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Variation in referral rates to emergency departments and inpatient services from a GP out of hours service and the potential impact of alternative staffing models
  1. Daniel Lasserson1,2,
  2. Honora Smith3,
  3. Sophie Garland4,
  4. Helen Hunt4,
  5. Gail Hayward5
  1. 1Faculty of Medicine, Division of Health Sciences, University of Warwick, Coventry, UK
  2. 2Department of Acute Medicine, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
  3. 3Faculty of Engineering Science and Mathematics, Department of Mathematical Sciences, University of Southampton, Southampton, UK
  4. 4Oxford Health NHS Foundation Trust, Oxford, UK
  5. 5Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  1. Correspondence to Professor Daniel Lasserson, Division of Health Sciences, University of Warwick Faculty of Medicine, Coventry CV4 7AL, UK; daniel.lasserson{at}


Introduction Out of hours (OOHs) primary care is a critical component of the acute care system overnight and at weekends. Referrals from OOH services to hospital will add to the burden on hospital assessment in the ED and on-call specialties.

Methods We studied the variation in referral rates (to the ED and direct specialty admission) of individual clinicians working in the Oxfordshire, UK OOH service covering a population of 600 000 people. We calculated the referral probability for each clinician over a 13-month period of practice (1 December 2014 to 31 December 2015), stratifying by clinician factors and location and timing of assessment. We used Simul8 software to determine the range of hospital referrals potentially due to variation in clinician referral propensity.

Results Among the 119 835 contacts with the service, 5261 (4.4%) were sent directly to the ED and 3474 (3.7%) were admitted directly to specialties. More referrals were made to ED by primary care physicians if they did not work in the local practices (5.5% vs 3.5%, p=0.011). For clinicians with >1000 consultations, percentage of patients referred varied from 1% to 21% of consultations. Simulations where propensity to refer was made less extreme showed a difference in maximum referrals of 50 patients each week.

Conclusions There is substantial variation in clinician referral rates from OOHs primary care to the acute hospital setting. The number of patients referred could be influenced by this variation in clinician behaviour. Referral propensity should be studied including casemix adjustment to determine if interventions targeting such behaviour are effective.

  • urgent care
  • systems
  • research
  • operational

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  • Handling editor Richard John Parris

  • Twitter @DanLasserson

  • Contributors DL conceived the study. HS undertook simulations and analysed data. GH contributed to study design, data collection and data interpretation. SG and HH contributed to data collection and data interpretation. DL wrote the first draft of the manuscript and all authors provided critical comment. DL is the guarantor.

  • Funding This study was not directly funded but HKS was supported by the Economic and Social Research Council (ESRC) Impact Acceleration Account (IAA) at the University of Southampton (grant award number ES/M500458/1). The work was supported by the National Institute for Health Research (NIHR) Community Healthcare MedTech and In Vitro Diagnostic Cooperative (MIC) based at Oxford Health NHS Foundation Trust and by the NIHR Applied Research Collaboration (ARC) West Midlands.

  • Disclaimer The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplemental information. The individual patient's data used for this service evaluation are held by the NHS Trust and are not available for sharing.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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