news focus: Failures in psychiatric services tend not to attract public interest or political response.Two reports into major service failures relate an all-too-familiar story.Paul Smith reports

Published: 14/02/2002, Volume II2, No. 5792 Page 14 15

The most curious aspect of the Rose Addis saga is that in many ways it was a missed opportunity.

If the leader of the Conservative Party wanted to embarrass the government on its NHS record, he could have cast an eye over two reports just published about mental health services. They had all the ingredients necessary for a direct political hit - management incompetence, underfunding, structural failures and the deaths of five patients and one member of the public.

But collapse of mental health systems has never had the strongest political allure.

The first report was into London's Charing Cross Hospital - run by West London Mental Health trust - after five patients died in the space of four months last year. The second was into the care and treatment by North Derbyshire Confederation of Adult Mental Health Services of Andrew Ackroyd, a service user suffering from schizophrenia, who killed his father in October 1999.

Neither makes easy reading for managers - particularly the Charing Cross report, which condemned virtually every aspect of the system from basic ward safety to staff communication to clinical governance procedures.

One area of concern raised by the reports was the inadequacies of assertive outreach programmes, one of the keystones of both the national service framework for mental health and the NHS plan.

The Health Advisory Service team, which investigated events at Charing Cross Hospital, said the hospital had no locally available specialist assertive outreach function at all. Nor did it 'hear of any firm plans to develop one'.

The possible consequences of such service gaps become apparent in the separate inquiry into Andrew Ackroyd, who had suffered from mental illness since he was a teenager. It often involved outbursts of violence and in 1986 he was sectioned under the Criminal Procedure (Insanity) Act after stabbing a theology student. Following a conditional discharge, he eventually came into contact with North Derbyshire's assertive community team (ACT).

The deterioration in his condition - due to his refusal to take his medication and an ability to mask his symptoms - was not sufficiently recognised.He last saw the team in October, 1999.

He was given an outpatient appointment, but a few days later his father was dead and he was pleading guilty to manslaughter on the grounds of diminished responsibility.

The report is detailed and acknowledges the complexities of the case, but it was still critical of the development of ACT.

'There were clear planning weaknesses associated with the establishment of the ACT, ' it said.

'While the planners followed the lead offered by the government for the establishment of assertive outreach services, the newness of this approach was not fully appreciated. The incremental approach to development was adopted. For ...any service development as new as this, such an approach is not appropriate.'

The report points out that current guidance on assertive outreach services was not available to the trust when the team was created in 1998.

Things have changed at West London Mental Health trust.

Chief executive Dr Julie Hollyman says the report has been a 'catalyst' for change. And Malcolm Munton, acting chief executive at North Derbyshire, says: '[Assertive outreach] has been strengthened.We have brought in a team leader and a dedicated consultant psychiatrist and staff-grade doctor and we clearly think it is working well.'

But for Sainsbury Centre for Mental Health director Dr Matt Muijen, the cases still raise concerns about the ability of some trusts to establish effective outreach programmes.

'The main concern as ever has been the pace of structural reform...trusts are having to cope with these upheavals while trying to ensure programmes like assertive outreach are doing what they are meant to do.

'There are concerns particularly when assertive outreach is seen by most people within the service as a good thing and especially when we welcome the direction of the government's mental health policy.

'But it is just the practical issues in delivering it.Too much change, lack of management capacity and too little resources.

It is the old story.'

Report of the Independent Inquiry into the Care and Treatment of Andrew Ackroyd .

North Derbyshire HA, 01246-231 255.