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Seeing the wood and the trees: the impact of the healthcare system on variation in primary care referrals
  1. Thomas Round1,
  2. Gary Abel2
  1. 1 School of Population Health and Environmental Sciences, King's College London, London, UK
  2. 2 Medical School (Primary Care), University of Exeter, Exeter, UK
  1. Correspondence to Dr Thomas Round, School of Population Health and Environmental Sciences, King's College London, London SE1 1UL, UK; thomas.round{at}

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It is generally accepted that quality improvement efforts in health service delivery are best guided by measurement of performance and activity. Because of this, there are thousands of metrics and indicators produced worldwide attempting to capture the processes performed by, and outcomes achieved by, healthcare providers. However, for any of these indicators to be most useful, the variability in the indicator should reflect the performance or activity of the organisation being profiled. For example, it has been shown that much of the variation in doctor communication skills and in non-steroidal anti-inflammatory drug (NSAID) prescribing can be attributed to individual physicians rather than the organisations they work for.1 2 Those are examples of variation being attributed to a lower level than that at which it is often measured—that is, performance measures for inappropriate NSAID prescriptions often focus on practices, even though variation may occur predominantly at the individual prescriber level.3

Yet variations in performance may also reflect features a level up from the typical performance measures. This is the issue addressed in this issue of BMJ Quality & Safety by Burton and colleagues4 in their analysis of UK data on fast-track referrals for suspected cancer from general practices. In this example, they present an analysis of how much variation in general practitioner (GP) referrals for suspected cancer is attributable to local health services rather than practices or their populations.

Referral pathways for suspected cancer have been available to GPs in England since 2000. These pathways enable rapid access to a specialist opinion or diagnostic test within 2 weeks (ie, 2-week wait (2WW) referrals) for patients with specified symptoms based on referral criteria defined by the National Institute for Health and Care Excellence guidelines.5 …

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