Opinions and experiences of tertiary-level mental health providers regarding the down-referral of patients: A qualitative study

Abstract

Background: Down-referral of patients from tertiary psychiatric hospitals to primary healthcare (PHC) is central to South Africa’s National Mental Health Policy, which advocates for decentralised, accessible and sustainable mental healthcare. This process supports continuity of care, reduces pressure on specialist services and promotes community reintegration. Despite these benefits, challenges such as limited PHC resources, poor medication supply, inadequate staffing and stigma undermine effective implementation. This study explored the opinions and experiences of mental health providers at Weskoppies Psychiatric Hospital, a tertiary psychiatric facility in Pretoria, South Africa, to better understand these challenges, perceptions and potential strategies.
Methods: A qualitative, exploratory design using grounded theory was employed. Purposive sampling was used to recruit 12 healthcare professionals who worked at the outpatient department and were involved in the down-referral process, with data collection continuing until theoretical saturation was reached. Semi-structured interviews were conducted. Data were analysed thematically.
Results: Five key themes emerged: (1) The importance of early planning for discharge and down-referral but inconsistently applied; (2) patient resistance, often driven by fear, stigma and distrust of PHC, complicates transitions; (3) perceived challenges at PHC included staff shortages, long waits and poor medication availability; (4) perceived stigmatisation; and (5) recommendations for improving the down-referral process including better communication, dedicated referral coordinators, use of outreach teams, improved documentation and dedicated mental healthcare providers at the PHC level.
Conclusion: Down-referral is necessary but challenged by systemic and relational gaps. Down-referral can be enhanced by improving PHC capacity, standardising discharge planning and reducing stigma. Patients and their families should be included in care decisions.
Contribution: This study provides insight into the lived experiences of healthcare providers managing down-referral from tertiary to PHC services. It highlights barriers and practical strategies that can inform policy implementation and strengthen community-based mental healthcare.