A qualitative study exploring variations in GPs' out-of-hours referrals to hospital.

Background: There is evidence of significant variations in hospital referral rates for GPs working in out-of-hours care.

Aims: To explain why there are marked variations in hospital referral rates for GPs working in out-of-hours care.

Design Of Study: In depth, face-to-face interviews with a purposive sample of GPs with different out-of-hours referral rates.

Setting: Bristol, UK.

Method: GPs were selected according to their rate of out-of-hours hospital referral. They were classified as high, medium, or low referrers. Five interviews were carried out with GPs from each of the three categories.

Results: High referring GPs are typically cautious and believe it is better to admit if in doubt. They express anxiety about the consequences of a decision not to admit, both for the patient and for themselves. They hold negative attitudes towards alternatives to hospital admission. Low referrers were more confident about their decisions and less often worried afterwards. Low referrers were positive about alternatives to hospital admission and described themselves as able to resist pressures from family or carers to have someone admitted. Low referrers also see hospitals as places to be avoided and viewed their goal as preventing an admission.

Conclusion: Educational programmes need to be developed to improve GPs' judgements of their competences and to build appropriate levels of confidence.