Abbie and her late father, James Harrison.
Julia Savage is a manager at Birkenhead Benefit Centre in Liverpool. She wrote a letter addressed to a GP regarding a seriously ill patient. It said:
“We have decided your patient is capable of work from and including January 10, 2016.
“This means you do not have to give your patient more medical certificates for employment and support allowance purposes unless they appeal against this decision.
“You may need to again if their condition worsens significantly, or they have a new medical condition.”
The patient, James Harrison, had been declared “fit for work” and the letter stated that he should not get further medical certificates.
However, 10 months after the Department for Work and Pensions (DWP) contacted his doctor without telling him, James died, aged 55, the Daily Record has reported.
He was clearly not fit for work.
His grieving daughter, Abbie, said: “It’s a disgrace that managers at the Jobcentre, who know nothing about medicine, should interfere in any way in the relationship between a doctor and a patient.
“They have no place at all telling a doctor what they should or shouldn’t give a patient. It has nothing to do with them.
“When the Jobcentre starts to get involved in telling doctors about the health of their patients, that’s a really slippery slope.”
Abbie said James had worked since leaving school at a community centre near his home. But his already poor health went downhill after the centre was shut down because of austerity cuts.
James had a serious lung condition and a hernia before the centre closed, and also developed depression and anxiety afterwards.
Abbie said: “He’d worked all his life. He wasn’t the kind of guy who knew anything about benefits.
“But as his health deteriorated, there wasn’t any chance he could do a job. He applied for employment and support allowance.”
James received Employment and Support Allowance (ESA), but only at the low rate of £70 a week, the same amount as jobseekers’ allowance. He was then sent to attend one of the DWP’s controversial Work Capability Assessments – and declared fit for work.
Despite that decision, Abbie said James remained in constant need of medical help and had to visit his doctor regularly.
However, the GP concerned repeatedly refused to give him a sick note, and James began to suspect the Jobcentre were to blame for this.
Abbie said: “He really needed a note. He was too ill to go to the constant appointments at the Jobcentre and he didn’t want to be sanctioned.
“He became convinced the DWP had been talking to his doctor behind his back.”
Although Abbie felt her father was confused, and didn’t think his explanation was right at the time, she later asked to see her father’s medical records. She found the letter in his file from Julia Savage, the manager at Birkenhead Benefit Centre, in James’s home city of Liverpool.
The letter was addressed to James’s GP.
Context: Government claims that work is a “health outcome”
James Harrison was very worried that his ill health interfered with his obligation to comply with the inflexible and constant conditions attached to his eligibility for welfare support, and that this would lead to sanctions – the withdrawal of his lifeline support, which was calculated to meet basic survival needs only.
The GP should have provided evidence that this was the case. The doctor was advised not to provide further fit notes by the DWP, however, unless James appealed. Yet the circumstances warranted that the GP provide a fit note.
In the document, doctors are warned of the dangers of “worklessness” and told they must consider “the vital role that work can play in your patient’s health”. According to the department, “the evidence is clear that patients benefit from being in some kind of regular work”.
The biopsychosocial model, with a current political emphasis on the psychological element, has become a disingenuous euphemism for psychosomatic illness, which has been exploited by successive governments (and rogue insurance companies) to limit or deny access to social security, medical and social care.
Nobody would deny that illness has biological, psychological and social dimensions, however, the model has been adapted to fit a neoliberal “small state” ideology – one that rests almost entirely on Conservative individualist notions of citizen responsibility, as opposed to a rights-based approach and provision of publicly funded state support.
This approach to disability and ill health has been used by the government to purposefully question the extent to which people claiming social security bear personal responsibility for their own health status, rehabilitation and prompt return to work. It also leads to the alleged concern that a welfare system which was originally designed to provide a livable income to those with disabling health problems, may provide “perverse incentives” for perverse behaviours, entrenching “worklessness” and a “culture of dependency”. It’s worth pointing out at this point that there has never been any empirical evidence to support the Conservative notion of welfare “dependency”.
Instead of being viewed as a way of diversifying risk and supporting those who have suffered misfortune and ill health, social and private insurance systems are to be understood as perverse incentives that pay people, absurdly, to remain ill and keep them from being economically productive.
The idea that people remain ill deliberately to avoid returning to work – what Iain Duncan Smith and David Cameron have termed “the sickness benefit culture” – is not only absurd, it’s very offensive. This is a government that not only disregards the professional judgements of doctors, it also disregards the judgements of sick and disabled people. However, we have learned over the last decade that political “management” of people’s medical conditions does not make people healthier or suddenly able to work. Government policies, designed to “change behaviours” of sick and disabled people have resulted in harm, distress and sometimes, in premature deaths.
The government have made it clear that there are plans to merge health and employment services. In a move that is both unethical and likely to present significant risk of harm to many patients, health professionals are being tasked to deliver benefit cuts for the DWP. This involves measures to support the imposition of work cures, including setting employment as a clinical outcome and allowing medically unqualified job coaches to directly update a patient’s medical record.
The Conservatives (and the Reform think tank) have also proposed mandatory treatment for people with long term conditions (which was first flagged up in the Conservative Party Manifesto) and this is currently under review, including whether benefit entitlements should be linked to “accepting appropriate treatments or support/taking reasonable steps towards “rehabilitation”. The work, health and disability green paper and consultation suggests that people with the most severe illnesses in the support group may be subjected to welfare conditionality and sanctions.
Many campaigners have raised concerns about the DWP interfering with people’s medical care and accessing their medical files. I wrote an article last year about how the government plans to merge health and employment services and are now attempting to redefine work as a clinical outcome. I raised concerns about the fact that unemployment has been stigmatised and politically redefined as a psychological disorder, and that the government claims, somewhat incoherently, that the “cure” for unemployment due to illness and disability, and sickness absence from work, is work.
In a critical analysis of the recent work, health and disability green paper, I said:
“And apparently qualified doctors, the public and our entire health and welfare systems have ingrained “wrong” ideas about sickness and disability, especially doctors, who the government feels should not be responsible for issuing the Conservatives recent Orwellian “fit notes” any more, since they haven’t “worked” as intended and made every single citizen economically productive from their sick beds.
It seems likely, then, that a new “independent” assessment and some multinational private company will most likely very soon have a lucrative role to ensure the government get the “right” results.”
The medical specialists are to be replaced by another profiteering corporate giant who will enforce a political agenda in return for big bucks from the public purse. Health care specialists are seeing their roles being incrementally and systematically de-professionalised. That means more atrocious and highly irrational attempts from an increasingly authoritarian government at imposing an ideological “cure” – entailing the withdrawal of any support and imposing punitive “behavioural incentives” – on people with medical conditions and disabilities. Doctors, who are clever enough to recognise, diagnose and treat illness, are suddenly deemed by this government to be insufficiently clever to judge if patients are fit for work.
The political de-professionalisation of medicine, medical science and specialisms (consider, for example, the implications of permitting job coaches to update patient medical files), the merging of health and employment services and the recent absurd declaration that work is a clinical “health” outcome, are all carefully calculated strategies that serve as an ideological prop and add to the justification rhetoric regarding the intentional political process of dismantling publicly funded state provision, and the subsequent stealthy privatisation of Social Security and the National Health Service.
“De-medicalising” illness is also a part of that process:
“Behavioural approaches try to extinguish observed illness behaviour by withdrawal of negative reinforcements such as medication, sympathetic attention, rest, and release from duties, and to encourage healthy behaviour by positive reinforcement: ‘operant-conditioning’ using strong feedback on progress.” Gordon Waddell and Kim Burton in Concepts of rehabilitation for the management of common health problems. The Corporate Medical Group, Department for Work and Pensions, UK.
Waddell and Burton are cited frequently by the DWP as providing “evidence” that their policies are “evidence based.” Yet the DWP have selectively funded their research, which unfortunately frames and constrains the theoretical starting point, research processes and the outcomes with a heavy ideological bias.
This framing simply shifts the focus from the medical conditions that cause illness and disability to the “incentives”, behaviours and perceptions of patients and ultimately, to neoliberal notions of personal responsibility and self-sufficient citizenship in a context of a night watchman, non-welfare state.
Medication, rest, release from duties, sympathetic understanding – the remedies to illness – are being appallingly redefined as “perverse incentives” for ill health, yet the symptoms necessarily precede the prescription of medication, the Orwellian renamed (and political rather than medical) “fit note” and exemption from work duties. Notions of “rehabilitation” and medicine are being redefined as behaviour modification: here it is proposed that operant conditioning in the form of negative reinforcement – which the authors seem to have confused with punishment – will “cure” ill health.
People cannot simply be “incentivised” into not being ill.
The political use of the biopsychosocial model to cut costs at the expense of people who are ill will undoubtedly have further extremely serious implications. Such an approach, which draws on behaviourism and punishment (such as the threat and implementation of sanctions) is extremely unethical and makes the issue of consent to medical treatment very problematic if it is linked to the loss of lifeline support or the fear of loss of benefits.
This is clearly the direction that government policy is moving in and this represents a serious threat to the health, welfare, wellbeing and human rights of patients and the political independence of health professionals.
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