Referral – Patching the Soul

A little while ago, someone I met from a third sector mental health organisation complained to me about their local community mental health team: ‘It’s a real nuisance when referrals miss the allocation meeting- then people have to wait for another week- and they might not get accepted…’

I’ve spent quite a bit of my working life trying to help things function more smoothly at the interface between primary care and specialist mental health care, so I wasn’t surprised to hear this- though disappointed that so many of the same issues keep coming up year after year- confirmed when I asked twitter whether the ‘traditional’ community mental health team allocation meetings still take place. In many places they clearly do. And that surprised me. Because this tweet pretty much summed up (for many I think) the inherent dysfunctionality of the enterprise:

More than a decade ago, my colleague Carolyn Chew-Graham and I researched the relationship between CMHTs and GPs in Manchester and Croydon,and, as part of this project, we obtained permission to record referral allocation meetings and analyse them- in addition to carrying out in-depth interviews with GPs and team leaders. We concluded that:

‘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.

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.’

When we interviewed the GPs, some were visibly distressed by the process of trying to get a person who they felt unable to help seen by mental health services. Others were more pragmatic:

These interviews were carried out in 2006, long before the current financial crisis in the NHS. In many places the same systems still exist. Are referral allocation meetings one of the lingering sacred cows (at least in some localities) of mental health care? And what does that signify about such services?

I attended my first allocation meeting at one of the first Community Health Centres, Brindle House in Hyde, more than 30 years ago. At the time we thought we were cutting edge, and perhaps we were, discussing the GP letters over coffee every Monday morning. A decade later, I helped to set up CMHTs from scratch after the closure of a mental hospital, and it soon became apparent that everyone in the team felt overloaded by the number of referrals. We tried to solve that problem, and didn’t entirely succeed, by setting up a primary care focussed team for people with common mental health problems- but it still worked in too similar a way to the CMHT. It wasn’t easy to get mental health workers out to work closer to primary care- yet it seemed to me that was where the solution lay. I’m still arguing this.

What twitter also told me was that in many places allocation meetings have been replaced by assessment teams, Single Points of Access and triage to attempt to control the pressure of referrals into the service- followed by case allocation by team leaders. Daily instead of weekly allocation prevents delays, and meetings can be reserved for discussing how to manage the flow (water metaphors abound). Caseloads are also more effectively managed than they once were. In my opinion, CMHT professionals should not have the freedom to say ‘I’m full’ whilst at the same time resisting supervision. When working with experienced mental health professionals in collaborative care research I have found that while many appreciate more support and supervision a few expect to work completely autonomously. I support the need for 3 types of supervision- case management, clinical and developmental- to acquire new therapeutic skills, but one or more of these may be absent. Meanwhile Single Points of Access (despite their woeful lack of evidence- this is the only study I’ve ever found) and ‘assessment teams’ are at risk of becoming the new ‘sacred cows’.

When I meet to work with a group of GPs, as I did only few days ago, it’s clear that they remain very unhappy at the difficulty accessing care for their patients- despite often having good working relationships locally. While many of the ways that the interface has been ‘reconfigured’ have helped to control the demand for access to care, the question arises whether they are really the best options for the whole system- in particular patients and service users. More resources would help, absolutely, but other things need to change too. The problem with some of these new structures and ways of working is that they have increased the problem of a person being assessed several times before anyone agrees to help them- if at all. Single points of access, although ostensibly better in many places than what has gone before, cut across existing relationships between teams and primary care, and can especially disrupt doctor-doctor communication- which GPs value. I really look forward to the proposals from the team currently working on the National Community Mental Health Pathway, but I suspect that not only ways of working need to change– but values have to be challenged too, particularly how staff arrive at their beliefs about who is ‘deserving’ and ‘not deserving’ of ‘care’. That might expose some other sacred cows and open them up for discussion.

I continue to believe that community services must work much more closely with primary care. As Emma Tiffin and her colleagues have shown in Cambridgeshire, supporting primary care with the local PRISM service ( PRISM presentation 7.12 ) who don’t accept referrals but requests for service (‘referral’ and ‘threshold’ are banned words- it’s about providing advice to GPs and supporting patients through to the best service option for them- not turning people away) things can be done differently. Services need to reconsider how they can provide a more open, accessible and helpful face to the community and that means working much more closely with primary care. Assessments should be as few as possible- and ideally the person who initially engages the person should continue to work with them. I know from talking to service users- and using services myself, how stressful that first meeting is- but so much important therapeutic work can be done in that one session. The key to ensuring this works effectively is the right kind, and level of supervision- with medical input essential.

Allocation meetings where decisions are made about whether or not to accept GP referrals, and who is going to take them, should be a thing of the past.

My last allocation meeting at Brindle House in 1984 ended with some of team performing a goodbye song- with new words to the music of Stairway to Heaven (they knew I was a Zeppelin fan). I found the verses recently when clearing out my study. Very happy memories-

but we have all moved on.

Not long ago the NHS introduced a patient feedback test asking people if they would recommend a service to their friends and family. I may have missed it, but I would have thought we should really be asking staff too if they would suggest that their friends or loved ones might want to use the mental health service in which they work? Would they be satisfied enough with the quality of care?

Supporting colleagues who are themselves suffering from mental health problems or have family members in need of help is always eye-opening. In some places it’s really hard to get through the barriers to care and access the kind specialist advice and help a person would really benefit from. I’ve been lucky in that, despite not being psychotic or actively suicidal (colleagues may disagree about the psychotic, I get fairly paranoid when I am really down) I’ve generally managed to get therapy when I’ve needed it. I have good GP care. I went privately for cognitive-behavioural therapy not only because of the impossible wait where I live, but because I wanted to see someone who knew something about depressive rumination. Even then, having helped me a great deal, he generously refused to accept payment from a fellow professional. I know most people are not quite as lucky as I have been.

Getting access to mental health care these days seems to depend on whether you want to kill yourself imminently or if you are hearing voices telling you to kill someone else. My colleagues in psychiatry get annoyed with me when I say you only need to ask these two questions now in the mental state assessment, but how easy is it really to see someone who can provide specialist advice on a serious mood disorder before you are at the end of your tether? Waiting list for psychological therapies are long, and they often don’t have parallel advice available to them for reviewing the often complicated medications that people are on and may have been taking for years. NICE guidelines say both should be available in severe depression, yet if you are under the care of the community mental health team (CMHT) some psychological therapies services will not see you until you are discharged from the care of the CMHT. I’ve heard this several times now. Why is this allowed to go on? It is contrary to national guidance. If it were happening for serious physical illness it would be a subject of a Radio 4 report. If people cannot access care when they are in the early stages of relapse, it is hardly surprising that they reach the point where detention sometimes seems to be the only option to those trying to care for them.

Do people who get depressed who work in mental health care have the same problem getting help? What do they think when they are told bluntly don’t ‘you don’t meet our referral criteria’ and get sent back to a GP who is asking for expert advice because he or she doesn’t know what else to do? Do they demand access and get it? Are they as lucky as I have been, because I think I have been fortunate to access skilled and high quality care. I know it can be done if there is a will.

I’ve pretty much worked in the community the last few years, but I’ve visited a lot of mental health units to talk to people about taking part in research. You only have to walk into a cancer unit, as I did not so many months ago to visit a friend, to be shocked at the gross disparity between the physical environments that people with mental health problems, and those who work with them, have to tolerate when compared with those who have physical illness. I know the entrance hallway isn’t always what the hospital is actually like inside, and the care provided in acute units has not escaped criticism either. We have the Francis Report after all. Nevertheless I cannot help feeling that the state of our shrinking, poorly staffed, ill-resourced and physically unappealing mental health units, separated as they were from physical health care a decade ago in the new Mental Health Trusts, are a sign of where our priorities lie as a society. I cannot imagine recommending that a member of my family should be treated in one now, although I have at other times in the past.

I’d be fascinated to hear from anyone who works in mental healthcare who would be perfectly happy for friends or family with severe mental illness to be (hypothetically at least) treated in their own service. Take the test.