Family Practice Advance Access originally published online on May 30, 2008
Family Practice 2008 25(3):181-190; doi:10.1093/fampra/cmn025
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Failure to improve appropriateness of referrals to adult community mental health services—lessons from a multi-site cluster randomized controlled trial
a Health Service and Population Research Department (HSPRD), Institute of Psychiatry, King's College London, Denmark Hill, London SE5 8AF, UK
b School of Community-Based Medicine, University of Manchester, Manchester, UK
c Park Royal Centre for Mental Health, London, UK
Correspondence to Mike Slade, Health Service and Population Research Department (Box 029), Institute of Psychiatry, King's College London, Denmark Hill, London SE5 8AF, UK; Email: mike.slade{at}lop.kcl.ac.uk
Received 9 October 2007; Revised 11 April 2008; Accepted 21 April 2008.
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Abstract |
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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 (ISRCTN86197914 [controlled-trials.com] ).
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.
Keywords. Community mental health services, primary care, primary–secondary interface, referral.
Slade M, Gask L, Leese M, McCrone P, Montana C, Powell R, Stewart M, Chew-Graham C. Failure to improve appropriateness of referrals to adult community mental health services—lessons from a multi-site cluster randomized controlled trial. Family Practice 2008; 25: 181–190.