To the Editor.
—Starfield and Simpson1 are to be complimented on their recommendations for strengthening the provision of primary medical services in the United States. However, I would go further and suggest that access to specialist services, except in the case of an emergency, should be only by referral from a primary care provider. Under the reformed health service it would be feasible for everyone to have a primary care provider of record. Only this provider would be granted the discretion to refer a patient for specialist care. In Britain it is unethical for a specialist to see a patient without referral from a general practitioner; penalties could be imposed on specialists accepting patients without referral. This policy would achieve considerable economy by avoiding the costly duplication of services that now occurs and would permit each provider to practice the type of medicine he or she does best. A