Face-to-face priority-setting in primary care
: a multiple-methods study in England and Japan

Student thesis: Doctoral ThesisDoctor of Philosophy (PhD)


Primary care physicians (PCPs) make decisions about allocating scarce resources. While the gatekeeping system has been in place since the establishment of the National Health Service (NHS) in England, Japan has traditionally used the open-access system. The study aimed to investigate formal gatekeeping and shared decision-making in face to face priority setting in primary healthcare settings in England and Japan.
First, a multiple-methods study was conducted using the data from the primary care consultation archive ‘One in a Million’ in England. Initially, a secondary qualitative analysis was undertaken. 60 cases were sampled based on responses to a pre-consultation questionnaire and transcripts were analysed using thematic analysis. A subsequent quantitative analysis entailed descriptive analysis and hypothesis-testing. Finally, in-depth interviews were undertaken with purposefully sampled 23 PCPs in England and Japan. Interview transcripts were analysed using a constant comparative technique.
The secondary qualitative analysis showed GPs’ ability to balance two agent roles for the patient and society in making allocation decisions, along with their engagement in a shared decision-making (SDM). Similarly, there was no significant difference in SDM occurrence between the patients who did not receive expected services and others. The interview study reported that England’s gatekeeping system restricted use of GPs’ clinical judgement and reduced available options for patients. GPs said they were thus often open about financial constraints with patients to manage their expectations. By contrast, Japan has almost no system to limit healthcare access and priority setting often relied on implicit judgments. Japanese PCPs’ willingness to make a referral were also influenced by several factors such as a fear of litigation.
If Japanese policymakers pursue a formal gatekeeping system, explicit criteria are needed to navigate fair resource allocation. However, it needs to find a balance between supporting patients’ and practitioners’ autonomy, as well as managing other incentives causing overtreatment.

Date of Award23 Jan 2024
Original languageEnglish
Awarding Institution
  • The University of Bristol
SupervisorAmanda L Owen-Smith (Supervisor), Tim Jones (Supervisor) & Joanna Coast (Supervisor)


  • Priority setting
  • Primary care
  • Health Economics

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