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General Practice

Survey of general practitioners' views of consultants' non-urgent referral of outpatients to other consultants

BMJ 1996; 312 doi: (Published 30 March 1996) Cite this as: BMJ 1996;312:821
  1. S Bridger, medical registrara,
  2. S R Cairns, consultant gastroenterologista
  1. a Royal Sussex County Hospital, Brighton BN2 5BE
  1. Correspondence to: Dr Cairns.
  • Accepted 4 January 1996

There are an estimated nine million new outpatient referrals each year.1 Between 60% and 80% of these referrals originate from general practitioners.2 Additional referrals arise predominantly from hospital departments. A study in Leicester found a cross referral rate of at least 17% from one clinic to another.3 In the years preceding fundholding the practice of referral between consultants seems to have been accepted.4 However, fundholding general practitioners have become increasingly aware of the cost and logistic implications of this practice and have begun to express their concerns.5

We investigated local general practitioners' preferences about the practice of non-urgent referral of outpatients between consultants.

Patients, methods, and results

We sent a questionnaire to all 165 general practitioners in the Brighton area. These questionnaires consisted of 10 specimen case histories, and on each of these the general practitioners were asked to select whether they would prefer the specialist to refer directly to another specialist or advise this option but leave referral to the general practitioner's discretion. We received 115 replies (70%), of which 49 were from fundholding general practitioners. Statistical analysis comparing the replies from fundholding and non-fundholding practices was carried out using odds ratios with 95% confidence intervals.

Eight of the case reports were perceived by the general practitioners as non-urgent tertiary referral. Two of the cases were perceived as being more urgent as the patient may have had an underlying malignancy. An example of the two types of cases and the general practitioners' replies are shown in table 1. In all cases non-fundholding general practitioners were more likely to prefer direct referral by consultants. In nine of these cases these differences were significant (P value varying between 0.00041 and 0.024). Case 2 was the only instance when there was no significant difference between the preferences of fundholding and non-fundholding general practitioners (table 1). Non-fundholding general practitioners indicated that they preferred direct referral by a consultant on 440 occasions out of a total of 621 responses (71%) compared with fundholding general practitioners, who indicated that they preferred this practice on 220 occasions out of a total of 486 responses (45%) (P<0.0001 with an odds ratio of 2.83 (2.2 to 3.7)).

Table 1

General practitioners' attitudes to consultants' referral of outpatients to other specialists: two sample cases*

View this table:


General practitioners expressed few concerns about consultants' referral of outpatients to other consultants in a study published in 1991.4 Since then health service reforms have led general practitioners and hospital specialists to re-evaluate this practice. We were surprised by the good response rate and the strength of feelings expressed by some of the doctors. Non-fundholding general practitioners stated that it was “a waste of time bringing patients out of the system,” and that “inter-consultant referral was quicker” and “reduces unnecessary paper work.” In contrast, fundholders commented that “consultants should only ever advise GPs,” and that “interconsultant referral is never appropriate” or “a fair option as the consultant cannot know where the GP has placed the contract.”

It was clear from this study that fundholding general practitioners are significantly less likely than their non-fundholding colleagues to want direct referral between consultants for patients with non-urgent problems. Fundholding general practitioners would like to participate more fully in decisions about the tertiary referral of their patients.

We thank staff of the audit department at the Royal County Hospital for their help in collecting and collating the data.


  • Funding None.

  • Conflict of interest None.


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