Big cities in Europe are characterised by social factors that can influence mental health and impact on the provision of mental health care. These factors include social inequalities, social marginalisation and fragmentation, large scale immigration, and a high proportion of mobile populations. Big cities tend to have higher levels of morbidity and higher costs of service provision than other parts of the same country. This leads to specific challenges, particularly in inner city areas. The paper summarises how mh services in London approach these challenges, how they are organised and how they have changed over the last 10 years. Services are provided by the NHS with an emphasis on care in the community. Whilst there have been large investments in mental health care and the establishment of a range of new teams with specialised functions over the last 10 years, recently funding has come under pressure and service provision may need to be reduced. There has also been a stronger focus on risk issues and the introduction of compulsory treatment in the community.

Taking the example of East London as the most deprived area in London, the paper will illustrate how traditional principles of sectorisation, catchment area responsibility and continuity of care have been put into question with potentially new solutions to old problems. The paper will also briefly describe how mental health care for socially marginalised groups is provided and compare the situation in London against that in other European capitals as investigated in the EC funded PROMO Study.