ABSTRACT
Most public systems attempt to use ‘gatekeeping’ (or a referral system) in an attempt to ration services to those with the highest-priority demands. In the UK it is intended that the whole population should be registered on the list of a general practitioner, who should act, in all cases other than emergencies, as the first point of contact with the health system. Whenever a case falls outside the general practitioner’s areas of competence, or requires specialist facilities, the general practitioner should refer the patient to an appropriate provider. In theory, this process should ensure that specialist and referral services are rationed towards those patients whose demands have been sanctioned as appropriate, or as ‘needs that should be met’ (see Box 19.1). In practice, the mechanism works imperfectly, general practitioners have widely varying rates of referral (Wilkin et al. 1989) and large numbers of patients directly attend Accident and Emergency departments for minor complaints that could be dealt with by the GP. In some cases this is because it is more convenient and in others because they have not been able to register with a GP (Lowy et al. 1994). Direct use of hospital outpatient departments is a common problem in developing countries (for example, in Zimbabwe: Hongoro and Musonza 1995), where mechanisms to enforce referral systems are not or cannot be applied. However, if the price mechanism were used to ration between levels of care, reliance would be placed on the patient’s own assessment of need for specialist services weighted against their higher price, and assessment of the risk of paying twice by paying a generalist for advice as to
Box 21.1 Setting the Pattern of Supply in Public Systems: Geographical Resource Allocation The pattern of supply is determined in public systems directly by public decision making. This usually has more centralised and decentralised components. Building a hospital will seldom be an option for a local health authority, but decisions to increase levels of equipment, or to develop a new service, may be.
