 hours a day, seven days a week, and could, at least theoretically, minimise unnecessary admissions to hospital. That responsibility has gradually eroded, and it was eventually destroyed altogether with the 2004 contract that transferred 24 hour responsibility to primary care trusts. General practitioners now act as gatekeepers for only 30% of the week (that is, from 8 am to 6 30 pm on weekdays only), which is not an effective filter.

Many patients, particularly those with recurring exacerbations of chronic illnesses (of which chronic obstructive pulmonary disease is probably …

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