Intended for healthcare professionals

Observations Body Politic

The role of NHS gatekeeping in delayed diagnosis

BMJ 2014; 348 doi: (Published 17 April 2014) Cite this as: BMJ 2014;348:g2633
  1. Nigel Hawkes, freelance journalist, London
  1. nigel.hawkes1{at}

How can people who need specialist care get it more quickly?

Say what you like about the NHS, but you have to admit it’s extraordinarily good at setting obstacles in the way of care. Sometimes it seems that the entire system is built on the principles of the medieval castle, with a series of redoubts, moats, and stout stone walls designed to defend against unwelcome intruders—that is to say, patients.

Gatekeeping is the watchword. Today even the gatekeepers have gatekeepers, those much abused receptionists in general practices who ration access to the GPs so assiduously that patients often get better before they’ve managed to arrange an appointment. Who’d be a receptionist when the clocks strike 8 am and the phones begin to ring? Only a service dedicated to keeping customers and providers apart could have devised a system so utterly demeaning. It turns patients into supplicants and receptionists into bouncers, neither being roles to which they aspired.

Two arguments are advanced for gatekeeping, one rather crude, the other more nuanced and intellectually pleasing. The first, that it saves money, seems to be true, in that studies have shown that systems with a strong gatekeeping function cost …

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