Gatekeeping in Healthcare – an evaluation

Gatekeeping in a healthcare system is a mechanism of care referral where the GP is the first point of contact in the patient’s care path. The patient relies on the GP to refer him or her to a specialist, laboratory, hospital care, or any other form of secondary care. This blog article considers the pros and cons of a model that holds the promise of providing better-quality healthcare to patients while at the same time reducing costs to the individual.

In Spain, the UK, the USA and Scandinavian countries gatekeeping is the common regulatory mechanism for public healthcare patient referrals to a specialist. In Austria, Belgium and many insurance schemes in Switzerland, there is no stringent gatekeeping mechanism and patients are free to approach primary or secondary care physicians of their choice as initial entries to a care path or care track.

In OECD nations universal access to healthcare is the norm -or at least aimed for. Legally no one is flat-out denied access to primary care. However, patients in a publicly funded system could be denied access to a specialist, despite a personal wish to see one.

Benefits of gatekeeping

It is argued that gatekeeping is a simple and effective measure to contain costs by reducing the volume of unnecessary interventions. Primary level healthcare and affiliated tests and diagnosis are on average less expensive than secondary and specialty care services.

It is also argued that GPs are better informed than their patients in regards to where and how to seek specialist care, in effect reducing the patient care path in search for an adequate and qualitative secondary care provider.

A 2014 study compared non-gatekeeping Austria and gatekeeping USA, showing that Austrian patients seek help in the secondary and tertiary sector four times more frequently than in the USA. The study revealed that a country lacking formal regulation in terms of primary to secondary and tertiary care referrals such as Austria, led to a high over-utilization of secondary and tertiary care facilities. On the other hand, Austrian patients consistently report a high satisfaction rate with their healthcare system, and Austria has built up its hospital capacity to accommodate the high influx of primary care needs.

Furthermore, it is an approximated two percent higher healthcare cost to the state to run a healthcare system without gatekeeping.

Concerns with gatekeeping

A study on healthcare gatekeeping from Germany reveals that GPs in Holland reported to feel denigrated to administrators of the healthcare system, when placed in the position of gatekeeper.

The average age of a patient that a GP attends to on a daily basis is increasing, which is logical seeing as the general world population is aging. Elderly aged patients are more likely to present a plurality of medical ailments and more frequently require medical care for comorbidities. In a traditional gatekeeping mechanism this elderly individual would be sent to several specialists, which is tiring, time-consuming and potentially delivering him or her a fragmented care approach. An ideal gatekeeping system would embrace innovative solutions, multiple competence centers, policlinics and the enhancement of ambulatory care expertise in hospitals.

In regards to financing, many GPs are compensated for their services via capitation rates and or fee-for-services. This creates some competition on the market to retain patients and if a GP were to hand over patients to a specialist too quickly, they could lose part of their funding. On the other hand, if a GP is too careful or reserved with forwarding patients to specialists, the patient may feel denied access to secondary healthcare.

Primary Care Physicians (PCPs) have different attitudes and thresholds to gatekeeping, sometimes resulting in an insufficient use or an excessive use of specialists.

When referring a patient to another practitioner, it is key to transfer all relevant clinical information back and forth between specialist and personal GP. However, in practice the amount and quality of information is often lacking for adequate decision-making, resulting in deceleration of the care path, repetitions of examinations, or incomplete follow-ups. The question of ‘patient owner’ is also interesting in this discussion, since it is debatable whether the specialist should serve for a single consultation only or partake in continued co-management. Either way, primary-specialty care has potential for a more integrated approach.

From TforG research, we learned that in Spain for example, COPD and asthma will be co-managed by a specialist for the duration of the condition (which is often a lifetime). The specialist will see the patient every 6 months to one year, depending on the gravity of the condition, whilst the GP will continue to see the patient more regularly every one to three months.

Observations and conclusion

It is important, though not always avoidable, that GPs and specialists must not compete for patients. Gatekeeping will only succeed if it promotes care co-ordination, whilst liberating patients and care providers from unnecessary bureaucratic protocols. The trend seems to be that nations with less stringent or no gatekeeping have greater patient satisfaction rates.

Healthcare systems in different countries apply different healthcare protocols and design care paths differently. Regardless of the mechanism implemented, the three main indicators to evaluate the success of the system remain: patient satisfaction, healthcare outcomes, and financial sustainability. Arguably, the latter two are the most important.

Looking at the multitude of factors from patient preference, self-confidence of the GP, financing models, care path efficiency, co-management and health insurance policies, gatekeeping is not a straightforward system.

In conclusion, care management should provide greater quality for patients whilst simultaneously reducing costs for the patient and the national healthcare system as a whole.

Gatekeeping has both positive and negative aspects, for the system and for the individual. The key to reconciling the issues lies in flexible and easy communication between the care providers of distinct entry points, where a GP could quickly consult a specialist to confirm or eliminate clinical concerns, and a specialist can pass detailed instructions to a GP for potential follow-ups. Another support to effective gatekeeping, is a thorough understanding and integration of care paths, to incentivize the collaboration of all parties, and to foster transparency.


External influences have a big impact on the patient care path. The insights generated by the TforG Care Track are crucial when taking strategic decisions concerning medical devices product positioning.
Learn more about how can you use the TforG Care Track to meet your objectives.

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About Laura Weynants

Performs primary and secondary market research to create country reports at TforG. Interviews KOLs and medical sector professionals to build on TforG’s healthcare market expertise and competence networks. Complementing five years of sustainability policy and CSR communication, she now focuses on grasping key medical market trends, structures and opportunities in medical sectors worldwide. Coming from an international background of living in Germany, Spain, USA, UK and Belgium, she has gained a keen insight in international organizations and language skills to perform first hand investigations. She graduated from Sussex University Brighton, UK with a BA English Literature and Sociology and achieved a Master Degree in Sustainability and Corporate Social Responsibility in EOI Business School in Madrid, Spain.