Factors influencing professional decision making on unplanned hospital admission: a qualitative study.

BACKGROUND Unplanned admissions to hospital are a challenge for healthcare systems internationally. In the UK variation in unplanned admission rates across geographical areas, general practices and GPs remains largely unexplained. AIM To identify factors influencing professional decision making around unplanned hospital admission. DESIGN AND SETTING Qualitative study with a purposive sample of health and social care professionals from three primary care trusts, two acute hospitals, social services and an ambulance service in the South West of England. METHOD Semi-structured interviews were conducted with 19 professionals. Interviews were audio-recorded and transcribed. Data were analysed thematically drawing on the constant comparative method. RESULTS The main factors influencing professional decision making around unplanned admissions were: lack of availability of seamless care on a 24/7 basis; 'professional tribalism' and poor information flow; service targets and performance management; commissioning culture and the impact of a 'market approach'; and clinical governance structures, tolerance of risk and the role of peer support. A tension was perceived between the need to reduce unplanned admissions by tolerating more risk in primary care and a risk averse culture in secondary and emergency care. CONCLUSION Professional decision making that leads to unplanned admission to hospital is influenced by a range of organisational and individual health or social care professional factors. Finding ways to modify and ameliorate the effects of these systems and individual influences should be considered an important goal in the design of new interventions.