Table 4

Table of quotes to illustrate the themes

Domain	Theme	Quote	Source
Coherence
	Communicating, sharing and understanding risk	‘Sometimes I hide it, just in case I cause an alarm, but I will start to cover it during the consultation if there is any risk, yes. It depends because, you know, some patients, if they’re anxious, when they see something like that, they become more anxious’	Male GP eRAT4
		‘If someone was very worried and they scored zero then I might be able to say, ‘Look, this is a scoring system that’s been developed,’ and it might just aid reassurance. Equally, if I was worried…I might just say, ‘Look, this is the scoring system, you’ve got quite a lot of points on this. It doesn’t mean it’s anything serious but it does mean we need to look into it more closely’’	Male GP 40 years old 7PCL20
	Collaboration and involvement with secondary care and existing guidelines	‘My concern is that the tools are not known to the secondary or hospital setup. So, I referred some patients, and I am concerned they may not recognise my QCancer referral…So, when I am thinking, if they see the patients I referred using QCancer, they will ask—who is this? Is this a new doctor, a new GP?’	GP, QCancer15
		‘There are criterion boxes often and very occasionally a patient doesn’t quite fit one of the boxes and you tend to worry…but I think if you can justify whether actually they’ve got 38% chance of colorectal cancer on this (tool) then I don’t think they would argue with that’	Male GP, eRAT 4
	One size fits all approach to training	‘Finally, data certainly highlighted that GPs might decide to refer on the basis of a holistic approach and, as many respondents emphasized, the approach of the individual GP and his/her level of clinical experience also plays a crucial part in the decision making process’	Author analysis, eRAT16 17
		‘Although the tool itself doesn’t look that bad on the training, in terms of the implementation and making it work in every single practice, I feel that the training was not bespoke’	Male GP, eRAT4
Cognitive Participation
	Clinical acumen vs protocol	‘I don’t think you can ever protocolise….make a risk schedule that is better than…experience’	GP, RAT 18 19
		‘Without the checklist I already know what to look for. I know that if it’s changed in size, if it’s irregular, that those are all serious…So I would have already gone through it anyway, with or without the (list) in front of me, so does it really matter? Probably not. It’s in my head like any other medical problem, I mean, I consult all day long’	Female GP 41–50 years old 7PCL20
	The medicolegal implcations	‘Quite a few partners were worried about any medical legal implications with that…what would be the implications? That was probably a point that put people off, really’	GP, eRAT16 17
		‘If that’s the NICE guidance and that’s in the CCG 2-week wait form, if you’ve got a score of 4 and you don’t refer, I think the lawyers would say that you’re not following guidance and they could sue you’	Female GP 41–50 years old, 7PCL20
Collective Action
	Increasing awareness	‘Normally I’d get a few investigations, get the results back and then based on that say do we need to do something, or I refer this on based on that. But I guess if I have a calculator saying it’s higher risk, it might prompt me to make a referral to a specialist a bit earlier’	Female GP 31 years old, QCancer 8
		‘It probably made us more aware than NICE guidance…it’s probably made me more aware of symptoms which I may have not been as aware of in the past’	Male GP, eRAT4
	Prompt fatigue	‘we have all sorts of prompts coming at …it gets a little bit distracting …you’re trying to sort out and you’ve got all these messages flashing up at you’	Male GP, QCancer 4
	Impact of IT integration	‘I suppose the prompt of a photo to be added would be helpful if they need to look through it’	Male GP 40 years old, 7PCL20
		‘There was a problem of accessing the tools as they are not integrated in our IT system. It was not easy downloading or googling the tools during patient consultation’	GP, QCacner15
		‘so much hassle…we had to spend so much time…trying to install it in every single desktop… couldn’t do it. I just gave up’	Male GP, eRAT4
	Time as a resource	‘if it’s actually going to make life easier…is it going to improve care for the patient? Or is it …time really spent in filling up proformas?’	GP, RAT 18 19
		‘I thought it was going to be time consuming using the tool. But…that will only be the case in the short term…it will be time saving in the long term, as the consultation, the assessments, investigations and referral processes will be faster’	GP, QCancer15
Reflexive Monitoring
	Unintended consequences	‘there is a potential for using the tools for screening….They could also be modified for asymptomatic patients’	GP, QCancer15
		‘Your chest X-ray is perfectly normal. Your cough settles…I still have to try and convince you to stop smoking, to exercise, to lose weight…it should be used as a relationship tool’	Female GP 50 years old, QCancer8
	Investigation and referral patterns	‘we were thinking that using the tools in consultation could result in unnecessary…over-referrals…I don’t think there will be over-referrals’	GP, QCancer 15
		‘I think our referral thresholds for lower GI have definitely gone down’	Cancer Lead GP, RAT18 19
	Think Cancer	‘Yes, I must admit ovarian didn’t come so high up…This really said hey, consider ovarian as well”	Male GP 46 QCancer8
		‘If I had a patient with a vague set of symptoms then finding and using the tool showed that it was an amber…I might have followed up the patient in a different way…I’d like to see you again, just to see how these symptoms are, um, rather than leaving it to the patient to contact us”	Cancer Lead GP, RAT18 19

eRAT, electronic Risk Assessment Tool; GP, general practitioner; NICE, National Institute for Health and Care Excellence; 7PCL, 7-point checklist; RAT, Risk Assessment Tools.