Table 6 Processes and context underpinning a referral – sub-themes (Theme 5)

Referral procedures

I think it fluctuated because originally we had booklets, and the referral form was paper. We’d leave paper pads in the practices and then say the practice nurse would keep the pad with her. So whenever she was running clinics like the pre-diabetic clinic or asthma clinic, or whatever, she’d then quickly fill the paperwork in and they’d be posted through to us or we’d go and pick them up. So sometimes then they couldn’t find a pad, the pad would get mislaid, you know, they’re all very busy themselves with their jobs. That then was replaced, we’ve now got this electronic referral system so they can email referral forms through to us. Again that has had some problems because if the practices haven’t got access to a computer there and then if they’ve got any clinics, they don’t necessarily get the referral forms through to us. (7)

You’d hope that with what we’ve got technologically now you could potentially, bring up the form that self populates in your computer system and email it off to a central address. That would be … the time it takes… to do stuff. It’s incredibly important because there’s so much time pressure all the time dealing with people that it is something that you can do relatively quickly. You don’t want to be spending time entering patient details. You’re already in the patient’s file. You don’t want to be putting details of what medications they’re on. They’re already on the system. You basically want to be saying, “This is the reason I’m sending the person to you. This is what I want help with.” … The rest of it you want to be done. And then you don’t want to be printing it off and taking to … or sending it, you know? You want it to be send-able from the screen you’re on and sent away and you know it’s got there. That’s what you want and if it works that way more referrals will happen for sure. (6)

Feedback mechanisms

Once they get up to speed and once we’ve had feedback from the people that have actually participated and hopefully most of it’s been pretty positive, they’ve bought in, they understand and they feel it’s a safe environment as well to send their patients to. (21)

I don’t know, but if they collect this information about how many clients they got on, and the feedback from the instructors, I know is just registered on the computer and whether it’s used or not I don’t know. But if they did disseminate that to the doctors and showed, cos I’m sure it shows in very positive light, how the scheme works, if that was disseminated to the doctors on a regular basis of the clients from the various practices who’ve gone there, I don’t know if any feedback exists. … the only feedback my doctor, my GP had, was feedback that I give him, and I give, I always give him what I felt was really high positive feedback. And he was quite complimentary on that, as well. (19)

Perhaps one of the biggest issues with it is I feel like I don’t know really know in detail what happens to people when they are there and, for whatever reason, because I’ve not had many people coming back telling me about it, that seems a bit … and not quite knowing what you’re putting people forward for is a barrier I think. … Feedback about how people do would help encourage you to do it. So then you can confidently say to the person, “This is what’s going to happen and I know this works because I’ve had several people it’s worked well for,” that sort of stuff. (6)

Workload

We’ve got a very good GP who sits on our steering group and he was very honest and he said, you know, you aren’t our priority when a patient comes through. Our priority is to diagnose and prescribe and then sometimes yours is seen as a nice to have service at the end. (7)

And if there’s less time in the appointment and you just haven’t got that time to talk at length about, wellbeing, you might just have spent an awful long time talking about say diabetes, might have spent a long time talking about the medication, getting the medication changed, talking to the GP. By the time you’ve done all that 15 min has gone and you haven’t got time then to talk about it, you know? (5)

Expanding pathways

As the referral scheme has moved on and we’ve introduced level four conditions, for example, falls, stroke, weight management, cancer, mental health, pulmonary, cardiac, what’s happened is referrers have referred to the correct pathway. So for example we may have had somebody referred on generic who, when you get them in for a consultation, needs level four intervention and not generic. So what has happened, the increase as we’ve added a new level four it’s opened the doors for health professionals to refer to the correct pathway so, yes, level threes have increased and level fours have increased. (3)