Intended for healthcare professionals

CCBYNC Open access

Explaining variation in referral from primary to secondary care: cohort study

BMJ 2010; 341 doi: (Published 01 December 2010) Cite this as: BMJ 2010;341:c6267
  1. Dulcie McBride, consultant in public health1,
  2. Sarah Hardoon, statistician2,
  3. Kate Walters, senior lecturer in primary care2,
  4. Stuart Gilmour, analyst3,
  5. Rosalind Raine, professor of healthcare evaluation1
  1. 1Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK
  2. 2Department of Primary Care and Population Health, Royal Free and University Medical School, University College London, UK
  3. 3King’s Fund, London, UK
  1. Correspondence to: D McBride dulciemcbride{at}
  • Accepted 14 September 2010


Objectives To determine the extent to which referral for defined symptoms from primary care varies by age, sex, and social deprivation and whether any sociodemographic variations in referral differ according to the presence of national referral guidance and the potential of the symptoms to be life threatening.

Design Cohort study using individual patient data from the health improvement network database in primary care.

Setting United Kingdom.

Participants 5492 patients with postmenopausal bleeding, 23 121 with hip pain, and 101 212 with dyspepsia from 326 general practices, 2001-7.

Main outcome measures Multivariable associations between odds of immediate referral for postmenopausal bleeding and age and social deprivation; hazard rates of referral for hip pain or dyspepsia and age, sex, and social deprivation. Analyses for dyspepsia were stratified for people aged less than and more than 55 years because referral guidance differs by age.

Results 61.4% (3374/5492) of patients with postmenopausal bleeding, 17.4% (4019/23 121) with hip pain, and 13.8% (13 944/101 212) with dyspepsia were referred. The likelihood of referral for postmenopausal bleeding declined with increasing age: the adjusted odds ratio for patients aged 85 or more compared with those aged 55-64 was 0.39 (95% confidence interval 0.31 to 0.49). Patients aged 85 or more with hip pain were also less likely to be referred than those aged 55-64 (0.68, 0.57 to 0.81). Women were less likely than men to be referred for hip pain (hazard ratio 0.90, 95% confidence interval 0.84 to 0.96). More deprived patients with hip pain or dyspepsia (if aged <55) were less likely to be referred. Adjusted hazard ratios for those in the most deprived Townsend fifth compared with the least deprived were 0.72 (95% confidence interval 0.62 to 0.82) and 0.76 (0.68 to 0.85), respectively. No socioeconomic gradient was evident in referral for postmenopausal bleeding.

Conclusions Inequalities in referral associated with socioeconomic circumstances were more likely to occur in the absence of both explicit guidance and potentially life threatening conditions, whereas inequalities with age were evident for all conditions.


  • We thank Steve Iliffe and Steve Morris for their comments on the paper.

  • Contributors: RR led the study and is the guarantor for the paper. RR and DMcB had the idea for the research. DMcB undertook the analysis. All authors participated in the study design, analysis, interpretation of results, drafting of the article, and approval of the final draft. All authors had full access to the data and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding: The King’s Fund provided support for access to the data. RR is partly funded by a National Institute for Health Research public health career scientist award and by the National Institute for Health Research University College London Hospitals/University College London Comprehensive Biomedical Research Centre. The opinions stated in this paper are those of the authors as individuals, independent from the funding sources. The funding sources had no role in the study design, analysis, interpretation, writing the report or decision to submit the paper for publication.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare (1) Financial support for the submitted work from the King’s Fund to access the data; (2) RR is partly funded by a National Institute for Health Research Public Health Career Scientist Award and by the National Institute for Health Research University College London Hospitals/University College London Comprehensive Biomedical Research Centre; (3) No spouses, partners, or children have relationships with commercial entities that might have an interest in the submitted work; and (4) have no non-financial interests that may be relevant to the submitted work.

  • Ethical approval: This study was approved by the London Research Ethics Committee, National Research Ethics Service (REC reference No 08/H0718/82).

  • Data sharing: Statistical code available from the corresponding author at dulciemcbride{at}

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

View Full Text