Introduction
Modern healthcare systems are often characterized by the principle of universal access, which is a fundamental aspect of health policy throughout Europe. The prevailing healthcare models in the region either ensure universal coverage or are decisively moving in that direction. Nevertheless, the universality of access is increasingly challenged by the structural and general phenomena that contemporary systems must address (Petmesidou et al., Reference Petmesidou, Guillén and Pavolini2020).
The growing impact of mental health conditions on individual well-being and healthcare systems represents one of the most pressing challenges for contemporary health services (Thornicroft, Reference Thornicroft2008; Arnaez et al., Reference Arnaez, Krendl, McCormick, Chen and Chomistek2020). The high prevalence rates of untreated mental disorders (Wittchen et al., Reference Wittchen, Jacobi, Rehm, Gustavsson, Svensson, Jönsson, Olesen, Allgulander, Alonso, Faravelli, Fratiglioni, Jennum, Lieb, Maercker, van Os, Preisig, Salvador-Carulla, Simon and Steinhausen2011; Shim et al., Reference Shim, Szilagyi and Perrin2022), persistent stigma, and substantial economic burden of mental illness (Doran et al., Reference Dorrian, Thorsteinsson, Di Benedetto, Lane-Krebs, Day, Hutchinson and Sherman2017) underscore the urgency of examining how mental healthcare is delivered, particularly within primary care.
To achieve universality and community-oriented objectives, health services were structured to integrate hospital care, primary care, and preventive services, promoting a more comprehensive approach to health that includes prevention, diagnosis, treatment, and rehabilitation. This was implemented by enhancing the role of general practitioners (GPs) as the central link among social services, health services, and patients. However, while GPs are consistently recognized as key actors in early detection and management (Lucas et al., Reference Lucas, Scammell and Hagelskamp2005; Grandes et al., Reference Grandes, Montoya, Arietaleanizbeaskoa, Arce and Sanchez2011; Stene-Larsen and Reneflot, Reference Stene-Larsen and Reneflot2019), few qualitative studies have analysed how they address patients’ mental health needs in daily practice or how their discretionary choices shape broader health outcomes.
This article contributes to filling this gap by offering empirical insights into the strategies employed by GPs in Spain and Italy in managing patients with mental disorders by examining 42 interviews with Italian and Spanish GPs and patients with mental disorders.
In Spain, 23% of patients attending primary care had experienced a mental disorder in the previous 12 months (Olivera et al., Reference Olivera, Benabarre, Lorente, Rodríguez, Pelegrín, Calvo, Leris, Idáñez and Arnal2008; Grandes et al., Reference Grandes, Montoya, Arietaleanizbeaskoa, Arce and Sanchez2011), while in Italy, approximately 38% of individuals with common mental health conditions are treated exclusively in primary care (Barbui et al., Reference Barbui, Papola and Saraceno2018). This burden is also reflected in pharmaceutical consumption: Spain shows one of the highest benzodiazepine use rates in Europe, which further increased during the COVID-19 pandemic (INCB, 2022; Ministerio de Sanidad, 2022), while Italy has maintained more stable patterns of psychotropic drug use (AIFA, 2022). Demographic ageing and loneliness exacerbate the risks of depression, cognitive decline, and suicidality (Luanaigh and Lawlor, Reference Luanaigh and Lawlor2008; Erzen and Çikrikci, Reference Erzen and Çikrikci2018; Pais et al., Reference Pais, Ruano, P. Carvalho and Barros2020). Although suicide rates in Italy (9.73%) and Spain (12.53%) remain below the EU average (16.75%) (EUROSTAT, 2024), suicide is the leading cause of death among Spanish youth aged 15–29 (Observatorio del Suicidio en España, 2023) and the third leading cause in Italy after accidents and cancer (Istituto Superiore di Sanità, 2022).
Drawing on Lipsky’s (Reference Lipsky2010) concept of Street-Level Bureaucracy (SLB), GPs can be understood as frontline actors who combine direct interaction with patients, constrained resources, and considerable discretion in decision-making (Harrison, Reference Harrison, Hupe, Hill and Buffat2015). This discretionary space requires them to balance their dual role as ‘state agents‘, implementing policies and procedures, and as ‘citizen agents‘ who respond empathetically to individual needs (Maynard-Moody and Musheno, Reference Maynard-Moody and Musheno2000). This negotiation between bureaucratic rules and human demands illustrates how GPs not only deliver care but also shape public policy outcomes through their everyday practices.
This perspective highlights the inherent tension between efficiency and standardization on the one hand, and relational, person-centred care on the other (Gofen et al., Reference Gofen, Strier, Gassner and Hupe2019). In the mental health field, GPs often serve as the first point of contact, but time pressures, heavy workloads, and fragmented services limit their ability to establish therapeutic relationships (Tai-Seale et al., Reference Tai-Seale, McGuire and Zhang2007; Giosa, Reference Giosa2024). In this regard, research by Lucas et al. (Reference Lucas, Scammell and Hagelskamp2005) shows how GPs feel less confident in managing mental health problems due to time constraints, limited knowledge of treatment options, referral pathways, and community resources.
Due to the lack of time and training, pragmatic coping strategies, such as increased reliance on medication, may prevail over more comprehensive approaches (Giosa, Reference Giosa2024). Acting as gatekeepers, GPs influence patients’ access to specialized mental health services through their discretionary decisions (Stene-Larsen and Reneflot, Reference Stene-Larsen and Reneflot2019; Giosa, Reference Giosa2024). Thus, GPs play a central role in negotiating patients’ eligibility and access to services, fostering their ‘candidacy‘ for care and cure (Dixon-Woods et al., Reference Dixon-Woods, Cavers, Agarwal, Annandale, Arthur, Harvey, Hsu, Katbamna, Olsen, Smith, Riley and Sutton2006).
Despite the ongoing demographic shift towards an increasingly aged population, the advancement of specialized mental health care for older adults has progressed at a relatively slow pace (Reynolds et al., Reference Reynolds, Jeste, Sachdev and Blazer2022). Consequently, treatment options for older patients with mental health issues remain limited, leading GPs to potentially rely on pharmacological prescriptions as the most accessible and immediate form of intervention for this patient group, thereby transforming their ‘candidacy to care‘ into ‘candidacy to drug‘.
These micro-level practices illustrate how professional discretion, organizational routines, and local adaptations interact with formal policy frameworks, linking everyday clinical work to broader structural and institutional processes. Against this backdrop, a set of pressing questions emerges: What does ‘universal access to mental health services from primary care‘ mean in practice? How do GPs navigate their dual role as state agents implementing standardized procedures and citizen agents responding to individual suffering? To what extent do discretionary choices shape patients’ eligibility and access to specialized care? By examining these questions through interviews with GPs and patients in Italy and Spain, this study illuminates the micro-level dynamics that ultimately drive institutional adaptation and the provision of equitable mental health care.
Aim
This study aims to examine how GPs in Spain and Italy manage patients’ mental health needs in daily practice and how their discretionary choices shape broader health outcomes.
Sample and methodology
The study was approved by the Ethics Research Committee of the Principality of Asturias and conducted and reported in accordance with the Consolidated Criteria for Reporting Qualitative Research.
Between June and November 2022, semi-structured interviews were conducted in Italy and Spain with two groups: GPs and patients with mental health disorders. 20 GPs participated, 10 in Spain (five females and five males, average age 51.1 years) and 10 in Italy (six females and four males, average age 41.3 years). 22 patients were interviewed, 11 in Spain and 11 in Italy, aged 28–75 years (average 52 years), with equal male and female representation. Participants were required to be at least 18 years old, and those with conditions that could worsen during the interview were excluded. Patients were first approached by their GPs or mental health professionals and, if interested, were contacted directly by the researcher.
Patient selection extended beyond age and sex to include diversity in type of mental health conditions, ranging from mild, recent-onset depressive and anxiety symptoms to long-standing bipolar and psychotic-spectrum disorders, several followed for decades in community mental health services. Severity ranged accordingly, from transient distress managed in primary care to chronic conditions requiring supported psychiatric housing.
All participants were informed about the study aims, assured of confidentiality, and signed a consent form in accordance with the General Data Protection Regulation. The interviews lasted at least 90 minutes, were audio-recorded, and conducted mainly in health centres or GP offices, with some held at participants’ homes or via video calls. Interviews with GPs focused on management strategies, discretion, and decision-making in mental health care, whereas patient interviews explored care pathways and personal experiences of accessing services.
The interviews followed a common topic guide with open-ended questions and storytelling to encourage rich accounts (Maynard-Moody and Musheno, Reference Maynard-Moody and Musheno2000). Recruitment was stopped once data saturation was reached, assessed iteratively during data collection: no new categories or meaningful variations in existing categories were emerging from additional interviews across either national site (Guest et al., Reference Guest, Bunce and Johnson2006; Francis et al., Reference Francis, Johnston, Robertson, Glidewell, Entwistle, Eccles and Grimshaw2010). The 20-GP and 22-patient sample was determined to be adequate given the focused comparative design and consistent saturation patterns within both countries.
The transcripts were analysed in the original language and coded using MAXQDA software for qualitative research. The codes were developed inductively and refined using theoretical input from SLB theory (Dubois and Gadde, Reference Dubois and Gadde2002). The credibility and trustworthiness of the results were established through peer debriefing by regularly meeting with supervisors to discuss coding and interpretations and by cross-referencing patient-reported data with information from GPs (Janesick, Reference Janesick and Ritzer2015).
Methodologically, Italy and Spain were selected as comparative cases because they share a common reliance on primary care as the principal gateway to mental health treatment, while differing in health service organization and resourcing. In both countries, GPs constitute the main point of entry for mental health concerns, with emergency departments and general hospital psychiatric units handling acute crises rather than dedicated psychiatric hospitals (Salvador-Carulla et al., Reference Salvador-Carulla, Costa-Font, Cabases, McDaid and Alonso2010; Volpe et al., Reference Volpe, Fiorillo, Luciano, Del Vecchio, Palumbo, Calò, Piras, Signorelli, Filippo and Piselli2014). Both national health systems cover psychopharmacological treatment and specialist psychiatric consultation, but publicly funded psychological therapy is comparatively scarce and unevenly distributed across regions in both countries (Salvador-Carulla et al., Reference Salvador-Carulla, Costa-Font, Cabases, McDaid and Alonso2010; Barbui et al., Reference Barbui, Papola and Saraceno2018). The two systems nonetheless diverge sharply in their de-institutionalization trajectories: Italy abolished standalone psychiatric hospitals outright, leaving a markedly lower density of psychiatric beds (9 per 100,000 inhabitants) than Spain, where some regions still operate psychiatric hospitals alongside an expanding community network (36 per 100,000 inhabitants) (EUROSTAT, 2021). Italian GPs additionally operate with greater autonomy as self-employed professionals managing their own appointment schedules, whereas Spanish GPs work within more standardized primary care centre structures. This combination of shared gatekeeping function and shared scarcity of psychosocial therapy, alongside divergent institutional history and organizational autonomy, makes the two countries a productive comparison for examining whether discretionary patterns are shaped more by organizational form or by resource constraint.
The age threshold used in the analysis was derived analytically from the data. While most GPs distinguished between ‘older‘ and ‘younger‘ patients qualitatively rather than with a precise cut-off, one participant explicitly stated an age limit of ‘60/65 years old‘ (GP6I). During coding, GPs’ treatment accounts for patients described as older consistently emphasized pharmacological management, while those for younger patients did not, even in the absence of an explicitly stated age threshold.
Principal findings
The analysis identifies two principal patterns in how GPs exercise discretion in managing mental health in primary care. The first involves a systematic age-based differentiation in clinical approach that shapes patients’ access to non-pharmacological care. The second is a counter-medicalization strategy through psychoeducation and the normalization of psychological distress. Read through Lipsky’s (Reference Lipsky2010) SLB framework, both patterns reflect how frontline professionals adapt their practice under conditions of resource scarcity. Interviewed GPs have between 1,200 and 2,020 patients, time-pressured consultations, limited referral options for specialist mental health care, and restricted access to community-based psychosocial services. Crucially, the effective space within which GPs exercise discretion – what Hupe (Reference Hupe2013) calls ‘discretion as used‘ – does not operate uniformly across patient groups. It is systematically wider for younger patients and narrower for older ones, producing differential access to care that challenges the substantive reach of universality, even within systems that formally guarantee it.
Age-based intervention: From counselling to minimal care
Among the coping strategies described by Lipsky (Reference Lipsky2010), the simplification of client categories is among the most consequential: when facing demand that exceeds available resources, street-level bureaucrats develop anticipatory judgements about the characteristics and needs of different user groups that routinize practice and reduce cognitive load. In this study, patient age functions precisely as such a heuristic. GPs in both Italy and Spain operate with an implicit, and sometimes explicit, age threshold of around 55–65 years, above which clinical reasoning shifts systematically towards pharmacological management:
Therefore, it depends on the age of the patient. I have an age limit of 60/65 years old. My first approach is a psychotherapeutic approach…there can also be a pharmacological approach, but always in agreement…if I have a seventy-year-old with sadness and depression, it is honestly more likely that I can then start with the medication (GP6I).
This is not simply a clinical judgement about what works for whom. It is a categorization practice that intersects clinical reasoning with structural constraints. Formally, GPs in both systems retain the authority to choose between treatment approaches for patients of any age; this is ‘discretion as granted‘ (Hupe, Reference Hupe2013). In practice, however, the conditions under which that authority is exercised differ substantially depending on patient age. For younger patients, GPs describe having the means as well as the authority to deploy psychosocial strategies: patients are perceived as more open to lifestyle change, consultations can include relational investment, and the biopsychosocial aspiration translates more readily into actual practice. For older patients, the formal authority remains, but structural conditions progressively close down the space within which it can be exercised, producing the gap between granted and used discretion that characterizes much of what Lipsky identifies as the moral stress of street-level work.
This distinction matters analytically because it prevents over-individualizing what are partly systemic phenomena. When GP5S observes that older patients prefer the convenience of medication and resist lifestyle change, this reflects a genuine clinical observation but also a structural situation in which older patients may have been socialized into a biomedical model of care across decades, may arrive in consultations where time is severely limited, and may have fewer available psychosocial alternatives. The GP’s anticipatory judgement reproduces a pattern that the system itself has produced.
Instead of relying on a tranquilizer, it would be better to address the underlying issues, perhaps by making lifestyle changes to reduce stress. However, many people, particularly older individuals, are reluctant to take this route and prefer the convenience of a pill (GP5S).
Nonetheless, GPs do exercise individual discretion within these constraints, and its effects are visible. In some accounts, the scope of engagement with older complex patients contracts dramatically:
It may not be elegant to admit, but she is one of those whom I tend to do the bare minimum for out of fear. It becomes overwhelming for her and the two others if I make myself even slightly more available beyond my work obligations. It is difficult to say, but this reflects the challenges of balancing professional duties with personal involvement and going beyond what is strictly required (GP1I).
This account illustrates what Lipsky (Reference Lipsky2010) describes as the psychological cost of unresolvable demand: the withdrawal of engagement as a coping mechanism. The GP does not exercise discretion to expand care; discretion is used, perhaps involuntarily, to contract it, transforming what the patient herself identifies as her core need into a residual encounter. The next patient, 63 years old and with a long history of psychiatric institutionalization, described what she sought in a healthcare specialist:
What matters most to me is someone who cares about me a little more. I am a fragile person…The important things? Humanity, kindness, and availability are the three. Someone who genuinely shows interest (P1I).
The gap between what universal care promises and what street-level practice delivers is nowhere more apparent than in this dynamic. In contrast, with younger patients, GPs in both countries describe actively adopting counselling and relational roles that go beyond the biomedical mandate, cultivating trusting relationships that they recognize as foundational to effective mental health management. GPs understand that patient disclosure is a prerequisite for effective mental health care, particularly in areas where stigma inhibits openness:
Addictions are something that people tend to hide, often out of shame. When you cross the line into dependency, you are aware that what you are doing is wrong, so you do everything possible to keep it hidden. Like most addicts, I hid it from my family, GP, and everyone around me (P10I).
If you have more confidence in him, you tell him more things than if you do not. So, I think that, yes, closeness also does a lot, and the fact that he is nice also does (P6S).
The following 44-year-old patient with a history of violence and depression described the profound impact of her therapeutic relationship with her GP. Her testimony illustrates how a physician’s attentive presence can cultivate deep security and lasting trust:
We have always had a good relationship. I am not sure if it is because I enjoy talking, and she is such a good listener. From my experience, I believe that it is incredibly important for doctors to listen to their patients. This gave me a great sense of security (P4S).
By cultivating trust, GPs exercise discretion in ways that actively shape what Dixon-Woods et al., (Reference Dixon-Woods, Cavers, Agarwal, Annandale, Arthur, Harvey, Hsu, Katbamna, Olsen, Smith, Riley and Sutton2006) call patients’ ‘candidacy‘: their practical capacity to access appropriate care. Younger patients, through this relational investment, are constructed as candidates for psychosocial care. Older patients, in the more contracted mode of engagement, are increasingly constructed, against the stated preferences of GPs themselves, as candidates for pharmacological management. This asymmetry is the central finding of this section: the effective space of discretion narrows with patient age, producing differential access that is structural rather than incidental.
Normalizing psychological distress: Discretion against medicalization
The second pattern of discretionary practice operates in the opposite direction. Across both countries, GPs describe a deliberate effort to resist the transformation of normal human distress into medical categories, and to equip patients with the knowledge and self-management skills to participate actively in their own care. Rather than using discretion to simplify and reduce, as in the age categorization heuristic described above, here GPs exercise it expansively, to humanize and complicate care within institutional settings that might otherwise reduce it to prescriptions.
In my opinion, the most important thing when discussing mental health now is to discuss health promotion and strengthening qualities (GP10I).
For example, if a person experiences significant symptoms of sadness following the death of a parent, but there are no risk factors or signs that pathological grief may develop, I tend to focus on providing health education (GP9S).
By explicitly naming distress as a normal part of human experience, GPs exercise discretion to withhold a medical label and redirect the encounter away from pharmaceutical management:
I explain clearly. I listen to and normalise the situation. – Let us see, you have a problem. I understand your suffering, which is also an educational effort. However, pain cannot be relieved by drugs…It is normal suffering and not pathological suffering. The suffering of life must be carried by each individual (GP6S).
This constitutes what Maynard-Moody and Musheno (Reference Maynard-Moody and Musheno2000) describe as ‘citizen agent‘ practice: responding to the full human situation of the person rather than implementing a standardized procedure. GPs also exercise this discretion in their management of medication prescribing, particularly around dependencies:
When benzodiazepines are prescribed for the first time, the prescription can be managed by explaining the side effects to the patient and stating that there must be an end date (GP1I).
This mode of practice is analytically significant because it operates against institutional incentives. Prescribing is faster, documentable, and produces a clear outcome within the consultation. Psychoeducation requires time, relational skill, and patient engagement without a guaranteed short-term result. That GPs invest in it, particularly with younger patients, reflects discretion used in deliberate tension with organizational pressures towards efficiency, and represents one of how frontline professionals can drive a biopsychosocial orientation from the ground up, rather than waiting for it to arrive through top-down reform.
The critical limitation of this pattern, however, is its age-selectivity. Psychoeducation and normalization are deployed primarily with younger patients, reinforcing the differential access produced by the categorization heuristic described above. The two patterns do not operate independently: they interact to produce a cumulative inequality of access to non-pharmacological care across the age spectrum.
Discussion
The findings raise an empirical question that is also a theoretical one: why do GPs in two primary care systems that differ so markedly in organizational architecture, scheduling autonomy, consultation loads, and de-institutionalization history converge so consistently in their age-based management practices?
This convergence is not incidental. It is analytically significant. From an SLB perspective, it suggests that the patterns identified in this study are not products of particular national or organizational arrangements but emergent features of the GP role under conditions of high demand and limited psychosocial resources, features that persist across different institutional configurations. Italian GPs, who manage their own schedules and retain greater autonomy over appointment structure, nonetheless describe the same contraction of relational investment with older patients as their Spanish counterparts who operate within more standardized health centre structures. The structural floor, below which the discretion granted by professional role cannot be exercised in practice, appears to operate at a level determined not by organizational model but by the availability or absence of psychosocial referral options, and by the clinical assumptions about older patients that GPs in both systems share.
This interpretation shifts the analytical weight of the findings. The age-based differences identified in this study risk being read as reflecting GP attitudes or professional culture, implying that change lies primarily in individual attitude transformation. The evidence suggests a different reading: the clinical assumptions GPs hold about older patients are themselves partly structural in origin. They reflect, and are reinforced by, a situation in which the absence of viable alternatives routinizes the pharmaceutical response, which in turn shapes patient expectations, which in turn confirms the GP’s anticipatory judgement. This is the medicalization dynamic that Conrad (Reference Conrad1992) describes: one that GPs individually aspire to resist (the normative orientation is consistently biopsychosocial) but structurally reproduce.
In the shift towards patient-centred care (Gofen et al., Reference Gofen, Strier, Gassner and Hupe2019), particularly with younger patients, some GPs choose to interact with individuals in a way that fosters more tailored and personalized care (Dixon-Woods et al., Reference Dixon-Woods, Cavers, Agarwal, Annandale, Arthur, Harvey, Hsu, Katbamna, Olsen, Smith, Riley and Sutton2006; Dunham et al., Reference Dunham, Scheid and Brandon2008). Rather than strictly adhering to a limited biomedical approach, they exercise discretion to navigate system constraints and explore alternatives such as seeking non-pharmacological interventions, educating patients about the nature of mental disorders, and promoting an understanding of mental health that does not rely solely on medication. In doing so, GPs function more as scaffolds, supporting patients’ capacity to understand, manage, and participate in care, reshaping and humanizing public service delivery. This is particularly important given that, within a strictly biomedical model, individuals with mental health conditions are often perceived as having limited autonomy (Pelto-Piri et al., Reference Pelto-Piri, Engström and Engström2013).
However, the space for GPs to adopt educational or relational roles is conditioned by broader systemic and cultural dynamics. The persistence of time constraints, limited resources, and entrenched patient expectations encourage pharmacological shortcuts (Giosa, Reference Giosa2024), specifically in the care of older adults. As Conrad (Reference Conrad1992: p. 211) writes: ‘Medicalization occurs here as a part of doctor-patient interaction, when a physician defines a problem as medical (i.e. gives a medical diagnosis) or treats a “social” problem with a medical form of treatment (e.g. prescribing tranquilizer drugs for an unhappy family life)‘. In this way, especially with older patients, GPs often end up prescribing medication to alleviate what are essentially social or existential conditions, such as loneliness, social isolation, sadness, or sleep problems, thereby reinforcing a biomedical approach to mental health.
A key contribution of this study lies in what it reveals about the concept of universality. Both the Italian and Spanish national health systems formally guarantee universal access to primary care. What the findings show is that universality at the point of access does not guarantee universality in the substance of what is accessed. For younger patients, formal access translates, through GP discretion, into encounters that include psychoeducation, motivational support, relational investment, and patient agency. For older patients, the same formal access translates, structurally, not incidentally, into encounters more likely to produce a prescription. The principle of universal care is not negated at street level; it is reconfigured into a practice that is formally universal and substantively differential.
This finding also extends the candidacy framework (Dixon-Woods et al., Reference Dixon-Woods, Cavers, Agarwal, Annandale, Arthur, Harvey, Hsu, Katbamna, Olsen, Smith, Riley and Sutton2006). The candidacy concept draws attention to how patients’ practical capacity to access appropriate care is shaped by the interaction between individual characteristics and frontline practices. This study shows that candidacy is age-structured in a way that exceeds individual GP-patient negotiation: it reflects a systematic pattern in which age serves as a trigger for differential discretion. Younger patients are constructed, through GP practice, as candidates for psychosocial care. Older patients are constructed, against the stated values of GPs themselves, as candidates for pharmacological management. The universality gap is not primarily a gap of access but a gap of candidacy.
In contrast, younger patients’ openness to psychosocial interventions and preventive strategies creates greater opportunities for GPs to exercise discretion expansively, fostering engagement that goes beyond medication. This dual perspective shows that equity of access cannot be assessed solely in terms of whether patients are seen by a GP but must also consider the quality, scope, and sustainability of the interventions available to different patient groups.
These findings point to two directions of practical implication. The first concerns structural conditions: improving the substantive equity of primary mental health care requires not primarily attitude change among GPs, whose stated values already align with biopsychosocial practice, but expansion of the psychosocial resources that would widen the effective space of discretion for all patient groups: community services, accessible psychological therapies, and specialist referral capacity with manageable waiting times. The second concerns training, specifically in the management of the relational and existential dimensions of older patients’ distress, equipping GPs with the tools to deploy psychoeducation and normalization across the age range rather than primarily with younger patients.
These findings also have broader applicability. The structural dynamics identified, resource scarcity narrowing the effective space of professional discretion and producing age-based differentials in access to non-pharmacological care, are likely operative in other healthcare systems facing similar pressures, including systems with different organizational models and welfare state configurations. The convergence across Italy and Spain, two systems that differ significantly in GP remuneration, scheduling autonomy, and organizational structure, suggests that these are not country-specific phenomena but features of the SLB role under general conditions of public sector resource constraint.
Conclusions
Summary of findings
These findings raise a fundamental tension between the normative ideals of universal access to healthcare and the realities of how mental health care is delivered in primary care practice. While the national health systems in both Italy and Spain guarantee access to primary care services, the form and substance of this access differ ‘at street-level‘ according to patient characteristics, particularly age. Evidence suggests that ‘universal access‘ does not necessarily translate into equitable or needs-based care. Instead, for older patients, access often becomes equated with access to medication rather than the broader range of psychosocial support strategies available to younger patients. This study underscores that advancing health equity requires attention not only to whether patients can reach a GP but to what they encounter when they do.
Limitations
The sample may not be entirely representative, which could lead to a biased portrayal of the phenomena studied. Additionally, the interpretive nature of qualitative research, which is influenced by researcher perspectives and contextual variability during data collection, restricts standardization and cross-study comparability. However, these are specific characteristics of qualitative research that, rather than merely statistically validating a statement or hypothesis, strive to deepen the understanding of a phenomenon (Gobo, Reference Gobo and Silverman2002; Griffiths et al., Reference Griffiths, Schweitzer and Yates2011). Second, given the decentralization and regional differences between the two national health systems, the findings may not be generalizable to the two national contexts. Third, although efforts have been made to minimize desirability bias through anonymity and a welcoming interview environment (Lindseth and Norberg, Reference Lindseth and Norberg2004; Bergen and Labonté, Reference Bergen and Labonté2020), such a bias cannot be entirely excluded.
Future research directions
Future research should examine how micro-level GP-patient interactions impact institutional frameworks and catalyse systemic changes. These aggregated individualized management strategies have broader effects (Rice, Reference Rice2013; Doblytė, Reference Doblytė2020), influencing macro-level policies and organizational practices within health services. SLB theory could explain how GP-patient interactions could transform the GP’s role from treatment provider to health counsellor, making patients active producers of health rather than passive consumers.
In addition, future research should explore the effectiveness of specific strategies tailored to older patients in primary care, specifically regarding mental health in the effort to reduce ‘the triple jeopardies of ageism, mentalism and ableism‘ (Reynolds et al., Reference Reynolds, Jeste, Sachdev and Blazer2022: 337). While current practices often default to pharmacological solutions, there is a need to examine whether alternative approaches, such as adapted psychosocial interventions, community-based support, or preventive educational programmes, can be effectively implemented for this demographic, and under what conditions they might improve both equity and quality of care.
Data availability statement
The data generated and analysed during the current study are available from the author on reasonable request.
Acknowledgements
The author sincerely thanks the participants for their time and their valuable contributions.
Author contributions
The author was responsible for the conception and design of the study, data collection, analysis, interpretation of the results, and manuscript writing.
Funding statement
This research was funded by a Severo Ochoa doctoral scholarship from the Principality of Asturias, Spain (Ref: PA-20-PF-BP19-129).
Competing interests
The author declare that no conflicts of interest exist.
Ethical standards
On 1 June 2022, the Ethical Research Committee of the Principality of Asturias granted ethical approval. All participants provided informed consent before the study.
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