A small increase in bed numbers is of little help to mental health services struggling to cope with rising demand and staff defections. Mark Gould reports

The revolving door in mental health is well documented: an over-reliance on emergency admissions and excessive pressure on beds leads to early discharge into a care vacuum - where the cycle repeats.

So how far have a range of loudly trumpeted government initiatives - including the national service framework - gone towards breaking the old pattern and taking the pressure off acute care?

Doctors and patients' groups believe is too early to say, and think the impact of increased funding into programmes like assertive outreach may be more visible in the next six to 12 months.

But the statistics for 2000-01 are not promising. There was a small increase in mental illness bed numbers in England, up to 34,214 from 34,173 in the previous year.

But in the same period, bed occupancy rates have risen slightly from 87.1 per cent to 87.4 per cent.And this is set against a backdrop of 10 years of rising demand and policies which saw a 50 per cent cut in beds, the majority of losses in the long-stay sector.

Royal College of Psychiatrists general and community psychiatry committee chair Dr Anthony Zigmond sums it up: 'There remains a shortage of alternatives to admission and a shortage of alternatives to discharge. Staffing levels in many acute units are very poor. There is a degree of violence on many wards that remains highly unacceptable.'

He blames much of the violence on 'the poverty of the range of therapeutic interventions', and says: 'We need more qualified staff to make the most of the range of therapeutic interventions that are necessary.'

Dr Zigmond is also concerned about the 'serious problem' with recruitment and retention of consultant psychiatrists. There is a 12 to 15 per cent vacancy rate in adult general psychiatry nationally, and in some places it is even higher.

The Department of Health has provided cash for 500 new secure beds to prevent patients being cared for in inappropriate settings.

It is hoped that the promised white paper setting out amendments to the Mental Health Act, including strengthened advocacy powers and living wills, will appear next year.

But some analysts believe it could be put back as far as 2004.

Following the NHS plan, the DoH allocated a further£330m over three years, partly to be used in the acute sector and partly to finance community-based projects such as assertive outreach and home treatment teams, outlined in the NHS plan and the framework, to ease acute pressures.

Richard Brook, director of mental health charity Mind, says these initiatives are welcome, but there is no evidence that they have taken the pressure off the acute sector.

'We have had reports that assertive outreach teams are merely relabelled versions of the old community mental health teams and they are not engaging positively. We hear of people phoning a team at 9pm and not seeing anyone until the next day - That is the same as it was two years ago.'Mr Brook is not certain how much of the new money is being spent in the acute sector, where patients still face the dangers of being housed on mixed wards. 'The government has still got some way to go to achieving its pledge on ending mixed-sex wards by 2002.'

Last year, South London and Maudsley trust was forced to spend nearly£1m on beds in the private sector. In a bid to break this dependence and ease pressure on acute services, the trust is spending£2.4m (its share of the£330m) looking at new ways of delivering inpatient care.

It is opening an 18-bed earlyonset unit for young people who are showing the first symptoms of schizophrenia. Next month, the trust opens Woman's Health, a unit run by women clinicians, which provides somewhere for women with early signs of mental illness to get targeted help for a short period, reducing the need for a stay in the acute unit.

The trust is also trying to ensure effective discharge by opening rehabilitation and hostel services in the community.

Paul Corry from the National Schizophrenia Fellowship says community initiatives are gradually emerging but that 'change is not happening fast enough'.

Mr Corry is also concerned that some of the best people working in hospitals are being enticed into community projects with new cash, leaving staffing problems for the acute sector.

Sainsbury Centre for Mental Health director Dr Matt Muijen thinks part of the problem is how the£330m is being used.

'There is an impression that the money is going into setting up the community services or being shifted away from mental health altogether, rather than into core acute services.

'There is an outflow of people from the acute sector, where there is still tremendous pressure on beds, and the reality is that we do not really have appropriate community services in place to make a difference.'

And he agrees with Mr Corry that perceptions that the future lies in assertive outreach may be damaging recruitment to conventional services: 'If you are offered the choice between working in a new high-profile community team or being stuck in a low-status acute unit, what would you choose?'