No extra government money will be made available for the community care programme for mentally ill people, despite two critical reports that condemned it as "confused" and "haphazard", yesterday.
Health leaders said no improvement was possible without new money, but Gerald Malone, the Minister for Health, said that resources were not the issue. He gave health authorities three months to improve supervision and treatment.
While ministers blamed bad practice for widespread ignorance among staff and patients, doctors' leaders put it down to a lack of trained staff and money, accusing the Government of an "abdication of responsibility" and calling community care a "flop".
The reports, from the Clinical Standards Advisory Group, an independent body which gives advice on clinical standards, and the Social Services Inspectorate, reveal that four years on from the creation of community care, staff and patients remain confused about what it entails and its implementation around the country varies widely.
Emergency care was roundly criticised and short-stay wards were described as "depressing, cramped and squalid".
None of the eight English districts visited by the advisory group had fully implemented the Care Programme Approach, under which the mentally ill are given a key worker and treated under a personal care package.
Most patients and their carers did not even know what it was, although they are meant to be closely involved. In some of these areas the Department of Health had been told that its implementation was complete, the advisory group's report said.
It produced a new protocol which sets standards in all areas of mental health community care, stressing local standards should be set, and co- operation between local authorities and health authorities encouraged.
Community care for the mentally ill has become a priority after high- profile cases, such as the killing of Jonathan Zito in a London Tube station by Christopher Clunis, a paranoid schizophrenic, and the stabbing of Jonathan Newby in an Oxford charity's hostel.
While neither report denied that in some districts they found good or even excellent practices, there were still too many cases where quality of care was unsatisfactory.
Four of 11 districts that the advisory group visited, approached an overall profile of achievement characterised as "good"; for two the profile was broadly "poor". Quality of care in several districts was described as "unsatisfactory", and only one had a well-developed plan. Only National Health Service districts and social services departments who did particularly well are identified in the reports. The Social Services Inspectorate, which looked at care in the community in five different areas found patients and carers had an "almost universal ignorance" about the existence of the Care Programme Approach. Where plans had been put into practice there was a "considerable variation" in their quality, "with varying degrees of commitment".
Only one social services department had a formal agreement between itself and the health authority covering the introduction and implementation of the CPA. The inspectorate said that joint working - close co-operation between local authorities and health authorities, recognised as an integral way to make community care work - was "patchy".
The advisory group said emergency care provoked most comment. Most acute wards consisted of large noisy rooms, with little privacy. In one district they were described as dangerous, with sexual harassment, theft and assault common.
Earlier this week, Stephen Dorrell, Secretary of State for Health, authorised Mr Malone to write to all NHS chairmen giving them a three-month deadline to develop plans and reminding them that "further urgent work is needed".
Areas in particular need of attention are said to be the targeting resources on the severely mentally ill, implementing the CPA, and managing, training and supervising staff effectively.
Mr Malone, said yesterday there was "no suggestion" that the policy of bringing the mentally ill back into the community was wrong. "This is not a resource issue. Bad practice at the end of the day costs as much as good practice."
But the author of the report, Professor Andrew Sims, said: "We certainly need more resources for mental health. This is something that must be urgently addressed." Dr Arnold Elliott, chairman of the British Medical Association's community care committee, added: "What we are seeing in many parts of the country is a lack of trained staff and a lack of resources to meet the spiralling needs of the mentally ill. Doctors believe that so far community care has been a flop not because the principle is flawed but because the Government has failed to provide the co-ordination or resources to make it succeed."
Derek Day, deputy director of the National Association of Health Authorities and Trusts, said caring for the mentally ill in the community was "the right approach", but it needed to be targeted in the same way as waiting lists had been. "We need more resources."
Mr Malone denied this. "There are authorities in very difficult areas where they are able, within their resources, to put best practice into place," the minister said.Reuse content