Intended for healthcare professionals


Rethinking primary care’s gatekeeper role

BMJ 2016; 354 doi: (Published 23 September 2016) Cite this as: BMJ 2016;354:i4803
  1. Geva Greenfield, research fellow in public health,
  2. Kimberley Foley, research support officer,
  3. Azeem Majeed, professor of primary care
  1. Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
  1. Correspondence to: G Greenfield g.greenfield{at}

Geva Greenfield and colleagues ask whether it is time to reconsider the role of the GP as gatekeeper to specialist services, and call for more evidence to guide future policy

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 spending2 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).

View this table:
Table 1

Arguments for and against gatekeeping

Ideally, gatekeeping ensures that patients see specialists only for conditions that could not be managed by a GP and are referred to an appropriate specialist, hence saving specialists’ time for more complex cases. However, the claim that gatekeeping is an effective cost containment method may be wrong.24 …

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