Clinician opinions about the appropriateness and severity of general practitioner referrals to specialist mental health services: a cross-sectional survey

A cross-sectional survey of 794 referrals from 41 general practices working in a defined catchment area is reported. The outcomes studied were the proportion of patients (1) declined on the basis of a referral letter, (2) not attending, (3) considered 'appropriate' by clinicians carrying out assessments and (4) judged to meet 'severity' criteria based upon risk or role impairment. Forty-one (5%) referrals were declined on the basis of their referral letter and 221 (27%) did not attend. Of the remainder, 125 (28%) were considered as inappropriate referrals. There was an inconsistent relationship between clinicians' opinions about 'appropriateness' and judgements in the four domains of severity: 66 (52%) of the 'inappropriate' referrals were judged to meet at least one of four severity criteria, whereas, conversely, of the referrals considered 'appropriate', 64 (20%) did not meet any risk or severity criteria. Nearly half (47%) of all referrals to psychiatric services either fail to attend or are considered 'inappropriate' when seen, findings which highlight serious inefficiencies at the interface between primary care and secondary mental health services. The policy of 'prioritisation' on the basis of severity has proved difficult to implement consistently. In order to reduce these inefficiencies, structured referral criteria are needed involving users, general practitioners and mental health service providers.