Medical Gate-keeping is, admittedly an issue that lies close to my life. I have experienced it and heard numerous anecdotes from others of similar experiences. Where does duty of care end and gate-keeping start? It’s question that many people have asked, and that many people have strong opinions on. I’ll be straight to the point, here’s my bottom line.
When it comes to medical care, inaction should never under any circumstance be the default action when patient safety is at risk.
I also am going to say that although gate-keeping can refer to many areas, I’m focusing on the area of Mental Health care in this post. I will most likely in the future link these to other areas of Medical care such as other specific mental illnesses, or trans* health care.
The Fallacy of inaction
Now that I’ve made my chance clear, let me explain briefly what I mean by the Fallacy of Inaction. Essentially, it is the human tendency to see not taking an action (inaction) as being a neutral stance, where in fact no such thing exists. Choosing not to do something, just as choosing to do it does. Take for example the choice between two pills, one kills you, one does not. Taking the former has a huge consequence, but does the latter? It entirely depends on perspective, and as we see things from the perspective of the present (the status-quo), then we would easily jump to argue it is a neutral choice. In reality however, these two paths are distinct and different, and from a non-subjective viewpoint are both very consequential choices.
Many will have realised the relevance this holds, especially those who have experienced this first hand. It is far easier for humans to justify ignoring a problem than choosing to deal with it. Identifying this as a purely psychological inaccuracy is essential when striving for a reasoned viewpoint.
Comparing Mental Illness and Physical Illness
A pattern emerges very quickly when you look at areas of medical care where significant complaints of gate-keeping arise. As a demonstration I’m going to compare the guidelines for treating Depression, and those for Thyroid Cancer. Depression has a 15% mortality rate , and Thyroid Cancer a 6% rate.  I intentionally chose similar ranges of mortality rates, as they have a vague implication on the seriousness with which these conditions should be treated. (This is simply common sense)
Now, I’m going to look at two documents which act as guidelines for the treatment of these two conditions, specifically where they state what is needed for patients to get access to care (Not medication, as the effectiveness is not comparable). It logically follows that with quite a higher mortality rate, depressed patients should find it more easy to reach proper care.  
Firstly, to start with Thyroid Cancer. There is actually very little to say. It almost assumes care as a given, and immediately explains the structure for which a Multidisciplinary Thyroid Cancer Team should be of access to patients with this disease. It is immediately apparent to me reading this that there is simply no question that these patients need to see these professionals. And the systems are in place that patients diagnosed with thyroid cancer are immediately put to the highest level of care for that illness. Nor anywhere does it qualify this with a severity or development of the cancer. (Another key point, the cases are treated equally when it comes to access to care)
Now, onto the much more clunky NHS protocols (Called the NICE guidelines). This document is quite long and arduous, however I’ll make my best effort to paraphrase it as best and as objectively as I can. Section 1.2 clearly lays out a “Stepped Care” system, with 4 steps, directly linking severity of the condition, to as they call it “Nature of the Intervention”. In practice, and summarising the steps, the higher up, the more professional care is given, and the more risky procedures are considered (ECT for example). To advance up the steps, it is inherent that patients negotiate an extra step than is necessary (Step 1 to Step n), however more likely that they will have to negotiate several steps. (Keep in mind there may be months wait between these step ups, when taking into account waiting times and several appointments over weeks). It’s also very worth mentioning that the differences between the Steps are extremely vague, and are more down to interpretation than anything.
It does not take long to start seeing the flaws in the system for dealing with depression. Firstly and foremostly, it represents a form of Restrictive Treatment. Where certain cases are restricted to access of certain care. The problem is apparent when you notice the mix of these restrictions. Because access to certain professionals is mixed in with types of treatment. “Multiprofessional care” as a great example is only listed in Step 4 alongside ECT. And while, yes treatment and seeing certain professionals go inevitably hand in hand when dealing with Mental Illness and talking therapies. The issue arises very quickly when you merge these two concepts in a tiered system of care which undermines itself. It simply does not make sense for someone with early development Thyroid cancer to be denied access to a higher qualified professional due to the lack of severity to their condition. This professional may well have essential details regarding the patient’s specific case.
The guidelines on Thyroid Cancer give only one area for failure regarding access to treatment. That is diagnosis. However the NICE guidelines for depression give a potential 4 or more areas in which patients can not be given sufficient access to care. Or, to relate to the title, 4 or more steps to gate-keep. It’s not that difficult to understand as a concept. If a case isn’t completely clear cut, between the steps, then there is a massive potential for error. You may be wondering why I mentioned the Fallacy of Inaction earlier. Well, here it is. Having established the system for dealing with Mental Illness is flawed (As an example Depression in the UK), and that there are many steps where failure to determine between which Step is required is very easy and the definitions very vague. Here is why there are so many complaints, why the system seems so flawed.
Because if you give someone an ambiguous decision, they will take the action which seems the least impactful from their perspective. They will deny the patient care. Give people a vague list of guidelines that could seem reasonable to determine patient’s access to care, and they will consistently and ruthlessly underestimate the severity of patient’s conditions. They will round down every single time.
Failure to account for the human aspect when structuring a system is a flaw with the system, not the people. It is simply infeasible to ask the humans working as professionals to be, well. Less human.
I do try to keep a fair standpoint, to stay reasonable and see things from other’s point of view. But I simply cannot see any way in which a tiered system which determines access to medical professionals who are qualified to help will ever work in practice. It does not and can not work. Cases can be too varied to allow for strict guidelines, and vague guidelines will consistently be misinterpreted. The solution however is right in front of us. You minimise restriction of care. You keep the steps or tiers or whatever you want to call them to an absolute minimum and make them as easy to navigate as possible.
The phenomenon of gate-keeping is in many ways a mix of a human flaw with a even more deeply flawed system. The detachment between what practically works and what seems reasonable is far too great. And mixing methods of treatment and access to qualified medical professionals is an exceptionally dangerous game which I would rather not play. I believe however much of this is due to a systemic stigma of mental illnesses as not being as real as physical illnesses (Despite the higher mortality rates, depression being much more restrictive with access to care than Thyroid Cancer). And while I’ve tried to stay as objective as possible throughout this post, I firmly believe that this stigma is not only the primary cause of the existence of the flawed system of Mental Health care, but also an additional tendency to underestimate severity of symptoms, and ultimately the death of sufferers of Depression and other Mental Illnesses.
Restricting access to Treatment is fundamentally flawed on many levels, and it needs to stop. Now.
 Stat obtained from: http://www.dnalc.org/view/1394-Depression-Mortality.html
 Stat obtained from: http://en.wikipedia.org/wiki/List_of_cancer_mortality_rates, sourcing (Kipfer, Barbara Ann. The Order of Things (Revised Edition), Random House, N.Y. 1998)