Fundholding has changed referral practice

BMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7028.445 (Published 17 February 1996) Cite this as: BMJ 1996;312:445
  1. Kevin Perrett
  1. Senior registrar in public health medicine Department of Public Health, Barnsley Health Authority, Barnsley S75 2PY

    EDITOR,—I disagree with Rebecca Surender and colleagues when they conclude that their study shows that fundholding has had little effect on general practitioners' referral rates.1 In the context of the longstanding and inexorable increase in all phases of activity in the NHS, it is expecting a great deal that fundholders would have reversed this trend for outpatient referrals. It is more reasonable to ask whether fundholders, relative to non-fundholders, have slowed down the rate of increase in referral rates.

    In the control practices chosen for the study the increase in NHS referral rates was 26.6% between phases 1 and 3 of the study. In the fundholding practices the increase was only 7.5%, a difference of 19.1%. On the basis of the fundholders' baseline referral rates of 107.3/1000 this represents a “saving” of 20.5 referrals per 1000 patients per year.

    Applying this figure to the mean list size (13044) of each of the fundholding practices means that 267 referrals per year, on average, have been avoided in each fundholding practice. In our district a typical outpatient appointment costs, at a conservative estimate, pounds sterling50. The avoidance of 267 referrals per practice represents a cost saving of pounds sterling13370 per practice. In my district this would be enough to purchase at least 27 hip replacement operations.

    I conclude that the study shows that fundholders have changed their referral decisions and that their rate of increase in NHS referral rates to specialist outpatient clinics was much lower than that in the control group of non-fundholders. This is an important achievement and has considerable cost saving implications.


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