The tensions between primary and secondary mental healthcare systems

Nada Khan is an Exeter-based GP and clinical academic, and an Associate Editor at the BJGP.

In a healthcare system under strain, mental health services are not immune.  In 2018 (pre-COVID-19), Mind conducted a survey which suggested that around 40% of GP appointments involve mental health. The impact of the COVID pandemic and increasing social deprivation have not lessened that need.1  Much of mental health demand is managed in primary care, and GPs are used to holding risk.  However, where GPs suspect more complex conditions or severe mental illness needing specialist therapies or medication, it’s often Community Mental Health Teams (CMHT) we turn to.

But things don’t always run smoothly when transferring patient care to specialist mental health services in the UK.  A recent British Medical Association (BMA) report describes an ‘overstretched’ mental healthcare system failing patients due to a lack of funding and tensions between often siloed general practice and secondary care services.2  This report, which the BMA carried out by interviewing doctors working across mental health services, general practice and emergency medicine, is a snapshot of the current dire state of mental health services.  The BMA report identifies several key problems in the provision of adequate services including a lack of sufficient funding, a lack of trained staff, the impact of social determinants on poorer mental health and the challenges of working in a siloed and overstretched service with tensions between general practice, community mental health and secondary and emergency care.

A lack of funding is limiting capacity in primary and secondary care

GPs feel they are increasingly managing increasingly risky mental health patients, with rising frustration that their referrals are being rejected. 

GPs feel they are increasingly managing increasingly risky mental health patients, with rising frustration that their referrals are being rejected.  Just as in general practice, CMHT teams are facing their own challenges in not having the workforce or capacity to meet those referrals. The BMA report focusses on how different components of the health care system each facing their own pressures are unable to take on and coordinate patient care.  Anyone keeping track of current negotiations for the 2024/25 GP contract will be aware of the challenges of limited core funding and its impacts on capacity, workforce and the primary care estate, but this is not a problem faced in general practice alone.  There is insufficient investment in the mental health estate, with increasing challenges in mental health workforce recruitment and retention with the number of people in contact with mental health services outpacing workforce capabilities.  Is any of this sounding very familiar?  If the capacity is not there to meet referrals, then the service will struggle to accept all appropriate referrals from general practice.

The challenge arises when GPs are referring patients where the need for specialist input is clear, at least from the perspective of the GP.  Writing recently here in the BJGP about how GPs can identify early signals of bipolar disorder, Catherine Morgan and colleagues discuss that identifying bipolar disorder also requires secondary care mental health services to be more responsive and conduct rapid assessments when patients are referred to their services.3  Speaking to me for a BJGP podcast, the authors make the point that due to the high thresholds for referral, and often the risk of referrals being rejected, even these high risk patients do not get seen routinely.

A qualitative study of GPs and those working in CMHT echoed these findings, suggesting that GPs expect CMHT to take on, assess and treat people with severe mental health needs, but also that GPs viewed CMHT as trying to ‘avoid’ taking on these referrals.  GPs also wanted access to advice and expert guidance from consultant psychiatrists especially around medications such as antipsychotics which are not typically initiated or titrated in general practice.  What’s interesting is that some CMHTs worked differently from others, with more flexible referral thresholds.  CMHT members admitted their lack of capacity, and not the always nature of the referral or the needs of the patients, influenced their decisions in referral meetings.4

…it’s worth acknowledging the system pressures at play to ease those cross-specialty tensions rather than fuel them.

The Mental Health Implementation Plan, launched in 2019, aimed to reduce barriers and clarify referral thresholds for severe mental illness (SMI).  The plan was to provide funding to all ICSs to develop and deliver, by 2023/24, new models of integrated primary and community care for adults with SMIs.  The models aim to provide support for those not meeting previous thresholds for secondary care and to ensure that people are not lost to follow-up following discharge from CMHTs.5  The BMA report, however, frames mental health funding strategies as ‘unambitious’, with planned funding not at the level needed to meet increasing service usage.  It’s a common refrain from general practice that funding and staffing aren’t meeting demand, and the same problem is impacting community mental health services.2

Complexity and gaps in care

The complexity of the mental health system in the NHS is seemingly designed to foster variations in care.  With regional variation between NHS Trusts in their offerings for psychological therapies, referral pathways are not always clear for GPs considering these therapies for their patients.  Professionals offer (or not) dialectical behaviour therapy (DBT), cognitive analytic therapy (CAT), Eye Movement Desensitisation and Reprocessing (EMDR), Compassion-Focussed Therapy (CFT) or trauma-informed CBT within NHS Talking Therapies or CMHT, with different referral criteria based on age and complexity depending on local professional capacity and expertise.  Additionally, many GPs have limited knowledge on the different and evolving types of psychological therapies, and are subsequently not confident in understanding which specific therapies may meet the needs of their patients when considering onward referrals.6

While understanding what services are available for patients is one side of the coin, the flipside is the increasing number of patients who don’t fit into a clear referral pathway based on their needs.  Primary Care Network (PCN) Wellbeing teams and NHS Talking Therapies are often unable to take on patients with complex social needs, substance misuse or childhood trauma, but these patients may not reach the referral thresholds for CMHT.  This creates a gap in care where GPs and patients are systemically excluded from support from specialist services.  A King’s Fund report from 2021 suggested that this gap should be a main priority for those redesigning local primary and community mental health services.  This redesign should include better two-way communication between primary and secondary care and a more collaborative and flexible service allowing expert input and advice from specialists for patients who might not meet specific referral criteria.7  As the authors of the King’s Fund report point out, implementing this kind of collaborative working takes time, relationship-building and trust.  The tensions between increasingly stretched primary and secondary care health providers can undermine that trust building as GPs try to find the right care for their patients.  It is the pressures on the system that are damaging patient care, and as a start, it’s worth acknowledging the system pressures at play to ease those cross-specialty tensions rather than fuel them.


  1. 40% of all GP appointments about mental health: Mind; 2018 [Available from:
  2. “It’s broken” Doctor’ experiences on the frontline of a failing mental healthcare system. London: British Medical Association; 2024.
  3. Morgan C, Ashcroft DM, Chew-Graham CA, Sperrin M, Webb RT, Francis A, et al. Identifying prior signals of bipolar disorder using primary care electronic health records: a nested case-control study. Br J Gen Pract. 2024.
  4. Chew-Graham C, Slade M, Montana C, Stewart M, Gask L. A qualitative study of referral to community mental health teams in the UK: exploring the rhetoric and the reality. BMC Health Serv Res. 2007;7:117.
  5. NHS Mental Health Implementation Plan 2019/20-2023/24. NHS England; 2019.
  6. Cullinan V, Veale A, Vitale A. Irish General Practitioner referrals to psychological therapies. Ir J Psychol Med. 2016;33(2):73-80.
  7. Naylor CB, A.; Baird, B.; Heller, A.; Gilburt, H. Mental health and primary care networks. The King’s Fund; 2020.

Featured image by Marco Bianchetti on Unsplash

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