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GP gatekeepers linked to reduced patient satisfaction

Link also found with lower cancer survival rates

Jo Carlowe

Tuesday, 26 March 2019

The GP gatekeeper role is associated with lower patient satisfaction, new research* finds, and possibly lower cancer survival rates.

It is well established that in the NHS, a GP referral is usually needed for a patient to see a specialist or to have hospital investigations, an arrangement known as gatekeeping. In health systems in other countries, patients can often go directly to specialists, bypassing general practitioners.


The costs and benefits of different policies on gatekeeping, which are important for developing cost-effective healthcare, have been studied in a new review of the research literature, carried out by Geva Greenfield of the Department of Primary Care and Public Health at Imperial College London, and colleagues.

The researchers found that gatekeeping was generally associated with lower use of healthcare resources and lower expenditure, and also with better quality of care.

However, patient satisfaction tended to be lower. Moreover, they found one study reporting lower survival rates of patients with cancer in gatekeeping schemes than those with direct access arrangements, although gatekeeping was not otherwise linked to delayed referral and diagnosis.

The authors comment that in the continuing search for models of care which reduce costs and potentially improve quality of care, the possible association of gatekeeping with delayed cancer diagnosis is of significant concern and needs further investigation.

Policymakers should, perhaps, focus more on collaboration between general practice and specialist medicine, aiming for a more unified and integrated approach to patient care, they conclude.

Responding to the findings, Professor Helen Stokes-Lampard, chair of the Royal College of General Practitioners said: "Gatekeeping schemes play a significant role in the triaging of patients in the NHS and beyond, and as this study shows, GPs worldwide are doing an excellent job of caring for patients in their communities, close to home, and keeping people out of hospital wherever possible.

"Unlike most other healthcare systems around the world, the NHS is free at the point of need and so financial implications do not play any role in the gatekeeping function of UK GPs – most of the studies included in this systematic review were based in the US.

"While it's clear to see why UK GPs are often called the 'gatekeepers of the NHS', we will always put the needs of the individual patient first and refer anyone who we think might need secondary care intervention. However, this research also highlights a chronic lack of access to diagnostic tests in primary care, which can have a huge bearing on referral rates for conditions such as cancer.

"GPs take cancer diagnosis extremely seriously, and it's credit to our colleagues' hard work that 75% of patients found to have cancer in the UK are referred after only one or two consultations, and that in the last five years the proportion of cancers diagnosed as an emergency dropped from 25% to 20%.”

She added: "Without access to the right diagnostic tests, however, this simply isn't sustainable and threatens the success of GP gatekeeping schemes across the country. That's why we desperately need GPs and our teams to have better access to high-quality diagnostic tools in the community, and the appropriate training to use them."


*Sripa P, Hayhoe B, Garg P, et al. Impact of GP gatekeeping on quality of care, and health outcomes, use, and expenditure: a systematic review. Br J Gen Pract, 25 March 2019. DOI:10.3399/bjgp19X702209

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