CMHTs (Community Mental Health Teams) provide specialist care to people experiencing mental health crises, as well as ongoing primary care support for people with chronic mental health conditions with the aim to prevent admittance to secondary or tertiary health care. Different professionals make up a CMHT but usually includes specialisms such as psychiatrists, psychologists, community psychiatric nurses, social workers, and occupational therapists.
This article examines the referral stage of the OT process: the attitudes of CMHTs receiving referrals, and the GPs who refer patients to them. The qualitative information was gathered via semi-structured interviews, referral meeting transcripts and questionnaires.
Problems with the referral process in CMHTs
Overall, Chew-Graham et al found a lack of consistency between CMHT teams, and referral criteria boundaries varied depending on the individual attitudes of CMHT team leaders. Referring GP’s knowledge of mental health issues and caution around risk also varied between individuals.
GPs felt CMHTs were trying to find ways to refuse referrals, and that referral criteria weren’t clearly defined making it hard to appeal any refusals. Some GPs also sometimes just wanted to access the expert knowledge of the psychiatrist but had to make a referral to the whole team in order to do this, as they cannot access the knowledge any other way.
CMHTs felt under pressure and were preoccupied by their own lack of capacity (more so than the needs of the patient), and felt that GPs manipulated the severity of referrals in order to force them to be accepted (eg by exaggerating the level of risk posed by a patient). The CMHT’s views on the competency of the referring GP held more weight than the identified needs of the patient when making decisions.
Both CMHTs and GPs reported that the psychiatrists within the CMHTs were prone to behaving as self-appointed leaders of the CMHT, with final say in accepting patients and without regard for the need to inform others of their decisions. It was also reported that they were often seen as disengaged from the teams and GPs.
Referral process: clear in theory, not in practice
Generally health professionals felt there was a clear process for deciding referrals, but analysis of tape-recorded referral meetings actually showed an unstructured approach in practice. Discussion didn’t follow ordered steps but switched mainly between five areas: clarifying information, discussing the referring GP, discussing patient risk, repeating previous information and irrelevant comments.
There was a lack of agreement over referral criteria and a vague definition of the term “severe mental illness” which the authors thought was a way for CMHTs to manage referrals and so their workloads with the limited resources available. This strategy is not compatible with the trend towards improved consistency and transparency in CMHT governance however. Problems were also identified around role confusion, role conflict and role strain (not enough capacity) within the CMHT.
In the future, Chew-Graham et al proposed that the introduction of Crisis Resolution teams (Johnson 2004), and improved access to psychological therapies (Layard et al 2006) may improve the tensions highlighted above.
Chew-Graham C, Slade M, Montana C, Stewart M & Gask L (2007) ‘A qualitative study of referral to community mental health teams in the UK: exploring the rhetoric and the reality’ BMC Health Services Research pp 1-9. Accessed at: http://www.biomedcentral.com/content/pdf/1472-6963-7-117.pdf on 18.04.16
Johnson S (2004) Crisis resolution and intensive home treatment teams. Community Psychiatry 3:9 pp 22-25
Layard R, Clark D, Knapp M, Mayraz G (2006) Implementing NICE guidelines for depression and anxiety. A cost-benefit analysis. Paper for the Mental Health Policy Group