Fewer than half of England's crisis resolution teams are fully set up, according to a leaked Department of Health report.

A survey of 243 teams - two-thirds of those in existence - revealed that two years after the target deadline, just 40 per cent say they are fully operational. This, the report concludes, 'suggests that we have yet to achieve a sustainable 'critical mass' of CRT activity nationally'.

The DoH, which commissioned the report, confirmed the finding as it issued updated guidance to the service setting out the requirements for fidelity to the CRT model.

Teams were seeing fewer patients than anticipated and reported 'considerable pressure' of referrals for assessments that do not subsequently lead to home treatment.

The researchers, led by Professor Steve Onyett from the University of the West of England and Care Services Implementation Partnership-South West, found that just over half were able to offer a full 24/7 service - a target that should have been met from December 2005. While almost all teams aspire to offer an alternative to admissions, around a third were not involved in 'gatekeeping' services.

Teams cited a lack of medical staff as a key obstacle to progress. And collaboration with local colleagues such as social workers and community mental health teams was perceived as 'a significant challenge to proper effective implementation of an effective CRT function'. The survey calls for adequate resources for CRTs and that the 'focus on gatekeeping and home treatment needs to be reiterated at all levels, particularly among commissioners, local managers and senior medical staff'.

Professor Onyett said: 'Some teams are doing some really good work but the picture is patchy. Given that CRT has been heavily performance-managed and that it contributes to star-ratings, it's a measure of where mental health sits in local health economy priorities that implementation is still patchy. 'I think they need support from local senior clinicians who can fight their corners more and make the case for CRT as not simply an assessment service but a credible home treatment service.'

The DoH confirmed that only 40 per cent of teams regarded themselves as meeting DoH guidance, but strongly denied this meant patients were receiving a poor service. On Friday it issued new guidance on 'fidelity and best practice', which sets out the five key requirements which teams should have 'fully in place': 'staffing and resources, gatekeeping role, referral pathways, whole-system working and audit and development'. These mirror precisely the concerns in the leaked report.The guidance stresses that CRT should provide gatekeeping services 'to all people requiring access to inpatient services or other emergency care' but that this depends on co-operation from all other parts of the service. The guidance also remarks that 'it is not good practice' for some teams to simply hand overnight services to accident and emergency departments.

A DoH spokeswoman said service improvements were demonstrated by figures showing increasing numbers of patients receiving home treatment 'up from 28,000 in 2003, with the latest data suggesting it will reach just under 100,000 in 2006-07'. 'Given how relatively recently crisis teams were established, we do not see it as surprising that, at this stage, only 40 per cent of services are providing a service that meets every requirement.'