Common mental health disorders like anxiety and depression affect one in six adults at any time (McManus et al., 2016). Since COVID-19, this figure has only been exacerbated (Opinions and Lifestyle Survey, 2020). Low socio-economic status can contribute to poor mental health (Patel et al., 2010), and employment has been particularly unstable throughout the pandemic. This shines light on the importance of equal access to psychological support services more so than ever; to prevent the negative impacts on life that result from unmet mental health needs.
In England, the Improving Access to Psychological Therapies (IAPT) programme had its debut in 2008. As its name suggests, its primary aim has been to increase access to evidenced-based psychological therapies. An important tool for this has been the ability to ‘self-refer’. This is because prior to IAPT, accessing psychological support required a GP referral, but studies showed that up to 70% of people experiencing distress did not contact their GP (Brown et al., 2010).
Although self-referral has several advantages – reducing stigma, difficulties accessing GP appointments – little investigation has been carried out as to its usefulness over time. In particular, this has not been investigated within populations at higher risk of developing mental health problems, such as those in low-income communities, and where accessing services is crucial.
Thomas and colleagues (2020) investigated this issue in their research, in which they aimed to examine “how IAPT referrals are made by GPs and how these referrals are perceived and acted on by patients from low-income backgrounds.”
Semi-structured interviews, lasting between 30 minutes and 2 hours, were carried out with 57 low income patients from two sites in South West England. Participants self-identified as living in poverty (unemployed or low paid work), and were seeking support for their mental health at the time of the study. Interview topics included expectations of treatment, experiences of GP appointments, and treatment options offered by the GP.
Semi-structured interviews were carried out with 10 GPs working in areas with a high number of low income patients. Interview topics included experience of supporting low income patients’ mental health, and how they perceived the available treatment options. Secondary data analysed 26 video-recorded GP-patient appointments where IAPT self-referral was discussed.
The interview data was analysed by 3 people using inductive and deductive thematic coding. Conversation analysis was used to pick out common themes in the video recordings. Initial analysis was conducted independently, and then the three team members came together to check for consistency.
Overall, GPs were in favour of self-referrals. However, most patients identified this as a barrier to accessing IAPT, deterring them from seeking help. The common themes that were identified are explored below.
Most GPs felt that self-referral was an important step in a patient’s recovery. GPs downplayed the challenges that could arise when self-referring, emphasising that this process was straightforward. This included comments like “it’s just a phone call” or “it’s just a local number”.
GP reasons for self-referral
GPs identified service-level benefits, like conserving limited resources, as a major advantage. GPs also identified service-user benefits, such as allowing patients to take ownership in their recovery, as another advantage.
GPs as referrers
GPs stated that referring patients was not routine practice. Reasons for referring patients included consultations at the end of the day, or if they felt that this would increase attendance. Patients stated that if a GP referred them, this validated their experiences.
Patient identified obstacles to self-referral
Patients felt self-referral was a barrier to accessing IAPT, feeling it undermined their needs. As the process felt overwhelming, support would have decreased this feeling. For example, patients experiencing low mood felt that their symptoms – such as decreased motivation – prevented them from self-referring.
Self-referring is a very hard process for somebody with mental health issues. It doesn’t matter if it’s anxiety, depression, whether it’s anything else. To self-refer, it is difficult unless you have that extra push. And trying to do it on your own, you don’t want to say you are weak, you need help.
Socio-economic status was an important obstacle in the self-referral process. Patients felt they were being ignored. When GPs didn’t appear to know enough about IAPT, this made this experience worse.
Patient experiences of IAPT
For those patients who did attend IAPT, there were some common themes in their experience. These included shared frustrations in waiting times, and the lack of diverse treatment options.
The authors concluded that:
- There was a disconnect between the positive beliefs GPs had towards the IAPT self-referral process and the experiences from low income patients;
- Low income patients found the self-referral process acted as a deterrent to IAPT, with over 40% not following through;
- Low income patients felt that GPs suggesting to self-refer impacted their self-worth, invalidating their experiences.
Strengths and limitations
Overall, it was good to see that the authors had set clear research aims, and their study presented is the first to their knowledge to explore this area. The qualitative method was appropriate for understanding service-users’ and GPs’ perceptions of the IAPT self-referral process. I personally found the study design a strength; it allowed for in-depth exploration of the views of the participants, highlighting the dichotomy of opinions between GPs and service-users. The interview data allowed for the personal accounts to be captured in rich detail, and with a large sample size of 57 service-users, this has provided a platform to amplify the voices of low income patients experiencing distress.
However, there are some limitations. Although there was a large sample of service-users, the small GP sample size of 10 decreases the ability to generalise the results.
The sample of service-users from this study self-identified as low income; therefore there may be some selection bias. Additionally, the participants were from two sites in the South-West, and the demographic data is not reported in detail. This brings into question whether the sample is culturally diverse, as a homogenous sample means we need to be cautious with how far we can generalise the findings. It is important to acknowledge interacting social factors – like ethnicity – in this subject area, as those from non-white communities are disproportionately impacted by unemployment, poverty, and lack of professional support (Equality and Human Rights Commission, 2016; Mermon et al., 2016), and are more at risk of societal inequalities. Therefore, these groups are more vulnerable to the development of mental health difficulties (National Institute for Mental Health in England, 2003). As systemic issues like poverty are the subject of the presented paper, it would have been interesting to see an acknowledgement of the interconnecting factors related to their experience.
Further research could look to see if the findings of this research generalise across the UK in other areas of poverty. This may influence services to create more effective support mechanisms within primary care, such as encouraging GPs to refer patients more routinely. This also highlights how systemic issues leave some of the most vulnerable members of society to slip through the net. Clinicians should remain patient-centred in their approach, and be sensitive to potential barriers highlighted in this study and supporting them in their referral.
I found the disconnect between GPs and service-users’ experiences particularly interesting. It highlighted the importance of language and interpersonal skills when communicating with service-users, which can quickly lead to invalidating lived experiences. As healthcare professionals are at risk of burnout and depersonalised care, this study corroborates the need to support healthcare workers so that their stretched resources do not prevent service-users from receiving appropriate support, and they remain patient-centred.
Overall, this study showed that the IAPT self-referral process can act as a deterrent for low income patients, despite the positive views from GPs. This is an important finding, and warrants further research and action to be taken to ensure equity of access to psychological therapies.
Statement of interests
Alice Potter currently works for an IAPT site in London, and has previously worked for an IAPT site in Somerset. Alice attended the University of Exeter who were involved in the DeStress project, but had no involvement in the research.
Thomas, F., Hansford, L., Ford, J., Wyatt, K., McCabe, R., & Byng, R. (2020). How accessible and acceptable are current GP referral mechanisms for IAPT for low-income patients? Lay and primary care perspectives. Journal of Mental Health, 29, 706-711.
Brown, J. S. L., Boardman, J., Whittinger, N., & Ashworth, M. (2010). Can a self-referral system help improve access to psychological treatments? British Journal of General Practice, 60, 365-371.
Equality and Human Rights Commission (2016) Healing a divided Britain: the need for a comprehensive race equality strategy.
McManus, S., Bebbington, P., Jenkins, R., Brugha, T. (eds). (2016). Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey, 2014. Leeds: NHS Digital.
Mermon, A., Taylor, K., Mohebati, L.M., Sundin, J., Cooper, M., Scanlon, T., & de Visser, R. (2016). Perceived barriers to accessing mental health services among black and minority ethnic (BME) communities: a qualitative study in Southeast England. BMJ Open.
National Institute for Mental Health in England. (2003). Inside Outside: Improving Mental Health Services for Black and Minority Ethnic Communities in England, London, Department of Health.
Opinions and Lifestyle Survey (2020). Office for National Statistics.
Patel, V., Lund, C., Hatherill, S., Plagerson, S., Corrigall, J., Funk, M., & Flisher, A. (2010). Equity, Social Determinants, and Public Health Programmes. In Blas, E., & Kurup, A. (Eds), Mental disorders: Equity and social determinants (pp. 115-134). World Health Organisation.