Background. GP referrals to secondary care are an important factor in the c
ost of running the NHS. The known variation in referral rates between docto
rs has the potential to cause tension within primary care which will be exa
cerbated by the latest reorganization of primary care and the trend towards
capitation-based budgets. The importance of postgraduate learning for GPs
has been recognized; continuing professional development is moving towards
self-directed practice-based learning programmes. Educational interventions
have been shown to alter doctors' prescribing behaviour. This, together wi
th the pressure on accounting for referral activity, makes the prospect of
improving, and possibly reducing, referral activity through educational int
erventions very attractive.
Objectives. This study complemented a randomized controlled trial (RCT) whi
ch investigated whether an intervention of the type which had reduced presc
ribing costs would have a similar effect on referral activity.
Methods. The context of the study, description of the characteristics of th
e practice and the issues seen as important by the doctors and practice man
ager were identified through preliminary semi-structured interviews. The pr
actice then held a series of educational in-practice meetings to discuss re
ferrals and issues arising from referrals. The audio- and videotaped transc
ripts were interpreted using content and group dynamic analysis. Participan
ts commented upon our preliminary findings. In addition, we used dimensiona
l analysis to induce a preliminary theory describing the effect of the inte
rvention on this general practice which enabled us to review the findings o
f the parallel RCT. The educational value of the meetings and the learning
needs of the participants were also assessed.
Results. Our complementary study showed no alteration of practice referral
rates following the educational intervention. The qualitative study, unencu
mbered by the assumptions inherent in the development of the hypothesis tes
ted in the RCT, highlighted the complexity of decision making in general pr
actice and the likely impact of historical background and a variety of inte
rnal and external pressures on this self-directive educational intervention
. The practice members described the individual and group learning needs id
entified as a result of the meetings.
Conclusion. The findings of this study raise important questions for develo
ping practice-based learning. The outcomes of self-directive interventions
in practices will be influenced by internal and external events both past a
nd present. Such outcomes may be qualitative and difficult to measure. They
are likely to differ from outcomes seen when interventions are applied to
groups of doctors who are not all members of the same practice.