Table 2

Results of questionnaire pilot

Response	Number of countries in which piloting PCPs agreed with statement	Number of countries in which piloting PCPs were unsure	Number of countries in which piloting PCPs disagreed with statement
Even if there are no ‘red-flag’ symptoms, we usually refer if we have a feeling that something is wrong.*	11	4	0
Here, high-quality care for an individual patient is always more important than costs.	5	6	5
If we have ‘over-referred’, our own income may be reduced.*	1	3	12
If we organise any investigations, we pay for that themselves.*	1	2	13
In some practices, patients often have to travel a long way to see a specialist.	9	5	2
Long waiting lists for specialists or tests mean that we sometimes delay a referral/special investigation until it is really necessary.*	1	10	5
Many primary care doctors have special investigations (eg, diagnostic ultrasound) in their practices.*	1	5	10
Missing a diagnosis of cancer is something that we particularly worry about.*	15	0	0
Patients can self-refer to specialists, so we do not need to act as a gatekeeper.	5	1	10
Patients sometimes criticise us if they think we delayed a cancer diagnosis because of a late referral.*	13	3	0
Paying for a specialist can be a problem for some of our patients.	5	4	7
Referral costs are usually paid by insurance companies, not primary care or hospital budgets.	6	3	7
Referring or not referring does not affect our income at all.	10	3	3
Some of our referral systems (eg, online referral systems) make the referral process more difficult.*	1	4	11
Specialists often try to reduce referrals to them.*	1	5	10
Specialists often welcome referrals.	6	7	3
Specialists sometimes criticise us if they think that a cancer diagnosis was slow because of a late referral.*	12	3	1
Specialists sometimes criticise us if they think that we should have been able to look after the patient ourselves.	7	5	4
There is a special, quick specialist appointment system for patients with suspected cancer.	8	3	5
Usually, patients prefer a general practitioner (rather than a specialist) to look after them.	6	6	4
We are asked not to refer patients with a low risk of cancer.*	1	4	11
We are asked to refer any patients with possible cancer early, even if there is a low risk of cancer.	6	7	3
We are likely to refer if the patient is very worried that he/she has cancer, even if there are no ‘red flag’ symptoms.*	12	2	1
We are likely to refer if the patient says that she/he would like to be referred, even if there are no red flags.	8	3	4
We are often worried about the risk of unnecessary (and possibly harmful) investigations.*	12	2	1
We are under media (newspaper, television) or public pressure to refer earlier.	5	4	6
We are under media (newspaper, television) or public pressure to refer less.*	1	3	11
We are usually very busy, so we sometimes refer to help reduce our workload.	6	5	5
We can easily email a specialist for advice.	5	3	8
We can easily telephone a specialist for advice.	5	5	6
We can refer directly to a named specialist.	8	4	4
We have a budget for patient care costs, but we share it with secondary care.*	0	2	14
We have a budget or quota (maximum limit) for referrals.*	1	3	12
We have a budget or quota (maximum limit) for special tests.	4	2	9
We have guidelines that help us decide which patients to refer.	7	2	7
We often refer to a specialist that we know personally.	8	6	2
We usually have enough time in the consultation to think carefully about whether the patient needs a referral.	6	6	4
We worry about the possibility of legal action or a formal complaint if we refer late.*	8	7	1
Writing a good referral letter takes time, and as we are usually very busy we sometimes delay making a referral.*	1	2	13

*These statements were removed from the final questionnaire because either (a) one or no piloting countries agreed with the statement, or (b) one or no piloting countries disagreed with the statement.