Intended for healthcare professionals

Rapid response to:


Rethinking primary care’s gatekeeper role

BMJ 2016; 354 doi: (Published 23 September 2016) Cite this as: BMJ 2016;354:i4803

Rapid Response:

Re: Rethinking primary care’s gatekeeper role- defying common sense, using bad evidence.

Geva Greenfield and colleagues obviously do think it’s time to “reconsider the role of the GP [as gatekeeper]”, as is evident from linguistic bias in their politicised depiction of an evidently foregone conclusion. Indirect, out-of-date, non-representative studies are cited here, for want of non-existent current evidence. The contention is that, not only does primary care gatekeeping not save the NHS money, but it also results in delayed diagnosis of cancers – suggesting that 5,000-10,000 people a year in England are dying because of the GP role as gatekeeper.

Greenfield’s evidence for its key assertions is more than twenty years out of date - being predominantly data from the 1990s, with pharma- sponsored research and gatekeeping studies from USA.
The referenced study on late cancer diagnosis did not look at gatekeeping. Delays in diagnosis contributing to lower 1yr survival rates in the 1990s were due to a lack of diagnostic and therapeutic capacity, late stage presentations of cancer, clinical/surgical practices, referral thresholds and pathways, and public health screening policies at that time. Greenfield’s use of the paper to link adverse cancer outcomes to gatekeeping per se is questioned (rapid response, below) by the study’s own authors.

Research showing that gatekeeping “is associated with lower utilization of health services (up to −78%) and lower expenditures (up to −80%)” - is discounted by the authors as “having low internal validity” and applicability “because it is from the US”. But the authors use similar such ‘invalid’ evidence to support their opposite contention. Conclusions gleaned from such selective use of unrepresentative studies undermine Greenfield’s imperative - that pilots for direct access to specialists are “needed” in the NHS now.

The wider GP’s gatekeeper role - as in clinical triage, clinical navigation, child safeguarding, individualised care, continuity, skills and experience - is ignored by framing the paradigm using Nigel Hawkes’s narrow, unreconstructed “mediaeval castle” metaphor for the NHS.

Removing GPs’ navigational triage (gatekeeper) role and allowing direct access to consultants in the NHS would incontrovertably have huge repercussions on secondary care in terms of capacity, increased NHS costs, and a shift by Consultants to take on the large, low-risk caseload management. Out of 340 million consultations annually in general practice only 5% of those on a high risk 2-week referral pathway were eventually diagnosed with a malignancy.

75% of eventual cancer diagnoses are picked up within three visits to a GP. A specialist will accrue a minimum of two visits to diagnose a cancer, assuming first-time pick up. Since the studies on which this paper relies were published, general practice has developed direct access investigations, GPwSIs, emailed Consultant advice, two-week referral pathways, and referrals audits. Barriers between primary and secondary care only exist due to capacity overload and H&SC Act Regulations' perverse incentives.

Greenfield identifies that “Gatekeeping works against the Government aims of shared decision making and integrated care”. Is the Government aiming to remove GPs’ roles?; to deprofessionalise GPs of their generalist knowledge and skills?; for GPs to be viewed as a mere hindrance to the exercise of choice? The paper advocates ‘choice’ as a consumer concept for people undertaking an often complex medical journey – as they have in the insurance-based USA? The paper also advocates “co-payments”.

The data do not even support piloting such a significant shift in medical practice in England without any contemporary or representative evidence. Far from dispensing with the gatekeeping system, France and Germany have both adopted it since these studies were done. Greenfield presents such an idea at such a time - perhaps to ride the wave of disruptive innovation. This is one of those ideas that feels increasingly like destructive aberration.

Competing interests: No competing interests

07 October 2016
Nick Mann
Well St Surgery London E9 7TA