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.
Health Service and Population Research Department (HSPRD), Institute of Psychiatry, King's College London, Denmark Hill, London SE5 8AF, UK. mike.slade@lop.kcl.ac.uk
Mike
M
Slade
Linda
L
Gask
Morven
M
Leese
Paul
P
McCrone
Carolyn
C
Montana
Robin
R
Powell
Mairi
M
Stewart
Carolyn
C
Chew-Graham
D000328:Adult; D003155:Community Mental Health Centers; D004739:England; D005194:Family Practice; D006801:Humans; D007407:Interviews as Topic; D001523:Mental Disorders / Q000175:diagnosis* / Q000628:therapy; D010817:Physician-Patient Relations; D011320:Primary Health Care; D012017:Referral and Consultation / Q000592:standards*; D012720:Severity of Illness Index