General Practice

Are community mental health teams providing an equitable service? Comparison of source of referrals with inpatient care

BMJ 1996; 313 doi: (Published 24 August 1996) Cite this as: BMJ 1996;313:476
  1. Richard Laugharne, clinical training fellowa,
  2. Simon Fleminger, senior lecturera
  1. a Joint Academic Department of Psychological Medicine, St Bartholomew's and the London Medical College, London E1 2AD
  • Accepted 11 April 1996

Some researchers have suggested that community mental health teams may have policies that result in those most in need not receiving priority for services and may thus not provide an equitable service.1 2 Referral practices of general practitioners have been suggested as a source of inequity.3 4 We investigated the factors affecting which patients are referred to a community mental health team by comparing the demographic characteristics of people referred to one community team with those of patients being admitted to hospital and also with the general population.


and results

The community mental health team serves a multiethnic population of 52 059 (of whom 32 783 are aged 15-64) in a deprived inner city area. It accepts referrals directly from general practitioners (many practice alone or in two-handed practices), psychiatric outpatient clinics, inpatient wards, social workers, health visitors, and elsewhere. We examined retrospectively consecutive referrals to the team over 18 months and also inpatient records. Information on the population was obtained from the 1991 census and records of the department of public health. The figures used were for adults aged 15-64 years. Over the 18 months 119 patients from the study area were admitted to the acute adult psychiatric wards and 513 were referred to the community mental health team. Patients referred to the team were significantly younger than those admitted as inpatients: 36.1 years (SD 12.0) v 39.1 (13.0) (t test 2.26, P = 0.024).

There was a large difference between referrals to the community mental health team, inpatient admissions, and the general population in terms of the size of general practice with whom subjects were registered. In the general population about a quarter were registered with practices with a single doctor, one half with practices with two, and one quarter with practices of three or more (table 1). The inpatient admissions showed no significant difference from this pattern, but there was a large overrepresentation of people referred to the community mental health team from large practices: the rate of referral from larger practices was four times that of the other two groups of practices. Of the patients referred to the team 310 were referred by their general practitioner and 195 from other sources. For those patients referred from primary care there was an even greater overrepresentation from larger practices (68.8% of referrals). For the referrals from other sources the distribution was closer to that of the general population, though larger practices were still over-represented (31.1% of referrals).

Table 1

Percentages of the general population registered with different sizes of practices and of psychiatric inpatient admissions and referrals to the community mental health team

View this table:


Patients registered with general practices of three or more doctors are four times more likely to be referred to the community mental health team than are patients registered with smaller practices, contrasting with the findings of the inpatient population, where the distribution of patients is little different from that of the general population. If anything, patients from large practices are underrepresented among inpatients, though not significantly so.

Our interpretation of the findings is that the rates of inpatient admissions are a crude indicator of levels of psychiatric morbidity. Therefore the different rates of referral to the community team reflect inequalities in accessing this psychiatric service rather than different levels of need. General practitioners from larger practices might have a lower threshold for referral or detect more mental illness, or general practitioners from smaller practices might refer more to the outpatient department and the accident and emergency department.


  • Funding None.

  • Conflict of interest None.


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