London's mental health services need a massive cash injection to reflect the high proportion of mentally ill people in the capital. That is the uncomfortable message for the Government in a report commissioned by its own officials at the Department of Health.

Some estimates from sources outside the Government put the number of people suffering from mental health problems as high as one in four - nearly four times as high as the problem outside London.

The Government, however, is failing to recognise this in the formula it uses to allocate money to different regions. Factors such as deprivation, unemployment and the proportion of single parents are taken into account, but no attempt appears to have been made to make an actual head count of those suffering from mental illness.

Recommendations for a radical rethink have come from the Mental Health Task Force, set up by the Department of Health this year to check on what is going wrong with the capital's mental health services.

It will suggest a major shift in resources away from the rest of the country and towards London, to cope with the growing crisis in caring for the mentally ill. The report is before ministers but has not yet been made public.

Nobody quite knows why the capital suffers such a poor level of mental health. It is thought that many sufferers drift into London looking for anonymity after the breakdown of relationships with family and friends. It is also suggested that poor housing may exacerbate mental health problems of those already living here.

A recent report for Wandsworth council, by International Consulting, suggested that mental health problems for Londoners were relatively widespread. Problems ranged from depression through to major psychosis.

Throughout London, the study estimated 22 per cent of the population suffered some form of mental illness, compared with 6.9 per cent of the population in England and Wales. In Inner London it is estimated that 28 per cent suffer some form of mental illness. Only a small percentage of these would need hospital admission, the majority being seen by their GPs.

The capital has 6,265 acute mental illness beds and, at the latest count, 5,934 patients formally sectioned under the Mental Health Act, although they represent the tip of the iceberg.

According to the mental health charity Mind, 7 per cent of mentally ill patients are sectioned. But in one London NHS trust the number of patients sectioned is as high as 35 per cent.

The Mental Health Task Force report, details of which have been leaked to Independent London, paints a picture of a system at breaking point because of woeful underfunding.

Members of the task force have spent three months visiting 12 health authorities whose hospitals have mental wards, particularly those likely to be affected by the Tomlinson proposals for reducing hospital beds. Their findings follow a damning report on the breakdown of community care services which led up to the murder of Jonathan Zito by Christopher Clunis at Finsbury Park Tube station in December 1992.

That report highlighted the failings of London's community services for mentally ill patients, with Clunis trapped in the 'revolving door - in and out of hospital with little or no support in the community.

As a result the Government introduced new supervision discharge orders for patients leaving hospital; a register of at-risk patients; and new guidance on discharging patients.

However, there are still problems getting hospital care when it is really needed.

Patients have to be suicidal or extremely dangerous to stand any chance of admission to a hospital bed, according to consultant psychiatrists.

An increasing number of hospitals offering acute mental beds are being forced to refer patients to hospitals outside of London. It is nothing unusual to send patients as far away as Yorkshire because beds are not available.

Dr Kait Goddard, consultant psychiatrist and medical director of the Bexley hospital NHS Trust, said lack of adequate community provision for patients who are mentally ill can lead to problems reaching crisis point, when emergency hospital admission is necessary. Some admissions could be avoided if sufficient community services were available, she believes.

Charles Waddicor, a member of the task force and director of housing and social services in Sutton, told a recent local authority conference that the

picture of services across London was extremely mixed.

'In parts of London, resources were stretched to the limit and beyond, he said. 'Dialogue between the agencies was intermittent or non-existent, closure programmes for hospitals appeared rushed and ill considered and services were not being properly targetted.'

The Audit Commission is also due to report on the state of the capital's mental health services this autumn. Early findings show London does have special problems, not just because of the high incidence of mental illness, but because of the wide variety of organisations involved in providing care - hospitals, social services departments and voluntary groups.

People also tend to move from one borough to another, causing far more problems in providing continuity of care than in other big cities where there will be only one health and local authority.

In some parts of London, beds on mental wards were heavily oversubscribed, sometimes as high as 120 per cent. That means patients who are discharged on a trial basis, whose bed would previously have been saved for them in case something goes wrong, find their bed has been given to someone else who needs it more than they do.

Dr Dinshaw Master, medical director of the Lewisham and Guy's Mental Health NHS Trust, said it has always been the case that people with severe mental illness tend to drift into big cities because they offer anonymity and are more able to accept unconventional behaviour. 'It is nothing new, but it is really coming home to us at the moment. A great proportion of our patients are not Londoners. They come from all over the country, he said.

Dr Master is not looking to boost the number of people in hospital. If anything he wants to get them out into the community.

'But it is impossible to manage the flow of patients at the moment. This is not shroud waving. My style is to keep people out of hospital wherever possible.

He is dubious, however, about any suggestion of shifting resources away from other parts of the country and into London. 'I think that would be robbing Peter to pay Paul. If services are okay outside London, I wouldn't want to take money away from them.

Caring. . . at a great distance

Guy's hospital often sends patients to Stockton Hall, a private hospital 250 miles away, outside York. Bexley hospital have had to send patients to Portsmouth or Oxford because it does not have enough beds.

The cost is enormous, up to pounds 300 a day for a bed. So many patients are being sent outside the capital that hospitals are way over budget. Last year Bexley paid pounds 90,000 to place their patients. So far this year it has spent about pounds 50,000. It is currently referring six patients a month to mental hospitals outside London.

The story is the same in Dagenham and Havering, where referrals outside London have increased from six in April 1993 to 17 in March this year.

The situation is worse at Lewisham and Guy's Mental Health NHS Trust. They have 107 acute hospital beds for severely mentally ill patients, some at Guy's, others at Hither Green and a handful at Bexley. That number is insufficient for the cases they have to deal with.

They treat the most difficult end of the spectrum, patients with severe depression, mania and schizophrenia. The mortality rate among schizophrenics is 15 per cent, due to a high suicide rate.

Despite the severity of the illnesses, most patients at the Guy's unit only stay on the ward for an average of 15 days. Consultants admit they are sending people home far sooner than they want to, but have no other choice.

Last year, the trust spent pounds 490,000 on places for patients in private hospitals outside London. It expects to spend at least pounds 1.2m this year.

'All that money could be used to develop NHS facilities, says the trust's medical director, Dr Dinshaw Master. We really need some heads banged together.'

The trust is trying to set up community based facilities, including 24-hour emergency home care for mentally ill patients.

Although it would be an expensive service, the money currently being spent on private places would more than cover the cost, Dr Master believes.

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