The principle of referral: the gatekeeping role of the GP

As far as I know, it is only in the UK that the principle of referral has been an accepted custom for as long as 100 years. The principle is simple. Apart from accidents and emergencies and a few ‘open-access clinics’ such as genitourinary medicine, if patients need to be seen by a hospital doctor they have to be referred by a GP. This often puzzles people from other countries, but it is something the British public takes for granted. The question of when and why the principle was introduced is the subject of this paper. From the time they were founded in the mid-18th century, the hospitals (which were financed solely by charitable subscribers) admitted both out-patients and in-patients on only one specified day of the week. Injuries from accidents, and obvious emergencies, were admitted at any other time. The rest, mostly patients with medical illnesses, were required to bring a ‘passport’ in the form of a letter of recommendation from a subscriber to the hospital (although this rule died out in the second half of the 19th century). Thus, the rules of the Radcliffe Infirmary in Oxford (founded in 1770) stated: ‘That the Out-Patients be assisted with Advice and Medicines only, and in no other way chargeable to the Infirmary … that they attend exactly at 11 o'clock ev. Saturday … and that no fresh medicine be given them, until they deliver their Phials or Gallipots and such medicines as they have not taken.’ 1 Two points must be made here. First, very few if any of the patients admitted to out-patients or in-patients were referred by GPs. Second, although the industrial revolution was associated with a huge increase in illness, hospitals before the mid-19th century provided a grossly inadequate medical service to the poor for whom they …