Bedlam as psychiatric services collapse

London runs out of beds as violence rises

London is failing the mentally ill, with services are near to collapse and unable to sustain the demands made on them, according to the most comprehensive study ever undertaken into mental health provision in the capital.

The capital is running out of beds, there are more acts of violence, more patients compulsorily detained and higher rates of admission than in any other part of the country, according to the King's Fund which produced the 400-page report.

It said that care in the community services are insufficient to cope with patients that do not qualify for secure beds. There are huge variations in residential care facilities across London and home treatment is available in only a few areas.

London has been at the centre of the debate over the treatment of the mentally ill with a succession of high-profile care-in-the community failures - among them the schizophrenics Christopher Clunis and Stephen Laudat, who went on to kill. A government report last year listing authorities that could not provide comprehensive mental health services before 1997 was dominated by London boroughs.

Rates for psychosis in inner London are double those of other inner cities and the higher admission thresholds in London mean that patients who are not psychotic or have not been compulsorily detained are less likely to gain access to an acute bed than in other parts of the country.

The Secretary of State for Health, Stephen Dorrell, said he acknowledged that mental health services in London were under pressure, but said that the Government had already responded to the problems. "Mental health has for many years been the Cinderella service but in the last five years there has been a striking shift in priorities," he said. "The funding formula has been changed to reflect the fact that there is a higher incidence of mental illness in London and consequently greater pressure on the services. We will keep the formula under review and if it can be demonstrated that it is not appropriately reflecting patient need then we will change it again."

But mental health charities said the report confirmed their worst fears and criticised ministers for not doing more to prevent the crisis. The charity Mind blamed the Government's "negligent" underfunding of community care for the "exceptionally difficult circumstances" in the capital.

"For years, Mind has been warning the Government that the failure to properly fund comprehensive community care would lead to a crisis," said Judi Clements, the charity's national director. "The failures highlighted by this report, and many others before, deserve a considered response from government, and not more knee-jerk reactions designed to boost opinion poll ratings."

Marjorie Wallace, chief executive of the charity Sane, called for a moratorium on bed closures. "It is disgraceful that seriously mentally ill people are either discharged too early or are not admitted to hospital for the care and treatment they need," she said. "Instead, they are being squeezed into hospital corridors ... forcing psychiatrists to make intolerable choices."

The report said that delays in getting a bed were frequent, with the average wait for admission to a secure unit being 24 hours, and seven weeks for residential accommodation with 24-hour staffing. The voluntary sector is having to play a larger role in providing care in the community while high intensity 24-hour community services are almost entirely absent.

"The findings ... describe a service in inner London that cannot be sustained because it is unable to meet the demands imposed on it," said the report.

"The crisis in inner London is not due to meanness among London's purchasers or to stick-in-the-mud attitudes among providers. The formulae for allocation resources to deprived inner city areas need to be revisited."

t London's Mental Health; available from the George Godber bookshop at the King's Fund, 11-13 Cavendish Square, London, W1M 0AN price pounds 15.

20 doctors, 1,700 cases:

'We need a miracle'

"It's like a mad game of pass the parcel," says Mark Salter in exasperated tones as he looks at the list of cases. It is the beginning of another normal day as a consultant psychiatrist in Stoke Newington, north London, writes Glenda Cooper.

In the following eight hours his team deal with a torture victim, a violent schizophrenic and a man who believes he is paralysed.

Married with two children, Dr Salter, 37, has worked in the area for 10 years. His team of 20 has 1,700 cases on the books at any one time. "We are supposed to have all the answers but we need a miracle to do what we need to. My team does a great job but there is not adequate funding in London."

From 9.15am the stream of patients begins - success stories like Sara, 16, whose sassiness belies her drug problems, or Paul, a highly intelligent schizophrenic who has knuckled down to take his medication. They are followed by Hassan, a Turkish victim of torture suffering post traumatic stress disorder after the deaths of his family, and Frank, whose mental problems are exacerbated by paedophiliac tendencies. Outside, aggressive twin brothers - both schizophrenics - have turned up to get their prescriptions. Dr Salter and their keyworker try to calm them down.

It is 1pm and after a quick bite in a greasy spoon Dr Salter races out on community visits.

The first is a deluded Bengali woman who is convinced that people are using her flat as a brothel.The second stop is a gloomy flat with overflowing ashtrays and the stench of urine. Dr Salter is seeing Iain, who thinks he is paralysed down one side although he has nothing medically wrong with him. His partner Mary is an alcoholic who rarely moves from her bedroom.

The last case is John, a violent schizophrenic who may have stopped taking his medication. "What do we do?" Dr Salter says. "We have to respect people's rights - we can't just take people in for apparently no reason because we're worried. But then if we don't and he starts taking someone's face off with a crowbar, Joe Public will blame us and say we should have done something."

The names of patients and some details have been changed.