Psychiatric tourism is overloading London beds

EDITOR,--A recent conference on metropolitan health care highlighted the plight of mentally ill people in London. Of special note was the serious shortage of admission beds in all urban areas in the United Kingdom,1 2 with the bed occupancy rate for mental health now well above 100%, with some units actually running at over 120%.3 Pressure seems greatest in inner London, and it is a far cry from the therapeutic standard of a bed occupancy rate no greater than about 85%.4 Such occupancy would allow patients to be placed in their catchment area ward, with effective aftercare and an allocated key worker, as envisaged in the care programme approach.

This shortage is generating extracontractual referrals to hospitals, both NHS and private, that are often far removed from the community from which the patient originates. The situation is exacerbated by the current shortfall in community care resources, and the increasing diversion of patients from the criminal justice system into the NHS. The lack of medium secure beds compounds the problem further. Such bed pressures have been identified as a key factor in the recent tragedy involving the homicide committed by Christopher Clunis.5

A factor not previously noted, in our view, is that inner London is acting as a magnet to people from all over the world. The need to seek anonymity in a metropolis has long been understood in relation to schizophrenic illnesses. But with our increasing integration into Europe and the worldwide economic recession, a considerable number of patients now seem to be emanating from the European continent. Many others arrive from Third World countries that lack adequate resources for psychiatric care. If such patients have relatives in Britain they tend to come to London (often on a visitor's visa) and have to be admitted to NHS facilities. Their access to a local address makes it difficult for administrators to establish true residency status.

A number of patients travel because of a “paranoid flight,” feeling they are being threatened in their home country. Once cared for in our NHS system they return every time their illness deteriorates, and their families cooperate in this. We estimate that at any one time at least a tenth of our inpatients are from abroad, but accurate figures are hard to obtain. Some even seek political asylum as a way of staying in Britain so as to obtain necessary treatment.

However, most of these patients do not figure on any census, and therefore no specific provision is made for their funding. It is often extremely difficult to arrange repatriation as most foreign embassies will not get involved, knowing that the British NHS and local social services will pick up the tab. Of course, once a visitor is detained under the Mental Health Act he (or she) is entitled to treatment under the NHS, and most acute psychiatric admissions in London (60-80%) are serious enough to require sectioning.

It has been suggested that bills should be sent to the Foreign Office, which may be able to make representations to foreign states. We suspect that this problem largely relates to central London but would be interested to hear other people's views. At least one London hospital (the Gordon) now refuses community care after discharge to nonresident foreign nationals. Given the current unacceptable state of bed provision in London, can the NHS afford to treat mentally ill people not ordinarily resident in Britain?