Are the serious problems in cancer survival partly rooted in gatekeeper principles?

As an experienced GP, I disagree with two aspects of this interesting paper.¹

First, rather than being an ‘unexpected … side effect’ of gatekeeping, more numerous delayed diagnoses are the inevitable price of fewer unnecessary investigations, that is one of the goals of gatekeeping. We need a study comparing the harm done by investigations (though this could never include patients' unnecessary worry and waste of time) in countries with and without gatekeepers, before deciding which system is superior.

Second, I do not believe that the authors' suggested explanations for delayed investigation and referral, such as financial constraints and fear of being ‘negatively judged by doctors in the secondary sector as referring unnecessarily’, are likely to be supported by the future research they wisely recommend. Instead, I think it will show that most of us try to work with individual patients to weigh up the chance of benefit from an investigation against its possible harms. Thus we already act as advisers who counsel the patients on what to do, as the authors recommend, with cost-effectiveness a very secondary consideration.

The public perception of our role as ‘“keepers” simply rationing care’ is already growing more prevalent in anticipation of GP commissioning. I hope this paper will not be cited in support of this unhelpful and ill-founded view.