This observational study analysed paediatric outpatient referrals to a district service in the UK in 1998 and compared results with studies conducted 10 y previously. Data was collected prospectively from the written correspondence on all new outpatient referrals offered appointments by paediatricians at Northampton General Hospital over a 3-month period. Two hundred and ninety-seven (66%) referrals were to general paediatricians, 108 (24%) to 'patch' community paediatricians and 47 (10%) to community paediatrician consultant clinics. The referral rate to general outpatients was 20/1000 per annum, similar to referral rates in 1988. Urogenital and cardiac problems have overtaken asthma as the most commonly referred conditions. Referrals to consultant community paediatricians were predominantly development and behaviour difficulties and were more complex than those referred to other groups. 'Patch' community paediatricians received 87% of their referrals from practitioners other than doctors and played a significant role in co-ordinating care in the community. They referred less than 3% for consultant assessment. The referral rate to general paediatric outpatients has remained stable over the last decade although the case mix has changed. For the first time, we provide population-based case mix and referral rates to community paediatricians. We highlight the important role of non-consultant career grade paediatricians in supporting clinical services in the community. Open access to some investigations for general practitioners (GPs) could be explored as a way of managing demand for general paediatric outpatient appointments.