Authors' response

We are grateful for the debate about positive and negative aspects of gatekeeping raised in three responses to our paper,¹ and we agree with the important research questions raised in these. First, let us stress that we are strong advocates of the gate-adviser or gatekeeper system, meaning that if any decision-makers will use our paper as an argument for removing the gate-adviser they have simply misunderstood the paper.

We want research that contributes to improving a basically good system. All three letters strongly support the need for such research.

Our own primary hypothesis is that healthcare planners have used the easy access to the frontline doctor as an excuse for long waiting lists for complicated clinical trajectories. But we also raise the question whether we as GPs have found the correct balance between necessary investigations and the protection of patients against unnecessary investigations. This is an important, but yet not fully answered, research question that is also raised in the letter from Polak.² We sincerely support the call for more research in the net effect of better access to diagnostic procedures.

Polak also points to the crucial question whether people may have an increasing perception of GPs as being rationing ‘keepers’ only. That this may have an effect on the way patients seek help is in accordance with new research.³ People may think that the GP is some kind of ‘barrier’ to medical care access and thus postpone attending the GP. Or people experience their nice and friendly GP as very busy and do not want to disturb them, exactly the point also made by Davies.⁴

One of the challenges in comparing differences between countries is the possible difference in how diagnoses are registered. Treasure⁵ has a very important methodological point in asking whether the 1-year survival is higher in the non-gatekeeper systems simply due to lead time bias. Lead time bias is definitely a possible explanation for the outcome of these types of comparative studies. The question is, however, whether such lead time bias can explain differences between countries of 5-10% in relative survival. A recent simulation study⁶ found that the difference in registration of a breast cancer diagnosis should be unlikely large if it should explain the differences between UK and Sweden. However, the effect of lead time bias in comparisons needs much more rigorous research.

We strongly agree with Davies that our data should be replicated using newer data and also data on other serious diseases. New research should also address if different remuneration systems may have impact on the quality of gatekeeping.

We were happy to see three academically well argued responses to our paper. A fourth response by Manassiev (posted on the BJGP Discussion Forum) seems to be very little in favour of discussing whether there could be side effects of gatekeeping. In many ways the response speaks for itself. In a proper way we point out that our study is an ecologic study.

The use of quintiles in the paper by Møller et al⁷ does not change anything as we used this in our calculations. We do not think that use of the 1- and 5-year relative survival of lip cancer would improve the paper as suggested by Manassiev. Manassiev may have different memories about gatekeeping in some countries, but we prefer research published in the literature. We have written our arguments for the use of 1-year survival and we kindly ask our readers to check them and compare with Manassiev's not quite academic approach. It is not correct that ‘the majority of sufferers of the top four cancers (lung, breast, prostate, and colon) would survive 1 year probably whatever the health system’. We do not agree with Manassiev about the incompetence of editors and reviewers and we trust that many readers are able to read papers without having passed Manassiev's research school on the shape of the earth.

In conclusion, we must realise that general practice has several key roles. One important role is to be aware of new, rare, but serious diseases that, in a timely way, should be guided through the healthcare system without delay that may influence prognosis. We need much more research on the impact of different organisational models on this key role.⁸