The disappointing star ratings for mental health trusts mark another low in what is turning out to be a dismal year for mental health services.

Following close on the heels of the botched mental health bill and the damning report into the death of David Bennett, last week’s publication of the NHS star ratings shows that, overall, mental health trusts have achieved little or no improvement in performance in the past year.

Of the 83 trusts in England, 23 received one star and seven no stars, while the number of three-star trusts rose by just one to 15. In 2002-3, the first year mental health trusts were assessed, only three failed to win any stars.

The Healthcare Commission, the independent watchdog which rates all NHS trusts, said the performance of mental health trusts "remains a cause for concern". In particular, it highlighted the quality of information collected about patient care as "simply not good enough".

It is a depressing picture, but many who work in the field suggest the ratings do not fairly reflect the quality of services and put the sector’s problems down to wider political and funding issues.

By the Healthcare Commission’s own admission, the assessments system needs "a new approach to allow a broader, richer picture of performance to be presented". This should be developed by 2005-6.

Others call for a more radical overhaul so that star ratings better reflect service quality.

Simon Lawton Smith, senior mental health policy adviser at the King’s Fund, says the ratings are "better than nothing" in that they indicate the direction a trust is going, although they are "not terribly sophisticated".

"There are lots of factors taken into account [for deciding a trust’s rating], but there’s no correlation between how many targets are achieved and the star rating," he says.

Terry Butler, joint chair of the Association of Directors of Social Services mental health committee, says the ratings are particularly crude for mental health trusts.

"They apply the same criteria to acute trusts, whereas patient experience and safety measures are more important for mental health trusts," he says.

Equally strange is the example of Buckinghamshire Mental Health Trust. Its zero rating was the result of a poor clinical governance review last October, which covers more areas than those assessed by the star ratings. Few other trusts were judged on this basis. Alison Bussey, nursing director at the trust, says its rating represents a one-week snapshot taken nine months ago. "We’ve made tremendous inroads since then and it’s very different to where we were last October."

However, Andrew McCulloch, chief executive of the Mental Health Foundation, while he lambasts the star system as a "dog’s breakfast, unrelated to outcomes", points out that many basic service standards are not met and that some trusts are still "living in the Stone Age".

More than a third of trusts have failed to set up satisfactory assertive outreach teams to provide support for difficult to reach patients, and a similar number have failed to meet care programme approach standards on recording information about patient care.

"One three-star trust failed to implement continuous performance assessment, while three others haven’t implemented assertive outreach," says McCulloch. "Performance is gradually improving but they are coming from an extraordinarily poor base, and there are major problems with facilities, staff morale, financial management and cleanliness."

A spokesperson for one three-star trust, South London and Maudsley, admits there are still major issues to address. "We carried out a survey that showed a third of patients were still not getting their treatment explained to them properly. The sector generally hasn’t been good at collecting and using quite basic information," he explains.

However, he says collating mental health information is more complex than in other parts of the health service. Measuring outcomes "is not as simple as replacing a hip".

Lawton Smith agrees. "It is harder to demonstrate that your services are improving people’s mental health. The one qualitative target - reducing suicide rates - is less controlled by services."

Reducing suicides by at least 20 per cent between 2000 and 2010 remains one of the national public service agreement targets. The other main mental health target - to improve life outcomes by ensuring all patients have access to crisis services by 2005 and child and adolescent mental health services by 2006 - is also the same. However, the original deadline for these in the NHS plan was 2004.

Lawton Smith says the targets focus more on outputs than outcomes. "It’s not measuring outcomes in terms of improving people’s mental health," he says.

Mental health is one of three priority areas for the NHS identified by the government, but Lawton Smith says it is slipping down the agenda as more attention is given to chronic heart disease and cancer.

Government critics say this view has been reinforced with the announcement last week that the Mental Health Act Commission is to be amalgamated into the Healthcare Commission.

Lawton Smith says there is a danger that the voice of mental health services could be lost in a bigger organisation. "If the bigger commission decides mental health is not this year’s priority, will that damage mental health services?"

Mental health charities Mind and Rethink argue that trusts’ poor performance in the star ratings is evidence that mental health is slipping down the government agenda.

Sophie Corlett, policy director at Mind, says: "The fact the picture has got worse over the past year is an indictment of the government’s lack of commitment to its own stated priorities. It is time for action instead of the rhetoric we’ve been fed so far."

Unsurprisingly, the government denies this, citing the inclusion of the mental health public service agreements and an extra £300m of investment in the sector in recent years.

However, critics say another problem is whether the extra funding is being given to trusts by commissioners of services, the strategic health authorities or primary care trusts.

The Department of Health says a survey last autumn proves that £262m extra had been spent on mental health, but recent studies by the Sainsbury Centre and the Royal College of Psychiatrists show that some primary care trusts and strategic health authorities continue to deny mental health trusts the money they need. "More monitoring of where the money goes has to be done and there should be a rating for PCTs and strategic health authorities for the distribution of resources," says McCulloch.

Bussey says that at a time when the demand for services is increasing, the funding isn’t.

"There is a shortage of specialist mental health nurses, doctors and social workers and we have to use agency staff to cover extra shifts. But commissioners are investing reasonably," she adds.

It is a time of record investment in the NHS, but that brings with it increased pressure to improve across all services. The ones that can show improvement most effectively inevitably get most attention from ministers - and mental health does not fall into that category.

One way of moving the political spotlight back onto mental health would be for the government to decide the direction it is going to take with the draft mental health bill, which provoked widespread protest over some proposals when it was published last year.

Butler says the current situation has caused uncertainty. "I don’t know if you’d call it a vacuum, but the sooner we have a decision on that and we know what the elements of it will be, it would be a real advantage," he adds.

A new draft bill is expected to be published and put to pre-legislative scrutiny in September. Maybe that will focus the sector’s mind and improve star ratings next year.