Peter Vedsted, Prof., PhD Frede Olesen , Prof., DrMedSci The Research Unit for General Practice

1. Cancer survival and the gatekeeper principle- have we missed some side effects of gatekeeper systems? Peter Vedsted, Prof., PhD Frede Olesen, Prof., DrMedSci The Research Unit for General Practice Research Centre for Cancer Diagnosis in Primary Care – CaP Aarhus University Denmark

2. UNIVERSITY OF AARHUS DENMARK Frede Olesen, Res. Unit for GP, Univ. of Aarhus, Denmark

3. The Research Unit for General PracticeAarhus University, Denmark Frede Olesen Research director Professor, dr.med.sci, FO@alm.au.dk Peter Vedsted Head of the CaP centre, vice director Ph.d., professor p.vedsted@alm.au.dk

4. Outline • The ‘primary care convention’ • Cancer survival caused surprise • The ecologic study • The perspectives

5. Primary Care Convention • The ’General Practitioner’ doing ’Family Medicine’ • a person-centred approach, • a unique consultation process, a relationship over time, • provide longitudinal continuity of care • Position in the healthcare system • first point of contact, open and unlimited access, • makes efficient use of healthcare resources…, managing the interface with other specialities ... The European Definitions of General Practice /Family Medicine, WONCA EUROPE, 2002

6. ’The gatekeeper invention’ • Precise point of entry and first contact • Right to refer to specialist treatment • Guidance, continuity and communication • Rationing and efficiency

7. A total health care system- integration:- the GP should be perfect in the inverted T- quality: balance in the inverted T • Vertical – towards the hospital • Horisontal – PHC team Hospital general practice Familie etc. Social care etc.

8. The question- do we fail in the vertical part?

9. About cancer and primary care • Lifetime cancer risk is 35%1 • At least >80% are seen in primary care2,3 • 90% present symptoms • 25% of total mortality1 Sources: 1. Albreht et al. European Journal of Cancer. 2008;1451–1456 2: Allgar et al. British Journal of Cancer 2005;92:1959–70 3: Hansen. Delay in the diagnosis of cancer [Thesis]. University of Aarhus, 2008

10. We were surprised… again… Møller H et al. British Journal of Cancer. 2009;101, S110–4

11. Have we ignored something? • The principle of a strong primary care sector, i.e. with general practice as gatekeeper, as first point of contact and with a list system, has documented advantages • However, are there adverse consequences? • Is the GP a ‘hostage’ in rationing care and in keeping waiting lists short? • Is it so difficult to refer that the threshold gets too high? • What is the consequence of the relation and repeated contact? Selected sources: Starfield B et al. Contribution of primary care to health systems and health. Milbank Q 2005;83:457-502. Walley J et al. Primary health care: making Alma-Ata a reality. Lancet 2008;372:1001-1007. Starfield B. Is primary care essential? Lancet 1994;344:1129-1133. Halm EA et al. Is gatekeeping better than traditional care? A survey of physicians' attitudes. JAMA 1997;278:1677-1681. Freeman GK et al. Continuity of care: an essential element of modern general practice? Fam Pract 2003;20:623-627. Goodwin N. Diagnostic delays and referral management schemes: how "integrated" primary care might damage your health. Int J of Integrated Care 2008; 8

12. The ecologic study • Is there an association between the organisation of general practice and the relative one-year cancer survival? • Data included: • The relative one-year survival for 42 cancers in 19 countries1 • The organisation of general practice (gatekeeper, list system, first point of contact)2,3 • Analysis: • Median survival, composite survival index 1: Møller H et al. A visual summary of the EUROCARE-4 results: a UK perspective. Br J Cancer 2009;101(Suppl 2):S110-4. 2: Boerma WG et al. Service profiles of general practitioners in Europe. European GP Task Profile Study. Br J Gen Pract 1997;47:481-6. 3: Saltman RB et al. Primary care in the driver's seat? 1 ed. Maidenhead: Open University Press; 2006.

13. Adverse effect of the gatekeeper system? Vedsted P et al. Are the serious problems in cancer survival partly rooted in gatekeeper principles?Submitted

14. Conclusion • Cancer is common, and most patients present with symptoms • Primary care is essential in early cancer diagnosis • Does the organisation with general practice as gatekeeper, as first point of contact and with a list system result in: • 5-7% lower one-year survival in cancer? • 2,000 lost person-years in Denmark each year? • We need to know! And if so – WHY?

15. Conclusion II: Have we ignored something? • Are there adverse consequences of gatekeeping? • Is the GP a ‘hostage’ in rationing care and in keeping waiting lists short? • Is it so difficult to refer that the threshold gets too high? • What is the consequence of the relation and repeated contact? • Even if a strong front line gives the best system • We must investigate side effects • Is gatekeeping the problem – not the strong front line?