Chris Lancelot: Spellbound by the magic of referral statistics

There is a belief among certain tribes that to know a person's name is to have power over them. 'How superstitious,' we say, feeling very smug. Yet we can make the same mistake over statistics.

Large numbers of NHS doctors and managers still hold the primitive, unscientific belief that having data on something means that they have power over it, but this could not be further from the truth.

Consider the present obsession with referral statistics. We have known for two decades that there is no relationship between the quality of a doctor and his or her referral rates. Good doctors may refer more because they diagnose more; or refer less because they can deal with more situations themselves. On the other hand, bad doctors may also have a high referral rate because they do not know what to do next; or they may refer little because they spot little.

Crude referral rates by themselves tell us nothing. Despite this, PCTs and practice-based commissioning groups frequently believe such statistics are important, and that they can use them meaningfully and powerfully. Quite fairly they want to improve the quality and cost-effectiveness of GP referrals, but invariably they attempt to do this by investigating those practices whose referral rates are significantly above or below the average.

But if there is no relationship between the quality of a doctor and their referral rates, then why bother? Surely they should be investigating the average practices as well? Maybe their average referral rate comes about because half their doctors haven't a clue and hardly refer anything, while the other half know precisely what they are doing and refer a lot because they spot a lot.

If we want to make the NHS more efficient then we must rid ourselves of our primitive belief in crude referral data. We should stop wasting time both collecting it and holding interminable meetings to discuss it. Instead we should develop tools that really will refine our referral patterns. The only effective method I know is where the consultant rates each referral for appropriateness: and yet this is the one statistic that everyone fights shy of collecting.

Ah, the magic of statistics. How beguiling it can be.

Dr Lancelot is a GP from Lancashire. Email him at

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