According to the World Health Organization, half of all people with ill health in Western Europe have mental illness, with the majority coming into the diagnostic categories of anxiety and depression. Such problems impose substantial emotional, social and economic burdens on those who experience them, their families and carers, and society as a whole.

The National Service Framework for mental health in England dictated that the majority of patients with common mental health problems should be managed in primary care. Currently 90% of people with mental health problems in the UK are managed by GPs. Primary care provides the first point of contact for many people and also act as a gatekeeper to other statutory services. GPs can refer patients to primary care mental health teams for short-term psychosocial interventions, but in reality have limited access to secondary care services.

The UK’s National Health Service (NHS) states it has an explicit access-driven health policy framework, yet there is evidence that individuals with high levels of mental distress may be unable to access care, either because it is not available or because the individual’s interaction with care-givers deters or diverts help-seeking. This is the premise of the AMP study (“AMP—Improving Access to Primary Mental Health Care” in Liverpool and Manchester), a National Institute for Health Research funded project (RP-PG-0606-1071). The aim of AMP is to increase equity of access to high quality mental health services in primary care. Groups with inadequate access to primary care include people, from black and minority ethnic (BME) communities, asylum seekers, homeless people and adolescents with eating disorders. Groups who receive inadequate help when they do access primary care include elders, people with advanced cancers, those at risk of long-term sickness absence, and people with medically unexplained symptoms (MUS).

As outlined by Kovandžić et al., research on access has been driven by two different disciplinary perspectives. Firstly, health services research has traditionally examined access to health care from the point of entrance to the formal system of care. The focus here is on supply-side factors, the availability of treatments, and on structural and organizational change to remove barriers, rather than on demand issues governing the journey of the patient in need. Key concepts such as demand, availability, utilization, and patterns of use are developed in a functionalist view of the relation between service provision and use. In addition, the literature has tended to focus on whether mental health issues are recognized by primary care practitioners.

Secondly, behavioral and social science traditions focus mainly on an “out-of-service” perspective, for example, on processes that happen before the point of entrance into formal systems of care, formulating the scope of research into an umbrella term of “help-seeking”. Broadhurst identifies a series of three-stage models of help-seeking, summarizing their variations in (a) problem definition, (b) deciding to seek help, and (c) actively seeking help. Access is conceptualized as an interaction between supply and demand of services mediated and codified by professionally defined needs for services. Dixon-Woods et al. describe a model of access which attempts to explain where barriers might be for people seeking care. Candidacy captures how people’s eligibility for healthcare is determined by the interaction between patients and health services. Following identification of candidacy, individuals attempt navigation and negotiation to gain a point of entry to health services. Rogers et al.’s. concept of recursivity refers to the interdependency between a user’s experiences of health services and her/his future actions in regards to health and help seeking. A further term, concordance, was used by Stevenson and Scambler to convey the need for the help seeker and the practitioner to find common ground in terms of what the problem and its subsequent solutions might be. Concepts such as candidacy, navigation, recursivity, and concordance imply that user perspectives and their interaction with clinicians in primary care are vital to understand the type of care given and received and its influence on future help-seeking.

Most of the literature around detection of mental health problems in primary care relates to depression and for over 40 years, GPs have been told that they fail to diagnose depression. Some studies, however, indicate that clinically significant depression (moderate to severe depressive illness) is detected by GPs at later consultations by virtue of the longitudinal patient-doctor relationship and it is milder forms, which may recover spontaneously, that go undetected and untreated. Some authors draw attention to the dangers of the erroneous diagnosis of depression in patients with a slight psychological malaise and little functional repercussion leading to the risk of unnecessary and potentially dangerous medicalization. Detection of depression may be poor if primary care clinicians lack the necessary consultation skills or confidence to make the diagnosis correctly. Initiatives to improve GPs’ skills in the detection and management of depression have been evaluated but such interventions alone have not led to improvements in patient outcome.

There is only a limited literature considering the patient perspective and this focuses on the limited value of Western approaches to mild and moderate depression in patients of different ethnic groups. This literature indicates that people may have difficulty in presenting their distress and discussing their concerns with their doctor, especially when they are uncertain that depression is a legitimate reason for seeing the doctor.

Some people consider that the GP is not the most appropriate person to talk to or believe that symptoms of distress should not be discussed at all in the primary care consultation. Others feel that they do not deserve to take up the doctor’s time or that it is not possible for doctors to listen to them and understand how they feel. Whilst previous literature attempts to explain the difficulties people from hard-to-reach groups have in dealing with mental health problems, they focus on understandings of mental illness, rather than access per se. This paper aims to explore help-seeking and access to care from the perspectives of potential patients from “hard-to-reach” groups.