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GPs go forth

The consequences of an underfunded mental health system

Editor’s blog

We hear a lot anecdotally about increased thresholds for mental health referrals. In 2016, we reported some commissioners insist that the patient has to have had suicidal thoughts before accepting a referral.

This has never been about making referrals more appropriate, as is claimed. This is about overstretched services being cornered into having to protect themselves from work as a result of years of underfunding of mental health care.

And despite all the Government’s insistence that they are prioritising mental health spending, from speaking to GPs I have no doubt things haven’t got better since then.

For GPs, this affects their ability to give patients the treatment they need. It also requires plenty of time to ensure the referral is right for fear of it being rejected.

If a patient who later dies by suicide doesn’t meet referral criteria, there is something rotten in the system

The case reported this week of 16-year-old Sam Grant - which followed the similar case of Lewis Doyle reported last month - shows that these reduced thresholds are not just academic, or a case of GPs worrying about themselves. Like so many things around GP workload, decisions to cut referrals have real consequences for patients.

We will never know what would have prevented Sam and Lewis dying by suicide. But we do know that if a patient who later dies by suicide doesn’t meet the referral criteria, then there is something rotten in the system.

Jaimie Kaffash is editor of Pulse. Follow him on Twitter @jkaffash or email him at

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Readers' comments (10)

  • ”But we do know that if a patient who later dies by suicide doesn’t meet the referral criteria, then there is something rotten in the system.”.
    Actually we don’t know that. Suicide is very very rare and very hard to predict except in retrospect. All the research into risk assessment tells you this. The huge amount of feeling that this case has generated amongst GPs is a signal of how vulnerable and abandoned GPs are feeling in managing these kind of cases.
    Mental health services need more staff and funding and GPs need more training so they feel more confident. In the old dates you could just pick up the phone and speak to another medical professional. Nothing has filled that gap.

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  • Huge assumptions from comment at 9.03
    Not all GPs need more training- but we do need more support - we are carrying and managing huge volumes of mental health Rita because the secondary care systems are so stretched.
    We simply don’t have the time ( 10 minute appts?) or appointment availability to offer this service- but we are carrying the can so we have to- care for the patient and their families / others involved when they are unwell.

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  • Vinci Ho

    I accept the argument that we should not judge these catastrophic cases purely on where the final responsibility lied as far as primary and secondary care are concerned. But the reality , as I wrote before , increasing hospital referral rejection(not just mental health ) has become a social norm and pattern in NHS . There is certainly problem of recruiting consultant psychiatrists nationally (as well as numerous unfilled consultant vacancies in different parts of the country ) and of course , we are very short of full time equivalent GPs . The ‘system’ itself is dysfunctional and no longer safe enough . That is the reality. The government and its recent predecessors cannot shy itself away from this reality under its watch despite all the claims of investing more .
    Primary and secondary care are like lips and teeth , question is why their ‘owner’ failed to keep them in healthy shape ?

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  • It was ever thus. I regularly used to get 'doesn’t meet the referral criteria' letters. I got the impression that this was the standard reply irrespective of the merits of the case - the sole objective being to keep referrals down to a manageable level. I suppose I should have invariably written back to say: "Please explain exactly why this doesn’t meet the referral criteria."

    A nurse practitioner who had a reputation for being very adept at dealing with teenage girls with mental health problems once confessed to having fleetingly thought in a moment of desperation: "If only she'd self harmed" ... because that was the key to getting these patients seen quickly.

    The other perpetual gripe was something that was called 'The Crisis Team' - which we used to call 'The 3 days After the Crisis is Over Team' as they were often very slow to respond - so we had to do our best to cope in the interim. To misquote Longfellow, "When they were good they were very, very good - but when they were bad they were horrid."

    Whatever the ins and outs of it, GPs are left feeling unloved and unsupported - which adds immeasurably to their stress levels.

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  • Underfunded? Or poorly managed and overburdened with unhappiness masquerading as illness and unrealistic expectations?

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  • Political targets ensure ccgs pay for leafleting campaigns to pursuade people they need some IAPT yet patients who present to the GP have their referrals rejected.

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  • @Stelvio
    Possibly- but whichever way the Govt is largely responsible current levels of unhappiness and unrealistic expectations as well as the underfunding.

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  • Brexit Brexit Brexit. That’s all they care about! Meanwhile people are dying!

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  • I think 9.03 sums it up very well.

    Unfortunately this is an area of medicine that does not really progress technically,the process is little changed in 100 years.

    There are no tests,scans,bloods or measures.

    Professors of psychiatry can teach,but never having done it,and never intending to do it,the guidance is somewhat suspect.

    We can obtain the referral criteria,as published,which appear to be generally wacky and disassociated from reality.We can let the family have these.We can send a truthful referral anyway in anticipation of rejection.

    However we cannot be sure there is any sure way of preventing any suicide

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  • Nobody can prevent a suicide if the person is determined.
    It is the blame culture, the not my responsibility but somebody else's that is the problem.
    The GP never asked the patient to jump or take an overdose.

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