It is five years since the King's Fund inquiry into mental health services in London, and researchers are taking another look. Ann McGauran reports

Published: 21/03/2002, Volume II2, No. 5797 Page 14 15

An inquiry into the state of mental health services in London is underway, five years after the last one. The same questions are coming around again.With the situation, according to one senior analyst, 'at or near crisis point', will the latest investigation by the King's Fund go beyond throwing more light on old problems?

Back in 1997, the King's Fund published London's Mental Health, and the report's key findings were incorporated into Transforming Health in London.It described inner London's mental health service as 'unsustainable'.

Have things got better or worse since 1997, and what might emerge during the 18 months of the new mental health inquiry?

Five years ago, 'no single service appeared to have a full range of desirable features'. That investigation found very high levels of mental illness - particularly in inner London - resulting in huge demand on extremely pressurised services.

It pointed out long delays for treatment. Gaps in the care net were identified, including a requirement for more responsive community-based services, bed provision for the acutely ill and rehabilitation facilities for those with longer-term problems.

Children, young people, those with severe and long-term illnesses and people from ethnic minorities were particularly poorly served.

King's Fund fellow in mental health Angela Greatley is leading the new work. She expects to see much more ev idence of community-based services and less reliance on inpatient beds.

There will, she says, probably be more community mental health teams dealing with people with very severe problems who are fairly stable in the community.

She expects to begin to see more specialist services such as assertive outreach - dealing with severely affected people with long-term problems who need help developing their quality of life. 'We would also expect to see some crisis intervention services for people who become acutely ill and need help in the community, ' she says. The inquiry will also ask whether acute beds are under the same pressure as in 1997.

The government set clear targets in the 1999 national service framework on mental health and the NHS plan the following year.

These included 335 crisis resolution teams and 220 assertive outreach teams by 2003.

The NHS plan also promised an extra annual investment of over£300m by 2003-04 to fastforward the framework.

What might mental health trusts in London be telling the inquiry?

East London and the City Mental Health trust chief executive Peter Horn says his organisation will meet the targets on assertive outreach. But while there is 'an awful lot more money going in', he says that has to be set against the fact that 'demand is very high'.

His trust is getting around 7.6 per cent extra next year - '5.6 per cent plus our earmarked mental health allocation' - but 'nearly 4 per cent of that is going on other increases in costs, including pay'.

He believes there is also a wider question of whether East London is getting an appropriate level of funding, given a 'very high level of need'. The capitation formula for allocating resources does not take that into account, he says.

Dr Trevor Turner is a consultant psychiatrist at Mr Horn's trust and a spokesman on London for the Royal College of Psychiatrists.

At the front line, he sees little sign ofimprovements.He says that of the three priority areas in the NHS plan, his 'Cinderella' specialty 'has gone back to the fireside'.His trust is under intense financial pressure and he argues that 'despite the promises', it has not been given the money for the new community teams.He wonders where the new staff are going to come from, given that existing mental health teams have problems in recruiting.

Additionally, there is, he says, a 15-18 per cent shortfall of consultant psychiatrists across England, with particular shortages in parts of London.

He says acute mental health wards in London are 'bursting at the seams'.He foresees no alleviation in the acute capacity problem since 1997 and demand for hospital beds 'continues to rise'.

He believes there is no evidence that the new teams are effective in taking pressure off acute wards.

Solutions should include a reformed Mental Health Act that brings in community treatment orders in order to 'cool demand' for acute care and 'proper highdependency 24-hour units - properly staffed' as promised by the government in the NHS plan.

He asks, 'Where are they?'

He wants an 'end to the inquiry culture'when things go wrong, which he sees as a waste of time and money. The royal college is looking at how to make the role of general adult psychiatrists less difficult to aid recruitment and retention, including revised job descriptions and reviews of 'how big a patch they should look after'.

Sainsbury Centre for Mental Health policy director Andrew McCulloch says the four key issues that need to be tackled are capacity, workforce, ethnicity and culture, and the burden of forensic psychiatry.

He points out that in Lambeth, Southwark and Lewisham a quarter of the mental health spend goes on forensic psychiatry alone.He questions whether 'we are getting people at the right point in the system'.He believes that London's mental health services are 'at or near crisis point' and says that what's needed from the new inquiry are 'solutions rather than diagnosis'.

The message seems to be that numerical targets have their place as a starting point, but it is time to move on by putting the emphasis on quality and keeping close watch on the results.