Patient pressure for referral for headache: a qualitative study of GPs' referral behaviour

Headache accounts for up to a third of new specialist neurology appointments, although brain lesions are extremely rare and there is little difference in clinical severity of referred patients and those managed in primary care. This study examines influences on GPs' referral for headache in the absence of clinical indicators.

Qualitative interview study.

Eighteen urban and suburban general practices in the South Thames area, London.

Purposive sample comprising GPs with varying numbers of referrals for headache over a 12-month period. Semi-structured interviews with 20 GPs were audio taped. Transcripts were analysed thematically using a framework approach.

All GPs reported observing patient anxiety and experiencing pressure for referral. Readiness to refer in response to pressure was influenced by characteristics of the consultation, including frequent attendance, communication problems and time constraints. GPs' accounts showed variations in individual's willingness or 'resistance' to refer, reflecting differences in clinical confidence in identifying risks of brain tumour, personal tolerance of uncertainty, views of patients' 'right' to referral and perceptions of the therapeutic value of referral. A further source of variation was the local availability of services, including GPs with a specialist interest and charitably-funded clinics.

Referral for headache is often the outcome of patient pressure interacting with GP characteristics, organisational factors and service availability. Reducing specialist neurological referrals requires further training and support for some GPs in the diagnosis and management of headache. To reduce clinical uncertainty, good clinical prediction rules for headache and alternative referral pathways are required.