Universality in daily primary care practice: a qualitative study of mental health management in Italy and Spain.

Abstract

Aim: This article examines how general practitioners (GPs) in Italy and Spain manage patients with mental health needs in daily primary care practice, and how their discretionary choices shape the substantive reach of universal access to care.

Background: Modern healthcare systems in Italy and Spain formally guarantee universal access to primary care. However, mental health services in primary care reveals persistent gaps between this normative principle and everyday practice. Drawing on Lipsky's Street-Level Bureaucracy (SLB) theory, GPs are understood as frontline professionals whose discretion operates within, and is shaped by, conditions of resource scarcity, time pressure, and limited access to psychosocial services.

Methods: A qualitative cross-national design was employed, including 42 semi-structured interviews with 20 GPs and 22 patients with mental health needs in Spain and Italy, conducted between June and November 2022. Data were analysed through an inductive-deductive coding process.

Findings: Two principal patterns of discretionary practice emerged. First, GPs exercise discretion differentially by patient age: investing in psychoeducation, counselling, and motivational support with younger patients, while moving more rapidly towards pharmacological management with older patients. This age-based categorization operates as a coping strategy that shapes patients' candidacy for psychosocial versus pharmacological care. Second, GPs actively normalize psychological distress as a counter-medicalization strategy, primarily with younger patients. Despite significant institutional differences between the two healthcare systems, these patterns converge across Italy and Spain, suggesting they reflect structural features of the SLB role under resource scarcity rather than system-specific dynamics.