1. Funded by: Danish Cancer Society | The Novo Nordisk Foundation 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. Funded by: Danish Cancer Society | The Novo Nordisk Foundation UNIVERSITY OF AARHUS DENMARK Frede Olesen, Res. Unit for GP, Univ. of Aarhus, Denmark

3. Funded by: Danish Cancer Society | The Novo Nordisk Foundation The Research Unit for General Practice Aarhus 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. Funded by: Danish Cancer Society | The Novo Nordisk Foundation Outline  The ‘primary care convention’  Cancer survival caused surprise  The ecologic study  The perspectives

5. Funded by: Danish Cancer Society | The Novo Nordisk Foundation 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. Funded by: Danish Cancer Society | The Novo Nordisk Foundation ‘We are essential’ - we learn and teach  Positive effects of being special:  the consultation and relationship - the continuity  focus on the person and not the disease  ensure access, equality, community-based and patient near  efficient and cost-effective Guthrie B, et al. Personal continuity and access in UK general practice: a qualitative study of general practitioners' and patients' perceptions of when and how they matter. BMC Fam Pract 2006;7:11. Hjortdahl P. General practice and continuity of care: organizational aspects. Fam Pract 1989;6(4):292-8. Levenstein JH, et al. The patient-centred clinical method. 1. A model for the doctor-patient interaction in family medicine. Fam Pract 1986 Mar;3(1):24-30. Freeman GK, et al. Continuity of care: an essential element of modern general practice? Fam Pract 2003 Dec;20(6):623-7. Hjortdahl P, et al. Continuity of care in general practice: effect on patient satisfaction. BMJ 1992;304:1287-90. Starfield B. Is primary care essential? Lancet 1994 Oct 22;344(8930):1129-33. Vedsted P, et al. Association between patients' recommendation of their GP and their evaluation of the GP. Scand J Prim Health Care 2008 Dec;26(4):228-34. Freeman G, et al. What future for continuity of care in general practice? BMJ 1997; 314:1870-1873. Grumbach K, et al. Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists. JAMA 1999; 282(3):261-266. Starfield B, et al. Contribution of primary care to health systems and health. Milbank Q 2005; 83(3):457-502. Walley J, et al. Primary health care: making Alma-Ata a reality. Lancet 2008; 372(9642):1001-1007. Haggerty JL, et al. Continuity of care: a multidisciplinary review. BMJ 2003; 327(7425):1219-1221.

7. Funded by: Danish Cancer Society | The Novo Nordisk Foundation ’The gatekeeper invention’  Precise point of entry and first contact  Right to refer to specialist treatment  Guidance, continuity and communication  Rationing and efficiency

8. Funded by: Danish Cancer Society | The Novo Nordisk Foundation 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 general practice Hospital Familie etc.Social care etc.

9. Funded by: Danish Cancer Society | The Novo Nordisk Foundation The question - do we fail in the vertical part?

10. Funded by: Danish Cancer Society | The Novo Nordisk Foundation About cancer and primary care  Lifetime cancer risk is 35% 1  At least >80% are seen in primary care 2,3  90% present symptoms  25% of total mortality 1 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

11. Funded by: Danish Cancer Society | The Novo Nordisk Foundation We were surprised… again… Møller H et al. British Journal of Cancer. 2009;101, S110–4

12. Funded by: Danish Cancer Society | The Novo Nordisk Foundation 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

13. Funded by: Danish Cancer Society | The Novo Nordisk Foundation 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 countries 1  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.

14. Funded by: Danish Cancer Society | The Novo Nordisk Foundation Adverse effect of the gatekeeper system? Relative one-year survival (%) CountriesMedian (%)p-value GatekeeperNo 773.4 0.004 Yes 1267.8 List systemNo 973.4 0.004 Yes 1066.3 First point of contact Always 1066.3 0.001 Depends 773.4 No 273.4 Vedsted P et al. Are the serious problems in cancer survival partly rooted in gatekeeper principles? Submitted

15. Funded by: Danish Cancer Society | The Novo Nordisk Foundation 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?

16. Funded by: Danish Cancer Society | The Novo Nordisk Foundation 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?