50 2 CHAPTER 2 As a result, another participant explained, GPs lost interest in, and were less capable of, functioning as the gatekeeper in MNC. ‘[…] You know what, it’s a self-fulfilling prophecy. Because fewer GPs practiced midwifery, an increasing number of them lost the expertise. And they thought this was just fine. […]’(P3) Our participants told us furthermore that GPs who did practice midwifery were not disadvantaged by the SGKL’s decision to grant midwives gatekeeping authority because the SGKL agreed that these GPs and midwives were equal primary midwifery care providers. As such, GPs practicing midwifery retained their gatekeeping authority. Belief in the gatekeeping system Second, the GPs in the SGKL ―including the chair, who was a GP, and the secretary, who was a doctor who had not chosen a speciality ―strongly believed that effective specialist care could only be achieved after risk selection by a gatekeeper in primary care. One participant explained this using the notion of ‘selective perception’ of risk: ‘[…] It is bad for patients to enter secondary care directly. […] A specialist cares for a population with a higher prevalence of morbidity compared to the GP, whose population is healthy […] For a paediatrician, measles is a deadly disease, but for a GP it is not. […] An obstetrician [like other specialists] has a selective perception in the sense that all his patients are ill. […]’ (P1) Our participants told us that based on these beliefs, the secretariat introduced the idea that the added value of specialist care to prevent or treat risk must be made explicit before referral is made. This became the rationale behind the guideline that assigns women to either the low, medium or high risk group (Associated document no. 6 & no. 22). All SGKL members agreed with this guideline (Minutes 11-02-1985). Belief in the gatekeeping competence of midwives Third, our data show that a further reasons behind the support of GPs in the SGKL for granting midwives the authority over risk assessment was because, like the GPs, midwives were primary care professionals and were thus considered competent for this task (Associated documents no. 70). We also learned via our interviews that some of the GPs’ representatives practiced midwifery and their positive personal experiences with risk assessment led them to agree with this decision. Joining forces to strengthen primary care Lastly, our participants told us that the GPs believed that supporting midwives as gatekeepers in MNC would ultimately work in their favour. As family doctors, GPs had long functioned as gatekeepers to specialist care. This role was emphasized, endorsed, and reinvigorated in 1974 by the Ministry of Health, Welfare and Sports. However, as one participant explained, GPs had ‘had to fight’ for that position and had done so by supporting the value of their work with scientific research. ‘[…] After the war, the GPs’ position was weak. […] Primary care almost disappeared. It never reached that point, but there was a time that medical specialists were of the opinion that patients should directly consult them. According to politicians, consulting the GP before 12 B. Goodarzi et al.