Interpretations of referral appropriateness by senior health managers in five PCT areas in England: a qualitative investigation
- 1Research in Practice for Adults, Devon, UK
- 2Health Sciences Research Institute, Warwick Medical School, University of Warwick, Coventry, UK
- 3Health Services Research Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Correspondence to Dr Aileen Clarke, Health Sciences Research Institute, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK;
Contributors NL was involved in study design and paper writing. She carried out data collection and led analysis. AC was the grant holder, undertook the study design, was involved in data analysis, wrote the final draft of the paper, is the corresponding author and will act as guarantor for the work. NM was involved in the study design, data analysis and paper revisions.
- Accepted 15 November 2008
Aim To explore interpretations of “appropriate” and “inappropriate” elective referral from primary to secondary surgical care among senior clinical and non-clinical managers in five purposively sampled primary care trusts (PCTs) and their main associated acute hospitals in the English National Health Service (NHS).
Methods Semi-structured face-to-face interviews were undertaken with senior managerial staff from clinical and non-clinical backgrounds. Interviews were tape-recorded, transcribed and analysed according to the Framework approach developed at the National Centre for Social Research using N6 (NUD*IST6) qualitative data analysis software.
Results Twenty-two people of 23 approached were interviewed (between three and five respondents per PCT and associated acute hospital). Three attributes relating to appropriateness of referral were identified: necessity: whether a patient with given characteristics was believed suitable for referral; destination or level: where or to whom a patient should be referred; and quality (or process): how a referral was carried out, including (eg, investigations undertaken before referral, information contained in the referral and extent of patient involvement in the referral decision. Attributes were hierarchical. “Necessity” was viewed as the most fundamental attribute, followed by “destination” and, finally, “quality”. In general, but not always, all three attributes were perceived as necessary for a referral to be defined as appropriate.
Conclusions For senior clinical and non-clinical managers at the local level in the English NHS,, three hierarchical attributes (necessity, appropriateness of destination and quality of referral process) contributed to the overall concept of appropriateness of referral from primary to secondary surgical care.
Funding Funding was obtained from the NIHR R&D SDO Programme. The National Co-ordinating Centre for the NIHR Service Delivery and Organisation Programme (NCCSDO), London School of Hygiene and Tropical Medicine, 99 Gower Street, London WC1E 6AA, UK, tel: 020 7612 7980; fax: 020 7612 7979; email: firstname.lastname@example.org. We are grateful for the comments of our referees.
Competing interests None.
Patient consent Obtained.
Ethical approval was obtained from the Multi Research Ethics Committee (MREC) for Scotland.
Provenance and peer review Not commissioned; externally peer reviewed.
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