Impact of GP gatekeeping on quality of care, and health outcomes, use, and expenditure: a systematic review

Abstract

BackgroundGPs often act as gatekeepers, authorising patients’ access to specialty care. Gatekeeping is frequently perceived as lowering health service use and health expenditure. However, there is little evidence suggesting that gatekeeping is more beneficial than direct access in terms of patient- and health-related outcomes.AimTo establish the impact of GP gatekeeping on quality of care, health use and expenditure, and health outcomes and patient satisfaction.Design and settingA systematic review.MethodThe databases MEDLINE, PreMEDLINE, Embase, and the Cochrane Library were searched for relevant articles using a search strategy. Two authors independently screened search results and assessed the quality of studies.ResultsElectronic searches identified 4899 studies (after removing duplicates), of which 25 met the inclusion criteria. Gatekeeping was associated with better quality of care and appropriate referral for further hospital visits and investigation. However, one study reported unfavourable outcomes for patients with cancer under gatekeeping, and some concerns were raised about the accuracy of diagnoses made by gatekeepers. Gatekeeping resulted in fewer hospitalisations and use of specialist care, but inevitably was associated with more primary care visits. Patients were less satisfied with gatekeeping than direct-access systems.ConclusionGatekeeping was associated with lower healthcare use and expenditure, and better quality of care, but with lower patient satisfaction. Survival rate of patients with cancer in gatekeeping schemes was significantly lower than those in direct access, although primary care gatekeeping was not otherwise associated with delayed patient referral. The long-term outcomes of gatekeeping arrangements should be carefully studied before devising new gatekeeping policies.

Effectiveness of primary care gatekeeping: difference-in-differences evaluation of a pilot scheme in China

“…Third, the patients were not able to select which group to participate in, therefore reducing the risk of selection bias seen in previous studies using cross-sectional or before-and-after designs. 19 Nevertheless, there are still some important limitations in our study that should be taken into consideration when considering its implications. First, the ability to generalise from our findings is limited as our samples were restricted to NCMS enrollees from a single district.…”

“…Third, the patients were not able to select which group to participate in, therefore reducing the risk of selection bias seen in previous studies using cross-sectional or before-and-after designs. 19 …”

“…10 18 Under gatekeeping, patients need to be referred by a primary care practitioner in order to access specialist care. A recent systematic review of the effectiveness of gatekeeping 19 found mixed results in terms of quality of care, health outcomes, utilisation and expenditure, with findings seemingly dependent on context. These studies were all done in high-income countries, where, unlike in China, primary care is provided by doctors specialised in primary care with a level of professional qualifications similar to those of hospital specialists.…”

Delegating home visits in general practice: a realist review on the impact on GP workload and patient care

“…Lower healthcare expenditure is associated with a GP's ability to carry out gatekeeping because of their ability to refer appropriately and in a timely manner. 56 The current review demonstrates that delegation in general practice may have a direct impact on a GP's ability to carry out gatekeeping.…”

Helen Salisbury: The confident gatekeeper

“…Investigating, diagnosing, and treating patients in primary care is far cheaper than in hospital. And patients who do go to hospital have a higher chance of accessing the correct department first time around than in health systems without primary care 12…”