The effect of deprivation on variations in general practitioners' referral rates: A cross sectional study of computerised data on new medical and surgical outpatient referrals in Nottinghamshire

Objective: To determine the effect of deprivation on variations in general practitioners' referral rates using the Jarman underprivileged area (UPA(8)) score as a proxy measure. Design: Cross sectional survey of new medical and surgical referrals from general practices to hospitals (determined from hospital activity data). Setting: All of the 183 general practices in Nottinghamshire and all of the 19 hospitals in Trent region. Main outcome measures: The relation between the referral rates per 1000 registered patients and the practice populations's UPA(8) score (calculated on the basis of the electoral ward), with adjustment for the number of partners, percentage of patients aged over 65 years, and fundholding status of each practice. Results: There was a significant independent association between deprivation, as measured by the UPA(8) score, and high total referral rates and high medical referral rates (P < 0.0001). The UPA(8) score along explained 23% of the total variation in total referral rates and 32% of the variation in medical referral rates. On multivariate analysis, where partnership size, fundholding status, and percentage of men and women aged over 65 years were included, the UPA(8) score explained 29% and 35% of the variation in total and medical referral rates respectively. Conclusion: Of the variables studied, the UPA(8) score was the strongest predictor of variations in referral rates. This association is most likely to be through a link with morbidity, although it could reflect differences in patients' perceptions, doctors' behaviour, or the use and provision of services.