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doi:10.1016/j.ijn
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International Journal of Nursing Studies 44 (2007) 387–395
www.elsevier.com/locate/ijnurstu
Gatekeeping access to community mental health teams:A qualitative study
Phil McEvoya,�, David Richardsb
aSalford PCT/University of Manchester, Manchester, UKbUniversity of York, UK
Received 6 January 2006; received in revised form 13 May 2006; accepted 21 May 2006
Abstract
Background: Gatekeeping access to services at the interface with primary care has been identified as one of the key
issues that community mental health teams (CMHTs) have to confront.
Objectives: The aim of this study was to develop a better understanding of the contextual influences that impact upon
the outcome of gatekeeping decisions.
Design: An interview-based qualitative study, informed by the philosophy of critical realism.
Setting: An urban catchment area in Northern England.
Participants: Twenty-nine interviews were conducted with gatekeeping clinicians and service managers.
Method: A convenience sample of clinicians was initially approached to take part in a series of semi-structured
interviews. This was followed up by a purposive sample of clinicians and service managers, as specific contextual
influences were identified and explored in detail. The emerging analysis was then subjected to critical scrutiny by a
further sample of gatekeeping clinicians.
Findings: A clear hierarchy of appropriateness was identified with four dimensions: severity, risk, beneficence and a
moral dimension. It was suggested that the salient contextual influences that shaped the hierarchy were: (a) the need to
fit in with strategic planning directives, (b) the burden of responsibility that clinicians carried, (c) the high number of
referrals and the relatively slow turnover of patients on clinical caseloads, (d) the position of CMHTs in the economy of
care and (e) the character of the relationship between clinicians and service managers.
Conclusion: The findings from the study support a multi-level view of the gatekeeping process within CMHTs, which
takes account of the role that key contextual influences play in shaping the range of options that are available to
gatekeeping clinicians.
r 2006 Elsevier Ltd. All rights reserved.
Keywords: Community mental health teams; Gatekeeping; Hierarchy of appropriateness; Key contextual influences
What is already known about this topic?
Previous qualitative studies have suggested that
g decisions have been largely determined
e front matter r 2006 Elsevier Ltd. All rights reserve
urstu.2006.05.012
ing author.
ess: [email protected] (P. McEvoy).
by individual clinicians and teams, rather than
through formal strategic control.
What this paper adds
�
d.
The study identified that access to community mental
health teams now appears to be more tightly con-
strained.
ARTICLE IN PRESSP. McEvoy, D. Richards / International Journal of Nursing Studies 44 (2007) 387–395388
�
A clear hierarchy of appropriateness was identified.�
It was suggested that the key contextual influencesthat shaped the form of the hierarchy were: the
influence of strategic planning directives, the burden
of responsibility that clinicians carried, the high
number and slow turnover of patients on clinical
caseloads, the structure of the economy of care and
the quality of the relationship between clinicians and
service managers.
1. Introduction
Generic community mental health teams (CMHTs)
are designed to promote integrated mental health care,
as a result of multidisciplinary working. They have
evolved since the late 1970s and they are now the main
vehicle for co-ordinating and delivering specialist com-
munity mental health care in England (Department of
Health, 2002; Onyett et al., 1995; Simmonds et al.,
2001). The Department of Health has consistently
recommended that CMHTs should refine their role by
focusing upon those in greatest need (Department of
Health, 1999a, b, 2002). However, it has proved difficult
to establish consistent priorities due to a combination of
factors including the lack of a consensus definition of
severe mental illness (SMI), pressure from primary care
providers to provide support to patients with common
mental health problems, a lack of alternative provision
and managerial reluctance to challenge clinical decisions
(6 and Peck, 2004: Colombo et al., 2003; Onyett et al.,
1997; Peck and Hills, 2000; Simpson et al., 2003).
Gatekeeping which is defined in the Dictionary of
Social Work as the control over acess to services
(Thomas and Pierson, 1995) is one of the key issues
that CMHTs have to confront (Singh, 2000). Previous
qualitative studies that have examined the working of
CMHTs have pointed to the arbitrary nature of the
gatekeeping processes at the point of entry from primary
care. It has been suggested that clinicians have dealt with
the pressures created by the high demand for their
services by muddling through, and that patterns of
practice have been determined by individual clinicians
and teams, rather than through formal strategic control.
While some clinicians and teams have focused exclu-
sively upon patients with SMI, others have taken on a
broader range of work in order to ‘rescue cases’ and deal
with acute crises (Kaner et al., 2003; Patmore and
Weaver, 1992; Wells, 1997). Although these studies have
offered a compelling insight into the internal workings
of CMHTs, they tend to examine actions of individual
teams and team members in isolation, without fully
exploring the impact of the organisational context
within which CMHTs operate. The aim of this
qualitative study was to develop a better understanding
of the salient contextual influences that shape the
outcome of gatekeeping decisions. The study was
informed by the philosophy of critical realism, which
stresses the importance of exploring the generative
mechanisms and structural relationships that influence
the outcome of material events and cultural practices
(Archer, 1998; Bhaskar, 1989; Sayer, 1992).
2. Methods
Twenty-nine interviews were conducted with the gate-
keeping clinicians and service managers between June 2000
and July 2003 in an urban catchment area in Northern
England. The interviews were conducted by the main
author (PM) who was working as a part-time community
psychiatric nurse (CPN) in the catchment area in which the
interviews were conducted. Permission was given by the
local research ethics committee to carry out the interviews
without having to apply for formal ethical approval. The
length of the interviews ranged from 25 to 105min, with a
median duration of approximately 55min. A selective as
opposed to a random sampling frame was employed and
potential interviewees were approached for different
reasons at each stage of the inquiry. In the initial stage
of the inquiry, a convenience sample of gatekeeping
clinicians was selected (12). These interviewees differed
with respect to their gender, ethnicity, disciplinary back-
ground and the seniority of their position, and the
interviewer endeavoured to draw upon their differing
perspectives in order to identify the significant issues that
needed to be explored. Each interview took the form of a
guided conversation (Rubin and Rubin, 1995) using a
schedule that covered six areas:
�
The clinicians’ background and previous experience.�
Their views concerning the core functions of the CMHTsand the significant developments that had taken place
within CMHTs during the course of their careers.
�
The nature of the referral process and the systemsemployed for managing referrals to the CMHTs.
�
Decision making criteria, grey areas and forums fordiscussing decisions within the CMHT.
�
Pressures on the CMHTs, for example, resourceconstraints, statutory responsibilities, pressures asso-
ciated with managing risk and the volume of referrals.
The interviews were audiotaped and transcribed using
QSR NUD*IST v4 (Qualitative Solutions and Research,
Non-numerical Unstructured Data Indexing, Searching
and Theorizing version 4). Using the method of constant
comparison (Strauss and Corbin, 1998) open codes were
developed to categorise and sort the data. In the second
stage of the inquiry, further interviews were conducted
with a purposively selected sample (Patton, 1990) of
service managers (5) and clinicians (6). Potential
ARTICLE IN PRESSP. McEvoy, D. Richards / International Journal of Nursing Studies 44 (2007) 387–395 389
interviewees were approached because it was thought
that they would be able to amplify the key contextual
influences that had been identified in the initial stages of
the inquiry. New themes were added to the schedule as
the inquiry was opened up in order to explore the impact
of structures and processes that had not previously been
considered in detail, such as the impact of the service
commissioning process. Using the logics of iterative
abstraction and retroduction (Yeung, 2003), a series of
more abstract axial and selective codes were created and
structural relationships postulated. In the final stage of
the inquiry, the emerging theory was subjected to critical
scrutiny by a further sample (6) of gatekeeping
clinicians. Using the interview procedure advocated by
Pawson and Tilley (1997), the interviewees were asked to
comment on the emerging theory and they confirmed its
validity. The majority of the interviewees were CPNs
(17). However, interviews were also conducted with
practitioners from other disciplinary backgrounds in-
cluding occupational therapy (1), social work (2),
psychiatry (4) and health/social service management (5).
3. Findings
3.1. Gatekeeping procedures
The CMHTs had moved from a ‘heterocratic referral’
process (Morrill et al., 1999) in which referrals were
randomly allocated to individual clinicians to an
integrated referral process. New referrals were delegated
to be seen by a CPN or psychiatrist using a standardised
assessment format, which incorporated a detailed profile
of the patient’s presenting complaint, a health and social
history, mental state examination and risk assessment.
Following the assessment assessors sought the views of
their colleagues and discussed the benefits of following
different courses of action. Peer supervision had a
collegiate character and the assessors were rarely
challenged directly. However, the supervision exerted a
moderating effect, as it tended to reinforce accepted
norms and strengthen the assessors’ resolve to refer less
‘appropriate’ patients to other services.
Some of us have real difficulties saying no. So if we
feel maybe that we’ll see them for a short period of
time we’re going to present those people in the team
meeting now. So that other people may say ‘‘No
that’s primary health care or no you shouldn’t be
getting involved ..’’. CPN 17
3.2. The hierarchy of appropriateness
Discussions about the criterion for accepting referrals
were framed within the general discourse of boundary
management and referral appropriateness.
You think this is not an appropriate referral for want
of a better phrase. CPN 7
There was a clearly understood hierarchy of appro-
priateness (Charles-Jones et al., 2003), which had four
dimensions: severity, risk, beneficence and a moral
dimension. The dimensions of severity and risk were
the dominant dimensions. Beneficence and the moral
dimension were most evident when marginal decisions
were made and a reasonable case could be made for
more than one course of action. The dimension of
severity was divided into three tiers based upon the
patient’s diagnosis, level of social functioning and
potential vulnerability (see Fig. 1 below).
Tier one consisted of patients with a psychotic SMI
such as schizophrenia and bi-polar affective disorder
who experienced moderate to high levels of symptoma-
tology and social impairment, co-morbid alcohol or
substance misuse, or other problems such as a learning
disability. The provision of multidisciplinary packages
of care to this client group was seen as the first priority
and main strength of the CMHTs.
Somebody that presents with fairly obvious psychotic
features .. wouldn’t be discharged. CPN 1
Tier two included patients who were identified as
having a non-psychotic SMI who were given long-term
support by the multidisciplinary team, plus a group of
vulnerable patients with moderate-to-severe depression
who were given short-term support by individual team
members because they were deemed to be at risk.
Patients within tier three were usually referred to
alternative resources and were seldom given access to
CMHT support. This tier included patients with mild-
to-moderate depression and anxiety, patients with a
primary diagnosis of a drug or alcohol disorder and
patients with life problems, as opposed to specific mental
health problems.
If it appears to be a mild, mild/moderate disorder.
Things that can be addressed through simple
medication or brief focussed counselling or whatever,
I refer it back to primary care and I never get
involved in treatment .. Psychiatrist 4
The dimension of risk was often closely allied
to the dimension of severity, as increases in the severity
of the patient’s mental health problems were often
accompanied by an increase in the scale of the appraised
risks, but the two were not synonymous. If the
gatekeeping clinician perceived that there was a
risk of an untoward event such as suicide, serious
violence or self-neglect, then the patient moved
further up the overall hierarchy of appropriateness,
irrespective of their ranking upon the dimension of
severity.
ARTICLE IN PRESS
Fig. 1. The dimension of severity.
P. McEvoy, D. Richards / International Journal of Nursing Studies 44 (2007) 387–395390
Patients you may see for short term follow up? PM
People who seem to be a sort of higher than average
level of risk y People who have had problems with
treatments that they have had from their GP who
seem particularly vulnerable .. CPN 5
Risk was distinctive among the four dimensions of the
hierarchy of appropriateness, as it tended to be
conceptualised in terms of striking a balance between
preserving the autonomy and choice on the one hand
and avoiding significant hazards on the other.
Clinicians emphasised the importance of doing this in
the context of a collaborative relationship. At the end of
assessment interviews, they routinely summed up their
findings and sought the patient’s view about how best to
proceed, before working out together the options that
could be pursued.
You’ve got to try to get them on board because if you
don’t you’re wasting your time. CPN 4
The dimension of beneficence was most evident when
the clinicians spoke of their feelings of regret about
having to refer patients on to other services. If there was
a clear window of opportunity to help alleviate the
patient’s problems and prevent any further deterioration
by engaging in short-term interventions, then the patient
was more likely to be offered support. The potential
impact of patients’ problems upon their dependent
children was also taken into account.
I mean you get somebody .. For example a lady with
panic disorder who is struggling at home with two
children who because of the panic disorder won’t let
the children play out. So it’s not just affecting her it’s
affecting the development of her children .. CPN 5
Like the dimension of beneficence, the moral dimen-
sion was much more prominent when clinicians dis-
cussed marginal decisions. Distinctions were made
between patients on the basis of how genuinely
deserving they seemed to be. At one end of the spectrum
were patients who were thought to be accessing services
under a false pretext. They were less likely to be offered
support. At the other end of the spectrum, clinicians
sometimes went beyond their strictly defined remit
because they felt that they had a moral duty to act in
the patient’s best interests. For example, a CPN
explained that she had taken a young woman with
borderline learning difficulties onto her caseload, after
consulting with her manager.
One particular girl, young girl erm .. I think she was
about 18, 19 she had a combination of borderline
learning difficulties and mild mental health problems
.. there wasn’t a service ... I ended up having to take
her because there was no-one .. no-where else. CPN3
3.3. Key contextual influences
Many contextual influences appeared to play a role in
shaping the form of the gatekeeping procedures and the
accepted hierarchy of appropriateness. However, the
most salient influences that were identified by the
interviewees were:
(a)
The need to fit in with strategic planning directives.(b)
The burden of responsibility.(c)
The high number of referrals and the relatively slowturnover of patients on individual caseloads.
(d)
The position of the CMHTs in the economy of care.(e)
The relationship between clinicians and servicemanagers.
ARTICLE IN PRESSP. McEvoy, D. Richards / International Journal of Nursing Studies 44 (2007) 387–395 391
3.4. The need to fit in with strategic planning directives
The service managers and senior clinicians indicated
that the CMHTs were subjected to much tighter
regulatory and budgetary control than in the past, when
clinicians had been able to define the parameters of their
own practice. NHS Trusts had a statutory duty to assure
the quality of clinical provision via clinical governance
and managers were accountable for the performance of
clinical services (Scally and Donaldson, 1998).
The health service is not a fully managed service yet.
But it will be. We’re on our way there, you can’t
ignore it .. Service Manager 4
The National Service Framework (NSF) for Mental
Health (Department of Health, 1999b) was very
influential because of the role it played in shaping
expectations about the way in which services were
configured and the form of the contracts that were
negotiated with service commissioners. The NSF identi-
fied the types of patients that can be expected to be dealt
with within particular tiers of service provision and set
performance indicators against which local services were
measured. Future investment in the CMHTs was
contingent upon their compliance with the key perfor-
mance targets.
Changes are decided within a local health economy in
respect to national strategic intent. For example, the
discussions in the LIT (local implementation team) as
to whether we invested in the local community teams
or went for new teams y Service Manager 4
The regulatory frameworks were reinforced by an
independent inspection system and the routine recording
of information about organisational performance had
made it easier for managers to monitor patterns of
clinical practice. The leverage that service managers had
was evident from the way in which managers had been
able to push through changes in working practices and
establish measures to monitor the CMHT’s perfor-
mance, despite opposition from front-line clinicians
including some of the consultant psychiatrists.
It’s in the NSF therefore y[our managers] react. We
were approached by senior management who wanted
to know how they could get patient appointments
within two weeks .. That was clearly a management
target, not a clinical one .. that’s infuriating ..
Psychiatrist 1
3.5. The burden of responsibility
The potential recriminations that could occur in the
event of an adverse incident, prompted clinicians to take
the potential impact of a worst-case scenario very
seriously. The imposition of the Care Programme
Approach (Department of Health, 1990), which was
designed to allay public fears about the policy of
community care by ensuring that effective safeguards
were put in place exacerbated their fears that they could
be singled out for blame if they failed to prioritise their
work or comply with formal procedures.
When the shit hits the fan society will come looking
for us. That’s been repeated time after time y Social
Worker 1
Most of the longer serving clinicians had been
involved in the care of at least one patient who had
either committed suicide or been involved in another
incident of a serious nature. Many of them said that
subsequent inquiries had validated their actions. Even
so, they were aware that they could be ‘hoisted by their
own petard’, if they failed to control the size of their
caseloads. It was becoming increasingly difficult to fulfil
their statutory requirements, without cutting corners
and taking avoidable risks. Hence, they curtailed their
impulse to take on more patients than they could
reasonably handle.
At the end of the day you know it won’t matter that
you were doing 101 other things .. You didn’t write
the notes and that’s the end of it .. CPN 17
3.6. The high number of referrals and relatively slow
turnover of patients on individual caseloads
Caseloads were well above the levels recommended by
the Department of Health (Department of Health,
2002). For example, CPN caseloads were in the range
35–55, even though the Department of Health has
advised that they should not exceed 35. Clinicians
stressed that their ability to take on extra work was
tightly constrained and that they needed to establish
clear priorities in order to cope with the pressures of
their work. Their frustration was apparent from their
complaints about their workloads and the number of
‘inappropriate referrals’.
When I sort of step back it just appears to me that
we’re being asked to do too much with too little
resource. The elastic is basically just being stretched
too far .. Psychiatrist 4
Clinicians accepted some patients with common
mental health problems on to their caseloads for short-
term work, as they felt obliged to intervene to deal with
crises. This added to their workload and created extra
pressures as it disrupted the scheduling of their work.
If you want an emergency service you’ve got to
accept the fact that people need to be available to
deal with the crisis as and when it happens .. Rather
than trying to provide a long term planned service
ARTICLE IN PRESSP. McEvoy, D. Richards / International Journal of Nursing Studies 44 (2007) 387–395392
where you’re booking people weeks in advance and
providing some sort of crisis/emergency stuff [as well]
.. CPN 4
A number of the service managers suggested that the
CMHTs could speed up the turnover of patients on
individual caseloads by utilising a step up/step down
model for the sub-group of the patients with SMI who
had moderate levels of symptomatology and were
relatively stable. However, the clinicians who were asked
about these proposals suggested that their managers
underestimated the importance of the maintenance work
that was done with this group of patients.
Many of the people that are apparently ‘sleepers’ are
maintained because the CPN occasionally tinkers
with their management and support at the appro-
priate time ... Psychiatrist 1
3.7. The position of the CMHT in the economy of care
Shifts in the contours of the economy of care were
anticipated as a result of the move towards the provision
of primary care based mental health services and more
specialist functional teams. However, it was anticipated
that CMHTs would retain a key role in supporting
patients with SMI and that they would continue to be
used as a default option, as they had less control over
their boundaries than other more specialist services that
had more specific functions.
Ultimately CMHTs are about enabling people to live
in the community aren’t they? In a way being the hub
of a system that enables as many people as possible
with mental health difficulties to live in the commu-
nity. Service Manager 3
3.8. The relationship between clinicians and service
managers
Service managers tend to adopt the new public
management discourse, which emphasises the need to
establish patient-centred services and curb the role that
professional self-interest plays in determining how
public services are run (Harrison and Smith, 2003).
They were seeking to develop a more distinctive
managerial culture and keen to implement strategic
policy directives. Clinicians tend to be much more
preoccupied with the ‘coal-face’ issues of their heavy
workloads. They were irritated by what they saw as
unnecessary managerial interference and sought to
defend their professional culture. However, although
the respective agendas of service managers and clinicians
differed, they had a coalition of interests that placed an
onus upon the establishment of clearly defined bound-
aries and both groups supported the concept of a tightly
focussed CMHT.
The overall function of the community mental health
team is to provide erm .. care, support and treatment
for people with serious mental illness. That is very,
very specific .. CPN 2
4. Discussion
Previous qualitative studies have suggested that gate-
keeping decisions have been largely determined by
individual CMHTs, rather than through formal strategic
control. This study indicated that gatekeeping clinicians
within CMHTs now appear to be more tightly
constrained, a finding that is consistent with the findings
of recent quantitative surveys, which have indicated that
CMHTs are targeting patients with SMI (Barr, 2000;
Keown et al., 2002; McEvoy et al., 2000).
The interviewees identified that patients were afforded
different levels of access depending on their position in a
hierarchy of appropriateness, which had four dimen-
sions namely severity, risk, beneficence and a moral
dimension. Supporting patients with SMI was regarded
as the CMHTs’ core function, and the concept of SMI
that underpinned the dimension of severity had two
threads, which bore a close resemblance to the differing
perceptions of SMI among CMHT members identified
by King (2001). The first thread encompassed patients
with schizophrenia and bi-polar affective disorder. The
second thread encompassed a small minority of patients
with anxiety, depression and personality disorders.
Supporting primary care was regarded as the auxillary
function of the CMHTs (Department of Health, 1999b).
Clinicians fulfilled this role, albeit reluctantly by
providing short-term support to patients with moderate
to severe depression who rated highly on the dimension
of risk due to the potential risk of suicide.
Marginal gatekeeping decisions were influenced by the
dimension of beneficence and the moral dimension of
the hierarchy of appropriateness. The dimension of
beneficence was based upon the principle of utilitarian-
ism, whereby acts that produce greater potential benefits
are likely to be chosen, ahead of others where the
benefits are not likely to be as great (Gandjour and
Lauterbach, 2003). The moral dimension was mediated
by the distinctions that the gatekeeping clinicians made
between undeserving and deserving patients. These
findings are consistent with many studies that have
examined how the kinds of services that are offered to
patients are influenced by the value judgements made by
clinical personnel (Hughes and Griffiths, 1997; Jeffery,
1979; Mizrahi, 1985).
The gatekeeping clinicians and service managers that
were intervieweed pointed out that gatekeeping deci-
sions were strongly influenced by the practices that were
institutionalised in the CMHTs’ referral systems, the
need to fit in with the strategic planning directives and
ARTICLE IN PRESSP. McEvoy, D. Richards / International Journal of Nursing Studies 44 (2007) 387–395 393
the demands that arose from the CMHTs’ position in
the economy of care. The single entry point for dealing
with referrals from primary care clarified the referral
pathway and promoted the adoption of consistent
working practices. It was backed by a dominant
coalition of senior clinicians and service managers. This
‘coalarchic authority structure’ (Morrill et al., 1999) was
deceptive, however, as it was strongly influenced by the
‘arms length’ control that was exerted by the Depart-
ment of Health. ‘Strategic directional guidance’ (Archer,
1995) in the form of the NSF for Mental Health and the
Care Programme Approach was reinforced by clinical
governance mechanisms such as the routine monitoring
of information about organisational performance and
an external inspection process.
Denis et al. (2001) have suggested that the most
powerful mechanisms for redefining professional bound-
aries and identities are those that utilise a combination
of mechanisms to control their behaviour, without
directly threatening professional autonomy. These con-
trol mechanisms were clearly in place and there were
clear incentives for both service managers and gate-
keeping clinicians to implement strategic planning
directives. Focussing the resources of the CMHTs upon
patients with SMI made it easier for managers to achieve
their performance targets and it limited the liabilities
that could arise for clinicians if they overstretched their
resources.
The majority of gatekeeping decisions were made on a
pragmatic basis, in contrast to the altruistic motives,
which Brown and Crawford (2003) highlighted in their
account of managerial control of CMHTs. The clin-
icians who were interviewed were resigned to the view
that the need for some form of defensive gatekeeping or
rationing is inevitable, as the external constraints that
impinged upon their practice gave them relatively little
room for manoeuvre. However, they could be criticised
for adopting a ‘near-sighted’ (Levy, 1991) ‘supply side’
outlook, as they failed to consider alternative ways of
utilising their resources. Some of the resources that were
invested in defensive gatekeeping procedures may have
been utilised more efficiently, if they had been deployed
in alternative ways. For example, recent developments
that extend the capacity of primary care to provide in-
house management of psychological problems illustrate
the potential benefits of exploring different models of
practice and ways of working (Richards et al., 2003).
Finally, the findings from the study indicate how
pervasive the culture of blame within the English mental
health services is perceived to be (Prins, 1999; Salter,
2003). Although none of the clinicians that were
interviewed had been involved in a major inquiry, they
were deeply suspicious of the inquiry system and lived
with the nagging feeling that they could be publicly
vilified. This sense of trepidation was exemplified by the
social worker who said that ‘‘when the shit hits the fan,
society comes looking for you’’. His remark was spoken
as a truism and it mirrors the feeling of vulnerability that
Peck and Norman (1999) identified among psychiatrists
working in CMHTs. There is a sense in which the
question of whether or not the clinicians perceptions
were accurate or not is immaterial, as they did have a
real effect. As a result of their reading of the situation,
they were more inclined to apply gatekeeping procedures
more rigorously than they may otherwise have done.
They feared that they ‘could be hoisted by their own
petard’, if they took on more work than they could
reasonably manage. Hence they curtailed the impulse to
take more patients on to their caseloads.
5. Concluding remarks
Nurses exercise a gatekeeping role in controlling access
healthcare resources across the world. For example, nurses
play a prominent gatekeeping role in telephone advisory
services (Holmstrom and Dall’Alba, 2002), general prac-
tice (Hegney et al., 2004) and in controlling the allocation
of beds on acute medical wards (Latimer, 2000). The
critical realist philosophy that informed this qualitative
study supports a multi-level view, which takes account of
the key contextual influences that shape the range of
options that are available to clinicians gatekeeping access
to CMHTs in Northern England. The authors hope that
this will stimulate interest in the further application of
critical realist principles in relation to gatekeeping and
other aspects of nursing practice.
The main limitation of the study was that the
dynamics of the interviews and the interpretation of
the data were influenced by the main author’s status as a
CPN interviewing colleagues in clinical practice. On the
one hand this may have helped to elicit shared
experiences, but it may have also cut off some avenues
of inquiry (McEvoy, 2001). The views of patients and
other key stakeholders were not canvassed and more
research is needed in order to develop a better under-
standing of how their perceptions of ‘appropriateness’
are likely to impact upon their help-seeking behaviour
(Goode et al., 2004). Further investigations using other
sources of data are also required to develop effective
ways managing the demand for services (Rogers et al.,
1998). If access to patients is to be opened up and
clinicians are able to move on from ‘playing Scrooge’
(Light, 1997), radical systemic changes within the
economy of mental health care may be required.
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