Dr Thomas Round considers the implications of the gatekeeper model in an age of tightening resources

A strong and effective primary care has been at the cornerstone of the NHS, with GPs acting historically as “gatekeepers”. Only around one in 20 GP consultations lead to a secondary care referral.1 Yet, faced with a growing, ageing and increasing co-morbid population, activity in primary and secondary care is increasing, without an increase in resources. Between 2009-10 and 2014-15 GP referrals to secondary care increased by 16% to nearly 13 million.2 There is also wide variation in referral rates to secondary care between GP practices,3 including for cancer,4 with evidence that up to 25% of referrals are unnecessary.5 

With the current state of NHS finances, primary care and CCGs have been under pressure to find efficiency savings, including referrals to secondary care. A recent investigation by Pulse magazine6 found that in at least nine CCGs, practices are being offered payments for keeping within targets for referrals and follow-ups, including for cancer. Yet research published in the BMJ7 showed the higher a practice’s use of the urgent referral pathway for suspected cancer (or two week wait), the better the survival rate.8

GPs are stuck between a rock and hard place; pressurised as gatekeepers to refer less to save money, but criticised for under referring, especially for cancer. Cutting through these headlines, referral management schemes are not new. These have been a response to the cost of rising outpatient attendances and waiting lists, and the variation in clinicians’ referral rate and quality.9

Yet there is little evidence referral management schemes work,10 with a recent review11 reporting that there is no “magic bullet” to managing demand for secondary care services. A report by the Kings Fund12 found that referral management strategies built around peer review, supported by consultant feedback, with clear referral criteria and evidence-based guidelines, were most likely to be cost- and clinically-effective. However, they argued that the greater the degree of intervention, the greater the likelihood the referral management approach would not present value for money.

When we look specifically at cancer, the UK and other countries with a “gatekeeper” system have relatively poorer cancer survival.13 Patient, doctor and system-related factors can all contribute to delayed cancer diagnosis,14 with a significant proportion related to primary care.13 Most of those with cancer present with symptoms, and most of these presentations are to primary care,15 yet the diagnosis of cancer is not straightforward, with many patients having multiple GP visits prior to referral.16

Concerns about diagnostic delays led to the implementation of urgent suspected cancer referral pathways, including the two week wait referral. Guidance on whether GPs should refer urgently is based on NICE guidelines, which have recently been updated.17 These updated guidelines explicitly lower the risk threshold of cancer for referral to 3% (compared to an implicit risk of >5% in the previous 2005 guidance) and support GPs use of their clinical judgement.

In 2014/15, over 1.5 million patients were referred via this pathway, an increase of more than 50% over five years.

Evidence now suggests that use of the urgent referral pathway is associated with a shorter time to diagnosis and treatment, and can impact on diagnosis and patient survival.18 The recent BMJ paper7 showed a 7% increase in mortality for patients from a practice with a low usage of urgent referral, compared with those from practices with higher rates of urgent referral.

It is predicted that 50% of the current UK population will develop cancer in their lifetime, placing further challenges on the health care system.

Cancer should be considered in the context of an ageing population with complex co-morbidity, in an era of budgetary restraint. In the future GPs may view themselves more as “expert generalists” and “door openers” rather than “gatekeepers”.


1. Foot C, Naylor C, Imison C. The quality of GP diagnosis and referral. London: The King’s Fund. 2010.

2. England N. Quarterly Hospital Activity Data. 2015.

3. O'Donnell CA. Variation in GP referral rates: what can we learn from the literature? Family Practice. 2000;17(6):462-71.

4. Meechan D, Gildea C, Hollingworth L, Richards MA, Riley D, Rubin G. Variation in use of the 2-week referral pathway for suspected cancer: a cross-sectional analysis. British Journal of General Practice. 2012;62(602):e590-e7.

5. Up to one quarter of GP referrals ‘avoidable’ Pulse Magazine 2015. Available from: http://www.pulsetoday.co.uk/up-to-one-quarter-of-gp-referrals-avoidable/20007690.article.

6. GP practices offered ‘ethically questionable’ incentives to cut urgent cancer referrals 2015 [cited 2015 9th November]. Available from: http://www.pulsetoday.co.uk/news/commissioning/commissioning-topics/referrals/gp-practices-offered-payments-to-cut-urgent-cancer-referrals/20030100.fullarticle.

7. Møller H, Gildea C, Meechan D, Rubin G, Round T, Vedsted P. Use of the English urgent referral pathway for suspected cancer and mortality in patients with cancer: cohort study. BMJ. 2015;351.

8. Thousands of cancer patients dying because GPs fail to refer for tests. Daily Telegraph. 2015 13th October.

9. Cox JM, Steel N, Clark AB, Kumaravel B, Bachmann MO. Do referral-management schemes reduce hospital outpatient attendances? Time-series evaluation of primary care referral management. British Journal of General Practice. 2013;63(611):e386-e92.

10. Akbari A, Mayhew A, Al‐Alawi MA, Grimshaw J, Winkens R, Glidewell E, et al. Interventions to improve outpatient referrals from primary care to secondary care. The Cochrane Library. 2008.

11. Blank L, Baxter S, Woods HB, Goyder E, Lee A, Payne N, et al. Referral interventions from primary to specialist care: a systematic review of international evidence. British Journal of General Practice. 2014;64(629):e765-e74.

12. Imison C, Naylor C. Referral management: lessons for success. Kings Fund, 2010.

13. Vedsted P, Olesen F. Are the serious problems in cancer survival partly rooted in gatekeeper principles? An ecologic study. British Journal of General Practice. 2011;61(589):e508-e12.

14. Walter F, Webster A, Scott S, Emery J. The Andersen Model of Total Patient Delay: a systematic review of its application in cancer diagnosis. Journal of health services research & policy. 2012;17(2):110-8.

15. Hamilton W. Five misconceptions in cancer diagnosis. British Journal of General Practice. 2009;59(563):441-7.

16. Lyratzopoulos G, Wardle J, Rubin G. Rethinking diagnostic delay in cancer: how difficult is the diagnosis? BMJ. 2014;349:g7400.

17. NICE. Referral guidelines for suspected cancer. 2015.

18. Neal R, Tharmanathan P, France B, Din N, Cotton S, Fallon-Ferguson J, et al. Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes; Systematic review. British Journal of Cancer. 2015.