How UK healthcare works
The United Kingdom is one of many countries that use a general practitioner as the mandatory first point of contact for non-emergency specialist care. Other countries let patients book specialists directly. Most of the world sits on a spectrum between the two. This is the map.
Dr Seth Rankin
MBChB MRCGP. Founder of LoveMyLife. Former NHS Commissioner and Managing Partner of Wandsworth Medical Centre.
23 April 2026
13 min read
When a patient in the United Kingdom is surprised that they cannot book an NHS specialist directly, the surprise is usually the product of experience in a country where they could. The UK gatekeeper model (explained in the dedicated article on why the NHS uses GPs as gatekeepers) is one of several ways that advanced health systems organise access to specialist care.
This article sets out how primary-care gatekeeping works in different countries, how the models vary, why each has emerged, and what the international evidence shows about the differences. It is intended for anyone interested in comparing the UK system with its peers. Sources are listed at the end.
There are two basic ways to organise access to secondary care.
Gatekeeping. A patient who wants specialist care is first seen by a primary-care clinician (usually a general practitioner), and specialist access follows from that clinician's referral. The gatekeeper is compulsory or heavily incentivised.
Direct access. A patient who wants specialist care books the specialist directly. No primary-care referral is required (although one is often welcomed).
Most countries sit somewhere between the two poles, with specific exceptions carved out for emergency care, paediatrics, sexual health, and some chronic-disease management programmes. The direction of travel across the last two decades has been toward more gatekeeping or incentivised gatekeeping, driven by demand management and cost-control pressures in almost every advanced health system.
The strictest gatekeeper systems are almost all publicly funded universal systems. A patient is registered with a GP or primary-care clinician, and referral to secondary care goes through that clinician.
The United Kingdom. The NHS uses GP gatekeeping for almost all planned specialist access. Emergency care, some mental-health services, sexual-health services, and optometry are direct-access. Analysed in detail elsewhere in this cluster.
The Netherlands. Every Dutch resident is registered with a *huisarts* (general practitioner) under a mandatory social health insurance system (*Zorgverzekeringswet*). The huisarts is the mandatory gatekeeper for almost all specialist care. Dutch primary care has a long-standing reputation for strong gatekeeping discipline; around 95 per cent of health problems that present to primary care are resolved there without a specialist referral. Nivel and the Netherlands Institute for Health Services Research publish workforce and activity data.
Denmark. Denmark operates a two-group system. Most Danes are in Group 1, which assigns them to a named GP and requires referral for specialist care. A smaller proportion pay a higher contribution to be in Group 2, which allows direct access to many specialists. Group 1 is the mainstream. Denmark's health system is structured around a single tax-funded model.
Norway. Under the regular GP scheme (*Fastlegeordningen*), every resident is assigned to a named GP and specialist access is gatekept through that GP. Norway introduced this model in 2001.
Finland. Most primary care in Finland is delivered through municipal health centres, with GP-led gatekeeping. An occupational health route runs in parallel for employees, and some direct access exists for private specialist care, but the public system is gatekeeper-based.
Sweden. Swedish patients are registered with a primary-care practice (*vårdcentral*) under a regional health system, and most specialist access is gatekeeper-mediated, although direct access exists for some specialties.
These five countries have in common: a tax or social-insurance-funded universal system, a list-based primary-care relationship, a strong GP role, and gatekeeping as the default access mechanism.
Spain. The Spanish National Health System (*Sistema Nacional de Salud*) is tax-funded and organised through regional health services. Every resident is registered with a family doctor at a *Centro de Salud* (health centre). Specialist referral runs through the family doctor. A parallel private-insurance market exists (about 20 per cent of Spanish residents hold private insurance), which offers direct specialist access outside the public system.
Portugal. The Portuguese National Health Service (*Serviço Nacional de Saúde*) is similarly organised, with registration at a family health unit (*USF*) or health centre. The *médico de família* is the gatekeeper.
Italy. Italian patients are registered with a GP under the Servizio Sanitario Nazionale and most specialist access is gatekeeper-mediated, although patients have some direct-access options. Regional variation is significant.
The pattern in southern Europe is broadly similar to northern Europe: tax-funded universal system, list-based primary care, gatekeeping as default.
Australia. Medicare Australia reimburses GP consultations and, for most specialist care, reimburses at a higher rate when the patient has been referred by a GP. Technically, an Australian patient can see a specialist directly (there is no legal prohibition) but they pay the full fee rather than receiving the Medicare rebate, which in practice creates a strong financial incentive for GP-mediated referral. The effect is a soft or "incentivised" gatekeeper system.
New Zealand. New Zealand primary care is organised through Primary Health Organisations (PHOs), with subsidised GP consultations and a referral-based route to specialist care in the public sector. Private specialist access exists directly and is entirely self-paid. The public-system gatekeeper is structural rather than legal.
Ireland. Irish primary care is mixed. Patients with a Medical Card or GP Visit Card receive free GP care and a referral-based route to public specialist care. Patients without either pay fees for GP visits and have a range of direct-access and referral-based options depending on the specialty and the insurance situation.
The Commonwealth models share a common root in the UK NHS tradition, with each country having adapted the approach to its own demographics, geography, and political settlement.
A third category sits between strict gatekeeping and direct access: systems where patients can technically see a specialist directly but face financial or administrative disincentives for doing so.
France. The French system made the most significant shift. Until 2004, French patients had near-unrestricted direct access to specialists under the national social insurance scheme. In 2005, the *médecin traitant* reform introduced a designated primary-care doctor for each insured adult. Patients who bypass their *médecin traitant* receive a substantially reduced reimbursement rate from the statutory insurance funds. The reform was explicitly designed as a demand-management mechanism. Roughly 90 per cent of French adults are now registered with a *médecin traitant*.
Germany's Hausarztzentrierte Versorgung. Germany is historically a direct-access system, but since 2004 many statutory insurers have offered a voluntary GP-centred care programme (*Hausarztzentrierte Versorgung*, HzV) in which patients who enrol agree to use their GP as the first point of contact in return for various benefits including reduced co-payments. Take-up varies by insurer and region.
Belgium. Belgian patients can see specialists directly, but reimbursement is higher when there is a GP referral and when the patient has registered a *Global Medical Record* with their GP. Similar incentive structure to France.
The trend across several direct-access systems has been to introduce GP-based options that reward the patient for using primary care as the first contact. This is the same underlying logic as strict gatekeeping: demand management, cost containment, and clinical coordination, delivered through incentives rather than rules.
Several large advanced health systems still operate largely without gatekeeping. In these, a patient can book a specialist directly and the system pays (or the patient pays) as a matter of course.
Germany. The German statutory health insurance (*Gesetzliche Krankenversicherung*, GKV) system allows direct access to specialists for most conditions. Patients book specialists in ambulatory practice (*Niedergelassene*) directly. The voluntary HzV programme exists as described above but is not the default. About 90 per cent of Germans are covered by GKV, with the rest on private insurance (*Private Krankenversicherung*, PKV).
Switzerland. Swiss patients can book specialists directly under their mandatory *Grundversicherung* basic insurance, although cost-saving variants of the insurance (such as *Hausarztmodell* plans) trade lower premiums for a GP-gatekeeper arrangement. Take-up of gatekeeper models has grown as premiums have risen.
Austria. The Austrian social-insurance system allows direct specialist access, similar to Germany.
Japan. Under the Japanese Statutory Health Insurance Scheme, patients have almost unrestricted direct access to specialists in private practice. One significant exception is a fee for patients who go to a large hospital outpatient department without a referral, introduced to reduce inappropriate demand on tertiary centres. The OECD notes that Japan combines high specialist utilisation with unusually low per-capita spending by developed-economy standards, a combination that is partly explained by the way the fee schedule works.
South Korea. Korean patients have largely direct access under the National Health Insurance system, with some referral-based incentives for tertiary care.
The United States. The US system has no single model. Under Health Maintenance Organisation (HMO) insurance plans, the primary-care physician is the gatekeeper. Under Preferred Provider Organisation (PPO) plans, patients can see specialists directly (often with higher out-of-pocket cost). Medicare and Medicaid have their own rules. The US is best understood as a set of parallel systems, each with a different answer to the gatekeeping question.
The comparative literature on gatekeeping versus direct access is consistent on some points and less settled on others.
Specialist utilisation is lower in gatekeeper systems. Gatekeeper systems typically run fewer specialist consultations per capita than direct-access systems. This is the most robust finding. OECD and Commonwealth Fund data are broadly consistent on this.
Imaging and investigation rates are lower in gatekeeper systems. Direct access tends to produce more scans, blood tests, and procedures, especially in fee-for-service insurance-funded systems.
Total healthcare spending per capita is lower in gatekeeper systems. Most publicly funded gatekeeper systems spend less per capita than direct-access systems, controlling for country wealth. The US is the most visible outlier.
Clinical outcomes are broadly comparable. On headline measures like life expectancy, amenable mortality, and population-level cancer survival, gatekeeper and direct-access systems deliver similar outcomes at the population level. Differences exist for specific conditions and there are active debates about whether some gatekeeper systems under-diagnose certain conditions, but the overall picture is that both models produce peer-level outcomes.
Access measures differ. Time to a specialist appointment is usually shorter in direct-access systems. Time to see a primary-care clinician is usually shorter in list-based gatekeeper systems. Patient satisfaction with each of these things varies accordingly.
Health inequalities play out differently. In direct-access systems with substantial out-of-pocket costs or insurance variation, inequalities tend to concentrate at the access level. In gatekeeper systems, inequalities tend to concentrate at the navigation level (health literacy, relationship with GP, time to pursue referrals).
No large international comparative analysis has found one model to be straightforwardly superior to the other at the whole-population level. The evidence supports the narrower claim that each model comes with a specific set of trade-offs.
Three patterns emerge from the international picture.
Strict gatekeeping fits publicly funded universal systems with a fixed or heavily controlled budget. The UK, the Netherlands, Scandinavia, and the Iberian peninsula are the clearest examples. Gatekeeping is the demand-management mechanism that keeps the system solvent within its fiscal envelope.
Direct access fits social-insurance systems with multiple funds, fee-for-service payment of providers, and per-episode billing. Germany, Japan, and the US PPO model are examples. The insurance mechanism is the cost-containment mechanism; gatekeeping is not structurally necessary because the money flows differently.
Incentivised gatekeeping fits systems that started direct-access and now want to manage demand. France after 2005 is the clearest example. It keeps patient choice formally intact while steering the majority of patients toward a GP-mediated pathway through financial incentives.
The Commonwealth systems (Australia, New Zealand, Ireland) sit across these categories: they blend public funding with Medicare-style fee rebates, and their gatekeeping is financial rather than strictly mandatory.
The UK's strict gatekeeping is therefore not unusual. It is one of the more common designs among countries with similar structural characteristics: universal coverage, tax funding, a fixed budget, and a list-based primary-care system. It is also a design that several originally direct-access systems have been moving toward, not away from, over the last two decades.
Primary-care gatekeeping is one of two main ways to organise specialist access in advanced health systems. The UK, the Netherlands, Scandinavia, Spain, Portugal, and most Commonwealth primary-care systems use mandatory or heavily incentivised GP gatekeeping. Germany, Switzerland, Austria, Japan, South Korea, and parts of the US system operate direct-access for most specialist care. France and several other originally direct-access systems have moved in the gatekeeper direction over the last twenty years through designated primary-care doctors and reimbursement incentives.
The international evidence supports a consistent pattern: gatekeeper systems run fewer specialist consultations, fewer investigations, and lower per-capita spending; direct-access systems produce shorter waits for specialists but higher overall utilisation. Clinical outcomes at the population level are broadly comparable across the two.
For UK patients, the relevant point is that the gatekeeper system is a design that sits comfortably among its peers. It is not an outlier; it is one of the main models that publicly funded universal systems use. Every design makes a trade-off; the UK has made a specific one.
OECD, Health at a Glance 2025. Comparative data on access, utilisation, and outcomes across OECD countries.
OECD, Health systems performance. Cross-country performance analysis.
Commonwealth Fund, Mirror, Mirror 2024. Comparative analysis of high-income health systems.
Commonwealth Fund, International Health Care System Profiles. Country-by-country health system descriptions.
European Observatory on Health Systems and Policies, Health Systems in Transition (HiT) profiles. Detailed country-specific health-system reports.
Nivel, Netherlands Institute for Health Services Research. Dutch primary-care research and data.
Services Australia, Medicare. The Australian public health insurance scheme.
Ministry of Health New Zealand, New Zealand health system. NZ primary-care structure and PHOs.
Danish Ministry of Health, Health system in Denmark. Danish healthcare organisation.
BMA, Health system comparison. International comparison of health systems.
King's Fund, How does the NHS compare internationally?. Analysis of UK health system relative to peers.
Nuffield Trust, International comparisons of health services. Independent analysis of comparative health-system performance.
Clinically reviewed
Dr Seth Rankin · MBChB MRCGP - Founder and Medical Director, LoveMyLife
Dr Seth Rankin qualified in medicine at Auckland School of Medicine in New Zealand in 1990 and worked as a junior doctor across New Zealand, Australia, and the UK before qualifying as a Member of the Royal College of General Practitioners (MRCGP) through the London Deanery in 2004. He was Managing Partner of Wandsworth Medical Centre from 2006 to 2016 and served as a Board Member of Wandsworth Clinical Commissioning Group for nine years. He is the founder of London Travel Clinic, London Doctors Clinic, London Medical Laboratory, and LoveMyLife.
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