Reactions of GPs to a triage-controlled referral system for cancer genetics

Background. The demand for genetic services is increasing as public awareness about 'predictive' tests increases and commercial marketing initiatives develop. In the UK, genetic services vary widely between regions. To manage demand, an all-Wales cancer genetics service based on telephone triage and referral guidelines was designed and implemented. Objectives. The aim of this study was to examine the reactions of GPs to a cancer genetics service controlled by referral guidelines and a triage system, and the perceived impact genetics will have on general practice. Methods. We conducted a structured qualitative study in primary care using sequential focus group discussions with 14 GPs, representing 12 practices divided into two groups (service providers and educationalists). The doctors were introduced to the 'new' genetics, briefed about the service and the referral guidelines and given an outline of the topics to be discussed. All discussions were recorded, transcribed and analysed. Results. The GPs in this study had not considered how they and their teams would handle the practical implications of the 'new' genetics. They had no major objections to a triage system as a means of regulating access to a scarce specialist service, but were concerned about two issues. First, that an insistence on the completion of a postal questionnaire as a means of obtaining an initial assessment could disadvantage some individuals and, secondly, that it was not clear to either the GP or the patient that the risk assessment would be undertaken by a telephone interview. Although there was some concern about yet another set of referral guidelines, participants accepted that the potential demand for cancer genetics services had to be regulated. Conclusion. The acceptance by GPs of this triage system represented a reluctant acknowledgement that primary care, in its present organizational form, cannot provide high quality genetic counselling. However, the realization that this represented a relinquishment of the normal generalist role led to the emergence of ambivalence and a wish to consider how best to accommodate this new need in primary care.