Commissioners are neglecting mental health inpatient services despite endemic levels of violence, overcrowding and untrained staff, a damning review has found.
Nearly a quarter of mental health inpatient beds are in trusts rated weak by inspectors, according to the first Healthcare Commission review focused on mental health inpatient services.
Every trust scored one out of four - resulting in a weak rating - for training staff in dealing with service users addicted to drugs and alcohol. Nearly half scored weak or fair for bed occupancy.
A fifth of trusts were deemed to have weak infrastructure for promoting safety and the vast majority scored weak or fair for levels of violence; none were rated excellent on either criterion.
The commission found that a focus on strengthening community services has meant acute inpatient services have not received the attention they need.
Primary care trusts were found to be taking little interest in improving services: only 18 per cent said commissioners were regularly attending acute care forum meetings. The forums, set up in 2002, are supposed to be the major vehicles for developing acute care services, and national guidance states that membership should include commissioners.
Healthcare Commission mental health strategy lead Anthony Deery told HSJ: "A lot of PCTs' budgets are tied up in acute inpatient care, so commissioners need to be more actively involved. They should... be taking part in these forums."
Mental Health Network director Steve Shrubb said it was vital managers and clinicians across the health economy learned to work together, given the focus on care pathways in the next stage review. But he said: "We don't want commissioners to micromanage providers."
Among the worst performing trusts there had been a lack of developed strategy - in other words a "dissonance" between the strategy and the reality on the ground, the report said. In some cases this was linked to trust mergers but in other trusts there was "a failure among senior managers and commissioners to understand the acute care pathway".
South Staffordshire primary care trust commissioning director John Wicks admitted there was a lack of specialist mental health knowledge in PCTs. In addition, the lack of provider choice and reliable performance measures led to "complacent relationships", he said, where providers were not always sufficiently monitored. He said service user input at his PCT's local mental health trust, South Staffordshire Healthcare foundation trust, had been central to its overall excellent rating.
In total, eight trusts, equivalent to 9 per cent of beds, were rated as excellent, 20 were good, 30 were fair and 11 were weak - the last category accounting for 23 per cent of beds.
No trust got an excellent rating against all four main standards involving safety, service user and carer involvement, effective care pathway and individual well-being.
According to the report, the results suggest that "the larger the trust, the greater the challenge in achieving consistent standards across all wards".
It recommends that commissioners take account of the particular challenges faced by those larger trusts, which tend to serve an urban, more deprived population.
The provider with the most beds, Northumberland, Tyne and Wear trust, was rated weak. Its acting chief executive Andrew Fairbairn said the assessment was carried out last summer and "in no way reflects the commitment of our staff".
Anthony Deery acknowledged that some of the data used in the review was old but said the commission had since visited 10 of the 11 weak trusts finding "slow progress", particularly in improving sexual safety.
The report also highlighted a number of positive findings, including good access to independent advocacy and to programmes to promote health, such as smoking cessation and healthy eating.
The commission assessed all 69 NHS trusts providing acute inpatient mental health services in England. This covered 554 wards, providing almost 10,000 beds for patients aged 18-65.
100 per cent - trusts deemed weak at training staff to deal with service users abusing alcohol or drugs
88 per cent - scored weak for explaining rights to detained patients
49 per cent - rated excellent for the range of activities provided for service users
30 per cent - rated weak for privacy and dignity; no trust was excellent
39 per cent - areas offering crisis accommodation
18 per cent - trusts where commissioners regularly attended acute care forum meetings
19 per cent - beds provided in trusts rated weak for safety
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