Guidelines partly explain differences in referral rates

Editor—Forrest et al provide a useful insight into the variation in specialty referral rates between the United Kingdom and the United States.¹ However, their assertion that, given the low referral rates in the United Kingdom relative to the United States, referral guidelines are unlikely to dramatically enhance the capacity of specialties by decreasing demand is both a non sequitur and probably untrue.

We studied the referral rates for dermatology across the 16 practices in a primary care group with a comparatively uniform population mix. We found variations ranging from 2 per 1000 practice population to 47 per 1000 (figure), and the dermatologists thought that around 60% of referrals were for conditions that should be easily manageable by general practitioners with access to the right information. The practice with the lowest referral rate had a clinical assistant in dermatology and had modified its referral process so that all patients were referred through her.

We found similar variability in orthopaedics and cardiology.

Referral rates can be reduced in many ways. The aim should be for the right patients to have access to the right level of skill at the right time without necessarily going to a hospital. The means to achieve this include better education, more community based expertise, mature clinical networks, and better use of technology such as clinical decision support (including referral guidelines) and telemedicine. There is plenty of room for improvement.

Figure.

Referral rates for dermatology to three trusts by 16 practices in primary care group