Mental health services and treatments are provided in a variety of settings and from a range of private and NHS providers. In the NHS, services are traditionally divided between primary, secondary and specialist care. It is estimated that about 90% of all people with mental health problems are cared for entirely within primary care (1). Only a small percentage of people with mental health problems require secondary care services such as community care and inpatient services, and an even smaller percentage of people require specialist care services (such as forensic services).

Primary care services in London are provided by 31 Primary Care Trusts. Inpatient and community mental health (secondary care) services are provided by nine mental health trusts in London, plus the Tavistock and Portman NHS Trust (which provides specialist therapeutic services) and Hillingdon PCT which provides community mental health services. (For contact details and links to these trusts please visit the London Development Centre website. Also see the LHO's PCT programme).

Further information on the range of services provided in London is available from the Centre for Public Mental Health. This unit undertakes an annual service mapping of all adult, children and adolescent, and older people mental health services on behalf of the Department of Health. Results of the adult and children and adolescent mental health service mappings are available online.

In the absence of centrally collected data on primary care and community services, the majority of this section will focus on inpatient figures.

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Inpatient care for people with mental health problems is provided under 5 main consultant specialties:

These specialties broadly map to the way services are provided and the first three represent the age groups served: general psychiatry largely deals with adults up to the age of 65, and old age psychiatry with those aged 65 and over. Child and adolescent services vary in their upper age limits and some young people aged under 18 years may be seen in adult services.

Over the last five years, admissions for mental health problems for London residents have dropped by 16% compared with 8% across England. Admission rates per 1,000 of the population have also dropped more in London since 1998/99 than England (see Blue Sky Thinking Discussion paper below). London has decreased its number of mental health inpatient beds by 9.8% between the years 1998/99 and 2002/03, compared with England which has seen a reduction in beds available by 8.2% (see table 1). However, London has a higher bed occupancy rate than England, 92% compared with 88% in 2002/03. (For more information on inpatient hospital care see Hospital Episode Statistics pages.)

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Standardised admission rates for the psychiatric specialties (ie people treated by a psychiatrist) have been calculated from the 2002/03 HES data for all the psychiatric specialties pooled, and for general psychiatry and old age psychiatry. For forensic and child and adolescent psychiatry, and for psychotherapy activity numbers were too small for analysis on a yearly basis. Table 2 shows the breakdown of admissions by age group and psychiatric specialty in London in 2002/2003. See Datasets.

Note on interpretation: It is important to note that variations in admission rates do not necessarily represent differences in prevalence rates between boroughs. Such variations may be due to differences in the availability and capacity of services. Further, admission rates depend upon the quality and accuracy of the data submitted by trusts.

For all psychiatric specialties pooled and for general psychiatry, in 2002/03:

For old age psychiatry:

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Evidence shows that those from black and minority ethnic groups (BME) are more likely to be:

Analysis of the HES data for 2002/03 for London residents shows that approximately 61% of all people admitted under a psychiatric specialty are White, and 15% are Black. In comparison, 52% of all hospital admissions for London residents are White, and 9% Black. These figures suggest a higher representation of people from Black ethnic groups being treated within the psychiatric specialties and a lower representation of other non-white ethnic groups.

Further analysis of HES for Forensic Psychiatry shows a clear over-representation of Black people in this specialty: of those admissions with a valid ethnic code (61%), 52% were Black and 36% were White. For information on ethnic coding in psychiatry see below.

In 2005 the Government published its report Delivery race equality in mental health care, a five-year action plan for reducing inequalities for Black and Minority Ethnic groups. The report also includes the Government's response to the recommendations made by the Inquiry into the death of David Bennett.

For further information on Ethnicity and Mental Health see Socio Demographic Factors and the LHO's Report Ethnic Disparities in Health and Healthcare.

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Analysis of the ethnic codes in HES data for London residents, 2002/03, shows that ethnic coding is better amongst psychiatric specialties (and therefore mental health services) than across all specialties. Of all psychiatric admissions, approximately 6% were coded using the 1995 ethnic codes, and 94% using the more recent 2001 codes. For all hospital admissions 12% were assigned a 1995 code instead of a 2001 code. For those admissions with a 2001 ethnic code, ethnicity was not stated in 26% of all hospital admissions, but in only 14% of all psychiatric admissions. This figure rises to 28% for all hospital admissions, and 18% for all psychiatric admissions if the 1995 codes are included.

For further information see Ethnic Health Intelligence Programme.

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The Mental Health Act (1983) is the legal framework in which all mental health professionals must adhere to when it is felt necessary to detain and treat a patient against their will. A new draft Mental Health Act was released in September 2004. For more information on Mental Health Act statistics see the Department of Health's mental health data pages.

Although London had similar psychiatric admission rates per 1,000 of the population in 2002/03, a higher proportion of admissions to London NHS mental health services were admitted under the Mental Health Act (1983) than the rest of England: an estimated 24% of admissions were under the Mental Health Act (1983) in London compared to 14% across England.

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The London Ambulance Service (LAS) NHS Trust records details of every ambulance call out. Each callout is assigned an incident type (cause of the callout). During 2001/02/03, psychiatric problems accounted for around 27,600 callouts and self-harm 49,200 callouts. This is approximately four per cent of all callouts in these years. However, mental health problems are thought to be significantly under-reported by ambulance staff. Borough level data is available under PCT indicators. Analysis of poisonings and overdoses by age, sex and borough are available on the Life Style and Behaviour - Drugs pages.

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There have been a number of reviews of mental health services in London, and many of these were reviewed themselves in the Review of 2003 London Mental Health Services Reviews.

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In April 2003 the National Institute for Mental Health in England (NIMHE) Acute Inpatient Care Programme commissioned the Sainsbury Centre for Mental Health to conduct a national benchmarking study of all acute wards in England. The results of this programme are expected early 2005. Further information will be added as it become available.

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A number of indicators for mental health service need have been developed, for example:

In 2003 the London Development Centre for Mental Health commissioned the London Health Observatory and the Institute of Psychiatry to develop indicators for mental health service activity across London whilst adjusting for socio-demographic need i.e. to understand how much of hospital activity within London is based on the socio-demographic profile of the local populations (3). Four indicators were developed which were based on a number of socio-demographic variables. It was found that these indicators were able to explain:

The demand for mental health services in London can therefore be explained to some extent by the sociodemographic profile of the local populations. However, significant variance across London remains unexplained. Clearly, demand for services based on activity provided does not necessarily equate to the actual need in the community. Further, a number of issues around data quality and completeness were noted in this study. Finally, service profiles need to be considered when interpreting these data, for example, bed use is dependent on number of beds available. Despite these issues, it is recommended that this methodology may be useful in supporting resource allocation and the commissioning of mental health services in London, and in future benchmarking of mental health services.

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As part of the King's Fund inquiry into mental health in London, a series of papers were produced looking at certain aspects of the city's mental health services. Two of these papers focused on London's mental health workforce and Financing mental health services in London. (4,5)

Date	Title	Format	View
28 Mar 2007	Commissioning for equity. Equal access, equal care? Can London deliver the race equality action plan for mental health? Executive summary
28 Mar 2007	Commissioning for equity. Equal access, equal care? Main report
8 Jan 2007	Commissioning for equity. An analysis of planned spending on adult mental health services in London for 2005/06
22 Sep 2006	Personality disorder capacity plans 2005
9 Aug 2006	Local variations in NHS spending priorities
14 Jul 2006	Benchmarking specialist mental health services in London: final report
12 Jul 2006	Benchmarking London’s mental health services: actions from 12 July 2006 event
1 May 2006	The development of a local index of need (LIN) and its use to explain variations in social services expenditure on mental health care in England
16 Dec 2005	Statistics of mentally disordered offenders 2004
1 Nov 2005	Mental Health In London: What are the Special Issues
10 Jun 2005	Availability of mental health services in London: a report for the major of London
10 Jun 2005	Deliverying race equality in mental health care
10 Jun 2005	Financing mental health services in London: Central funding and local expenditure
10 Jun 2005	Improving the quality of psychiatric inpatient care in London
10 Jun 2005	London's mental health workforce: a review of recent developments
10 Jun 2005	London's state of mind: King's Fund Mental Health Inquiry 2003 - summary report
19 Apr 2005	Review of 2003 London Mental health Service Reviews - Powerpoint Presentation
6 Apr 2005	Admissions for Psychiatric Specialties and All Specialties for London residents by ethnic group, 2002/03
6 Apr 2005	Directly Standardised Rates for Admissions to Hospital for Old Age Psychiatry, all ages and 65 years and over, 2002/03
4 Apr 2005	Directly standardised admission rates for General Psychiatry, by gender, age range and borough (2002/03)
4 Apr 2005	Directly Standardised Rates for Admissions to Hospital for Psychiatric Specialties, all ages and by age groups, 2002/03
17 Feb 2005	Rate of Ambulance Call Outs for Specified Conditions, 2001-2003, Borough Level
3 Aug 2004	Ethnic disparities in health and health care: a focused review of the evidence and selected examples of good practice. Full report
25 Mar 2004	Between worlds: interpreting conflict between black patients and their clinicians
28 Feb 2004	Indicators of mental health activity in London: adjusting for sociodemographic need

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1. Evidence summarized in Sainsbury Centre for Mental Health (2002) An executive briefing on primary care mental health services London.
2. Keating F, Robertson D and Kotecha N (2003) Ethnic diversity and mental health in London: recent developments King's Fund: London.
3. McCrone P. & Jacobson B. (2004) Indicators of Mental Health Activity in London: Adjusting for sociodemographic need London Health Observatory, Institute of Psychiatry, Kings College London, London Development Centre for Mental Health: London.
4. Genkeer, L, Gough, P. and Finlayson, B (2003) London's mental health workforce: a review of recent development King's Fund: London.
5. Aziz, F, McCrone, P, Boyle, S, Knapp, M (2003) Financing mental health services in London: Central funding and local expenditure King's Fund: London.

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• Centre for Public Mental Health - Durham University - Home page
• Centre for Public Mental Health - Adult mental health service mapping
• Centre for Public Mental Health - Children and adolescent mental health service mapping
• Department of Health - HES data
• Department of Health - Mental Health data
• Department of Health - Securing better mental health for older adults
• London Development Centre
• The London Directory
• Institute of Psychiatry
  King's College London, De Crespigny Park, London SE5 8AF Tel: +44(0)20 7836 5454
• King's Fund - Mental Health Pages
  11-13 Cavendish Square, London W1G 0AN Tel: 020 7307 2400 Fax: 020 7307 2801
• National Institute for Mental Heath in England
  Acute Care Programme
• Sainsbury Centre for Mental Health
  The Sainsbury Centre for Mental Health, 134 Borough High Street, London SE1 1LB Tel: 020 7827 8300 Fax: 020 7403 9482

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