but also a constraining straitjacket for subsequent empirical studies. Since the NHS reforms of 1991 the "problem" of outpatient services is being redefined.
Consultants' workload in outpatient clinics David Armstrong, Mick Nicoll
The impact on hospital resources of variability in referral rates among general practitioners was of concern throughout the 1980s. The overall number of patients referred to outpatient clinics, however, has increased only slowly since the NHS began; in contrast, the number of new outpatients seen by each hospital consultant has declined appreciably. Ironically, despite this decline, further increasing the number of consultants is now being presented as a solution to the demand for outreach clinics in general practice.
During the 1980s the considerable variability between general practitioners in referral rates of patients to hospital outpatient clinics was identified as a health services problem. A large amount of research literature began to accumulate, with debates about the true extent of the variability and its possible causes.' In part, the concern seemed to be about the underreferral or overreferral of individual patients, but the underlying agenda concerned the cost implications of general practitioners with high referral rates.2 A central assumption of research into general practitioner referrals was that the costs of the outpatient service were a direct consequence of general practitioners' clinical decisions to refer. There was some recognition that patients were "recycled" by hospital doctors through their clinics-often unnecessarily3but it was still the general practitioner who referred the patient to the expensive, hospital sector in the first place. However, instead of starting from the assumption that it is referral decisions by general practitioners that underpin pressure on the costs and resources of outpatient services, it is possible to approach the problem from the hospital end of the referral process in terms of changes in the overall load imposed on the outpatient clinic. The question then becomes: What has been the impact of general practitioner referrals on the numbers of patients attending outpatient clinics, and have those numbers changed significantly in recent years? This question can be answered with reference to routine data on health service activity and staffing collected and published by the Department of Health throughout the NHS.4 Data are for England only since 1971; for earlier years data for Wales were also included in the totals.
Department of General Practice, United Medical and Dental Schools of Guy's and St Thomas's Hospitals David Armstrong, reader in sociology as applied to medicine Mick Nicoll, research assistant
Correspondence to: Dr Armstrong. BMJ 1995;310:581-2
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Doctors and referrals Figure 1 shows the relation between new referrals to outpatient clinics and the number of general practitioners and consultants during the history of the NHS. The number of general practitioners has increased only slowly, from 22091 when the health service began to 27888 in 1991. In comparison, new outpatient referrals increased by 53% over the same period, from 5 9 million in 1949 to 9 0 million in 1991. This means that the referral rate per general practitioner per year increased by 22% over the four decades. A changing population demography (in terms of numbers and age profile), as well as advances in medical treatments that made referral a more appropriate management option, might account for most of this rise. During the same period, however, the number of 4MARCH1995
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whole time equivalent consultants increased by 316%, from 3 488 in 1949 to 14 502 in 1991. The number of new outpatients seen per consultant per yeaht has declined in almost every year since the health service began and is therefore much smaller now than in 1949. In 1949 the average consultant saw 1680 new patients a year; in 1991, 618 (fig 2). Despite a large reduction in psychiatric inpatient beds and a shift towards community care during the period the patterns for both psychiatric and non-psychiatric services are similar (fig 3). One reason for this decline in the number of new 581
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of an outpatient service overwhelmed by patients inappropriately referred. General practitioners have often complained that consultants retain their patients in the outpatient system unnecessarily; indeed, evidence exists that this is so. But general practitioners have also maintained that this recycling of patients has become worse in recent years, so blocking access for new outpatient referrals. The ratio of new to old outpatients, however, has remained fairly stable throughout the NHS, falling from 1:3-2 in 1949 to 1:3 in 1959, rising to a peak of 1:3-4 in 1982, and falling again to 1:341 in 1991. This stability also means that the number of old outpatients seen by clinic doctors has also declined since the NHS began.
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patients seen by a consultant might be a changing ratio of senior to junior doctors-in which junior doctors take on more outpatient activity to release the consultant for inpatient work. The number of junior doctors, however, increased by 253% over the same period, a lower rate of increase than consultants (fig 1). In effect, regardless of whether the number of new outpatients are considered by consultant, junior doctor, or any clinic doctor, work with new outpatients has declined throughout the period under review. Perhaps some of the more recent new patients present more difficult management problems than in the past; consultants may be spending more time with each patient and more time on the wards managing inpatients or doing administrative work. Even so, the progressive reduction in consultants' clinical workload in outpatient clinics needs to be seen in the context of images
WAY
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Locating health service problems The stereotypic picture of outpatient clinics underlying research into the primary-secondary interface over the past decade has shown a service increasingly overwhelmed by general practitioner referrals and of hard pressed consultants struggling to cope with the demand. Yet while general practitioners have been responsible for some increase in referrals to hospital, any "inefficiencies" in the service need to be more firmly identified in the hospital sector. Individual general practitioner referral rates do vary, but even this problem is probably much smaller than early estimates of up to a 23-fold difference between general practitioners serving areas with similar populations.5 Why should the research community get so fixated on an apparent problem of inefficiency in general practice when the effect on use of resources was small compared with declining productivity in the hospital sector? The research strategies of funding bodies, in particular the Department of Health, must bear some responsibility-though such strategies still beg the question of why research focuses on general practitioner referrals. Perhaps it was the contemporary concern with clinical variability that made general practitioners more suitable subjects for study than hospital doctors, particularly as they were seen as initiating the referral. Also, the traditionally higher status of consultants may have been a factor in keeping the spotlight from their declining workload in outpatient clinics. But the lesson seems to be that the initial definition of a research problem provides not only a supportive framework but also a constraining straitjacket for subsequent empirical studies. Since the NHS reforms of 1991 the "problem" of outpatient services is being redefined. In particular, the fact that fundholding general practitioners are allowed to ask for consultants to run outreach clinics in their surgeries has raised fears that there might be a severe shortage of consultants to staff such clinics if these became more widespread. Given the underlying historical trend for consultants to see fewer and fewer new outpatients, it seems ironic that the outpatients problem is beginning to be redefined in terms of a need for yet more consultants. 1 Wilkin D, Doman C. General practitioner referrals to hospital: a review of research and its implications for policy and practice. Manchester: Centre for Primary Care Research, 1990. 2 Acheson D. Variations in hospital referrals. In: Smith GT, ed. Health, education and generalpractice. London: Office ofHealth Economics, 1985. 3 Armstrong D, Brown K, Tatford P, Armstrong P. Inappropriate reattendances in out-patient departrnents. Pueb& Heath Med 1992;14:173-6. 4 Department of Health. Health and personal sociol sernnces statistics. London: HMSO, 1973 to 1994. 5 Moore AT, Roland MO. How much variation in referral rates among general practitioners is due to chance. BMJt 1989;298:500-2.
T'he average consultant seesfewer new outpatients nowadays than 4Oyears ago
582
(Accepted 9 December 1994)
BMJ voLuME 310
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