Factors influencing the referral of patients to psychiatrists by general practitioners.

The investigation was carried out among a defined population of 27,000 occupying a valley about 6 miles long and nowhere more than half a mile wide. The inhabitants live in eight named townships strung out along the valley floor to form what amounts to a continuous narrow ribbon of urban-type housing. Physical features of the local mountain landscape clearly establish the boundaries of the valley community, except at its lower end where the valley joins another similar valley and where, for the purposes of this study, an arbitrary line of demarcation is drawn. From the point of view of mental health services the valley population is in the catchment area of Morgannwg Hospital, Bridgend (2,300 beds), and is in the administrative county of Glamorgan. The hospital is 15 miles from the valley, but members of the staff conduct an out-patient clinic in a general hospital only 9 miles away and also provide a domiciliary consultant service. A few patients from the valley are also admitted to Whitchurch Hospital, Cardiff (800 beds; 13 miles distant), the staff of which conduct an out-patient clinic in Cardiff Royal Infirmary, 17 miles from the valley. There are virtually no private psychiatric facilities in South Wales and it was evident on talking to the general practitioners in the valley that referral to a private psychiatrist outside South Wales was an extreme rarity. The general practitioners whose practices form the basis of this study comprise all those working in the valley in 1959 and consist of eight male married doctors with an age range of from 37 to 70 years (mean 53 2). The mean time since registration as medical practitioners was 26 4 years (range 7 to 37). All eight doctors had spent the greater part of their working lives in the valley. Four of them were working single-handed; the remaining four were in two partnerships of two doctors each, making six practices in all. For purposes of analysis the practices will be designated A, B, C, D, E, and F. As will be seen from Table I, the position in 1959 was that practices A, D, E, and F were manned by one doctor each, designated Doctor Ai, Di, Ei, and Fi respectively, while practices B and C were partnerships of Doctors Bi and Bii, and Doctors Ci and Cii. All six practices were long-established and changes in the doctormembership during the period under scrutiny for this inquiry were relatively slight. In almost 9 yearsfrom January 1, 1951, until September 20, 1959four changes in the practices in the valley took place, as shown schematically in Table J.