The provision of clinical psychology services within a general hospital: An analysis and interpretation of referral rates

 SMJ 2003 48(3): 76-81

Introduction

Clinical psychologists have the potential to contribute to the treatment of psychological and behavioural aspects of diseases in virtually all major medical specialities.¹ In recent years the UK has seen a significant expansion in the role of psychologists within general hospitals.² Despite this, clinical psychologists continue to be seen by other health care professions as a "virtually unknown group".³ Hence, a marketing task is required for the profession to ensure that the effectiveness of clinical psychology reaches its target population.⁴

Perception of need is an important factor in referral rates, in particular within the environment of general medicine and surgery. The biomedical model of care predominates in these areas of medicine, potentially promoting patient passivity. Moreover, it is often ineffective in treating a range of seemingly physical disorders, as many patients seek medical services for psychologically based problems.⁵ In contrast, clinical psychology introduces psychosocial management strategies which may conflict with traditional medical practice,⁶ due to a lack of understanding of psychological practice.⁷

The attitudes and behaviours of health professionals influence expectations regarding health problems.⁸ A number of studies demonstrate the under-diagnosis of mental health problems in patients with physical disorders.⁹ This suggests some carers consider physical and psychological health problems as distinct. This may lead to underprovision for patients with both difficulties. Perception of need has also been implicated in health outcomes. Physician's perceptions may impact on outcome by affecting the patient's cognitions and behaviour, or by altering medical procedures and treatments as a result of their beliefs.¹⁰

Fundamentally then, psychological care provision within the setting of the general medical setting requires ?. By moving away from traditional biomedical models of care, it may be possible to establish a system that identifies and addresses the psychological needs of the patient.  Further study of the attitudes of health professionals may counterbalance previous attention given to the attitudes of service users.⁸ If included in a wider research agenda, this may positively influence the individual professional's understanding of their role and knowledge of psychosocial health issues, in turn improving the future delivery of health services in the future.

Therefore, in this study, medical and surgical consultants were asked about the clinical psychology service offered to departments within a general hospital. The Department of Clinical Psychology under study, has offered psychological service to medical and surgical departments for eighteen years, and regularly receives referrals from a number of departments. However, not all departments refer. Thus, a primary aim of the study was to examine why certain departments fail to utilise the service. Further aims included;

1. To differentiate between high/regular and occasional/non-referring departments on the basis of referral patterns and referral decision factors.   

2. To assess the level of knowledge regarding clinical psychology among departmental representatives. It was hypothesised that high/regular referring departments would demonstrate a higher level of knowledge and understanding than low/non-referring departments.

3. To examine the perception of present and future need for a clinical psychology service. It was hypothesised that high/regular referring departments would report a greater perceived need for the service and would demonstrate a greater level of acceptance for psychological input to the care of patients.

Methods

Participants. All nominated departmental representatives were hospital-based consultants (n = 15) with a mean of twelve years experience at that level of practice.

Materials. An eighteen item, semi-structured interview integrating Likert type, categorical and open-ended questions was developed for the study (Appendix 1). Items were included which related to relevant literature. This eighteen item interview included Likert type, categorical and open ended questions. Participants were also invited to offer additional information and discuss issues relating to the provision of the clinical psychology service in more depth.

Procedure. The lead consultant from each medical and surgical department in the hospital (n = 15) nominated a departmental representative to participate in the study. All representatives had knowledge of referral practices within the department. All participants were met in their own departments, and interviewed for an average of twenty minutes.

All participating departments were allocated to a high/regular (H/R) or occasional/non-referring grouping by way of median split analysis. This approach was adopted due to the large range of referrals (0-30). The median number of referrals per year was calculated (median = 1 referral). Those departments above the median allocated to the H/R group. These were infectious diseases, neurology, gynaecology, anaesthetics, haematology, general surgery and general medicine. Those below were allocated to the O/N group. These were radiology, accident and emergency, dermatology, orthopaedics, urology, cardiology, renal and ENT. Representatives allocated to the O/N group were asked question 7 (Q7; Appendix 1), in addition to other interview items.

Results

Referral Patterns and Processes Reported by Departments. All representatives were aware that a psychological service was available within the hospital. Three departments (20%) reported they became aware of the service because they specifically looked for it, the remainder (80%) could not recall how they became aware of the service. Half of the O/N group said that they would not refer to the department. The remaining four O/N departments in that group reported they would refer 1-5 patients to the service each year. In the H/R group, 28.6% identified 16-20 patients as their most representative referral rate, 28.6% identified 6-10 patients, whilst 42.8% opted for 1-5 patients. No representatives in the O/N group who said they referred, felt they were making full use of the service. Reasons included an awareness of limited resources, and a lack of psychological understanding among colleagues (e.g. one surgical consultant stated, "If they can't operate, they don't want to know"). In the H/R group three of the seven representatives said perception of a long waiting list prevented them from making full use of the service.

Question 7 was only administered to participants in the O/N group. All eight participants identified, as reasons for non-referral, a lack of information about the service and the role of clinical psychologists. A quarter of the departments considered the service as irrelevant to patient care, although all believed that clinical psychologist had a role to play in the hospital. All occasional referring departments (n = 4) perceived the waiting list to be too long, whilst six non-referring departments reported they might refer to another agency (e.g. psychiatry, GP) prior to clinical psychology.

All participants in the O/N group considered "waiting times for treatment" and a "good outcome from previous referral" as important in their decision to refer (see Table I). There was a significant difference between the responses of the O/N group and the responses of the H/R group (waiting list, c2(1)=4.29, p < 0.05; good outcome, c2(1)=4.29, p < 0.05). Both groups identified patient motivation to seek psychological support as important in their decision process. The H/R group (n = 7) also believed that knowledge of a member of staff at the Department of Clinical Psychology was important.

Table I - Factors involved in the decision to refer: A comparison of high/regular and occasional/non-referring departmental responses

Level of Knowledge and Understanding about Clinical Psychology Practice as Demonstrated by Departments. Respondents from both groups suggested that the treatment of anxiety, depression, psychosexual difficulties and adjustment to life events were services offered by clinical psychologists. The H/R group identified behavioural management as a service offered by clinical psychologists significantly more often than the O/N group (c2(1) = 4.77, p < 0.05; see Table II). All participants in the H/R group recognised that relaxation training was also offered by the service. Hypnotherapy and advice about medication (included as distracters) did not differentiate between the groups.

Table II - Types of services offered by the Department of Clinical Psychology as perceived by departmental representatives: A comparison of high/regular and occasional/non-referring departmental responses 

^*p< 0.05

Participants in the H/R group rated pain management and psychological preparation for physical treatment as significantly more relevant to their department than did the O/N group (pain, Mann-Whitney U = 6.0, p < 0.05; psychological preparation, U = 6.5, p < 0.05; see Table III). Overall, behavioural management, adjustment to life events, neuropsychological assessment and relaxation techniques were rated highly relevant by the H/R group. A similar pattern was observed in the O/N group, although relevance ratings provided by these representatives were lower.

Table III - Relevance ratings as reported by departmental representatives for services offered by the Department of Clinical Psychology: A comparison of high/regular and occasional/non-referring departmental responses

* P< 0.05                                                                                                      

Overall, both groups most commonly identified adjustment to life events (n = 11), behavioural management (n = 13), neuropsychological assessment (n = 10) and relaxation techniques (n = 13) as services offered by the Department of Clinical Psychology. They also rated these services as relevant to their departments (adjustment, mean = 7.45, SD = 1.86; behavioural management, mean = 6.45, SD = 2.7; neuropsychological assessment, mean = 6.4, SD = 2.5; relaxation, mean = 7, SD = 2.2).  Overall, the H/R group rated all services as significantly more relevant than did the O/N group (U = 39, p < 0.01). The overall mean relevance ratings for the H/R and O/N groups were 7.2 and 4.9 respectively.

Most participants in the H/R group (71.4%) reported they would wait no longer than one month for a clinical psychologist to contact their patient following a routine referral. The remaining two (26.8%) participants were prepared to wait up to three months. For an urgent referral, 71.4% would not wait longer than one week. The remaining departments (n=2) would accept a wait of no longer than one day. In the O/N group, 75% would wait for up to one month following a routine referral, whereas two departments (25%) would wait up to three months. In terms of an urgent referral, 37.5% would like contact with a clinical psychologist within one day, whilst 62.5% would be prepared to wait for up to one week.

Perception of Need for a Psychological Service as Reported by Departments. The H/R group currently perceive the service as significantly more important to patient care than the O/N group (U = 9.5, p < 0.05). In general most participants in the O/N group (75%) did not feel that they currently had enough information about the service, while 71.4% of the H/R group felt that they did have enough information. Despite this, only one participant from the H/R group felt that they did not need further information about what the clinical psychology service could offer their department. Sixty three percent of the O/N group and 85.7% of the H/R group indicated interest in talks by a clinical psychologist within their department.

All H/R participants believed that clinical psychology had a future role to play in departmental patient care. Six out of the eight participants in the O/N group believed that psychology had a future role. Every consultant stated that one-to-one contact was appropriate within the hospital. Fifty percent of the O/N group felt that ward, consultancy, group and support work would be beneficial to their patients. In the H/R group 85.7% thought that ward and consultancy involvement would be beneficial and 57.1% felt that group and support work could benefit their department.

Discussion

Referral Patterns and Processes Reported by Departments. Although all departments were aware that the service existed, few could recall how they became aware of it. This suggests a lack of effective "marketing" by clinical psychology. The low level of perceived use of the service also supports this observation. Many departments reported that a long waiting list prevented them from referring. When asked informally, a number of participants indicated that they thought the waiting list to be longer than one year and all believed it to be more than six months for all referrals. In practice, the waiting list is generally less than two months, with most urgent referrals being seen within two days. Some years ago the waiting list was long due to staff shortages, but the length of the current waiting list has obviously not been communicated to those who found it to be a problem in the past.

Long waiting lists were identified by non-users as a barrier to referrals. A lack of information and understanding about the role of clinical psychologists was also identified as a reason for non-referral. However, very few departments believe clinical psychologists have no beneficial input to offer. This lack of understanding is perhaps reflected by the fact that non-referrers believe that a "good outcome from a previous referral" is important in their decision to refer. This suggests departments may be sceptical of clinical psychology. Among the referring group a greater understanding of clinical psychology was demonstrated, as all participants identified the importance of "knowledge of a member of staff at the Department of Clinical Psychology". It is recognised that these participants believe that good communication is vital if they are to gain satisfactory input to appropriate referrals.

Level of Knowledge and Understanding about Clinical Psychology Practice as Demonstrated by Departments. The overall impression of clinical psychology within the hospital appears to reflect rather traditional attitudes towards psychological practice. Most participants reported the work of psychologists included the treatment of depression, anxiety, stress reactions and psychosexual problems. However, when comparing referring and non-referring groups, referring departments were aware of more contemporary psychological interventions (e.g. pain management, psychological preparation for physical treatment) and were more likely to perceive these as important in care.

Desired maximum waiting time for treatment was higher than could be provided by the service. However, there was little difference between referrers and non-referrers in terms of preferred times. This suggests that even though referring departments would like to see shorter waiting times, they are still prepared to refer even with the current length of the waiting list. It may also mean that these departments are aware of the time pressures on the clinical psychology department and consequently only refer priority cases.  As noted, non-referring departments lack knowledge about the true length of the waiting list believing it to be, in some cases, more than one year. This further highlights the need for greater communication and information sharing between clinical psychology and other hospital departments.

Perception of Need for a Psychological Service as Reported by Departments. Not surprisingly, referring departments perceive a greater need for psychological input than non-referring departments. This seems closely related to the level of knowledge about psychological services held by departmental members. Despite the high levels of understanding among referring departments, most were still keen to hear more about potential clinical psychology input, reflecting a more open attitude and greater interest in psychological issues.

The majority of departments were open to the possibility of involving psychologists in patient care. Non-referring departments again displayed a more traditional view of this, tending to be less keen to use clinical psychologists in ward settings and were less interested in consultancy.

Assessment of Reasons For Referral/Non-Referral. Overall, the main reason for non-referral was a lack of understanding about the role of clinical psychologists in hospital settings. This is compounded by very traditional views about clinical psychology and psychological issues in healthcare. Lack of knowledge about the clinical psychology service in general (i.e. waiting list times, psychological services relevant to particular departments) seems to be another salient reason for not referring. This is exacerbated by poor communication and information sharing between such hospital departments and the Department of Clinical Psychology.

In contrast, reasons for referral are opposite to those above. Referring departments display a detailed knowledge of the psychological services they require, an open attitude towards psychological issues in medicine and surgery and a willingness to communicate directly with the Department of Clinical Psychology.

Limitations

The small sample of participants in this study limits the generality of the findings. A larger sample would have been desirable, but was not possible due to time constraints. Possible differences between the referring and non-referring groups may also have been masked by extraneous variables. Furthermore, it would be unrealistic to suggest that the views of one consultant were a representative reflection of an entire department. The nature of the sample selection has probably yielded participants with more positive views of clinical psychology within their department. This has been taken into consideration in the interpretation of results. In short, a larger scale study may have revealed more striking results.

Participants found some questions difficult to respond to with certainty. For example, when asked about their views on clinical psychology within medicine and surgery (i.e. Q11; Appendix 1), they found it difficult to generalise their views outwith their own department. This may have skewed results, with participants identifying services they thought may be beneficial to their own department rather than to medicine and surgery in general.

Implications

These results support previous research suggesting that the work of clinical psychologists is poorly understood among health care professionals.³ Therefore, clinical psychologists need to educate these professions in order to further develop psychological services.⁴ Some of the less positive views of psychology result from a lack of understanding about psychological practices⁷ and the tendency for some healthcare professionals to adhere strictly to the biomedical treatment model.⁶

This study gives rise to a number of findings and recommendations for the provision of psychological services to general hospitals. Education is vital to ensure that medical and surgical departments are made aware of relevant psychological services. Continued communication is imperative. Attracting referrals from departments will be pointless if these referrals are inappropriate and are not based on a good understanding of psychological practices. A lack of understanding of the psychological service was demonstrated by a number of departments, but in most cases these representatives were keen to learn more about the service. It seems that their low referral rates relate more to this lack of knowledge rather than to antipathy towards clinical psychology in general.

Conclusion

Clinical psychologists and medical practitioners can both learn from these findings. There is a growing awareness within the medical profession that psychological input can greatly benefit some groups of patients within general hospital settings. In general though, the level of understanding and knowledge of these psychological practices is still rather low. It is the task of clinical psychologists who work in these settings to appropriately market their services, educate potential referring agents and promote good communication with these departments. Findings suggest the majority of those interviewed would support such steps. Through this, those who subscribe to the biomedical and psychosocial models of healthcare may extend their appreciation of the strengths and weaknesses of their own approach to treatment. As a result they may find more common ground, thereby improving the level of psychological care within the general hospital setting.  

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