Table 5

Health system items and their factor analysis loadings The highest-scoring component for each item is italicised.

Health system itemComponent
Factor 112345
 I am able to refer to a specialist that I know personally. 0.68 0.420.090.03−0.14
 Here, specialists usually welcome referrals. 0.68 0.020.12−0.04−0.11
 I can easily telephone (or email) a specialist for informal discussion and advice. 0.68 −0.120.110.17−0.12
 I am able to refer directly to a named specialist. 0.62 0.220.220.13−0.26
 I usually have enough time in the consultation to think carefully about whether the patient needs a referral. 0.57 −0.02−0.320.070.12
 My colleagues sometimes criticise me if I have referred a patient to them, but they think that I should have been able to manage the patient myself. −0.51 0.250.140.120.31
Factor 2
 Seeing a specialist can be a problem for some of my patients because of the financial cost to them.−0.08 0.59 −0.170.270.24
 We have access to a fast-track specialist appointment system for patients with suspected cancer.0.05 −0.54 0.340.34−0.03
 We have a budget or quota (maximum limit) for diagnostic tests.−0.27 0.54 −0.060.25−0.26
 Referral costs are usually paid by insurance companies, not hospital or primary care budgets.0.30 0.46 −0.05−0.190.23
 Patients can self-refer to specialists, so GPs do not need to act as gatekeepers.0.34 0.44 0.04−0.300.11
 In my practice, patients often have to travel a long way to see a specialist.−0.26 0.38 −0.090.370.36
Factor 3
 I am usually very busy, so I sometimes refer to help reduce my workload.−0.320.19 0.60 −0.09−0.01
 I am likely to refer if the patient says that she/he would like to be referred, even if there are no ‘red flags’.−0.020.29 0.53 −0.340.16
 We are under media (newspaper, television) or public pressure to refer earlier.−0.200.08 0.51 −0.09−0.16
 The local health system encourages us to refer any patients with possible cancer early, even if there is a low risk of cancer.0.260.11 0.36 0.230.20
Factor 4
 Common presentations are covered by local or national guidelines that usually give advice on which patients to refer0.05−0.250.33 0.55 0.15
 In general, patients prefer a GP, rather than a specialist, to look after them.0.250.19−0.02 0.41 0.08
Factor 5
 Here, high-quality care for an individual patient is always more important than costs.0.30−0.260.010.05 0.57
 Referring or not referring does not affect me at all financially.0.31−0.290.08−0.34 0.55