Primary and Secondary Care, and referring to mental health services

Where there is no immediate risk of harm to the person or others, the first step is usually to encourage them to contact their GP, or offer to help them arrange or attend an appointment. Ensuring that someone experiencing homelessness is registered with a GP is an important first step in accessing the healthcare and support they may need.

GPs often have a good understanding of a person's mental health history and may already have a care plan in place. They can assess mental health needs, provide support within primary care, coordinate care, and refer people to specialist mental health services where appropriate. Although, in exceptional circumstances, a GP may make an urgent referral without carrying out an assessment, specialist mental health services will usually expect the GP to have assessed the person where possible.

Many mental health needs are now managed within primary care. GP practices often include mental health professionals, such as Community Psychiatric Nurses (CPNs), and can provide access to psychological therapies through NHS Talking Therapies services (formerly IAPT). For some people, receiving support through their GP feels more accessible and less daunting than attending a specialist mental health service. Some NHS Talking Therapies services also accept self-referrals, although a GP referral may be more appropriate where someone's needs are more complex.

Primary care mental health services are generally suitable for people with mild to moderate mental health difficulties who can be safely supported without specialist intervention. People with more complex mental health needs, higher levels of risk, or co-occurring substance use are more likely to require support from specialist mental health services.

Some specialist mental health services will only accept referrals from people who are registered with a GP within their local service area. Although this requirement can sometimes be challenged, particularly where there are significant risks, it is best to help someone register with a GP as early as possible. Doing so will make it much easier to access specialist services if they are needed later.

People experiencing homelessness can face difficulties registering with a GP because some practices incorrectly ask for identification, proof of address, or immigration documents before accepting them. However, NHS guidance is clear that:

- GP practices can register someone with no fixed address by using the practice address.

- GP practices cannot refuse to register someone because they cannot provide identification, proof of immigration status, or proof of address.

If a GP practice refuses to register someone, you can challenge the decision using the NHS guidance on patient registration.

If someone prefers to register independently but is encountering difficulties, you can provide them with a "My Right to Access Healthcare" card. This reminds GP reception staff that people experiencing homelessness have the same right to register with a GP as anyone else.

Some areas also have GP practices or specialist primary care services that focus on supporting people experiencing homelessness. If you are unable to resolve registration issues with an individual practice, your local Integrated Care Board (ICB) should be able to advise on how people experiencing homelessness can access primary care in your area.

Mental health referral pathways vary across different areas, so it's difficult to give generic advice. Many services have moved away from single teams providing a broad range of care towards larger, more specialised teams responsible for functions such as triage, assessment, short-term intervention, or longer-term treatment.

To identify the correct referral route, search for the NHS mental health service covering your local area. If you are unsure, the individual's GP surgery should be able to advise on the local referral process.

When making a referral, include any information that may affect how the person is contacted, assessed, or supported. For example, note if they require an interpreter or if there are known risks, such as aggressive behaviour. Providing clear information helps ensure the referral reaches the most appropriate team. For example, someone experiencing a first episode of psychosis would usually be referred directly to an Early Intervention in Psychosis service rather than a general adult mental health team.

Mental health services carry out an assessment to understand a person's needs. This typically covers their current symptoms, physical and mental health history, social circumstances, family history, and any risks.

The assessment can feel intrusive, particularly for people with a history of abuse or trauma, as it involves detailed personal questions. Individuals have the right to have you or another trusted person with them during the assessment, although the assessor may ask to speak to them alone for part of it.

After the assessment, the individual may not receive an immediate decision. Complex cases are often discussed by a multidisciplinary team before the most appropriate support or treatment is agreed.

Read our multi-disciplinary team meetings guidance here.

Long-term community mental health teams focus on recovery, with the aim of helping people reach a point where their needs can be managed in primary care. These multidisciplinary teams may include psychiatrists, community psychiatric nurses, social workers, support workers, occupational therapists, and clinical psychologists.

Following assessment, individuals are usually allocated a Care Coordinator, who oversees their care and coordinates support. Some people may only see a psychiatrist, while those with more complex needs may receive input from several professionals within a team.

Individuals should receive a care plan setting out the support they will receive and who will provide it. Care plans should be reviewed regularly, and other agencies involved in the person's care should be invited to reviews where the individual consents.

These teams may also act as the gateway to more specialised services, such as psychotherapy or forensic mental health services, which often require referral following a comprehensive mental health assessment.

Care Coordinators often manage large caseloads and may not always be immediately available. If you have urgent concerns and cannot reach the Care Coordinator, ask to speak to the team's Duty Worker, who can provide advice and support.

These teams are often called Crisis Teams or Crisis Resolution/Home Treatment Teams and are available for specific cases of acute mental health needs. Their primary role is to provide an alternative to hospital admission by delivering intensive short-term support, often through daily or twice-daily visits, either to prevent admission or to enable early discharge from hospital.

Home Treatment Teams usually accept referrals only from mental health assessment or recovery teams, as they are often the gatekeepers for hospital admission. They carry out their own assessment to decide whether someone can be safely supported in the community or requires inpatient care.

They are often unable to work with people who are sleeping rough because it is difficult to provide intensive treatment and safely monitor risk in an uncontrolled environment.

A Home Treatment Team may decide not to accept a referral for several reasons, including:

- there is no need for intensive medication monitoring or daily clinical input;

- the person would struggle with seeing different staff members rather than one consistent worker;

- the level of risk does not require daily monitoring;

- existing support from other agencies can be increased instead; or

- intensive support is likely to reinforce dependency on services, as can occur with some personality disorders or anxiety disorders.

People can be admitted to a psychiatric hospital in several ways. If they are able to give valid, informed consent, they may be admitted voluntarily.

If a person lacks the mental capacity to decide about admission because of an impairment or disturbance of the mind or brain, they may be admitted under the Mental Capacity Act (MCA) following a Best Interests decision. This is only possible if they do not object to admission or treatment.

In some cases, where the restrictions placed on the person amount to a deprivation of liberty, additional authorisation is required. Although the Deprivation of Liberty Safeguards (DoLS) have been used for this purpose, they are being replaced by the Liberty Protection Safeguards (LPS), which provide similar legal powers.

Where a person needs hospital treatment but refuses admission, lacks capacity and objects, or is likely to withdraw their consent, they may be detained under the Mental Health Act (MHA). This process, commonly referred to as "being sectioned", can only be carried out by specially trained professionals, who usually refer to it as detention rather than sectioning.

A person can only be detained under the Mental Health Act (MHA) if they have a mental disorder of a nature or degree that warrants hospital treatment, and they present a risk to their own health or safety, or to others, that justifies detention.

Before this can happen, they must undergo an MHA assessment. This is usually carried out by an Approved Mental Health Professional (AMHP), a Section 12-approved doctor with specialist psychiatric training, and a second doctor, usually an independent psychiatrist. The Home Treatment Team is often involved in the assessment process. Assessments can take place wherever the person is, although, where necessary and lawful, the police may take someone to a place of safety for assessment.

The assessment team must balance the person's need for treatment and risk management against their right to make their own decisions. Because detention is a serious and potentially distressing intervention, it is only used when the legal threshold is met.

An MHA assessment may result in no further action, follow-up by a GP or community mental health team, support from the Home Treatment Team, voluntary admission, admission under the Mental Capacity Act where the person lacks capacity but does not object, or detention under the Mental Health Act.

If your client is not admitted to hospital following an assessment, the AMHP should be able to explain the reasons for the decision and discuss what support you and other services can provide instead.

In an emergency, when you cannot wait to seek advice from mental health services, call the police. This should be reserved for situations where a person is experiencing severe mental health symptoms or distress and presents an immediate, serious risk of harm to themselves or others.

Although the police are not mental health professionals, they play an important role in keeping people safe during a mental health crisis. They receive training in responding to mental health incidents and will often manage the immediate risk before involving mental health services.

If the person is already receiving support from a mental health team, contact the team as soon as possible to let them know what is happening so they can take any necessary action.

If someone is behaving aggressively or presents an immediate risk to themselves or others, the police have several powers available. They may intervene to prevent a breach of the peace, arrest the person if a crime has been committed, or encourage them to attend hospital or contact their mental health team if urgent care is needed.

Where someone appears to have a mental disorder, needs urgent care or control, and is unwilling to attend hospital, the police may use Section 136 of the Mental Health Act to take them to a place of safety for assessment. This is usually a specialist mental health assessment suite. Section 136 can only be used in places accessible to the public and cannot be used to remove someone from their own home.

Mental health services often have high demand and limited capacity, so they rely on referrals containing clear, relevant information to prioritise who needs support and how quickly.

Referrals may be delayed or declined if important details are missing. Wherever possible, the referral should be made by the professional who knows the person best, so they can clearly explain concerns and respond to any questions from the service.

Note that the approach to referral forms varies from service to service, so it's really important that you read each one thoroughly to understand what information is required.

Sometimes you won't have all the information needed, especially when someone is new to your service or reluctant to share details. Gather as much information as possible and explain any gaps in the referral, including the reasons for them, as this may provide important context.

Use clear, accurate, and specific language rather than dramatic or vague descriptions or support requests.

Explain your concerns with evidence, such as the nature and severity of any self-harm, what medical attention has been provided, or specific behaviours that make you concerned about risk.

Avoid labels such as “dangerous” unless you can provide clear examples, as referral information becomes part of a person’s health record and can affect future risk assessments and access to services.

Use plain descriptions rather than medical terms. Instead of using broad labels such as “psychosis” or “depression”, describe the person’s thoughts, speech, behaviour, and symptoms, as these provide a clearer picture of their needs and level of risk.

Make referrals reliable, appropriate, timely, and clear. Avoid marking all referrals as urgent, as this makes it harder for services to prioritise genuine emergencies.

Discuss the decision with the practitioner involved to clarify concerns and understand their rationale, if it does not appear to meet the person’s need

If needed, seek support from your manager to escalate concerns appropriately.

Mental health services can't support everyone experiencing mental health difficulties, so referrals may be declined or people may be discharged after assessment. Common reasons include:

Substance misuse: It can be difficult to assess mental health needs when someone is intoxicated, as drugs or alcohol can worsen symptoms or cause experiences such as hallucinations or delusions. Where substance misuse is the main concern, referral to drug and alcohol services may be recommended, although joint working with mental health services may sometimes be appropriate. In some areas, there may be access to a 'dual diagnosis' service where substance use and mental health needs can be addressed at the same time.

Personality difficulties: A diagnosis of personality disorder does not automatically exclude someone from mental health support, but engaging in longer-term therapeutic work can take time. The stability, trust, and support you provided can be an important foundation before someone is ready for structured therapy.

Existing support: If someone is already receiving appropriate care from other services, additional mental health input may be unnecessary or confusing. A decision not to offer specialist support can sometimes reflect progress and recovery rather than a lack of need.

Needs below the threshold for secondary care: Specialist mental health services generally support people with moderate to severe or enduring mental health problems. If someone does not meet this threshold, they may be directed to their GP or primary care mental health services instead.

Good partnership working means creating a shared care plan that includes the support you already provide. Maintain regular communication and ensure mental health teams understand your role, as many of your actions may be therapeutic even if they are not formal interventions.

Working together during hospital admission

If a person is admitted to hospital, stay in contact with ward staff and attend reviews where possible, especially before discharge. This helps ensure a safe, coordinated plan, particularly as the period after discharge can be high risk. Be clear about what support your service can and cannot provide, especially where homelessness may affect discharge planning.

Working together after referral

Continue communication after a referral is accepted. Sharing your observations can help tailor care plans, and mental health teams may provide advice on challenges such as poor engagement, anxiety, or complex behaviours. Joint working can improve support and help teams respond consistently to the person’s needs.