Effect of deprivation on general practitioners' referral rates

BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7112.882a (Published 04 October 1997) Cite this as: BMJ 1997;315:882

Study should have used deprivation index that is independent of age

  1. Ted Williams, Director of public healtha,
  2. Antony Jackson, Statistics and information officera,
  3. Deborah Turbit, Specialist registrar in public health medicinea
  1. a Croydon Health Authority, Surrey CR0 6SR
  2. b Prescribing Support Unit, Brunswick Court, Leeds LS2 7RJ
  3. c Department of General Practice and Primary Care, St Bartholomew's and the Royal London School of Medicine and Dentistry, Queen Mary and Westfield College, London E1 4NS
  4. d Department of General Practice, Medical School, Queen's Medical Centre, Nottingham NG7 2UH,
  5. e Trent Institute for Health Services Research, Medical School, Queen's Medical Centre

    Editor—There is a fatal flaw in the objective of the study by Julia Hippisley-Cox and colleagues: the Jarman underprivileged area (UPA(8)) score is used as a proxy measure to determine the effect of deprivation on variations in the outpatient referral rates of general practitioners.1 It is hardly surprising that there is a correlation between the Jarman score and referral rates; the Jarman score was devised specifically to predict workloads in primary care.2 3

    The Jarman index included as one of its factors the proportion of elderly people living alone, which correlates strongly with the proportion of elderly people in a population. Indeed, the category of elderly people living alone was given the strongest weighting by general practitioners because they knew that the population of elderly people was the major factor which would influence their workload. It is equally well known that age has a strong influence on referral rates. Elderly people are far more likely than young people to be referred to hospital; this is the reason for the age-cost curve in the national resource allocation formula.4

    The fact that the Jarman index correlates with referrals by general practitioners is a statement of the obvious—it confirms that the index measures what it claims to measure. Practices with high Jarman scores will almost certainly have a high proportion of elderly people and therefore have high rates of referral. To claim that this correlation shows a link with social deprivation is to miss the point. The age structure of a population is not an indicator of deprivation, and many of the most deprived practice populations, such as those found in the inner cities, will have …

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