Gate-keeping or free access: what do patients prefer: a European study.

Background: Health care systems can be subdivided into systems where access to health services is largely unrestricted and systems where specific health care providers (GPs mostly) perform a ‘gate-keeping’ role. Several studies showed that ‘gate-keeping’ health care systems not only seem to be more cost/effective but even seem to have better health outcomes, although this latter observation is not unchallenged. However, since demand-driven health care has become an important issue, another relevant criterion to judge the appropriateness of a health care system is to ask the opinion of the population, the health services’ users. Aim: The aim is to relate the judgment of the population about the role and function of General Practitioners with the degree of accessibility of a health care system. Methods: Accessibility of a health care system was measured as follows: a list of 17 health care providers/ facilities was sent to experts in 18 European countries with the question whether these providers/facilities were accessible directly or via prescription or referral. Countries’ scores ranked from 13% (Portugal) to 76% (Greece and Sweden) of all services
being directly accessible. The scores were validated by comparing them with the judgment ‘gate-keeping’ or ‘non gate-keeping’ derived from an international comparative study in GP-practice profiles of Boerma and Fleming (1998). Patient-evaluation scores were derived from a study by Wensing and Grol, who collected data in 14 European countries, about the evaluation of several aspects of General Practice (The Europep instrument) For these 14 countries the relationship between the degree of accessibility of health services and patient evaluation of GP-services was established (by linear regression methods). Results: a) The accessibility list proved to be a valid instrument to establish
the degree of direct accessibility of a health care system. b) The higher the degree of direct accessibility of a health care system is, the more positively GP-services are valuated by the population. In gate-keeping systems GP’s are less popular than free-access system, both in a general sense and more specifically on organizational aspects. c) This general association between accessibility and patient-evaluation of GP-services has two exceptions: France and Spain. In France there is free access to almost all health services and patients are rather negative about GP-services. In Spain where, generally, access to health services is indirect, patients are rather positive. Conclusions: There are more arguments than the patients’ view in advocating a gate-keeping health care system (cost/effectiveness, health outcomes), but, in a demand led health care system the patients’ judgment should be taken seriously. Undeniably GP-services in gate-keeping systems are viewed more negatively than GP-services in free-access systems. It remains intriguing , however, why the negative evaluation regards GP-services, that are universally freely accessible. Unfortunately, evaluation data on hospitals and specialists or other health services were not available. A further
investigation into the exceptional outcomes in France and Spain could give more insight in the
mechanism of the observed relationship.