Summary
– Our National Health Service faces unprecedented demand for services and associated financial challenges in the coming years. In this whitepaper we focus on the seemingly unstoppable growth in secondary care referrals to hospitals. How can these referrals be proactively managed to deliver better care and reduce, or at least contain, the pressure on NHS budgets? 
The growth in acute hospital referrals is driven by a rapidly aging population, compounded by increasing referral rates by GPs. We can do little to manage the demographic changes (increased life expectancy is a good thing), but we urgently need to understand what is driving up hospital referrals and how they may be substituted by more effective local care pathways.
In this paper we review the extensive and unwarranted clinical variation uncovered by work on the 2011 NHS Atlas of Variation. These findings are backed up by our own research. Why does the propensity of GPs to make hospital referrals vary so much? At worst, this can harm patients; at best it highlights poor allocation of scarce NHS resources or outright waste.