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Original papers: P. Walker, O. G. Haeney, and P. C. Naik Attitudes to referral to community mental health teams: a questionnaire study Psychiatr Bull 2005; 29: 213-214 [Abstract] [Full text] [PDF]

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Attitudes to Referral

Ross J Hamilton, University of Aberdeen   (16 June 2005)

Who should be referred to Community Mental Health Teams?

Reena M Roy   (21 June 2005)

Attitudes to Referral 16 June 2005
Ross J Hamilton, Consultant Psychiatrist Department of Mental Health, University of Aberdeen Send letter to journal: Re: Attitudes to Referral rjh{at}hsru.abdn.ac.uk Ross J Hamilton, et al.	Sir: Walker and colleagues' questionnaire study (Psychiatric Bulletin, June 2005, 29,213-214) concerns attitudes to referral to a community mental health team (CMHT). The authors conclude that uncertainty exists over appropriate referral criteria and this issue has been highlighted previously with respect to tension at the primary care/secondary care interface (Gask et al, 1997). My own observations as a former general practitioner now a consultant psychiatrist leading a CMHT lead to some hesitation in accepting the findings of such questionnaire surveys at face value. In a nutshell I fear a significant Hawthorne effect comes in to play in such studies of referrers' and providers' views (Mays 1995). In my experience the responses elicited are as much a reflection of the responding clinicians' relationship with the institution inviting the response, as they are a true reflection on views of referral criteria. Within our own CMHT we are bombarded with so many questionnaires and surveys that our stock response is usually "who wants to know?". Lest it be thought that we sit paralysed within this paranoid position we have introduced screening clinics for triage of new referrals to our CMHT in the face of ever increasing numbers of referrals from our general practice colleagues (Hamilton et al 2002). GASK, L., SIBBALD, B. & CREED, F. (1997) Evaluating models of working at the interface between mental health services and primary care. British Journal of Psychiatry, 170, 6-11. MAYS, N., & POPE, C. (1995) Qualitative Research: Rigour and qualitative research. British Medical Journal, 311, 109-112. HAMILTON, R., GORDON, P. & NAJI, S. (2002) Service Innovation: The first year of a brief psychiatric screening clinic in primary care. Psychiatric Bulletin, 26, 218-22
Who should be referred to Community Mental Health Teams? 21 June 2005
Reena M Roy, Specialist Registrar in Psychiatry Send letter to journal: Re: Who should be referred to Community Mental Health Teams? rroy{at}doctors.org.uk Reena M Roy	I read with interest the article by Walker,Heaney and Naik (Psychiatric Bulletin, June 2005,29,213-214). I think it raised some valid issues that there is some uncertainty about who should be referred to Community Mental health Teams, and that due to this there is much variability in referral patterns. However, I did feel that the method was flawed in a number of ways. Using the ICD 10 definitions of the ten common psychiatric disorders, and then asking GPs and General Adult Psychiatrists to decide whether each individual with each disorder would need referral to a CMHT does not relate to what should be current practice amongst doctors. The ICD 10 definitions are used to make a diagnosis but it is not the only tool we use to decide whether an individual needs to be referred to a CMHT. Most clinicians should take into account the individual patient's circumstances including his/her social and psychological needs. No matter what the diagnosis, if a patient was particularly vulnerable or was displaying a risk of harm to themselves or others, they would benefit from the multi-disciplinary and enhanced level of care that is provided by a CMHT. Many variables would need to be considered at an individual level before any doctor should decide to refer to a CMHT. It should never be a 'yes' or 'no' decision dependent on only the ICD 10 diagnosis. Some patients prefer to have sole treatment from their GP possibly due to the reduced stigma and cope well. However, others with the same condition benefit from the 'Care Programme Approach' that is usually undertaken and audited by a CMHT. The benefits of having a 'care coordinator' that acts as an advocate and supervises the ongoing needs of the patient can be multiple. The patients's choice should always be considered when a referral is made to a CMHT. I also noticed that dual diagnosis patients were not considered. Many patients may fit the criteria for several psychiatric conditions and this would surely influence their referral to a CMHT? They state that the Royal College needs to research and provide guidance as to which patients should be referred to mental health services. I do not agree with this as I feel that the Royal College should be encouraging doctors to think laterally and to not rigidly follow guidelines when it comes to important decisions about any individual person's care. Reena Roy Specialist Registrar, Wickham Park House, Royal Bethlem Hospital, Beckenham, Kent, BR3 3BX, email: rroy@doctors.org.uk tel:07944 734 679 fax:0208 776 4576