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ORIGINAL PAPER
D o g e n e r a l p r a c titio n e r a ttitu d e s a n d
c h a r a c te r is tic s o f th e ir p r a c tic e s
e x p la in p a tte r n s o f s p e c ia lis t r e fe r r a l ?
Martin Roland, Jeremy Grimshaw, Richard Grol, David Shanks, Anthony Johnson, Ian Russell, Ross Taylor
Objectives: To describe attitudes of general practition­
ers to their work, and to relate these to characteristics
of their practices and to rates of specialist referral.
M ethods: Data were collected from 109 Scottish gen­
eral practitioners. Questionnaires were used to meas­
ure doctors perceptions of their responsibilities, their
tolerance of uncertainty, their perception of benefits
resulting from specialist referral, and perception of the
incidence of a range of conditions which might require
specialist referral. Rates of specialist referral were
measured prospectively over a one-year period.
Results: There was wide variation in the responses to
all questionnaires. More developed practices (e.g. com­
puterised, with access to hospital beds) reported a
greater sense of responsibility for the care of their own
patients, and perceived less benefit from specialist
referral. Doctors who perceived serious disease as
relatively uncommon and those who saw themselves as
M artin Roland, director of research and development.
N ational Primary Care Research and D evelopm ent Centre, 5th
Floor , Williamson Building , University o f Manchester, O xford
R o a d , M anchester M 13 6PL, United Kingdom.
Jeremy Grimshaw, programme director.
Health Services Research Unit , University o f Aberdeen, D epartm ent
o f General Practice , Forsterhill Health Centre , Aberdeen AB9 2A4,
United Kingdom.
Richard Grol, professor of general practice.
University o f Nijmegen, PO Box 9101, 6500 HB Nijmegen, the
Netherlands.
David Shanks, reader in experimental psychology.
University College, G ow er Street, London WC1 E 4BT, United
Kingdom.
Anthony Johnson» medical statistician.
M RC Biostatistics Unit> Forvie Site , Cambridge CB2 2SR, United
K in gdom .
Ian Russell, professor of health sciences.
University o f York, D epartm ent o f Health Sciences, Heslington,
York Y O l 5 D D , United Kingdom.
Ross Taylor, senior lecturer in general practice.
University o f Aberdeen, D epartm ent o f General Practice, Forsterhill
Health Centre , Aberdeen A B 9 2A 4, United Kingdom.
*
i
Correspondence to: Professor M Roland.
Submitted: i 1th M arch '1997; accepted in revised form: 8 th October
1997.
European Journal of General Practice, Volume 3, December 1997
responsible for a wide range of conditions referred
fewer patients to specialists. Doctors working in prac­
tices which conducted regular audits and those who
had access to hospital beds also referred fewer patients
to specialists.
Conclusions: Attitudes of general practitioners to their
roles, and the types of practice in which they work, are
related to their use of hospital specialists. If, as in the
UK at present, general practitioners take an increasingly restricted view of their ccore responsibilities’, this
could increase the numbers of patients referred to spe­
cialists. However the results of this study are also con­
sistent with the view that, given appropriate practice
development, general practitioners could carry out a
greater proportion of work which is currently referred
to specialists.
Eu r j Gen Tract 1997;3:143-7.
Introduction
There is wide variation in the rates at which individual gen­
eral practitioners refer patients to specialists. Although
some of this variation is due to chance,1previous research
suggests that some of the variation in individual doctors5
referral behaviour may be related to their work satisfac­
tion,2their willingness to take risks,3their individual clin­
ical skills,4’5their response to pressure from patients,6and
the context in which the referral decision is made.™ In most
studies it has not been possible to explain more than a
modest proportion of the variation in terms of character­
istics of the doctors, their practices, or their patients.'0,11
In many countries, it is policy to move a greater propor­
tion of care from the secondary sector to primary care. The
success of such moves may depend on the willingness of
general practitioners to take on new roles. In the UK, in­
creasing movement of care from secondary to primary sec­
tors has led to conflict between general practitioners and
the government about the tasks which should be carried
out in general practice. The attitudes of general practition­
ers to their roles and responsibilities is an important fac­
tor which will need to be taken into account. Better
understanding of these attitudes will help to improve the
organisation of care at the interface between primary and
secondary care.
143
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Denominator=workload (n=51)
s
Regression
0,007
0,014
0.036
0.023
16,6
7.7
0.084
42.54
-16.5
Number of consultations
Practice has access to hospital beds
of serious disease
mao
eve
error
H tr
r := 0 .3 7
Denominator=iist size (n=104)
Perceived incidence of serious disease
Regular clinical audits
Extent of GPs—responsibilities
4:
mu
eve
Standard error
Regression coefficient
»4.8
54,8
.5
17.7
"3 C
1.2
0.0016
0.
0.
'V*
w ww y n f_w w < m yn»n">.n » i"11111
—
r r iT ir i- ii-------- -----------r - i - i ---------- r - T T r ^ i T f t " .............................. *......... .................................................................................................................................... ................
mean score computerised: 36,6, not
Appendix
te.ri.sed 40
of uncertainty
Questionnaire to measure
(Statements 1-5 from Grol
«un
»»«WMMPWWaUMIWWIWWHH
i-p
C l of
f * f t *-~4 Ì
.1, A%«*V
%_ ƒ
\J *
/ * <*,,,/ ^
♦0*0)
WWW'
nee
in c
IV.
i
o
n in ta
The responses to this questionnaire ai
There were no significant re
to these questionnaires arid any of the available doctor oi
¡ifHWwmnJiip riyiw ffj fcr^iexiiÿtwfiWBea
Respondents recorded agreement/disagreement with the follow
ing statements on a five-point scale:
• When in doubt it is preferable to refer to a specialist than to
wait and see.
A GP must not take any risks with physica ness
As far as physical complaints are concerned, a GP should do
everything possible to find out the cause of the complaint.
er the certain to the uncertain
A GP must
* As a GP, you must always be aware that each complaint can be
the start of a serious i ness
GPs should be more prepared than other doctors to be
uncertain about a diagnosis.
practice, treatment often has to start without a clear
diagnosis
l.vWl
*h«ri
v ,.^
<a
y*
V. Associations wi
Wi
'es or rere tra
»
rom 6 1 to 344 t rrais per
ra
51 genera
year, and for th
•Ï «
c ollected,
T)
where w o r
data
e regression
1.00 con. sul tat ions. In the mu
*
*
i
i ii n m
ant associ.
a
bers of patients referred, two of the questionnaire
two practice
f
c
<
y
m
as a factor in
multiple
WOÎ
s of
e ), n u n i
a lysis (available for less than half
aC't
of con
referrals were significantly related to the n
ility for hospital
sultations., to the practice having respc:
incidence of r
is e a s e
beds, and to the
The proportion, of variance in numbers of pa
(t a b 1e
o
was
tients referred
>r
increased to
ber of consultations
Va r ia s
of the practicedoctor-rel;
consultations in
Rates of referral were 3.5
practices with access to
s 37% of practices in this pre
rural ai:
4.2 referrals/1
in those without
una di usted mean
to
scores on the
serious i
scale
doctors with referral rates in the
om quarti les
were 36.6 and 39.9.
In the
s
is usineC list
serious i
is relatively
i.a c
lower rates of referral to hosnita
w
a
those
.ving in practices which carried
regular c
table 4). The unac
mean s es on the per
ity scale
s with referra
47
the top and bottom quartiles were 50.9
n
Rates of r
•jftn j
/
4'#
3, *" t" 4
■ f& n
\s &
rfn.'
í
items were scored 1 (strongly
5 (strongly disagree), except items 6 and 7
which were scored in the reverse direction.
(Ht
■fi
/A
/•dM
Referral data were available for 104 (88%) doctors
. Extent
J 1* '
of g e n e ra
c ti tí o rie rs ’ resp o ns
*
ì
Fhe responses to this questionnaire are shown in table
Doctors believed that they should have a wider range of
responsibilities if they came from practices having resp onsibility for hospital beds (mean score 45.9 (beds), 50.8 (no
zxit*
e n c e = l.4-8.4, p=0.001 o r
beds)
11 OI
worked in computerised practices (mean score 4 .0 c o m
5 6.2 (n o t c o m p u terised), CI o f d iffe r en c e= 1.9 0.004)
13.9
Using scores on the tolerance of uncertainty scale in the ap
, trainers were more tolerant of uncertainty (mean
score trainers: 24.1, non. trainers: 21.1, Cl of difference
2.3-3.7, p=0.017), as were doctors who saw smaller num.
bers of patients each week (p=0.002).
iet its
ms
*
Òt referral
/t¡¡
K.i
The responses to this questionnaire are shown in table 2,
Doctors in computerised practices perceived less benefit
146
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European Journal of General Practice, Volume 3 , December 1997
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