The impact on hospital resources of variability in referral rates among general practitioners was of concern throughout the 1980s. The overall number of patients referred to outpatient clinics, however, has increased only slowly since the NHS began; in contrast, the number of new outpatients seen by each hospital consultant has declined appreciably. Ironically, despite this decline, further increasing the number of consultants is now being presented as a solution to the demand for outreach clinics in general practice.

During the 1980s the considerable variability between general practitioners in referral rates of patients to hospital outpatient clinics was identified as a health services problem. A large amount of research literature began to accumulate, with debates about the true extent of the variability and its possible causes.1 In part, the concern seemed to be about the underreferral or overreferral of individual patients, but the underlying agenda concerned the cost implications of general practitioners with high referral rates.2

A central assumption of research into general practitioner referrals was that the costs of the outpatient service were a direct consequence of general practitioners' clinical decisions to refer. There was some recognition that patients were “recycled” by hospital doctors through their clinics—often unnecessarily3—but it was still the general practitioner who referred the patient to the expensive, hospital sector in the first place. However, instead of starting from the assumption that it is referral decisions by general practitioners that underpin pressure …