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

Mike Slade, Linda Gask, Morven Leese, Paul McCrone, Carolyn McCrorie, Robin Powell, Mairi Stewart, Carolyn Chew-Graham

Research output: Contribution to journalArticlepeer-review

24 Citations (Scopus)


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).Results. Two hundred and eighty-one GPs made 1061 mental health referrals. The intervention was only partly implemented with 25\OR 1.18, 95\.91–1.53) or secondary outcomes. Post-referral primary care contact rates were higher for the intervention group (IRR 1.36, 95\.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.
Original languageEnglish
Pages (from-to)181-190
Number of pages10
JournalFamily Practice
Issue number3
Early online date30 May 2008
Publication statusPublished - 1 Jun 2008
Externally publishedYes

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