Failure to improve appropriateness of referrals to adult community mental health services--lessons from a multi-site cluster randomized controlled trial.

BACKGROUND: Non-clinical factors impact on decisions about whether to refer a patient from primary care to specialist mental health services. The aim of this study was to investigate whether introducing a standardized assessment of severity improves agreement on referrals. METHODS: Multi-site mixed-method cluster randomized controlled trial, investigating GP referrals from 73 practices (408 839 patients) to 11 community mental health teams (CMHTs). Intervention group GPs were asked to complete a Threshold Assessment Grid (TAG) rating of mental health problem severity. CMHTs rated referral appropriateness. RESULTS: Two hundred and eighty-one GPs made 1061 mental health referrals. The intervention was only partly implemented with 25% of intervention group GPs completing TAGs. No difference was found in appropriateness (OR 1.18, 95% CI 0.91-1.53) or secondary outcomes. Post-referral primary care contact rates were higher for the intervention group (IRR 1.36, 95% CI 1.07-1.73). Qualitative data identified professional and organizational barriers to implementation. CONCLUSIONS: Asking GPs to complete a TAG when referring to CMHTs did not improve primary-secondary care agreement on referrals. Low implementation means that uncertainty remains about whether introducing a severity-focussed measure into the referral process is beneficial. Introducing local protocols to manage demand at this interface may not be successful and more attention needs to be paid to human and organizational factors in managing interfaces between services.

Loss of doctor-to-doctor communication: lessons from the reconfiguration of mental health services in England.

OBJECTIVE: To explore the tensions across the primary-secondary interface when referral from primary care is to a team and to inform service developments in other specialties. METHODS: A nested qualitative study within a randomized controlled trial of primary care and Community Mental Health Teams (CMHTs) in Croydon and Manchester, UK. For the qualitative study, interviews were carried out with general practitioners (GPs), psychiatrists and managers or clinical leads of the CMHTs. RESULTS: GPs described the need for access to specialist knowledge, which they perceived to lie with the psychiatrist, and referral to a team was not perceived to allow this access. A personal threshold was identified by GPs after which they referred the patient to secondary care. CMHTs and psychiatrists recognized that this personal threshold differed between GPs, but their criteria for accepting referrals did not seem to allow for a flexible response to referral requests, leading to the referral being labelled as 'inappropriate'. The lack of direct doctor-to-doctor communication was perceived by respondents to contribute to a fragmentation of patient care. Strategies were described whereby the system was bypassed to achieve doctor-to-doctor communication, which undermined the team. CONCLUSIONS: Development of intermediate or 'Tier 2' services beyond the mental health services, where the GP refers to a team rather than to a specialist (hospital consultant) could benefit from reflecting on experiences with mental health services. There is a danger that new community services for the physically ill will engender the same level of confusion and discontent described by GPs and other health professionals in this study who are concerned with mental health care. Flexibility is needed within care pathways, including the provision of direct doctor-to-doctor communication together with approaches to minimize the marginalization of non-medical professionals.

A qualitative study of referral to community mental health teams in the UK: exploring the rhetoric and the reality.

BACKGROUND: Generic community mental health teams (CMHTs) currently deliver specialist mental health care in England. Policy dictates that CMHTs focus on those patients with greatest need but it has proved difficult to establish consistent referral criteria. The aim of this study was to explore the referral process from the perspectives of both the referrers and the CMHTs. METHODS: Qualitative study nested in a randomised controlled trial. Interviews with general practitioner (GP) referrers, CMHT Consultant Psychiatrists and team leaders. Taping of referral allocation meetings. RESULTS: There was a superficial agreement between the referrers and the referred to on the function of the CMHT, but how this was operationalised in practice resulted in a lack of clarity over the referral process, with tensions apparent between the views of the referrers (GPs) and the CMHT team leaders, and between team members. The process of decision-making within the team was inconsistent with little discussion of, or reflection on, the needs of the referred patient. CONCLUSION: CMHTs describe struggling to deal with GPs who are perceived as having variable expertise in managing patients with mental health problems. CMHT rhetoric about defined referral criteria is interpreted flexibly with CMHT managers and Psychiatrists concentrating on their own capacity, roles and responsibilities with limited consideration of the primary care perspective or the needs of the referred patient. TRIAL REGISTRATION NUMBER: ISRCTN86197914.