PROSPECTIVE-STUDY OF TRENDS IN REFERRAL PATTERNS IN FUNDHOLDING AND NON-FUNDHOLDING PRACTICES IN THE OXFORD REGION, 1990-4

Objective-To compare outpatient referral patterns in fundholding and n on-fundholding practices before and after the NHS reforms in April 199 1. Design-Prospective collection of data on general practitioners' ref errals to specialist outpatient clinics between June 1990 and January 1994 and detailed comparisons of three phases-October 1990 to March 19 91 (phase 1), October 1991 to March 1992 (phase 2), and October 1993 t o January 1994 (phase 3). Setting-10 first wave fundholding practices and six non-fundholding practices in the Oxford region. Subjects-Patie nts referred to consultant outpatient clinics. Results-NHS referral ra tes increased in fundholding practices in phase 2 and phase 3 of the s tudy by 8.1/1000 patients a year (95% confidence interval 5.7 to 10.5) , an increase of 7.5% from phase 1 (107.3/1000) to phase 3 (115.4/1000 ). Non-fundholders' rates increased significantly, by 25.3/1000 patien ts (22.5-28.1), an increase of 26.6% from phase 1 (95.0/1000) to phase 3 (120.3/1000). The fundholders' referral rates to private clinics de creased by 8.8%, whereas those from non-fundholding practices increase d by 12.2%. The proportion of referrals going outside district boundar ies did not change significantly. Three of the four practices entering the third and fourth wave of fundholding increased their referral rat es significantly in the year before becoming fundholders.Conclusions-N o evidence existed that budgetary pressures caused first wave fundhold ers to reduce referral rates, although the method of budget allocation may have encouraged general practitioners to inflate their referral r ates in the preparatory year. Despite investment in new practice based facilities, no evidence yet exists that fundholding encourages a shif t away from specialist care.