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Improvements in mental health care called for

A report from the Clinical Standards Advisory Group says that the quality of care for people with schizophrenia was unsatisfactory or poor in well over half of the districts that it surveyed last year. The group trained several multidisciplinary teams and sent them to inspect and assess purchasers and providers of mental health care in 11 NHS districts and health boards.

Despite finding many examples of good practice the group called the general performance disappointing. None of the eight English health districts inspected had implemented the care programme approach fully. Patients with serious mental illness are meant to have their needs for health care and social care assessed, have individual care plans run by named key workers, and have their care reviewed regularly.

The gaps in care were not explained by social deprivation, unemployment, or other confounders. The two main reasons for the gaps, says the group, were poor communication between health and social services and low morale.

The report suggests that staff in both health and social services would feel much more positive about caring for people with schizophrenia and implementing central policy if they had stronger local leadership, particularly from psychiatrists. In addition, the report warns that moving community psychiatry nurses away from consultant led teams into primary care teams may divert nursing care away from the most ill and vulnerable patients.

The report recommends that purchasers and providers should listen to the local experts--experienced psychiatrists and social workers--when contracting for mental health services. It says that contracts must specify that central guidance is implemented and audited and suggests that its own assessment protocol could be used to conduct such audits. The new standardised protocol was used by the inspection teams to rate 20 key elements of each mental health service and to give each a score.

A similar but less comprehensive protocol was used by the Social Services Inspectorate to produce its latest report on mental health care. The inspectorate, a division of the Department of Health that monitors the quality of the provision of social services, also concluded that the care programme approach is not being followed consistently.

The inspectorate assessed five social services departments in England and found patchy and sometimes inadequate implementation of national mental health policy. Part of the problem, says the report, is the splitting of responsibility between health and social services.

On the one hand, health authorities are expected to set up and monitor care programmes for all patients receiving specialist mental health care; on the other hand, social services departments are responsible for assessing and providing the social care that mentally ill people need in the community.

Both systems are meant to overlap seam-lessly, and both are meant to be run by special key workers. But the Social Services Inspectorate found that many staff, as well as users and carers, in the five areas surveyed did not know which key workers should be doing what. The report urges health authorities to take a stronger lead in coordinating care.

Mental health charities said that the two reports contained few surprises and that they already knew from their own contacts that standards of care were generally inadequate. Mr Gary Hogman, of the National Schizophrenia Fellowship, said, "Mr Malone's three month deadline for health authorities is pointless: they won't be implementing the care programme approach fully by November." He said, "The Department of Health--along with the Departments of Social Security and Environment--should be convincing the Treasury that services for seriously ill people need better funding."--TRISH GROVES, BMJ

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