GPs have long been regarded as the gatekeepers of the NHS, responsible for the delicate task of juggling the clinical needs of individual patients with the general health of the wider population.
But faced with rising referral rates and targets for ever more demanding efficiency savings, the tendency among NHS managers has been to simply build more gates.
Pulse reported in February that a third of GPs now have their referral decisions screened by a referral management centre – and this week we reveal that in many cases, referrals are being rejected not by GPs or consultants, but by nurses, physiotherapists and even podiatrists.
For many GPs, instinctively, there's something about this that sticks in the craw. Generally, the decision to refer a patient is a carefully considered one, the product of a GP's experience and training, and based on one or more face-to-face consultations.
For an anonymous nurse working to a set protocol in a remote referral management centre to reject that carefully considered decision out of hand is professionally frustrating, to say the least.
The primary concern, of course, is patient safety. Both GPs and consultants this week told Pulse they feared under-qualified medical staff were inappropriately rejecting referrals because they did not conform to inflexible algorithms.
Viewed from on high, this represents a small administrative glitch. On the ground though, there's a very human impact. Put bluntly, patients who need and are clinically deserving of treatment are not getting it, on the say-so of someone not necessarily qualified to make that decision.
There's the suspicion, too, that money, which was the driving factor for primary care organisations bringing in referral management centres in the first place, is also the reason why some refuse to employ medically qualified staff.
Last month, a King's Fund researcher calculated that using referral management centres can cost up to £20 per outpatient attendance. Small wonder then that those running them are keen to keep overheads to a minimum – but if so, it may prove a false economy.
There's no doubt that some GPs could work on their referral rate, and there's some evidence that peer review can improve referral behaviour.
But using underqualified staff in referral management centres makes a blunt tool blunter – and in the long term, patients in need who go untreated are likely to cost the NHS more.
What's hardest to accept about the use of nurses and other non-medical professionals to triage GP referrals is the implied lack of faith that GPs can live up to their traditional gatekeeper role.
It's a crisis he argues makes the reforms outlined in the health bill essential – and whether GPs agree with his answer or not, they are acutely aware of the question.
Yet it's hard to square handing GPs the purse strings to the NHS and trusting them to find unprecedented savings, while at the same time using underqualified staff to second-guess their individual referral decisions.
GPs are the NHS's gatekeepers precisely because they have the clinical knowledge to make intelligent, informed and cost-effective referral decisions. Regardless of what new roles they are asked to take on over the next couple of years, this is one they should keep.
Steve Nowottny, deputy editor