Worried well force aside the mentally ill

Psychiatrists fear that the counselling craze is depriving those who really need help

BILLY is a highly disturbed young man. He has a history of manic depression. At the moment he is seriously manic, so he is being looked after in an acute psychiatric ward. In a couple of weeks he will be sent home. He is going to need a lot of support. But he may not get it - because the money is being spent instead on counselling for the "worried well".

The "worried well" is a term heard increasingly among psychiatrists. They use it - many of them scathingly - to describe a growing group of patients with minor, everyday personal problems, who are also often middle- class and highly articulate and are demanding psychotherapy on the NHS.

"We are being swamped by the psychotic who need intensive care, but being asked to spend our money providing counsellors," says Dr Trevor Turner, Billy's consultant psychiatrist at Homerton Hospital in east London. "The vociferous worried well keep turning up at the doctor's with personal problems they used to take to their priest, and demanding counselling, because it's thought to be a Good Thing. They're much better equipped to voice their 'choice' than a seriously disturbed schizophrenic, hiding in his bedroom gibbering. So the GP gives it to them, because it's what the punter wants."

Dr Turner is exposing a dispute which cuts to the root of how the health service should be run. Who should it primarily serve - the influential majority or the desperately needy minority?

On the one hand are psychiatrists accusing GPs - notably fundholders - of using their new-found purchasing power to create a supermarket health service: one that provides therapy, that supposed panacea for every modern malaise, at the expense of acute care for the psychotic. On the other are GP fundholders and therapists proclaiming a new Jerusalem: a service that meets ordinary people's everyday needs and will make vast savings in the long term. They deny that counselling is being bought at the cost of acute mental health care, and fire off accusations of professional paranoia and jealousy. The two sides concur only in their conviction that counselling will continue its ascent as the NHS's Big Idea - to devastating effect, say some.

The acute psychiatric ward at Homerton Hospital is bright, comfortable, immaculate. It accommodates 17 seriously mentally ill patients, most of whom will be back out into care-in-the-community within a month. To cope, they will rely heavily on community psychiatric nursing. GP fundholders took responsibility for this service in April last year.

Matt Muijen, director of the Sainsburys Centre for Mental Health, explains: "The patient comes out to find that his community psychiatric nurse has been replaced by a counsellor, because that's what the GPs want. But a counsellor is no good at all to him - so he has another breakdown." The patient has become, at best, a renewed pressure on hospital beds; at worst, a public danger.

The National Association of Health Authorities and Trusts says there is already anecdotal evidence of this happening. But Dr Rhidian Morris, chair of the National Association of GP Fundholding Practices, dismisses the idea.

"Money is simply not being taken away from psychiatric services," he says. "Psychiatrists have an enormous power complex, and they've become paranoid about it. You might find the odd example of it, but that would be because, in fact, the psychiatric services were not meeting the needs of the local population."

Who can best assess the mental needs of the local population? GPs argue that they, on the front line, are uniquely placed to do so. But consultant psychiatrist Dr Massimo Riccio says the GPs' perspective is skewed, because 30 per cent of people with chronic mental illness are not even registered with a doctor. "They cannot get it together," he says.

A recent admission to Homerton Hospital had been found locked in her home, nooses tied around her two young children's necks, having just set light to the flat. She was suffering paranoid delusions, but nobody knew, because she did not have a doctor.

The greatest change to date in mental health care has taken place in the GP's surgery itself. More and more practices are offering counselling services, paid for by the GP's own budget or, in the case of non-fundholders, the health authority. Graham Curtis-Jenkins, director of a trust dedicated to promoting this service, says: "These people are not the worried well - they are the worried sick, and a very great burden on our health service. If you get a half-decent counselling service going, you can solve all sorts of related physical disorders like asthma and irritable bowel syndrome. And in Gloucestershire, a counselling team managed to cut referrals to psychiatric services by 35 per cent."

That is what worries Dr Riccio. "The door is opening for under-qualified people to be working as counsellors. A patient may come in and say he is depressed, and the counsellor may not be skilled enough to see when the problem is more acute. It's potentially explosive."

Mr Curtis-Jenkins retorts: "You do a patient-satisfaction study, and you'll find that it's the patients themselves who say they don't want to be sent off to a psychiatrist and stigmatised. They just want someone to listen to them. They are voting with their feet - and it's a revolution."

The counsellors' greatest selling point is their claim to a preventive function. This is a persuasive argument: nip problems in the bud with a little light counselling, and the patient will not, five years down the line, have developed a psychiatric disorder. Dr Riccio concedes the theory's appeal, but says there is no medical evidence to support it. None of the admissions to Homerton Hospital, in other words, could have been prevented had someone talked them through their marital problems a little while earlier.

Counselling on the NHS is nonetheless hugely popular. Demand for it outstrips supply, and counsellors point with pride to the many patients they have helped return to work, make better parents, lead happier lives. There is a real conflict of legitimate interests here which far exceeds petty professional jealousy. But there is, too, a temptation to compare competing priorities in stark terms of economic efficiency.

"There is an assumption that once you are mad, that's it. All we are going to do is wipe your bottom from there on. So there's more economic gain from working with the worried well. That's frightening - we are heading towards 1930s Germany then," says Dr Turner.

"And it's untrue. You can be gibbering in the haystacks in June, and by September be back at work. But only if you get the right treatment."

If there are to be casualties in the new, consumer-driven NHS, according to Mr Muijen, it will be those who do not queue up at the counter, demanding the care they want to buy.

"The problem is not the violent case - he will always be put in a bed and looked after. The problem is the schizophrenic sitting at home in his bedroom, highly disturbed and forgotten.

"He isn't the one who is going to push you under the Tube this morning - but if he doesn't get help, he may well be the one who pushes you under the Tube tomorrow."