The nested qualitative study attempted to explore what factors influenced why referrals were made (from a primary care perspective) and why referrals were accepted or rejected (from the CMHT perspective). The analysis suggested that respondents' own understanding of the purpose and function of the CMHT influenced both referral to and acceptance by the CMHTs. Thus, this paper will explore professionals' views about the functions of the CMHT, explanations of how decisions were made about eligibility for care by the team, and views about the way in which the primary/secondary interface functions. The paper will utilize and present data from the qualitative interviews, and transcripts of the allocation meetings. Data presented in this paper are identified by respondent's profession (GP – General Practitioners, TL – Community Mental Health Team Leaders and Psych – Consultant Psychiatrists) and team or practice identifier.
Function of the CMHT
All respondents, both GPs and respondents from CMHTs, described the function of CMHTs in general terms, and as defined by current policy documents, to provide care for patients with severe and enduring mental health problems:
'...The function of the team is to assess and treat people with severe and enduring mental health needs'. (TL 24/3)
GPs articulated their need for the CMHT to carry out the assessment of a patient in crisis but also to support them in assessing and managing people that they themselves were having difficulty managing:
'...where you feel you've done everything you can and you're not getting anywhere, so it's for advice as much as anything else.' (GP 643)
'...I wanted a consultant's opinion rather than it being an urgent situation where somebody was suicidal, it was just a consultant's opinion where, where a patient was really, extremely challenging to treat...(GP 601)
'...and sometimes you feel, you know, you're treating the patient and you still need the support. Just to, sort of, for the consultant or specialist to say,"'yes, what you're doing is right, just carry on".'(GP399)
Some GPs suggested that it was a Consultant or Specialist opinion for "expert knowledge", rather than team input, that they needed.
CMHT leads agreed that the team should have the dual roles of carrying out an assessment of patients referred to them (often in crisis) and the need to provide some continuing care for some patients:
'well, obviously when there is a crisis, that's an easy referral....' (TL 5/2)
'...I'd always view the CMHT as having a primary and integral role as the first port of call in terms of accessing the secondary services...' (TL 10/1)
'....providing community input to people with long standing mental health needs and attempting to maintain some kind of optimum level of health at home and prevent hospital readmission and sort of improve the quality of life for people with mental health needs' (TL 23/2)
Psychiatrists' views echoed those of their CMHT team leaders:
'...the ones (patients) who need help in terms of assessment of their mental state or the risk, ongoing risk, or some treatments which can be carried out in the community...' (Psych 24/1)
'I think the CMHT has probably got two principle functions, which is probably the thing that is difficult for us combining the two. I think the bulk of the work that they do is with patients with severe and enduring mental illness where they act as care co-coordinators and provide a range of interventions and support and monitoring functions for some quite poorly people, with a whole range of severe mental illnesses. But then this team in addition to that is providing initial assessment, crisis response, triage type service for referrals from a variety of sources...' (Psych 23/1)
CMHT leads identified a tension in trying to fulfil more than one role:
'...not necessarily always sort of psychosis or and enduring mental illness, but a long term problem that that persons been experiencing which hasn't been able to be dealt with in primary care....and it's more difficult there, I mean, that varies, doesn't it?' (TL 23/1)
'...theoretically, we have an operational policy which suggests we work with people with severe mental health problems, but we get all kinds of people referred...'(CMHT 15/2)
Reflection over this lack of clarity and how they managed it within the team often led CMHT leaders to suggest that their own team did not necessarily behave in the same way as neighbouring teams in order to accommodate more referrals and offer flexibility:
'...I think the way that we work, I suppose we have our own characteristic, which is, I think, we're a very flexible team, we probably have a lower threshold for accepting assessments than others...' (TL 12/1)
Interviews with all the CMHT respondents contain reflections and admissions of the conflicts they work within – conflict between the need to be responsive to crises, and to carry out acute assessments, and their role in providing ongoing care for people with long term (severe and enduring) problems, and some respondents were unhappy with the recent policy directives that governed their roles:
"...we've become too specialised...used to see everything... [I] used to enjoy the variety of having brief interventions...now looking after people for 5–7 years...the service has not grown to look after those we used to see like people with depression, anxiety and neuroses..." (CMHT 23/2)
Referral- a confusion of purpose?
All GPs interviewed recognized that the role of the CMHT was to provide care for people with severe mental illness, although there were varying views on what constituted "severe mental health problems" and some GPs described a lack of clarity over criteria for referral and noted that there had been a change over time in the sort of patients accepted by the team:
'...You've got to be very fantastically suicidally depressed to reach their criteria actually.' (GP 657)
'...well its also just that they're a bit awkward, I think, they always managed to see a few people without schizophrenia and bipolar, of the most difficult cases, and now they've stopped doing it. I think they've just decided that they're not going to do it...' (GP 652)
Some GPs felt that more clarity about referral criteria was needed, whilst others wanted less restriction on their ability to refer:
'...I think it should be left quite open and if a GP feels that they need the CMHT, then that's what should happen rather than having strict criteria then you will have patients on the boundary and where do they go?...' (GP 273)
GPs generally viewed CMHTs as trying to avoid taking on referrals and describe a variety of strategies in order to force the desired response from the team:
'if you don't get a tick in the right box you're in real trouble and you have to make an effort and start jumping up and down and swearing at people' (GP 616)
'...but you don't want to say somebody's dangerous when really you don't think they are just to get them seen quicker. I wouldn't do that.' (GP 638)
Some CMHT respondents felt that the role of the GP should be to carry out an adequate risk assessment themselves prior to referring the patient to the team, but others suggested that they understood the reasons why some GPs could not do a reliable risk assessment:
'...well, they don't seem to even try to make an assessment, they just refer...some GPs, anyway...' (TL 18/3)
'...I don't feel that they should have make those decisions, [about who to refer] they have enough decisions to make, you know...I don't think they should have to do that...' (TL 23/1)
'...I think for a lot of GPs it's.... for them, there are issues around how comfortable or competent they feel in dealing with people with mental health issues' (TL 17/8)
'...they might not have, em, .felt confident in doing that (risk assessment), and having to put something to paper which they could be later on taken up on...' (Psych 23/1)
There was evidence that CMHT leads recognized the tactics used by GPs, particularly describing how some GPs exaggerated the risk posed by the patient in order to ensure that the referral was accepted:
'...GP might be inclined to, on the referral, to exaggerate the risk...they shouldn't have to make those risk assessments, you know, it's then another role for GPs who are very busy and have five or ten minutes with client maximum, makes it difficult..." (TL 23/1.7)
Psychiatrists attached importance to their prior knowledge of the GP making the referral and to the history of previous referrals from that GP:
'..there are few GPs, not ones that I work with, that you tend to know are more anxious, so they'll be more panicky about somebody's level of risk. And... there are other GPs who..... are more relaxed, so, you know they may say somebody who is not risky, and you may feel more, you know, more anxious about that, erm, cos you know, you know some people are much happier carrying a degree of risk than other people...you do get a feel for the GPs and their thresholds for requiring, requesting support.' (Psych 22/1)
'Well we sometimes hear ourselves say "well I'm not sure whether that person is suitable or not but that GP doesn't refer very often and they're normally very astute in their assessment so lets give it a go" would be one thing. Does it work in the opposite direction? Probably without us being too conscious of it. There are certainly some GPs who we perhaps think aren't good referrers and that might make us less inclined to just accept their referrals' (Psych 23/1)
Psychiatrists- a confusion of role?
As a member of the CMHT, the psychiatrist can influence whether or not referrals are accepted by the team. Both Psychiatrist and CMHT respondents described how they perceived that the expert knowledge lay with the Consultant:
'...the consultant provides I suppose expertise and advice specifically around medication and diagnosis...' (CMHT 13/1)
'...I suppose my role would be to the clients that other members of the team are worried about, or if it's not their field of expertise, for example, a diagnosis is required or err medication issues need to be addressed' (Psych 25/1)
But Psychiatrists had great difficulty defining their own individual role within the 'team':
'I think my role is to maybe try and integrate the more medical assessments with the psychological and the CMHT assessments and perhaps, I do believe that doctors do probably have a more holistic view of the patient, in that we have a different perspective in terms of the longitudinal history of the patient, rather than having a cross sectional view. And while, so we have got sort of, a multi disciplinary view, but also I think a more longitudinal assessment of the patient.' (Psych 23)
Similarly GPs had some difficulty in defining whether the Psychiatrist was part of the team or separate from it:
'...they don't come out into the community, they don't, they have never made that transition, they live behind the brick walls of the hospital...' (GP 628)
'....part of the team as opposed to being the top of the very narrow pyramid...' (GP 643)
CMHT respondents also expressed very different views on the role of the psychiatrist and how they fitted into their team. Some respondents saw the consultant as a leader:
' ...both consultants take a very, very strong lead in team...' (TL 17/2)
'...they have the sort of final say, I would say, within our team in the meetings about whether it's appropriate or not appropriate...' (TL 23/1.2)
or reported that the Psychiatrist behaved as a leader, without being integrated into the team:
'...Our psychiatrist continues to work in the way that he's always worked. And so therefore it's been, the process has been more slow I think for this team in developing in different ways...' (TL 11/7)
'...Occasionally they'll make kind of unilateral decisions that may affect other people, wont always communicate that, they don't always perceive the need to...' (TL 10/3)
Others reported that the Psychiatrist was disengaged from the team:
'...he doesn't see himself as working in the community at all.' (TL 23/1.2)
and more particularly from the GPs:
'...there's a big gap between our consultant and the GPs, you know, he doesn't have any direct contact with them he doesn't know them, so that changes the relationship.' (TL 23/1.5)
However psychiatrists were well aware of the tensions within the team around their own role:
'My main role myself is, I think is from the clinical point of view of being a leader for the whole team...'(Psych 24/1)
Particularly when it came to deciding who should or should not be seen by the team, which sometimes led to disagreement with the rest of the team:
'...And usually it's me then saying 'I think we should see this patient'. I think CPNs, psychologists have more the tendency to say "Well we should really not see this patient".' (Psych 23/1)
How were decisions about referrals made? The rhetoric and the reality
CMHT leads and Psychiatrists described how decisions were made in their team in a language which reflected current policy rhetoric:
"...(we) advise GPs in particular where we do link-working into other organisations..."(TL 13/1)
Some CMHT leaders described their team as having inclusive criteria in contrast to other services:
"'..other specialist teams tend to operate quite a strong, what we call it, an exclusive criteria..." (TL 10/2).
Others admitted that their service operated very strict criteria for accepting a referral:
"...we offer almost a psychosis service" (TL 24/2)
Attempts to clarify exactly how CMHTs how decisions were made and particularly management issues, indicated that it was sometimes unclear how decisions were made within the 'team':
'well, how the decision is made? that's a difficult one. how we assess whether it's severe, emm, whether we agree, we don't always, even if there were strict criteria, erm...' (T17/6)
There was a similarity in the way that the referral system was described at most of the sites:
'...Well it's logged and then the urgent, urgent ones are dealt with on duty, so somebody would go and assess somebody as part of the duty system. And those that are deemed to be routine are brought to referral allocation meeting, and we discuss them. And sometimes we will do things like say this isn't, there's not enough information or you can just tell they're not eligible and we'll make a decision, maybe someone will liase with the GP about that particular client. Or if they are eligible, we allocate somebody to go out and do the assessment. And the next part of the meeting is about feedback from assessments that people have conducted over the past week or so. And then we make a decision about whether they're eligible for services or not'.(TL 24/2)
The reported process of decision-making within the allocation meeting also varied little from site to site, although was difficult to tease out in the interviews:
Interviewer: Could you describe your role within the team, please?
A: That's a big one. How long have you got? (laughter) I mean I see my role at the moment as team leader, as a leader as opposed to team manager. I think there is a difference in that...And my role is to support and kind of lead and direct...... You know empowering, empowering the staff really. So not taking responsibility for them, but giving them the skills I suppose to be able to kind of improve on their role and functioning.
Interviewer: Okay, excellent. So how does your team work?
A: How does it work?
A: I mean we're a team, a multidisciplinary team that's made up of, we have four CPNs (Community Psychiatric Nurses), we have two social workers, we have an occupational therapist, a support worker, medics, a doctor, and SHO (Senior House Officer) and two team secretaries. And very much the team does work together ...it's a team kind of role in accepting referrals and processing referrals. And through that process the team then, you know, takes the information from a referral and will decide you know whether to work with that referral. Whether we need to maybe pass that referral on to other services, and redirect it through, or send it back. But how we decide that, erm... Have I gone off at a tangent? (TL 11/3)
The taped meetings demonstrated four areas of discussion about whether or not a referral was accepted (Table ). Inconsistency was observed in how decisions were made on whether a referral was accepted or not. Conversations tended to switch between clarifying information, inconsequential comments, comments about the referrer, comments about risk and reiterating what has already been said. It was usually difficult to identify a point in the discussion at which a clear decision was made.
Analysis of the allocation meeting transcripts
The findings from the analysis of the taped meetings were thus in marked contrast to the more structured and organised way in which participants reported that decisions came about within meetings.