Inequalities in referral pathways for young people accessing secondary mental health services in south east London

The present study found that those who identified as Black African were more likely than those who identified as White British to be referred from secondary health or social/criminal justice services compared to GP, and the effect was most pronounced for those aged 16–17 years, with a sevenfold and sixfold increase in odds for the Black African and Black British groups, respectively. Our findings are consistent with evidence from a previous study conducted in south east London which found that African–Caribbean patients were significantly less likely to access care through a general practitioner than were White British patients, with less than 30% of African–Caribbean patients accessing care in this way [11]. Similar patterns have been found in young people accessing NHS-provided Child and Adolescent Mental Health Services (CAMHS) [48, 49]. We also found that less than 20% of Black African patients were referred to services by a general practitioner which is in line with the previous studies [11]. Our findings suggest that Black individuals living in south east London, particularly those who identify as Black African, may face barriers to accessing primary care that their White British counterparts do not. For example, previous research conducted with south east London residents suggest that there are ethnic group differences in whether help for mental health problems is sought from friends, family or religious leaders, with evidence for Black African individuals being more likely to seek help from a religious leader and less likely to seek formal help [50]. Further qualitative research with individuals from the same community sample found that reasons for not seeking professional help for mental health problems included perceiving their problems as normal or unsuitable for professional help, negative expectations of professional help, believing informal strategies were sufficient, fearing being stigmatised for having a mental disorder and help-seeking, and self-perceptions of being strong and/or self-reliant [51]. The intensity and nature of stigmatising beliefs about mental illness are affected by cultural beliefs and vary between ethnic minority groups [52]. For example, within some Black communities in the UK, people with mental health problems are seen as violent or dangerous [53]. As a result, families can both stigmatise the person with mental illness, and in turn, themselves be stigmatised through association. Such stigma can act as a barrier to young people seeking help for mental health problems, particularly if they can only access services when taken by a parent/caregiver.

Crucially, our findings show that ethnic variations in referral source are greatest for those aged 16–17 who may already face difficulties accessing mental health services or transitioning from adolescent to adult services [54]. This study highlights the importance of providing support to ethnic minority adolescents accessing secondary mental health care through their GP and ensuring that it is maintained after they turn 18. There remains a lack of robust research available on transitional care for adolescents accessing mental health services. Further research is needed on young people’s journeys through the transition from adolescent services to adult services.

Our results showing that Black African and Black Caribbean individuals were approximately twice as likely as White British individuals to be referred to inpatient services compared to outpatient services support findings from the previous studies which show that ethnic minorities are more likely to be referred to inpatient services than their White counterparts [15, 17]. Conversely, “Other” ethnicity was associated with decreased odds of referral to inpatient services compared to outpatient services. However, it is hard to draw conclusions from this finding as we were unable to discern which ethnicities were included in this category due to insufficient recording of these data in the clinical records.

It was found that Black African individuals in the 16–17 group and Black British individuals in the 18–29 group were more likely than those who identified as White British to be referred to emergency services compared to outpatient services. These findings partially support our second hypothesis that ethnic minority individuals, especially those aged 16–17, would be more likely than White British individuals to be referred to emergency services compared to outpatient services. Our findings are consistent with the existing literature that shows ethnic minorities are more likely than White individuals to use emergency mental health services [15]. Together with the finding that Black African individuals are less likely to access secondary mental health services through their GP and are more likely to be referred by social/criminal justice services, our results suggest that Black African individuals experience more negative pathways to care at both the point of access to secondary mental health services and also once they have been accepted for treatment. Being referred from social/criminal justice services and being referred to emergency services are both characterised by involuntary admission at a point of crisis with severe and long-lasting consequences for the individual. These findings suggest that Black African individuals may not receive the help which they need in time, perhaps because of a reluctance to use mental health services or as a result of other cultural and systemic barriers to care [55, 56], resulting in the worsening of symptoms over time until drastic last-resort measures are taken. Moreover, it has been found that Black African adolescents are less likely to stay in treatment than their White peers, further highlighting the importance of providing culturally appropriate mental health treatments for young people from ethnic minority backgrounds [57‐59].

The final set of findings is related to the associations between referral source and referral to inpatient services compared to outpatient services; emergency services were dropped from the analyses due to low cell sizes. The results showed that those referred from secondary health services or social/criminal justice services were significantly more likely than those referred from GP to be referred to inpatient services compared to outpatient services. This result suggests that those who are referred to services via more adverse pathways (i.e., secondary health services and social/criminal justice services compared to GP) may find themselves being referred for high-intensity treatment requiring admission to hospital (i.e., inpatient treatment compared to outpatient treatment). To the best of our knowledge, there are no recent studies conducted in the UK that examine the relationship between referral source and referral to inpatient and outpatient services. Overall, the findings from this study suggest that inequalities in referral destination may be perpetuated by inequalities generated at the point of access.

In this study, we used an innovative data resource that allowed us to identify a large cohort from an ethnically diverse area and assess differences in referral pathways for each ethnic minority group. Most of the research in this area has been conducted in the US and often lacks the power to look at the differences between Black African and Black Caribbean groups. Using natural language-processing applications to extract detailed information on ethnicity from unstructured or free text, this study was able to identify Black African, Black Caribbean, and Black British individuals. Psychiatric case registers that include complete electronic health records offer exciting opportunities for future research into the referral pathways of young people living in south east London. They do, however, have important limitations: much information of interest is not recorded in a standardised way and the data available, and their quality, depend upon clinicians’ accuracy and timeliness in reporting of clinical information. This is particularly pertinent to the SLAM BRC Case Register, which draws data directly from routine administrative and clinical sources (rather than the older generation of registers which have been more involved in the collection and cleaning of incoming data) [29, 31]. This results in a high proportion of missing data and the need for clinician engagement in the process of generating data of this nature for research purposes. Importantly, migration status was missing for approximately half of the sample. This highlights the need for clinicians to routinely collect this information; however, this may be challenging given the current contentious political and social debates around migration. In addition, referral source was missing for almost a quarter of the sample due to insufficient recording of these data. Further missing data meant that variables used in adjusted models had high proportions of missingness and we were not able to look at the relationship between referral source and admission to emergency services due to low cell sizes. The generalisability of the findings beyond the study setting is unclear and further research in other settings is needed. In different areas of the UK, or indeed different areas of London, mental health services that are available to young people will vary widely, as will the age at which individuals are discharged from child and adolescent services and referred to adult services [3, 60]. Furthermore, the study uses a psychiatric sample of patients whose anxiety and depression symptoms have penetrated through primary care services to secondary mental health care, representing more severe end mental disorder rather than primary care level mental disorder. Therefore, findings could not necessarily be extrapolated to primary care samples only. Nonetheless, this study provides urgently needed evidence on the inequalities in referral pathways for young people accessing secondary mental health services.

It is becoming more widely acknowledged that a person’s age does not necessarily dictate need. Although there must be age “cut offs” for services and certain provision, it is important to identify inequalities in health services that could impact the cover provided to young adolescents, especially as they transition to young adulthood. The current system is failing to provide adequate support in childhood/early adolescence when issues may be at their most treatable. The Royal College of General Practitioners recommends that GP trainees in the future should receive specialist-led child health and mental health training, and GP surgeries should aim to be more “youth friendly” by involving young people in patient participation groups, communicating practice news over social media (Twitter and Facebook), and increasing the use of digital technology as a means to connect with their younger patient population. Community organisations such as Black Thrive (www.​blackthrive.​org.​uk), which brings together Lambeth’s Black communities and service providers to reduce the inequality and injustices experienced by Black people in mental health services, need to be ubiquitous in ethnically diverse areas. At an individual level, clinicians need to receive regular implicit bias training to ensure that they do not overlook certain behaviours in some ethnic groups which may be the hallmarks of mental health problems. At a structural level, health inequalities can also be tackled by introducing affirmative action policies to lower the threshold for certain ethnic groups that have a long history of facing barriers to accessing health services.