• Phil McEvoy and David Richards.
• Salford PCT/University of Manchester, Manchester, UK. pmcevoy@fs2.nu.man.ac.uk
• Int J Nurs Stud. 2007 Mar 1;44(3):387-95.

BackgroundGatekeeping 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.ObjectivesThe aim of this study was to develop a better understanding of the contextual influences that impact upon the outcome of gatekeeping decisions.DesignAn interview-based qualitative study, informed by the philosophy of critical realism.SettingAn urban catchment area in Northern England.ParticipantsTwenty-nine interviews were conducted with gatekeeping clinicians and service managers.MethodA 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.FindingsA 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.ConclusionThe 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.

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