General practitioners’ referrals to specialist health services. Exploring elements and factors in the referral process having an impact om patients’ access to specialty care
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Background: The referral process between first and second line health care is complex and multidimensional, with medical, interpersonal, logistical, legal, as well as indeterminate aspects. There is a great need to explore the various elements and factors having an impact on the referral process.
Main objectives: The objective of this thesis has been to study general practitioners´ and hospital consultants´ role in the referral process, from the moment the GP decides to refer a patient to hospital, until the hospital consultant assesses the referral and prioritizes the patient for further investigation or treatment in specialist health care. The specific aims for the three sub-studies were to identify and describe 1) general practitioners’ reflections on and attitudes to the referral process and their cooperation with hospital consultants, 2) hospital consultants’ reflections on and attitudes to the referral process and their cooperation with general practitioners, and 3) potential characteristics of GPs’ referral practice by investigating their opinions about referring and their self-reported experiences of what they do when they refer.
Design and methods: The first two parts were qualitative studies. General practitioners and hospital consultants were interviewed and a systematic text condensation method was used for analysis. The third part was a quantitative cross-sectional study of GPs’ impressions and feelings about referring and a registration of a selection of data on the work done by referring to hospital during one month, analysed by using a principal component analysis and abduction.
Results: The GPs expressed a dual responsibility towards patients and the national health system. Many experienced pressure from patients to be referred; the younger doctors especially specified this as a frequent reason for a referral. All the participants expressed a willingness to change according to guidelines, as long as such guidelines were the result of a consensus between hospital specialists and general practitioners. The hospital consultants experienced a considerable workload assessing referrals and prioritizing patients for further investigation and treatment. They emphasized the importance of precise referrals as essential for a reasonable and fair prioritization process. All focused on the importance of good communication and cooperation with the referring GPs. Good referrals were considered to make the prioritization process easier. As for the typologies, younger male GPs experienced more heavy work-load and patient pressure when they referred to hospital. The experienced female GPs referred in a more patient-centred way, completing the referrals during the consultation with the patient present.
Conclusions and implications: Many factors have an impact on the referral process and the individual referral rates. Good communication and cooperation by phone or electronically between hospital consultants and GPs are important factors to make the referral process more balanced, and the participants more like partners. More use of electronic decision support systems for the referring physicians can make this process more standardized and predictable for both partners. Educating and training GPs in professional competence and personal confidence as well as a more patient-centred way of referring, making priority decisions and completing the referrals during the consultation may be timesaving for the actors and can be associated with less work-load.