Table 1.

Summary of results framework: factors influencing GP referrals to cardiology in deprived and affluent areas

Identifying problemsMaking decisions about referralsNavigation of the healthcare systemExternal pressures
All areasHistory and examinationNeed for reassurance: patient, family, or GP.GPs keen to improve the quality of referrals through educational relationships and communication between primary and secondary care
Investigation resultsResources: time, investigations, and experience.
Medication issuesGP personality and situation: stress and fatigue.
Colleague referral behaviour and knowledge
GPs working in most deprived areasHigh rates of multimorbidity, mental health, and social problems for patients with lower health literacy make the identification of problems complex for GPs, especially for patients whose first language is not EnglishDecision making is more challenging when working in areas of higher deprivation due to complex patient presentation.GPs need to act as ‘navigators’ as well as ‘gatekeepers’ of care because of patients being challenged in navigating complex referrals systems.Reducing referrals can be especially challenging and frustrating when working in deprived areas as GPs are striving for the best health for their patients.
Patients from more deprived areas can be fearful, reluctant, and deferential, leading to referral decision making in most deprived areas to be ‘doctor led’.GPs aware of their patients needing emergency admissionsFearful of the advent of financial reasons not to make referrals but happy to embrace strategies to improve the quality of referrals
GPs working in least deprived areasPatients are more likely to have higher health literacy, making identification of the presenting complaint more obvious for GPsPatients from least deprived areas are more articulate with higher expectations of GPs leading to referral decision making in least deprived areas to be ‘patient led’Patients have candidacy and are able to negotiate the elective outpatient system independently and also make use of the private healthcare sectorReducing referrals can be challenging in part due to medico-legal fears of the implications of referral decisions