Avoidable referrals? Analysis of 170 consecutive referrals to secondary care

To determine appropriateness of referrals from primary care to secondary care.

Retrospective evaluation of appropriateness of referrals from a single-handed general practice: evaluations carried out independently by referring doctor and by second general practitioner who worked in same area and had access to similar secondary care services.

168 referrals made between 1 October 1990 and 31 March 1991 and followed up for up to 12 months by matching with available information on outcome of episode of care.

Appropriateness of referral and reasons for inappropriate referrals.

110 referrals were agreed to be appropriate and 58 were considered avoidable. The reason for 32 of the inappropriate referrals was lack of resources: 10 were due to lack of information (mainly failure of hospitals to pass on information to general practitioner), nine were due to a deficient primary health care team; five were due to insufficient use of home care nurses, three were due to absence of direct access to day hospital, and five were due to lack of access to general practitioner beds or other facilities. Most of the remaining 26 avoidable referrals were because available resources had not been fully used, because recognised management plans had not been followed, or because of lack of skills to perform certain procedures.

Many theoretically avoidable referrals were due to managers' and politicians' decisions about allocation of resources, but some inappropriate referrals could be avoided by assessment of general practitioners' needs for further knowledge and skills.