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The European study of referrals from primary to secondary care


1. To define and compare national referral patterns.
2. To identify cohorts of general practitioners in each country with high and low referral patterns and to compare practice/doctor characteristics both within each country and internationally.
3. To examine delay patterns for specialist consultation and for surgical treatment.
4. To provide individual general practitioners with summarized referral data.
Referrals from primary to secondary care are known to be widely variable both within and between countries. This study defined national referrals patterns of general practitioners, compared characteristics of high and low referring doctors and examined delays in the referral process. The database included 1548 general practitioners working in 15 countries, each contributing information about 30 consecutive referrals.

Information from this study concerned the differing workloads of doctors in the various countries and presented data on the influence of general practitioner workload on the referral process. The delay between referrals from primary care and the appointment with a specialist in secondary care was also detailed.

The problem of variability in the way doctors perform is well known. This study has shown that it exists to a similar extent in all countries regardless of the healthcare system and was present even after careful standardization for the age and sex composition of patients consulting.

The fact that doctors with a high workload seem to refer less patients than doctors with a low workload was quite a surprising finding. In addition, it was evident in several of the countries examined individually. In general, countries in which there was a very high consultation rate (ie high utilization of primary care) there was also a high referral to secondary care but in most countries, there was a gradient of high to low referring doctors which was inversely related to workload. It would appear therefore that doctors with a low referral pattern were providing a high number of services in terms of consultations per patient.

The situation in the Federal Republic of Germany suggests that patient demand is determining the distribution of healthcare. This is satisfying both to patients and to health care providers who are remunerated accordingly. There is here however, a serious challenge to the system of insurance based healthcare without centralized c ontrol of reimbursement levels.
This study arose out of a background of increasing costs in the provision of healthcare in all European countries and large differences in expenditure on healthcare between the countries.


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Royal College of General Practitioners
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54 Lordswood Road Harborne
B17 9DB Birmingham
United Kingdom

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