Advice & Refer in Mental Health

How advice and refer works in Mental Health in the NHS, and how it could be improved

Mental health waiting lists in England have reached a scale that is difficult to comprehend. In 2024/25, 1.81 million people were referred to NHS Talking Therapies alone.  More than one million children in England had active referrals to NHS mental health services during 2024–25, marking the first time annual referrals surpassed the one million mark. And CAMHS waiting lists in some areas exceeded 18 months for an initial assessment. Adult community mental health teams are managing caseloads well above safe levels in many trusts.

The demand problem in mental health is well documented. What gets less attention is the referral pathway problem that sits underneath it.

Why mental health referrals fail in the same way acute referrals do

The structural issues in mental health referral pathways are almost identical to those in acute care. GPs making referrals without specialist input. Referrals arriving in secondary care with insufficient clinical context. Cases sitting in queues before being triaged. Patients not knowing the status of their referral or when they might be seen.

The consequences in mental health are arguably more serious. A patient waiting six months for a CAMHS assessment is not simply waiting for a clinic appointment. They are waiting for a clinical opinion that may determine whether they are safe, whether they need urgent intervention, or whether they can be supported in primary care with the right guidance. Delayed triage in mental health is not a waiting list problem. It is a clinical risk problem.

The case for Advice & Refer in mental health starts from the same place as it does in dermatology or cardiology: a GP with a clinical question should be able to get specialist input before making a referral, rather than sending a patient into a queue and waiting weeks to find out whether the referral was appropriate.

The community mental health transformation context

NHS England's community mental health framework, which has been rolling out since 2019, explicitly aims to shift the model away from threshold-based referral systems toward more flexible, integrated care. It’s designed to support children and adult mental health waiting lists to decline. Patients should be supported closer to home, with specialist input available earlier in the pathway rather than only after a formal referral to a secondary care service.

That is the direction of travel. The gap between the policy ambition and what is operationally available to GPs in most areas remains wide. A GP concerned about a patient's mental health still largely faces the same binary choice they faced a decade ago: refer to a service with a long waiting list, or manage in primary care without specialist input. The middle ground — fast, documented specialist advice that helps the GP decide what this patient actually needs — is not consistently available through existing referral infrastructure.

The same argument applies to the NHS-wide Advice & Refer push. The policy intent is right. The tools needed to make it work at scale have not yet caught up in mental health the way they are beginning to in some acute specialties.

What mental health A&R triage actually looks like in practice

Effective Advice & Refer in mental health requires more than a message from a GP to a community mental health team. It requires the right clinical information at the point of triage, a fast response, a documented outcome, and a clear next step for the patient and referrer.

That means the GP being able to share relevant clinical history, risk indicators, and their own assessment quickly and in a structured format. It means the specialist being able to review that information with enough context to give a meaningful response, rather than requesting more information before they can say anything useful. And it means the outcome of that exchange being recorded and visible to everyone involved, including the patient where appropriate.

In CAMHS pathways, where young people and their families are often waiting for a CAMHS referral in significant distress, the communication element matters as much as the clinical one. A parent who has been waiting months for an assessment with no update is not just frustrated. They are often managing a child who is struggling, without any support or guidance while they wait.

Digital pathways that include patient and family notification as part of the workflow close that gap. The family knows the referral has been received, knows when it has been reviewed, and knows what the outcome is. That does not shorten the waiting list. But it changes the experience of being on it, which matters in mental health more than almost any other specialty.

Where community mental health referrals go wrong

Two patterns appear consistently in community mental health referral pathways:

The first is inappropriate referrals — patients sent to secondary care services who could have been managed in primary care with the right guidance, adding to waiting lists that are already unmanageable. 

The second is delayed escalation — patients who are referred but whose needs are more urgent than the referral conveyed, because the referral pathway did not give the GP a way to communicate that effectively or gave the triaging team insufficient context to identify it.

Both are addressable through better triage. A structured digital A&R pathway in mental health gives GPs a way to seek specialist input before referring, which reduces inappropriate referrals. It gives triage teams richer clinical information, which helps them identify urgency accurately. And it creates a documented record of the clinical exchange, which matters for governance and patient safety in a specialty where both are under particular scrutiny.

What ICBs should be asking about mental health referral pathways

Mental health has been slower than acute care to adopt structured digital triage at scale, partly because the community mental health transformation has focused on workforce and service redesign, and partly because the complexity of mental health presentations makes standardisation harder.

Neither of those is an argument against trying. The referral pathway problems in mental health are the same as everywhere else, and the case for fixing them is, if anything, stronger. ICBs reviewing their community mental health referral pathways should be asking the same questions they are asking about acute specialties: 

• What proportion of referrals could have been handled differently with earlier specialist input? 
• How long does triage take? 
• What happens to patients while they wait?

The answers tend to point in the same direction.

To discuss what structured digital mental health triage could look like in your mental health pathways, get in touch with the Cinapsis team. You can also read more about what good Advice & Refer implementation looks like across specialties.