Services take another hit with miserable performance ratings

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

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

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

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.

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