The role of NHS gatekeeping in delayed diagnosis.

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 a bit less than those without. The second, entertainingly explored in a BMJ article, Nigel Mathers and Paul Hodgkin’s 1989 fairy tale “The Gatekeeper and the Wizard,” argues that gatekeepers are better at spotting those who are well and wizards (specialists) better at spotting those who are ill. Stopping those who are well from accessing wizard care optimises the efficiency of the whole system. If so, why do NHS outcomes generally lag behind those of other systems? The Sunday Times has been running a series about care of patients with cancer. It recently featured the story of a young musician, Jake McCarthy, who went to his GP with nausea, numbness in one arm, and severe headache. The GP diagnosed migraine and sent him away with a prescription. McCarthy subsequently died at the age of 24 from a brain tumour. “If only they’d sent Jake for a scan” was the headline. The piece was accompanied by a commentary from Harpal Kumar, chief executive of Cancer Research UK, who argued that GPs need better training to spot symptoms of cancer. That’s doubtlessly true (when did you last see an argument for worse GP training?), but it amounts to saying that gatekeepers should aspire to become wizards. The UK has around 330 000 new cancer diagnoses every year and roughly 40 000 GPs. The average GP may thus expect to see, in an average year, about eight new cases of cancer. Brain tumours represent only one in 70 of all cancers, so a typical GP will see one every decade or so. Over that period the GP would have seen thousands of patients with headaches who did not have a brain tumour. Expecting GPs to divine the one true case out of thousands of non-cases is asking for miracles. It isn’t going to happen, ever. One reason why cancer outcomes are worse in the NHS is delay in diagnosis, and that seems to be inseparable from gatekeeping. If referral to specialist care and diagnostic services requires a GP’s nod, delay is bound to happen, even if GPs unfailingly give the nod to the right patients. As they often don’t—and not only in cancer but in other time critical diagnoses—delays can quickly become non-trivial. It surprises me that more studies haven’t looked at the effect of gatekeeping on outcomes, especially as several countries have in recent years strengthened the gatekeeping role. One study that compared 19 European countries found that those with strong gatekeeping consistently had a lower rate of survival among cancer patients at one year than those without, even though treatment regimes were similar. Britain and Denmark, both systems with strong gatekeepers, come out poorly in such comparisons. Systems (Japan’s, for example) that allow patients to refer themselves to any doctor, generalist or specialist, strike terror into NHS managers but don’t seem to perform too badly. But if that’s a leap too far, how can the NHS escape the consequences of delay and dissuasion that are so much a part of its DNA? One way patients have discovered for themselves is to leap the barriers by ignoring GPs altogether and turning up at hospital emergency departments. This is a logical, sensible, and (since emergency department waiting times came down) practical way of accessing specialist care without the 8 am telephone call and the argument with the gatekeeper’s gatekeeper. Of course, such patients get censured for being “in the wrong place,” but wrong for whom?Only a system that puts patients a poor second to staff could think such a criticismworth making.