Accessibility and pathways to psychiatric care in a community-based mental health system

The careful analysis of pathways to specialist mental health care, within the context of community-based services, is important because it allows a detailed understanding of the inter-relationship between the component parts of the whole system of care. Moreover, it permits a comparison of service functioning to made over time, and is one way to operationalise the measurement of accessibility to services. The aims of this study are to describe: (i) the pathways followed by patients with new episodes of care to community-based mental health services, (ii) the time intervals from onset of the problem to first contact with services, and then to onward referral to specialist care (accessibility), and (iii) to explore the short-term costs associated with different pathways.

Using data from the South-Verona Psychiatric Case Register, all new patients referred to any of the facilities which are part of the South-Verona Community Psychiatric Service (CPS) over a 6-month period (November 1999 - May 2000) were eligible to enter the study. Patients were interviewed by telephone using the Italian translation of the WHO Encounter Form. The costs of care provided in the 3 months following the index contact were assessed for all patients.

The most common route to mental health services is via a GP (40%), followed by a referral from a hospital doctor (26%) and self-referral (23%). The median interval from onset to direct contact with the South-Verona CPS (12 weeks) was shorter than the intervals from onset to direct contact with other service providers (the median interval for contact with GPs and hospital doctors was 24 weeks). The intervals varied considerably from 1 week (for attempted suicide), to 1.5 years (for disturbed behaviour). The results of backward regression modelling revealed a significant relationship between patients' characteristics and community costs or total psychiatric costs (44% and 53% of the variance explained respectively).

When the results are compared with a directly comparable earlier study in South-Verona, it is apparent that between 1991 and 1999 an increasing proportion of patients with insomnia and somatic disorders presented first to GPs, while a decreasing proportion of patients over the years sought care directly from specialist care. An increase in the role of local GPs as gatekeepers has, therefore, emerged. A prompt assessment by the South-Verona CPS of the patients' presenting problems was also confirmed, and this can be explained by the 'drop-in' approach at the Mental Health Centre, where patients can seek specialist care directly, without previously attending GPs. This method of measuring time intervals along pathways is proposed as a way to operationalise accessibility to services in future.