Category: Work and Health Programme

Tories propose nudge, big business AI initiative and ‘personal responsibility’ in place of adequate health care funding

Health spending by govt

A breakdown of spending on health care under each government up to 2016. Under the Major government, we saw a post code lottery of health care provision and patients were left for hours on end in hospital corridors. It’s a grim consideration that the Major government spent rather more on health care than the Conservatives in office since 2010.

Earlier this year, the prime minister was warned that patients being treated within the National Health Service are dying prematurely in hospital corridors, in a letter from A&E chiefs outlining “very serious concerns” about patient safety. 

Sixty-eight senior doctors in charge of some of the busiest accident and emergency departments in England and Wales said safety compromises are becoming “intolerable”. 

The letter includes accounts from frontline A&E doctors, one of whom warned 120 patients a day were being treated in corridors because of a lack of space on wards.

The letter said: “The fact remains that the NHS is severely and chronically underfunded. We have insufficient hospital and community beds and staff of all disciplines especially at the front door to cope with our ageing population’s health needs.”

Other issues raised in the letter, first reported in the Health Service Journal, include patients waiting up to 12 hours for a bed after doctors had decided to admit them, with queues of 50 patients waiting in one emergency department. May said that the cancellation of 55,000 appointments  was “part of the plan” for the NHS last winter, but said of her government’s response “nothing is perfect”.

The National Health Service (NHS) faces significant financial problems in many different areas. It is succeeding in treating more patients than in the past, but this rise in public need for health care, and rising costs coupled with very tight budgets, are translating into widespread pressures on the capacity of staff and managers to keep up with past performance and the standards the service sets itself.” 

Lengthening queues for treatment are happening despite the NHS treating more patients. In England, Scotland, Wales and Northern Ireland, the number of episodes of care provided in NHS hospitals has been rising. In England, for example, the number of episodes of care overseen by a hospital consultant has risen 11.4% between 2010/11 and 2015/16. It is just that the rise in the treatment provided is not keeping pace with the even faster rise in the number of people coming forward.

At the same time, EnglandScotland and Wales have all started in different ways to look at reducing the provision of treatments that may be deemed of ‘less benefit’ to patients. That means that some people who would have had treatment on the NHS before may not in future. 

This decade health services have seen some of the lowest spending increases in their history. In England, real annual increases are only around 1% a year.

Real terms spending has also been roughly flat per person since 2010 in WalesScotland and Northern Ireland.

This compares to an average increase of nearly 4% over the history of the NHS reflecting the fact that, as the OBR has found, an aging population, new technology and rising wealth all tend to increase health spending in a country.

Matt Hancock, the demedicalisation of illness and the neoliberal psychosocial model

Matt Hancock, the Secretary of State for Health and Social Care, has called on patients to have greater responsibility for their own health in the launch of new a policy paper entitled Prevention is better than cure which outlines a vision for a “new 21st-century focus on prevention”.

He says he wants to “radically change the focus of health and social care onto prevention”. 

Last month I wrote an article that pre-empted Hancock’s policy paper, published yesterday. I wrote critically about a number of his proposals in Government plans to use your phone and online data to police your lifestyle and predict ‘threats’ to your health.

Hancock has called for an increase in ‘social prescribing’ – refering patients to classes and community groups – in a bid to “shift the balance” away from GPs ‘automatically prescribing drugs for many illnesses.’  socialprescribing

He said in September“The evidence increasingly shows that activities like social clubs, art, ballroom dancing and gardening can be more effective than medicines for some people and I want to see an increase in that sort of social prescribing.” 

In practice, social prescribing means that GPs, nurses and other healthcare practitioners work with patients to identify non-medical opportunities or interventions that will help, improving support and the wider social aspects of their lives. The services that patients can choose from include everything from debt counselling, support groups, allotments and walking clubs, to community cooking classes and one-to-one coaching.

Both evidence and commons sense suggests that social prescribing may be particularly appropriate and beneficial for isolated, marginalised groups. It is a needs-led community provision that supports and enhances psychosocial health and wellbeing. However, Hancock seems to think it may be used as a substitute for medicine. 

The psychosocial approach has already been used to cut the budget for disability welfare support, with some tragic consequences. Now, the same approach in the form of social prescriptions is being proposed to cut the NHS bill. The University of York has already produced research to show that there is little good quality evidence that social prescribing is cost-effective

The Conservative government have made a link between social prescriptions, cost-cutting and (as I deeply suspected) as a mechanism of extending behavioural modification (euphemistically called “nudgingby the government’s team of behavioural economists and decision-making “experts”).

Nesta, who now partly own the government’s Behavioural Insights Team (the Nudge Unit) are of course at the forefront of promoting social prescriptions among medical professionals, firmly linking what is very good idea with very anti-democratic Conservative notions of behaviour change, citizen responsibility and small-state ideology. So, it’s no longer just about helping people to access a wider range of community-based services and support, social prescribing has also places strong emphasis on “encouraging patients to think about how they can take better care of themselves.” 

Nesta may have a whooping ‘cognitive bias’ here. A ‘perverse incentive’. It’s called the ‘profit’ incentive.

The same (bio)psychosocial model has been used to disingenuously trivialise and euphemise serious physical illnesses, implying either a psychosomatic basis or reducing symptoms to nothing more than a presentation of malingering tactics. This ploy has been exploited by medical insurance companies (infamously by Unum Provident in the USA) and government welfare departments keen to limit or deny access to medical, social care and social security payments, and to manufacture ideologically determined outcomes that are not at all in the best interests of patients, invalidating diagnoses, people’s experience and accounts, and the existence of serious medical conditions

Unum was involved in advising the government on making the devastating cuts to disabled people’s support in the UK’s controversial Welfare Reform Bill.

Hancock said in his speech at the International Association of National Public Health Institutes: “Prevention is also about ensuring people take greater responsibility for managing their own health.

“It’s about people choosing to look after themselves better, staying active and stopping smoking. Making better choices by limiting alcohol, sugar, salt and fat.”

Hancock claims it is not about “patronising” patients, “It’s about helping them make better choices, giving them all the support we can, because we know taking the tough decisions is never easy.”

“In the UK, we are spending £97bn of public money on treating disease and only £8bn preventing it across the UK”.

“You don’t have to be an economist to see those numbers don’t stack up.”

public spending

No, the numbers don’t stack up. Approximately 14 billion is spent by the Department of Health on things like public health initiatives (which aim to improve people’s health so they don’t need to use the NHS as often), education, training, and infrastructure (such as IT and building new hospitals). 

The Conservatives said in their 2015 election manifesto they would provide £8 billion in government, and expect another other £22 billion in savings from the NHS. The Nuffield Trust said this still left unanswered questions on funding:

“£8bn is the bare minimum to maintain existing standards of care for a growing and ageing population …

“improving productivity on this scale [£22 billion] would be unprecedented”

The Conservative government followed through on the commitment and then started claiming it was giving £10 billion, providing the NHS what it asked for, and more.

In their 2017 election manifesto, the Conservatives said they would increase NHS spending by at least £8 billion in real terms over the next five years, and increase funding per head of the population for the duration of the parliament.

Last year the think tanks said there would be a £4 billion gap in health spending in 2018/19 alone, but the £1.9 billion provided by the government at the end of last year meant that “around half of the minimum gap we calculated has been filled.”

They said even based on the government’s current spending plans there is likely to be a spending gap of over £20 billion by 2022/23. 

Approximately 44 % of NHS trusts—which provide secondary care to patients who’ve been referred there by a GP—were in the red in 2017/18. The figure was 65% just among acute hospital trusts—which make up the bulk of NHS trusts across England.

Collectively they finished 2017/18 with a deficit of around £960 million.

In this context, social prescriptions are used to maintain the status quo, and are likely to be part of a broader process of responsibility ascription – based on the traditional Conservative maxim of self-help, which is used to prop up fiscal discipline and public funding cuts, the extensive privatisation of public services, defense of private property and privilege, and of course, the free market. The irony of the New Right, neoliberal, paternalistic libertarianism is that the associated policies are not remotely libertarian. They are strongly authoritarian. It’s a government that doesn’t respond to public needs, but rather, it’s one that pre-determines public interests to fit within an ideological framework.

Theresa May has pledged millions of pounds to use Artificial Intelligence (AI) to “improve early diagnosis of cancer and chronic disease.” In a speech delivered earlier this year, May also called for the industry and charities to “join the NHS in creating algorithms that can predict a patient’s care requirements based on their medical records and lifestyle information.” 

The government believes that early intervention would provide “less invasive, more affordable and more successful care than late intervention,” which they claim “often fails.”  

While the government has assumed that the unmatched size of the NHS’s collection of data makes it ideal for implementing AI, many are concerned about data privacy.

Importantly, May’s proposal would (once again) allow commercial firms to access NHS data for profit.

In April 2018, a £1bn AI sector deal between UK Government and industry was announced, including £300million towards AI research. AI is lauded as having the potential to help address important health challenges, such as meeting the care needs of an ageing population. 

Major technology companies – including Google, Microsoft, and IBM – are investing in the development of AI for healthcare and research. The number of AI start-up companies has also been steadily increasing. There are several UK based companies, some of which have been set up in collaboration with UK universities and hospitals.

Partnerships have already been formed between NHS providers and AI developers such as IBM, DeepMind, Babylon Health and Ultromics. Such partnerships have attracted controversy, and wider concerns about AI have been the focus of several inquiries and initiatives within industry, and medical and policy communities. 

Last year, Sir John Bell, a professor of medicine at Oxford university, led government-commissioned review. He said that NHS patient records are uniquely suited for driving the development of powerful algorithms that could “transform healthcare” and seed an “entirely new industry” in profitable AI-based diagnostics. 

Bell describes the recent controversy surrounding the Royal Free hospital in London granting Google DeepMind access to 1.6m patient records as the “canary in the coalmine”.

“I heard that story and thought ‘Hang on a minute, who’s going to profit from that?’” he said. 

Bell gave the hypothetical example of using an anonymised data for chest radiographs to develop an algorithm that eliminated the need for chest x-rays from the ‘analytical pathway’.

“That’s worth a fortune,” he said. “All the value is in the data and the data is owned by the UK taxpayer. There has to be really serious thought about protecting those interests as we go forward.”

However, Bell highlighted a “very urgent” need to review how private companies are given access to NHS data and the ownership of algorithms developed using these records.

Hancock, the recently appointed health secretary, is now planning a “radical” and highly invasive system of “predictive prevention”, in which algorithms will use detailed data on citizens to send targeted “healthy living messages” to those flagged as having “propensities to health problems”, such as taking up smoking or becoming obese. 

People’s medical records will be combined with social and smartphone data to predict who will pick up bad habits and stop them getting ill, under radical government proposals. Of course this betrays a fundamnetal assumption of the government: that illness arises because of  bad “lifestyle choices.” 

In the policy paper released yesterday, Hancock says “Prevention means stopping problems from arising in the first place; focusing on keeping people healthy, not just treating them when they become ill. And if they do, it means supporting them to manage their health earlier and more effectively.

This means giving people the knowledge, skills and confidence to take full control of their lives and their health and social care, and making healthy choices as easy as possible.”

And: “Last year, over 20 million people used the NHS website. Over the next ten years, digital services will become even more widespread, and the first point of contact for many. The management of health will move out of clinical settings, and into the hands of people. Devices and applications will provide guidance and support around the clock.”

Hancock also said that Public Health England will look at “harnessing digital technology” as a form of “predictive prevention”, potentially leading to targeted health advice for people based on their their location and lifestyle. 

His focus is on “improving health, reducing demand for public services and supporting economic growth.

And: “Predictive prevention will transform public health by harnessing digital technology and personal data – appropriately safeguarded – to prevent people becoming patients. The availability of public data, combined with the existing understanding of wider determinants of health, means we can use digital tools to better identify risks and then help the behaviours of people most in need – before they become patients.

“Historically, public health has dealt with populations as a whole – a one-size-fits-all
approach. The power of predictive prevention comes from enabling people to look at their health in the context of their own life, their own circumstances, and their own behaviour. “

“This means moving beyond a simply clinical view of a body system or disease. It means envisioning a world where everyone can understand their own risks, both in their genetic make-up and from their personal behaviour. We will be able to empower people to make positive changes – and not always in ways we have traditionally thought about.”

Whenever the Conservatives use words like ’empower’, ‘help’ or ‘support’, I worry, because the ideological context of neoliberalism changes the political meaning of these Orwellian Conservative signpost words. Similarly, when Conservatives use the word ‘sustainability’, it is invariably with a view to making catastrophic funding cuts to social safety net provision and wider public services. 

Hancock says more than once: “The ambition is to prevent people becoming patients.”

Inevitably, he came to : “We want to ensure better integration between health and employment support services to help people with health conditions to enter and stay in work. This means ensuring people receive work-related advice and support within the NHS as part of making work a health outcome; on the basis that good work is good for health.” The basis is unverified.

The government conducted a survey in 2011 that showed if people believed that work is good for them, they are less likely to take time off. There is no evidence that demonstrates work is good for health. There is evidence that suggests people who are well enough to work generally do. It is not possible to ‘make’ work ‘a health outcome’. People are either healthy enough to work or they are not. The fact that healthier people work on the whole does not make work ‘good’ for people’s health. Poverty is historically linked with poor health. In work poverty has risen over the last decade. Having a job is no guarantee of escaping poverty or ill health. 

Job coaches are already asking GPs to refer patients to them, and have even suggested that GPs should make sick notes conditional on patients making an appointment with a work coach. 

Hancock’s proposals hint at a plan to extend conditionality in health care. 

Helen Donovan, Professional Lead for Public Health at the Royal College of Nursing, said: “We welcome the fact that the Health Secretary is making prevention a priority, and clearly recognises that a focus on public health will keep people healthier for longer and save the NHS money and resources in the long run.

“But Matt Hancock must realise his plans will start at a disadvantage as local authorities struggle with planned cuts to public health budgets of almost four per cent per year until 2021. While it’s clear he sees that prevention isn’t an optional extra, we need to see properly funded, accountable services delivered by a fully staffed nursing workforce backed by adequate resources. Disadvantaged areas emerge worse off without these vital services with life expectancy and the poorest bear the brunt of underinvestment in public health.”

Jonathan Ashworth MP, Labour’s Shadow Health and Social Care Secretary, said: “The Tories have imposed swingeing cuts to public health services, slashing vital prevention support such as smoking cessation services, sexual health services, substance misuse services and obesity help.

“In local communities, years of cuts and failed privatisation have resulted in health visitor and school nurse numbers falling, whilst children are losing out on the key early years health interventions they need.

“Many of the aims announced today are laudable but the reality is currently a further £1bn worth of cuts to health services including public health are set to be imposed by this Government next year.”

He added that unless the cuts were reversed, the green paper (planned for next year) would ”be dismissed as a litany of hollow promises”.

Simon Capewell, a professor of public health and policy at Liverpool University, said the minister was right to emphasise the need for effective prevention of epidemics such as obesity, type 2 diabetes and dementia.

But he added: “We must recognise the huge power of our lived environment, and avoid naively just focusing on ‘personal responsibility’ and ‘individual choices’. People do not ‘choose’ obesity or diabetes or cancer. They have just been overwhelmed by a toxic environment.”

The big drop in the last decade in the number of  UK citizens who smoke showed that firm, consistent government action was the best way to boost public health, Capewell said.

He added: “Mr Hancock can celebrate previous health successes with tobacco control. That success was built not on victim blaming, but on strong tax and regulation policies to reduce the ‘three As’ of tobacco affordability, availability and acceptability.”

Ministers need to take similarly tough action now against “the production of the commodities which harm people’s ill health, including junk food, cheap booze and fixed-odds betting terminals,” he said.

Hancock has of course denied that the government’s austerity programme had an impact on public health. In an interview for the BBC’s Today programme Hancock said: “The biggest impact on your health from the economy is whether or not you have got a job, and there are record numbers of jobs in this country.”

This of course is utter rubbish. If Hancock’s magical thinking was true, health in the UK would have dramatically improved over the last few years in line with ‘record employment levels’. But it hasn’t. The Conservatives are a party that prefers dogma over evidence, ideology over public services and the pseudopsychology of nudge over policies that meet public needs. 

Several health organisations have highlighted that local councils in England have had to cut their public health budgets in recent years, and will do so again next year, because Hancock’s department of health and social care has reduced their grants to divert more money to frontline NHS services. Many local councils have delivered preventative health programmes, but are now finding it increasingly difficult to deliver the statutory services. 

Jonathan Ashworth, the shadow health secretary, heavily criticised Hancock’s remarks. “From telling people to stand up in meetings to now lecturing people about their habits, while cutting £1bn from health services, isn’t a serious plan for improving the health of the nation,” he said.

public spending

Over the weekend Theresa May said the Conservatives “are now the natural party of the NHS” and said the Government was putting the public health system, created 70 years ago, on a path to “prosper for another 70 years and more”. That is most certainly an empirically unverified statement. 

It’s utter rubbish.

Matt Hancock Health secretary at his office

Update
Related  

Demedicalising illness and deprofessionalising healthcare: Rogue company Unum’s profiteering hand in the government’s work, health and disability green paper

GPs told to consider making fit notes conditional on patients having appointment with work coach

Government plans to use your phone and online data to police your lifestyle and predict ‘threats’ to your health

Cash for Care: nudging doctors to ration healthcare provision

Rationing and resource gatekeeping in the NHS is the consequence of privatisation

 


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The NHS is to hire 300 employment coaches to find patients jobs to “keep them out of hospital.”

Image result for cognitive therapy for unemployed protests

The government has a problem with the public actually using public services

The government announced the creation of the Joint Health and Work Unit and the Health and Work Service in 2015/16, both with a clear remit to cut benefits and “get people into work.” Given that mental health is a main cause for long-term sickness absence in the UK, a key aspect of this policy is to provide mental health services that get people back into work.

There has already been an attempt to provide mental health services for people who claim social security support, which includes a heavily resisted pilot to put therapists into job centresAnother heavily opposed government proposal was announced as part of the  health and work pilot programme to put job coaches in GP surgeries
The proposals have been widely held to be profoundly anti-therapeutic, potentially very damaging and professionally unethical. 

With such a narrow objective, the delivery will invariably be driven by an ideological agenda, politically motivated outcomes and meeting limited targets, rather than being focused on the wellbeing of individuals who need support and who may be vulnerable. I also discovered almost by chance back in 2015 that the Nudge Unit team have been working with the Department for Work and Pensions and the Department of Health to trial social experiments aimed at finding ways of: “preventing people from falling out of the jobs market and going onto Employment and Support Allowance (ESA).” 

“These include GPs prescribing a work coach, and a health and work passport to collate employment and health information. These emerged from research with people on ESA, and are now being tested with local teams of Jobcentres, GPs and employers.”  Source: Matthew Hancock’s conference speech: The Future of Public Services

GPs have raised their own concerns about sharing patient data with the Department for Work and Pensions – and quite properly so. Pulse reported that the Department for Work and Pensions (DWP) planned to extract information from GP records, including the number of Med3s or so-called “fit notes” issued by each practice and the number of patients recorded as “unfit” or “maybe fit” for work, in an intrusive move described by GP leaders as amounting to “state snooping.”

Part of the reason for this renewed government attack on sick and disabled people is that the government’s flagship fit note scheme, which replaced sick notes five years ago in the hope it would see GPs sending thousands more employees back to workto reduce sickness-related absence, despite GPs having expressed doubts since before its launch, has predicably failed.

The key reason for the failure is that employers did not take responsibility for working with employees and GPs seriously, and more than half (59%) of employers said they felt unable to support employees by making all of the legally required workplace adjustments for those who had fit notes signed as “may be fit for work.” Rather than address this issue with employers, the government has decided instead to simply coerce patients back into work without essential support.

Another reason for the failure of this scheme is that most people who need time off from work are ill and genuinely cannot return to work until they have recovered. Regardless of the government’s concern for the business and state costs of sick leave, people cannot be simply ushered out of illness and into work by the state to “contribute to the economy.” When a GP says a person is “unfit for work”, they generally ARE unfit for work, regardless of whether the government likes that or not.

The government have planned to merge health and employment services, and are now attempting to redefine work as a clinical outcome. Unemployment has been stigmatised and politically redefined as a psychological disorder, the government claims somewhat incoherently that the “cure” for unemployment due to illness and disability, and sickness absence from work, is work.

The latest strand of this ideological anti-welfare crusade was recently announced: the NHS is to hire 300 employment coaches who will find patients jobs to “keep them out of hospital.” The Individual Placement and Support services (IPS) is aimed at ‘supporting’ people with severe mental illness to seek work and ‘hold down a job’. Job coaches will offer assistance on CVs, interview techniques and are expected to work with 20,000 people by 2021. Pilot schemes running in Sussex, Bradford, Northampton and some London boroughs suggest that the coaches manage to find work for at least a quarter of users. The scheme is to be extended nationwide. 

The roll out of mental health employment specialists across the country is based on  analysis of the pilots, which is claimed to show that 2,300 patients have been helped into work in the last year. However, the longer term consequences of the programme are not known, and it is uncertain if there will be any meaningful monitoring regarding efficacy, safeguarding and the uncovering of unintended consequences and risks to participants.

It is held that those in work tend to be in better health, visit their GP less and are less likely to need hospital treatment. The government has assumed that there is a causal relationship expressed in this common sense finding, and make an inferential leap with the claim that “work is a health outcome”.

However, support for this premise is not universal. Some concerns which have been reasonably raised are commonly about the extent to which people will be ‘pushed’ into work they are not able or ready to do, or into bad quality work that is harmful to them, under the misguided notion that any work will be good for them in the long run. 

Of course it may equally be the case that people in better health work because they can, and have less need for healthcare services simply because they are relatively well, rather than because they work. 

Undoubtedly there are some people who may be able to work and who want to, but struggle to find suitable employment without adequate support. This section of the population may also face the lack of knowledge, attitudes and prejudices of potential employers regarding their conditions as a further barrier to gaining appropriate employment. The scheme will be ideal for supporting this group. That is, however, only provided that engagement with the service is voluntary, and does not become mandatory. 

It must also be acknowledged that there are some people who are simply too ill to work. Again, it’s a serious concern that this group may be pressured and coerced to find employment, which may prove to be detrimental to their wellbeing. Furthermore, placing them in work may present unacceptable risk to both themselves and others. How can we possibly know in advance about the longer term risks presented by the impact of an illness, and the potential effects of some medications in the workplace? If something goes catastrophically wrong as a consequence of someone taking up work when they are too unwell to work, who will hold the responsibility for the consequences?

In the current political context where the public are told “work is the route out of poverty” and “work is a health outcome”, people feel obliged to try to work, when they believe they can. But what happens when they are wrong in that belief? Who is responsible, for example, when someone has a loss of consciousness or an episode of altered awareness, caused by a condition or medication, while operating machinery, at the wheel of a taxi, bus or refuse waggon? 

Harry Clarke, who believed that he was fit for work, suffered a loss of consciousness on 22 December 2014 while at the wheel of a moving refuse lorry in Glasgow city centre, resulting in six deaths and leaving 15 people injured. Following numerous warnings from the court about his right to remain silent, Clarke refused to answer key questions about numerous doctors visits and medical tests for dizziness, fainting, vertigo, heart problems, tension headaches, operations on hands and knee pain dating back to 1976. However, one of the biggest revelations of the inquiry was Clarke’s lengthy medical history, which showed he had suffered episodes of dizziness and fainting for decades prior to the tragic crash.

Yet during an inquiry about the case, a health care professional who assessed the Glasgow bin lorry crash driver for the renewal of his HGV licence in 2011 would have deemed him only “temporarily unfit to drive” if she had known he had fainted the year before the accident. Furthermore, Clarke’s conditions would probably not have made him eligible for Employment and Support Allowance (ESA). Dr Joanne Willox told the inquiry panel at Glasgow Sheriff Court that she saw Mr Clarke on 6 December 2011 at the request of his employer Glasgow City Council to complete a HGV renewal application form with him which was to be submitted to the DVLA. 

Dr Willox, an occupational medical adviser for the private company Bupa, on behalf of Glasgow City Council, did not have access to his medical records. She could have requested the records with the patient’s consent if she considered it necessary, though this was not the normal practice and it may have taken time to get the records.

She said it would have been “helpful” to have the records. The inquiry revealed that Clarke had a history of fainting and dizziness, and had in fact previously suffered a similar episode while at the wheel of a stationary bus, in 2010.

The horrific case highlights several issues, not least that employment of people with unpredictable or undiagnosed medical conditions does not only pose a threat to the person, but it may potentially be contrary to public safety, too. It also highlights that a privately contracted occupational health professional who had no knowledge of Clarke’s medical history, was unsuitably tasked to make a judgement about his potential ability to work as a refuse waggon driver. Employing people who are ill and later found to be unfit for the role is potentially in contravention of the Health and Safety at Work Act. 

Another horrific example of the dangers presented by placing trust in unqualified bureaucrats and the state – who have ideological interests that often lie in conflict with those of patients – to make decisions about citizens’ health and welfare arose when a manager at Birkenhead Benefit Centre in Liverpool 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.” (My emphasis)

The job centre manager was wrong. The health care professional, assessing the patient on behalf of the private company contracted to carry out the ESA assessment, on behalf of the government, was wrong. 

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.

He was clearly not fit for work.

James’ 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.” (See Jobcentre tells GP to stop issuing sick notes to patient assessed as ‘fit for work’ and he died.)

It has become very evident over recent years that the labour market is not delivering an adequate income for many citizens and despite “record levels of employment”, the problem seems to be getting bigger. The government’s answer to the problem has been to extend punishment those on low pay, rather than tackle employers who pay exploitative, low wages.

The neoliberal narrative and Conservative antiwelfarism

Some of the underpinning language used to justify this approach also troubles me, as it is clearly couched in economic terms. It’s about cutting costs, propping up the economy as a whole and “rewarding” tax payers. Here, it is implied that people who are ill are somehow a burden on tax payers. However, most people who become ill have also worked and contributed to the Treasury. Furthermore, people who aren’t in employment also pay taxes, too, be it VAT, council tax, or a range of other stealth taxes from which even the poorest citizens are no longer exempted. 

Claire Murdoch, NHS England national mental health director, said: “Helping people with mental ill health to find and keep a job is good for individual wellbeing and good for the health of our economy. Tackling severe mental illness is not just about getting medication and treatment right, but ensuring people can recover to live independently with their condition, including the reward and satisfaction of getting and keeping a job.

In our 70th year, mental health is one of the NHS’ top priorities, and ensuring services are integrated, so people get whole-person care, means our patients get better outcomes and taxpayers are rewarded as treatment is more efficient. One in seven of us will go through mental ill health whilst at work, so delivering a safety net, to help people back in to work when they fall ill, will minimise harm and make our country’s workforce more productive.”

NHS England say: “As part of patients’ care and support package, work coaches in NHS Individual Placement and Support (IPS) services, offer advice about finding a job, help them to prepare for an interview and can speak with potential employers about how someone’s condition can be managed so that they can work effectively while staying in good health.

“The trained specialists also improve the health of people with severe mental illness, reducing the need for urgent hospital admissions and GP appointments. Research shows that type of support can free up as much as £6,000 per patient, which can be invested in other frontline care.”

Again, the language is loaded, it’s a narrative with a scattering of casual cost-cutting phrases and prioritises a ‘productive workforce.’ There isn’t any discussion regarding the claim to ‘minimise harm’, it seems to be assumed that work in itself will take care of that. It’s also a little worrying that employers and work coaches are to be included in the ‘management’ of employees’ illnesses. When I am ill, I don’t want the advice or ‘management’ of a boss or a work coach, I want impartial medical diagnosis, treatment and advice from my doctor, not a ‘nudge’ or trite armchair psychology and pseudoscientific platitudes from the state.

It’s difficult to see how someone with a serious, chronic or progressive illness, can actually ‘manage’ their illness and ‘move back into work.’ The use of the extremely misinformed, patronising and very misleading term manage implies that very ill people actually have some kind of choice in the matter.

Implicit in this narrative is the idea that illness is caused by deviant behaviours. The ‘cure’ therefore, is to simply address and remedy the faulty behaviours. 

The sick role and the resurrection of Talcott Parsons: disciplining disabled people

There is a lack of coherence within the narratives of contemporary Conservative governance, which is simultaneously neoliberal – grounded in free market principles and the ideal of a small, ‘non-intrusive’ state – and paternalism – which is founded on an authoritarian, large, extremely intrusive state, which is designed to tell people what is best for them and nudging citizens’ behaviours towards government defined policy outcomes.

The tension between neoliberalism and paternalism which outlines current policy approaches to disability and employment policy is filled with ambiguity, inconsistency and contradiction in its definition and understanding of the subject, the nature of the ‘problem’ and the policy ‘solutions’. On the one hand, neoliberalism is a doctrine that demands the withdrawal of social support mechanisms such as welfare, health care and public services, on the other, paternalism is based on state interventions designed to extend politically defined ‘optimal outcomes’.

These apparently contradictory narratives have been embodied in discipline of behavioural economics, which is largely aimed at enforcing the alignment of public expectations, attitudes and behaviours with neoliberal outcomes. It’s a prop for dogma and the status quo. Behavioural economics is concerned with reducing citizens’ expectations of social provision, while enforcing self reliance, and with providing justification narratives for neoliberal policies. 

I have written critical accounts of this somewhat draconian Conservative neoliberal paternalism on more than one occasion. The Conservatives place emphasis on highlighting the obligations of citizens, rather than on their rights, and this is why the work of Talcott Parsons in the early 1950s is especially appealing to them. 

Behavioural medicine was partly influenced by Talcott Parsons’ The Social System, 1951, and his work regarding the sick role, in which he analysed in a framework of citizen’s roles, social obligations, reciprocities and behaviours within a wider capitalist society, with an analysis of rights and obligations during sick leave. From this perspective, the sick role is considered to be sanctioned deviance, which disturbs the function of society. (It’s worth comparing that the government are currently focused on economic function and enhancing the supply side of the labour market.)

Behavioural medicine more generally arose from a view of illness and sick role behaviours as characteristics of individuals, and these concepts were imported from sociological and sociopsychological theories.

However, it should be noted that there is a distinction between the academic social science disciplines, which include critical perspectives of conflict and power, for example, and the recent technocratic “behavioural insights” approach to public policy, which is a monologue that doesn’t include critical analysis, and serves as prop for neoliberalism, conflating citizen’s needs and interests with narrow, politically defined economic outcomes.

We have a government that has regularly misused concepts from psychology and sociology, distorting them to fit a distinct framework of ideology, and justification narratives for draconian policies, usually entailing the diversion of public funds from public services and the provision of social security to wards rewards for the wealthiest citizens, usually in the form of tax cuts. Parsons’ work has generally been defined as sociological functionalism, and functionalism tends to embody very conservative ideas. 

From this perspective, sick people are not productive members of society; therefore this deviation from the norm must be policed. This, according to Parsons, is the role of the medical profession. More recently, however, we have witnessed the rapid extension of this role to include extensive State policing of sick and disabled people, and the introduction of increasingly coercive measures to push citizens into self managing their health conditions, while the medical profession have been increasingly politically sidelined in their provision of advice, care and support, regarding sickness and employment.

Last year, the government proposed extending ‘fit note’ certification beyond GPs to a wider group of non-specialist healthcare professionals, including physiotherapists, psychiatrists and senior nurses, to better ‘identify health conditions and treatments’ to help workers go back into their jobs faster. This is very worrying, since it entails the diagnosis and treatment of conditions by people who are not qualified to undertake this role.

‘Fit notes’ are specifically designed to ‘help’ patients develop a return to work plan, and are meant to be tailored to their individual needs. However, the introduction of fit notes –  a somewhat Orwellian title that refuses to acknowledge people get ill, or permit citizens time to recover, which replaced sick notes –  failed to produce an increase in a more rapid return to work for patients generally, mainly due to the fact that employers failed to support patients with adequate workplace adjustments to accommodate their return.  

It seems many of the psychosocial advocates have ignored the rise of chronic illnesses and the increasing pathologisation of everyday behaviours in health promotion. Parson’s sick role came to be seen as a negative referent rather than as a useful interpretative tool. Parsons’ starting point is his understanding of illness as deviance. Illness is the breakdown of the general “capacity for the effective performance of valued tasks” (Parsons, 1964: 262). Losing this capacity disrupts “loyalty” to particular commitments in specific contexts such as the workplace.

Theories of the social construction of disability also provide an example of the cultural meaning of certain health conditions. The roots of this anti-essentialist approach are found in Stigma bErving Goffman (1963), in which he highlights the social meaning physical impairment comes to acquire via social interactions. The social model of disability tends to conceptually distinguish impairment (the attribute) from disability (the social experience and meaning of impairment). Disability cannot be reduced to a mere biological problem located in an individual’s body  (Barnes, Mercer, and Shakespeare, 1999). Rather than a “personal tragedy” that should be fixed to conform to medically determined standards of “normality” (Zola, 1982), disability becomes politicised.

The issues we then need to confront are about the obstacles that may limit the opportunities for individuals with impairments, and about how those social barriers may be removed.

From a social constructionist perspective, emphasis is placed on how certain illnesses come to have cultural meanings that are not reducible to or determined by biology, and these cultural meanings further burden the afflicted (as opposed to burdening “the tax payer” , the health services, those with profit seeking motives, or the state.)

So to clarify, it is wider society and governments that need a shift in disabling attitudes, perceptions and behaviours, not disabled people.

The insights that arose from the social construction of disability approach are embodied in policies, which include the Disability Discrimination Act 1995, which included an employers’ duty to ensure reasonable adjustments/adaptations; the more recent Equality Act 2010 and the Human Rights Act 1998, which provides an important tool for disabled people to use to challenge discrimination, violations to their human rights and unacceptable treatment.

In contrast, Parsons invokes a social contract in which society’s “gift of life” is repaid by continued contributions and conformity to (apparently unchanging, non-progressive) social expectations. For Parsons, this is more than just a matter of symbolic interaction, it has far more concrete, material implications: “honour” (deserving) and “shame” (undeserving) which accompany conformity and deviance, have consequences for the allocation of resources, for notions of citizenship, civil rights and social status.

Parsons never managed to accommodate and reflect social change, suffering and distress, poverty, deprivation and conflict in his functionalist perspective. His view of citizens as oversocialised and subjugated in normative conformity was an essentially Conservative one. In fact, the instituted Nudge Unit at the heart of the Cabinet Office and a proliferation of nudge-laden behaviourist policies over recent years indicates this view is a Conservative ideal. 

Furthermore, Parsons’ systems theory was heavily positivistic, anti-voluntaristic and profoundly dehumanising. His mechanistic and unilinear evolutionary theory reads like an instruction manual for the capitalist state.

Parsons thought that social practices should be seen in terms of their function in maintaining order and social structure. You can see why his core ideas would appeal to Conservative neoliberals and rogue multinational companies (such as Unumwho had a hand in the government’s Work, Health and Employment green paper). Conservatives have always been very attached to tautological explanations (insofar that they tend to present circular arguments.)

One question raised in this functional approach is how do we determine what is functional and what is not, and for whom each of these activities and institutions are functional. If there is no method to sort functional from non-functional aspects of society, the functional model is tautological – without any explanatory power to why any activity is regarded as “functional.” The causes are simply explained in terms of perceived effects, and conversely, the effects are explained in terms of perceived causes). 

Because of the highly gendered division of labour in the 1950s, the body in Parsons’ sick role is a male one, defined as controlled by a rational, purposive mind and oriented by it towards an income-generating performance. For Parsons, most illness could be considered to be psychosomatic.

The ‘mind over matter’ dogma is not benign; there are billions of pounds and dollars at stake for the global insurance industry, which is set to profit massively to the detriment of sick and disabled people. The eulogised psychosocial approach is evident throughout the highly publicised UK PACE Trial on treatment regimes that entail Cognitive Behaviour Therapy (CBT) and graded exercise. By curious coincidence, that trial was also significantly about de-medicalising illnesses. Another curious coincidence is that Mansel Aylward sat on the PACE Trial steering group. 

Work will set you free


Arbeit macht frei
(‘work makes you free’) is a German expression which comes from the title of a novel by German philologist Lorenz Diefenbach, Arbeit macht frei: Erzählung von Lorenz Diefenbach (1873), in which gamblers and fraudsters find the path to virtue through work. The Weimar Republic in the 1920s, and later, the Nazis, found the leading character of Diefenbach’s book, whose achievements are defined by ‘concentrating on doing his work’, compelling.

The phrase was used to promote German employment policies. The slogan was placed at the entrances to a number of Nazi concentration camps. It strikes as an almost mystical declaration that self-sacrifice in the form of endless labour does in itself bring a kind of spiritual freedom. However, given the true role of concentration camps such as Auschwitz during the Holocaust as well as the individual prisoner’s knowledge that once they entered the camp, freedom was not likely to be gained by any means other than their death, the terrible and cruel irony of the slogan becomes clear. And the lie. 

Though the context and wording has changed –  “work is a health outcome” – and full employment at any cost is the neoliberal goal, the idea that work has some mystical benefit, such as curing illness, or even simply alleviating poverty and inequality, remains a lie. 

The British Psychological Society (BPS) has expressed concerns about the idea  that employment (of whatever type) should be recognised as a “health outcome”. The Society recognise that suitable work can be good for wellbeing – but this very much depends on the type and quality of work and its social context. 

Furthermore, my own view is that the IPS programme will make it more difficult to ensure and maintain the political independence of health professionals. The private and confidential patient-doctor relationship ought to be a safe space, where citizens may address medical health problems, and doctors can provide support for people who are ill. The government is creating yet another space for an intrusive, overextension of the coercive arm of the state to “help people into work”, regardless of whether or not they are actually well enough to cope with working.

Placing employment advisors in the NHS will not address inequality, and the social conditions that are the consequence of political decision-making and imposed economic frameworks, so it permits the government and society to look the other way, while the government continue to present mental illness as an individual weakness or vulnerability, and a consequence of “worklessness” rather than a fairly predictable result of living in a highly unequal, competitive society, and arising because of experiences of living stigmatised, marginalised lives because of politically expedient policy-directed material deprivation. 

Feeding a myth 

I found a document almost by accident, while researching the Health, Work and Disability green paper a couple of years back. It presents further evidence that government policy is not founded on empirical evidence, but rather, it is often founded on deceitful contrivance. The Department for Work and Pensions research document published back in 2011 –Routes onto Employment and Support Allowance– said that if people believed that work was good for them, they were less likely to claim or stay on disability benefits. 

It was decided that people should be “encouraged” to believe that work was “good” for health. There is no empirical basis for the belief, and the purpose of encouraging it is simply to cut the numbers of disabled people claiming ESA by “encouraging” them into work. Some people’s work is undoubtedly a source of wellbeing and provides a sense of purpose.

That is not the same thing as being work being miraculously “good for health”. For a government to use data regarding opinion rather than empirical evidence to claim that work is “good” for health indicates a ruthless mercenary approach to fulfill their broader aim of dismantling social security and relentless determination to uphold their ideological commitment to supply-side policy, regardless of the harmful social costs.

From the document: “The belief that work improves health also positively influenced work entry rates; as such, encouraging people in this belief may also play a role in promoting return to work.”

The aim of the research was to “examine the characteristics of ESA claimants and to explore their employment trajectories over a period of approximately 18 months in order to provide information about the flow of claimants onto and off ESA.”

The document also says: “Work entry rates were highest among claimants whose claim was closed or withdrawn suggesting that recovery from short-term health conditions is a key trigger to moving into employment among this group.”

“The highest employment entry rates were among people flowing onto ESA from non-manual occupations. In comparison, only nine per cent of people from non-work backgrounds who were allowed ESA had returned to work by the time of the follow-up survey. People least likely to have moved into employment were from non-work backgrounds with a fragmented longer-term work history. Avoiding long-term unemployment and inactivity, especially among younger age groups, should, therefore, be a policy priority. ” 

“Given the importance of health status in influencing a return to work, measures to facilitate access to treatment, and prevent deterioration in health and the development of secondary conditions are likely to improve return to work rates”

Rather than make a link between manual work, lack of reasonable adjustments in the work place and the impact this may have on longer term ill health, the government chose instead to promote the cost-cutting and unverified, irrational belief that work is a “health” outcome. Furthermore, the research does conclude that health status itself is the greatest determinant in whether or not people return to work. That means that those not in work are not recovered and have longer term health problems that tend not to get better.

Work does not “cure” ill health. To mislead people in such a way is not only atrocious political expediency, it’s actually downright dangerous.

As neoliberals, the Conservatives see the state as a means to reshape social institutions and social relationships based on the model of a competitive market place. This requires a highly invasive power and mechanisms of persuasion, manifested in an authoritarian turn. Public interests are conflated with narrow economic outcomes. Public behaviours are politically micromanaged. Social groups that don’t conform to ideologically defined economic outcomes are politically stigmatised and economically outgrouped.

Nicola Oliver, from Northamptonshire Healthcare NHS Foundation Trust, said: “Employment support linked to mental health means people can live the life they want to lead.

“If you help someone into a job they really like – which means they are inspired to get up in the morning and want to manage their symptoms – they’re likely to say to their clinician ‘This is what I want to do, help me to overcome these barriers.’ In this way, you’re motivating the person to manage their own condition” (My emphasis).

Mental health employment specialists in the IPS service are part of community mental health teams. They currently operate in parts of the country including Sussex, Bradford, Northampton and some London boroughs, which have seen 9,000 people in the past twelve months. NHS England will be providing £10 million funding to expand access over the next two years, with further investment to follow. By 2021, NHS England anticipates that 20,000 people with severe mental illness will receive tailored care and employment advice via the NHS, suggesting that around 5,000 people with mental ill health avoid unemployment thanks to ‘better health care’.

IPS is one of a number of integrated mental health services which are being introduced or expanded across England, as part of NHS England’s Five Year Forward View for Mental Health, described as a “transformation and investment programme to improve care between 2016 and 2021.”

People can only work when their basic needs are met

maslows_hierarchy_of_needs-4

Despite the government’s rhetoric on welfare “dependency”, and the alleged need for removing so-called “perverse incentives” from the social security system by imposing a harsh conditionality framework and a compliance regime – using punitive sanctions – and work capability assessments designed to preclude eligibility to disability benefits, research shows that generous social security regimes make people more likely to want to work, not less. I have written at length over the last few years about why a punitive welfare system can never work, as the government claim, to “incentivise people to find employment. See, for example, The Minnesota Starvation Experiment provided empirical evidence that demonstrates clearly why welfare sanctions can’t possibly work as an “incentive” to “make work pay”).

The government’s welfare “reforms” have already invited scathing international criticism because they have disproportionately targeted cuts at those with the least income. Furthermore, the government have systematically violated the human rights of those with mental and physical disabilities. In a highly critical UN report which followed a lengthy inquiry, it says: “States parties should find an adequate balance between providing an adequate level of income security for persons with disabilities through social security schemes and supporting their labour inclusion. The two sets of measures should be seen as complementary rather than contradictory.”

However, the UK government have continued to conflate social justice and inclusion with punitive policies and cuts – dressed up in the language of “incentives” and “nudge” – aimed at coercing disabled people towards narrow employment outcomes that preferably bypass any form of genuine support and the social security system completely.  (See –UN’s highly critical report confirms UK government has systematically violated the human rights of disabled people).

It’s hardly the case that the state has an even remotely credible track record of assessing people’s medical conditions, nor is it the case that this government bothers itself with empirical evidence, or deigns to listen to concerns raised by citizens, academics, professionals and charities regarding the harm that their policies are causing. This is a government that can’t even manage to observe basic human rights, let alone care about citizen’s best interests, health and wellbeing. In a political context of savage cuts to essential support and services for disabled people, and such blatant disregard of the legislative frameworks that outline their fundamental rights, it is very difficult to trust that this government have the best interests of disabled people in mind with the formulation of Work, Health and Employment related programmes. 

The government’s aim to prompt public services to “speak with one voice” to promote work as a health outcome is founded on highly questionable ethics. This proposed multi-agency approach is reductive, rather than being about formulating expansive, coherent, comprehensive and importantly, responsive provision.

Employment is not therapy. Ultimately, the IPS programme is all about (re)defining the behaviours, experience and reality of a social group to ensure they conform to government ideological incentives and to justify dismantling public services (especially welfare, and increasingly, the NHS – see, for example, Rogue company Unum’s profiteering hand in the government’s work, health and disability green paper).

This is form of gaslighting intended to extend oppressive political control and behavioural micromanagement. In linking receipt of welfare with health services and “state therapy,” with the single intended outcome explicitly expressed as employment, the government is purposefully conflating citizen’s widely varied needs with economic outcomes and diktats, isolating people from traditionally non-partisan networks of relatively unconditional support, such as the health service, social services, community services and mental health services.

Public services “speaking with one voice” will invariably make accessing support conditional, and further isolate already marginalised social groups. It will damage trust between people needing support and professionals who are meant to deliver essential public services, rather than simply extending government dogma, prejudices and discrimination.

Conservatives really seem to believe that the only indication of a person’s functional capacity, value and potential is their economic productivity, and the only indication of their moral worth is their capability and degree of willingness to work. But unsatisfactory employment – low-paid, insecure and unfulfilling work – can result in a decline in health and wellbeing, indicating that it is poverty and growing inequality, rather than unemployment, that increases the risk of experiencing poor mental and physical health.

facade welfare

 


 

Charities not allowed to criticise authoritarian government ministers

Image result for gagging clause UK

Charities and groups contracted to deliver the government’s new Work and Health Programme have been told they must not be critical of the work and pensions secretary, Esther McVey.

A clause in the contract for those delivering the programme stipulates that signed-up charities must “pay the utmost regard to the standing and reputation” of McVey and the Department for Work and Pensions (DWP). However, such contracts that prevent charities from speaking out do not align with government claims of  “transparency”. 

Turning Point, the RNIB, the Royal Association for Deaf People, and the Shaw Trust are among charities that have agreed to act as providers of services under the programme – which focuses on supporting disabled people and other disadvantaged groups into work in England and Wales. It does not operate in Scotland.

There are currently at least 22 organisations – covering contracts worth £1.8 billion – that have been required to sign the clauses as part of their involvement with Department for Work and Pensions programmes.

The existence of an extraordinary clause was revealed through a freedom of information (FoI) request by campaigning website the Disability News Service (DNS)You can read the report on the disclosure in full here.

DNS says the clause states that the contractor “shall pay the utmost regard to the standing and reputation” of DWP and ensure it does nothing to bring it “into disrepute, damages the reputation of the Contracting Body or harms the confidence of the public in the Contracting Body”.

The contract defines the “Contracting Body” as the work and pensions secretary – Esther McVey, who was criticised and heckled last week in the Scottish Parliament as she attempted to make a defence for Universal Credit and the hated rape clause.

All of the disability charities contacted by DNS have insisted that the clause – which DWP has been using since 2015 – will have no impact on their willingness to criticise McVey or the Department.

Shaw Trust said the “publicity, media and official enquiries” clause had been present “in previous DWP contracts” and “does not and has not impinged on our independence as a charity”.

A DWP spokeswoman said: “The department did not introduce this clause specifically for the Work and Health Programme contract.

“It has been used in DWP employment category contracts since 2015.

The contract is the framework which governs the relationship with DWP and its contractors so that both parties understand how to interact with each other.

“The clause is intended to protect the best interests of both the department and the stakeholders we work with, and it does not stop individuals working for any of our contractors from acting as whistle-blowers under the provisions of the Public Interest “Disclosure Act 1998, nor does it prevent contractors from raising any concerns directly with the department.”

So how do charities raise concerns about the impact of draconian Conservative policies, without being “critical of the work and pensions secretary, Esther McVey,” or get around the problem of “paying the utmost regard to the standing and reputation” of the DWP, exactly? 

The UK government has “systematically and gravely” violated the human rights of disabled persons, a fact that was verified by the United Nations (UN) investigation, the findings of which were published in 2016. The UN report documented multiple violations of disabled people’s rights, including the way that they are politically portrayed as being lazy and a “burden on taxpayers”, the harm to health caused by unfair assessments, the cuts to legal aid and curtailed access to justice, the imposition of the bedroom tax and the ending of the Independent Living Fund, in addition to the cuts made to the welfare safety net.

The government have dismissed these findings in their entirety. Yet a truly democratic, accountable and transparent government would have monitored and assessed the impact of their punitive policies, and launched an inquiry to explore the correlation between their policies and practices and the distress, harm, premature deaths and suicides that have been well documented and evidenced over the past few years. 

This authoritarian gagging clause emphasises a toxic oppressive culture, and an intention of the government to silence its critics. However, it is unenforceable insofar as it purports to preclude a worker or group from making a protected disclosure, under the Public Interest Disclosure Act 1998. Whistleblowing legislation has been amended since the Public Interest Disclosure Act 1998, by the Enterprise and Regulatory Reform Act 2013 and the Small Business, Enterprise and Employment Act 2015.

The 2013 Act, among other things, introduced a public interest test. In order to benefit from whistleblower protection a disclosure must “in the reasonable belief of the worker making the disclosure” be “made in the public interest”. 

The 2015 Act created a power for the Secretary of State to impose reporting requirements on prescribed persons (bodies to which whistleblowers may disclose information).  It is claimed that these requirements would cover matters such as the number of whistleblowing disclosures received and investigated. 

In an era of  outsourcing and public sector commissioning, most contracts issued by NHS trusts, local authorities and central government departments, or by their prime providers, now include such restrictions on providers speaking freely or releasing any information without permission.

The Panel on the Independence of the Voluntary Sector included in its 2014 report a specific request to the government that such clauses be outlawed. Nick Hurd, then the Minister for Civil Society, said in a priceless Orwellian response that it was the government’s ambition for the UK to be “the most transparent and accountable government in the world”; but he said it had a duty “to ensure all publicly released information is accurate and validated, and contracts with providers are designed to reflect this”. 

That’s a government denial clause, by the way. 

Asheem Singh, director of public policy at the charity chief executives body Acevo, said in 2014 that gagging clauses are unacceptable and charities and social enterprises should challenge them.

“There is no doubt that many confidentiality clauses in government contracts are designed to protect not the public but the department or the ministers concerned,” he says. “We need an open, transparent system where data is freely shared. We have reams of data protection legislation that is designed to protect the vulnerable. Contractual confidentiality clauses that aim to prevent ‘bringing a department into disrepute’, as one example puts it, merely protect officialdom.”

Exactly.

However, the right to whistleblow if individuals believe there has been serious wrongdoing remains. If it’s in the public interest, there is a right to disclose and be protected from any consequences, and that is the law.

You can read about the laws and protections regarding whistleblowing and gagging clauses here.

Image result for gagging clause UK

Update 9 October 2018

The media has finally decided this issue is newsworthy.

At least 22 organisations – covering contracts worth £1.8 billion – have been required to sign the clauses as part of their involvement with programmes getting the unemployed into work, The Times  has reported.  

Officials at the Department for Work and Pensions (DWP) denied they were “gagging clauses” intended to prevent criticism of ministers or their policies, insisting they were just “standard procedure”. However a spokesman confirmed that the contracts did include references to ensure both parties “understand how to interact with each other and protect their best interests”. The signatories to contracts must undertake to “pay the utmost regard to the standing and reputation” of the Work and Pensions Secretary, the newspaper reported, adding that they must “not do anything which may attract adverse publicity” to her, damage her reputation, or harm the public’s confidence in her. 

The disclosure comes after McVey confirmed that some people would be worse off as a result of the introduction of Universal Credit, saying the Government had taken some “tough decisions”. However, this was contradicted by Downing Street

Former prime minister John Major called for a rethink of the planned roll-out of UC to more than two million claimants of existing benefits, warning the Government risked a poll tax-style backlash if the policy was seen as unfair.

The Department for Work and Pensions has announced that from April 2019 Citizens Advice (CA) and Citizens Advice Scotland (CAS) will receive a total of £51 million to help people with universal credit claims. This move in itself shows how unfit for purpose the Universal Credit (UC) process is, as people need support in simply claiming it. 

CA and CAS  have been given a role in supporting  claimants through every step of making a UC claim and ‘managing their money when it arrives.’ The main focus will be on budgeting advice and digital support. 

£12 million is being provided to CA and CAS to set up the service by April 2019, with a further £39 million being paid from April onwards.

The government funding has understandably raised concerns about the freddom that CA and CAS will have to campaign in relation to the failings of UC.

Secretary of State for Work and Pensions Esther McVey said:

“This brand new partnership with Citizens Advice will ensure everyone, and in particular the most vulnerable claimants, get the best possible support with their claim that is consistently administered throughout the country.

“Citizens Advice are an independent and trusted organisation, who will support people as we continue the successful rollout of Universal Credit.”

Gillian Guy, Chief Executive of Citizens Advice, said:

We offer independent and confidential advice to millions of people every year, and have already helped nearly 150,000 people with Universal Credit. We’ve seen first-hand what can happen when people struggle to make a claim and their payments are delayed.

“We welcome the opportunity to provide even more people with the help they need with Universal Credit, and deliver a consistent service through the Citizens Advice network across England and Wales.

“Delivering this service will give us even greater insight into the Universal Credit system. We’ll continue to share our evidence with the government to help make sure Universal Credit works for everyone.”

The problem is that’s what he thinks.

Related 

Rogue company Unum’s profiteering hand in the government’s work, health and disability green paper

 


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Cognitive Therapy for the Unemployed: G4S Crooks to Deliver ‘Service’ in Surrey, Sussex and Kent.

I broke this story in 2016: G4S are employing Cognitive Behavioural Therapists to deliver “get to work therapy”.

The following excerpts are from Ipswich Unemployed Action:

Image result for cognitive therapy for unemployed protests

“We are saving the taxpayer £120 million a year in benefit savings.” Sean Williams – Welfare to Work, Managing Director, G4S.

“Carillon’s collapse, which involved the farce of having fire-engines on standby today in Oxfordshire in case the company could not deliver school meals for one of their many outsourced contracts, has not stopped the government from continuing their policy of giving large sums of money to private companies to deliver ‘services’.

The problems of Universal Credit have tended to obscure other aspects of the government’s welfare policy.

One of the most outrageous sides is this, which we have previously posted on.

It is part of the Work and Health Programme, rolling out this year.

Service Providers for the Work and Health programme

It will be run by five service providers across six regions in England and Wales. The successful providers were:

  • Shaw Trust (Central England and Home Counties)
  • Reed in Partnership (North East)
  • Ingeus (North West)
  • Pluss (Southern)
  • Remploy (Wales)

In 2015 the Guardian published this letter signed by more than 400 psychologists, counsellors and academics signed an open letter  protesting against chancellor George Osborne’s plans, laid out in the latest budget, to embed psychological therapy in a coercive back-to-work agenda. (I wrote about this in 2015, here: Psychologists Against Austerity: mental health experts issue a rallying call against coalition policies.)

The linkage of social security benefits to the receipt of “state therapy”, as announced in the chancellor’s latest budget, this is totally unacceptable. “Get to work therapy” is manifestly not therapy at all. With the ominous news that Maximus (the US company replacing Atos to do work capability assessments) will also be managing the new national Fit for Work programme, it is time for the field’s key professional organisations to wake up to these malign developments, and unequivocally denounce such so-called “therapy” as damaging and professionally unethical.

More generally, the wider reality of a society thrown completely off balance by the emotional toxicity of neoliberal thinking is affecting Britain in profound ways, the distressing effects of which are often most visible in the therapist’s consulting room. This letter sounds the starting-bell for a broadly based campaign of organisations and professionals against the damage that neoliberalism is doing to the nation’s mental health. For now, we call on all the parties in this election – and particularly Labour – to make it clear that they will urgently review such anti-therapeutic practices, and appropriately refashion their much-trumpeted commitment to mental health if and when they enter government.

To remind us of this Kitty S jones wrote last year:

A major concern that many of us have raised is regarding consent to participation, as, if benefit conditionality is attached to what ought to be a voluntary engagement, that undermines the fundamental principles of the right to physical and mental care. Such an approach would reduce psychologists to simply acting as agents of state control, enforcing compliance and conformity. That is not therapy: it’s psychopolitics and policy-making founded on a blunt behaviourism, which is pro-status quo, imbued with Conservative values and prejudices. It’s an approach that does nothing whatsoever to improve public life or meet people’s needs.


Kitty noted that: 

The highly controversial security company G4S are currently advertising for Cognitive Behavioural Therapists to deliver “return-to-work” advise in Surrey, Sussex and Kent.

This is yet another lucrative opportunity for private companies to radically reduce essential provision for those that really need support, nonetheless, costing the public purse far more to administer than such an arrangement could possibly save, despite the government’s dogged determination to rip every single penny from sick and disabled people and drive them into low paid, insecure jobs.


Yes, G4S is a player in the delivery of the “new Work and Health Programme 2017 – 2020/21. Commissioned by the Department for Work and Pensions, the programme is intended to assist people who are long term unemployed or who have disabilities and health conditions into work.”

You can read the rest of the post in full here.

Other related posts:

Workfare coercion in the UK: an assault on persons with disabilities and their human rights Anne-Laure Donskoy

The power of positive thinking is really political gaslighting

The new Work and Health Programme: government plan social experiments to “nudge” sick and disabled people into work

Rogue company Unum’s profiteering hand in the government’s work, health and disability green paper

Nudging conformity and benefit sanctions: a state experiment in behaviour modification

The connection between Universal Credit, ordeals and experiments in electrocuting laboratory rats

IAPT is value-laden, non-prefigurative, non-dialogic, antidemocratic and reflects a political agenda

G4S are employing Cognitive Behavioural Therapists to deliver “get to work therapy”

 

Ipswich Unemployed Action.

Image result for cognitive therapy for unemployed protests“We are saving the taxpayer £120 million a year in benefit savings.” Sean Williams – Welfare to Work, Managing Director, G4S.

Carillon’s collapse, which involved the farce of having fire-engines on standby today in Oxfordshire in case the company could not deliver school meals for one of their many outsourced contracts, has not stopped the government from continuing their policy of giving large sums of money to private companies to deliver ‘services’.

 The problems of Universal Credit have tended to obscure other aspects of the government’s welfare policy.

One of the most outrageous sides  is this, which we have previously posted on.

It is part of the Work and Health Programme, rolling out this year.

The key service providers are:

Service Providers

It will be run by five service providers across six regions in England and Wales. The successful providers were:

  • Shaw Trust (Central England and Home Counties)
  • Reed…

View original post 1,558 more words

Work as a health outcome, making work pay and other Conservative myths and magical thinking

Originally I wrote much of this in a very long article about Unum’s involvement in the government’s Work, Health and disability Green Paper, earlier this year. Sometimes, though, some points get lost in the volume of other issues raised, so I thought I would make sure these particular issues have more visibility in this shorter article.

There is plenty of evidence that indicates government policy is not founded on empirical evidence, but rather, it is ideologically framed, and often founded on deceitful contrivance. A Department for Work and Pensions research document published back in 2011 – Routes onto Employment and Support Allowance said that if people believed that work was good for them, they were less likely to claim or stay on disability benefits.

So a political decision was made that people should be “encouraged” to believe that work was “good” for their health. There is no empirical basis for the belief, and the purpose of encouraging it is simply to cut the numbers of disabled people claiming Employment and Support Allowance (ESA) by “helping” them into work.

Another government document from 2014 – Psychological Wellbeing and Work – says: We know that being in work is good for wellbeing and that mental health problems are an increasing issue for the nation and so the Minister for Welfare Reform and the Minister for Care and Support jointly sought to expand the evidence base on common mental health problems.  

A number of Government programmes assess and support those with mental health difficulties to work, but it is internationally recognised that the evidence base for successful interventions is limited. 

The Contestable Policy Fund gives ministers alternative avenues to explore new thinking and strategies that offer cross-Government benefits. This report was commissioned through this route.” 

And: “Within the time and resources available for this study the research team did not undertake extensive assessment of the quality of the evidence base (eg assessing the research design and methodology of previous studies)”

The government have gone on to declare with authoritarian flourish that they now want to reinforce their proposal that “work is a health outcome.” Last year, a report by the Mental Health Task Force and chaired by Mind’s Paul Farmer, recommended that employment should be recognised as a “health outcome”.  I’m just wondering how people with, say, personality disorders, or psychosis are suddenly going to overcome the nature of their condition and successfully hold down a job for a minimum of six months.

Mind those logical gaps… 

This has raised immediate concerns regarding the extent to which people will be pushed into work they are not able or ready to do, or into bad quality, low paid and inappropriate work that is harmful to them, under the misguided notion that any work will be good for them in the long run.

The idea of the state persuading medical professionals to “sing from the same [political] hymn sheet”, by promoting work outcomes in health care settings is more than a little  Orwellian.

Gaslighting narrative has become common political practice. Sick and disabled people who have their lifeline support cut are being “supported” into work. People who are too ill to work are said to have “fallen out of employment”and “parked on benefits”, as if these are not rational decisions made by competent people who know that they cannot work any longer, and that quite often, to continue doing so would place themselves and/or others at risk.

Benefits are paid for by people when they work as a social security, for in case they encounter difficult times. People tend to claim what they need, rather than becoming “parked” on benefits.

The idea that work will somehow set us free from illness is a very dangerous one.

Conservative narratives are comprised of glib, intentionally misleading, disdainful and patronising language from an utterly ruthless elite running the country into the ground, leaving such an unkind and uncaring society for the next generation, with nothing left of the “from the cradle to the grave” provision that previous generations have relied on. 

Sick notes have been renamed “fit notes” and disability benefit is now “employment and support allowance”, emphasising the linguistic behaviourism and ultimate priorities of a “small state” neoliberal government. 

Work is the only route out of poverty. If you can’t work, that’s just too bad.

Some people’s work is undoubtedly a source of wellbeing and provides a sense of purpose and security. That is not the same thing as being “good for health”.

For a government to use data regarding opinion rather than empirical evidence to claim that work is “good” for health indicates a ruthless mercenary approach to fulfill their broader aim of dismantling social security and to uphold their ideological commitment to supply-side policy.

From the first document“The belief that work improves health also positively influenced work entry rates; as such, encouraging people in this belief may also play a role in promoting return to work.”

The aim of the research was to “examine the characteristics of ESA claimants and to explore their employment trajectories over a period of approximately 18 months in order to provide information about the flow of claimants onto and off ESA.”

The document also says: “Work entry rates were highest among claimants whose claim was closed or withdrawn suggesting that recovery from short-term health conditions is a key trigger to moving into employment among this group.”

“The highest employment entry rates were among people flowing onto ESA from non-manual occupations. In comparison, only nine per cent of people from non-work backgrounds who were allowed ESA had returned to work by the time of the follow-up survey. People least likely to have moved into employment were from non-work backgrounds with a fragmented longer-term work history. Avoiding long-term unemployment and inactivity, especially among younger age groups, should, therefore, be a policy priority. ” 

“Given the importance of health status in influencing a return to work, measures to facilitate access to treatment, and prevent deterioration in health and the development of secondary conditions are likely to improve return to work rates”

Rather than make a link between manual work, lack of reasonable adjustments in the work place and the impact this may have on longer term ill-health, the government chose instead to promote the cost-cutting and unverified, irrational belief that work is a “health” outcome. Furthermore, the research does conclude that health status itself is the greatest determinant in whether or not people return to work. That means that those not in work are not recovered and have longer term health problems that tend not to get better.

The fact that government policy papers lack coherence, consistent logic and rationale is very troubling, because it indicates plainly that government policy is being driven by assumption, prejudice and ideology.

The government mantra “making work pay” was nothing to do with improving falling or stagnating wages and job insecurity, or poor working conditions. It was all about making sure that the conditions attached to social security eligibility are so punitive and wretched that only those people who are absolutely desperate will put themselves through the harshly punitive and stigmatising claim and conditionality process.

“Making work pay” is really all about making social security appear unsustainable and untenable. It’s about a governments’ priorities and choices expressed in Orwellian soundbites. It’s about a “business friendly” government that will always make sure your employer makes a hefty profit at your expense. It’s about the introduction of ordeals in order to deter people from claiming the welfare support that they paid for, for when they need it. It’s ultimately about dismantling the gains of our post-war settlement. It’s about the neoliberal small state and Conservative dogma. 

Work does not “cure” ill health. To mislead people in such a way is not only atrocious political expediency, it’s actually downright dangerous.

As neoliberals, the Conservatives see the state as a means to reshape social institutions and social relationships based on the model of a competitive market place. This requires a highly invasive power and mechanisms of persuasion, manifested in an authoritarian turn. Public interests are conflated with narrow economic outcomes. Public behaviours are politically micromanaged. Social groups that don’t conform to ideologically defined economic outcomes are politically stigmatised and outgrouped. 

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. 

This is the dangerous, irrational, savage and neoliberal mindset behind the cuts to disability support. Medication, rest, release from duties, sympathetic understanding – remedies to illness – are being redefined as “perverse incentives” for “sickness behaviours”, yet the symptoms of an illness necessarily precede the prescription of medication, the Orwellian (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. Imagine trying to sell the bordering-on-psychopathic idea that medicine provides perverse incentives which encourage “sickness behaviours” in patients to doctors, preventing them from recovering in a timely manner so they can promptly return to work.

I’m sure that oncologists everywhere will be relieved to see that their cancer patients simply needed to be told to pull themselves together, and that what they need is a stiff talking to, instead of the soft options entailing mollycoddling, chemotherapy and surgery. 

This is the same kind of thinking that lies behind the broader welfare sanctions, which are state punishments entailing the cruel removal of lifeline income for “non-compliance” in narrowly and rigidly defined “job seeking behaviours.” Sanctions are also described as a “behavioural incentive” to “help” and “encourage”people into work. People who are ill, it is proposed, should be sanctioned, too, which would entail having their lifeline basic health care and money for meeting their basic needs removed. 

Many qualitative accounts from first hand witnesses, extensive research and empirical evidence has repeatedly demonstrated that welfare sanctions make it less likely that people will find employment: taking essential support from people with very limited resources profoundly demotivates, distresses and harms people, rather than “incentivising” them to find work. (See also: Benefits sanctions: a policy based on zeal, not evidence and The Nudge Unit’s u-turn on benefit sanctions indicates the need for even more lucrative nudge interventions, say nudge theorists.)

The darker meaning of David Cameron’s comments about “ending a culture of entitlement” back in 2010 has become clearer. He wasn’t only talking about perceived attitudes and referencing erroneous, unverified and unfounded notions of “welfare dependency”: his party’s aim was and still is about reducing public expectations of a supportive and rights-based relationship with the publicly funded state – one that has evolved from the post-war settlement to ensure that everyone in the UK can meet their basic human needs. It’s no coincidence that we have witnessed the savage reduction of social security and rationing within our national health care systems since 2010.

This government is serious threat to all of those institutions and public services that contribute to make us a civilised society. In 2017, I should not have to say that poor and ill people cannot be simply punished, bullied, harassed (or “nudged”) out of being poor or ill. As politically inconvenient as poverty and disability are, no amount of authoritarian state gaslighting, abuse, bullying and harassment will “cure” those of us afflicted with either. 

The government’s new behavioural medicine is rather old news, sociologists abandoned the sick role concept decades ago

Related image

Behavioural medicine was significantly influenced by American sociologist Talcott Parsons’ The Social System,1951and his work regarding the sick role, which he analysed in a framework of citizen’s roles, social obligations, reciprocities and behaviours within a wider capitalist society, with an analysis of rights and obligations during sick leave.

From this perspective, which is an essentially socially conservative one, the sick role is considered to be sanctioned deviancewhich disturbs the function of society and the moral economy . (It’s worth comparing that the government are currently focused on economic function, enhancing the supply side of the labour market and the moral economy within a neoliberal framework.)

Behavioural medicine more generally arose from a view of illness and sick role behaviours as characteristics of individuals, and these concepts were imported from Functionalist sociological and sociopsychological theories.

However, perhaps it should be pointed out that there is a distinction between the academic social science disciplines, which include competing and critical perspectives of conflict and power, for example, and the recent technocratic “behavioural insights” approach to public policy, which is a monologue that doesn’t recognise the need for citizens’ democratic consent to behavioural change, nor does it recognise controversy or include critical analysis. It serves as prop for neoliberalism, conflating citizen’s needs and interests with narrow, politically defined economic outcomes. 

We have a government that has regularly misused concepts from psychology and sociology, distorting them to fit a distinct framework of ideology, and justification narratives for draconian policies. Parsons’ work has generally been defined as sociological functionalism, and functionalism tends to embody very conservative ideas. From this perspective, sick people are not productive members of society; therefore this deviation from the norm must be policed. This, according to Parsons, is the role of the medical profession.

More recently we have witnessed the rapid extension of this role to include extensive State policing of sick and disabled people.

It seems many of the so-called psychosocial model advocates have ignored the rise of  chronic illnesses and the pathologisation of everyday behaviours in health promotion. Parson’s sick role came to be seen as a negative referent (Shilling, 2002: 625) rather than as a useful interpretative tool. Parsons’ starting point is his understanding of illness as deviance.

Illness is the breakdown of the general “capacity for the effective performance of valued tasks” (Parsons, 1964: 262). Losing this capacity disrupts “loyalty” to particular social commitments in specific contexts such as the workplace.

Theories of the social construction of disability also provide an example of the cultural meaning of certain health conditions. The roots of this anti-essentialist approach are found in Stigma by sociologist Erving Goffman (1963), in which he highlights the social meaning physical impairment comes to acquire via social interactions.

The social model of disability tends to conceptually distinguish impairment (the attribute) from disability (the social experience and meaning of impairment). Disability cannot be reduced to a mere biological problem located in an individual’s body (Barnes, Mercer, and Shakespeare, 1999).

Rather than a “personal tragedy” that should be fixed to conform to medically determined standards of “normality” (Zola, 1982), disability becomes politicised. The issues we then need to confront are about the obstacles that may limit the opportunities for individuals with impairments, and about how those social barriers may be removed.

From a social constructionist perspective, emphasis is placed on how certain illnesses come to have cultural meanings that are not reducible to or determined by biology, and these cultural meanings further burden the afflicted (as opposed to burdening “the tax payer” , the health services, those with profit seeking motives, or the state.)

So to clarify, it is wider society and governments that need a shift in disabling attitudes, perceptions and behaviours, not disabled people.

The insights that arose from the social construction of disability approach are embodied in policies, which include the Disability Discrimination Act 1995, which included an employers’ duty to ensure reasonable adjustments/adaptations; the more recent Equality Act 2010 and the Human Rights Act 1998, which provides an important tool for disabled people to use to challenge discrimination, violations to their human rights and unacceptable treatment.

In contrast, Parsons invokes a social contract (an idea which Cameron ran with when he described the “big society” with increased citizen responsibility) in which society’s “gift of life” is repaid by continued contributions and conformity to (apparently unchanging, non-progressive) social expectations.

For Parsons, this is more than just a matter of symbolic interaction, it has far more concrete, material implications: “honour” (deserving) and “shame” (undeserving) which accompany conformity and deviance, have consequences for the allocation of resources, for notions of citizenship, civil rights and social status.

Parsons, like the contemporary Conservatives, never managed to accommodate and reflect social change, suffering and distress, poverty, deprivation and conflict in his functionalist perspective. His view of citizens as oversocialised and subjugated in normative conformity was an essentially Conservative one. Furthermore, his systems theory was heavily positivistic, anti-voluntaristic and profoundly dehumanising. His mechanistic and unilinear evolutionary theory reads like an instruction manual for the neoliberal state.

Parsons thought that social practices should be seen in terms of their function in maintaining order and social structure. You can see why his core ideas would appeal to Conservative neoliberals and rogue multinational companies. Conservatives have always been very attached to tautological explanations (insofar that they tend to present circular arguments.

One question raised in this functional approach is how do we determine what is functional and what is not, and for whom each of these activities and institutions are functional. If there is no method to sort functional from non-functional aspects of society, the functional model is tautological – without any explanatory power to why any activity is regarded as “functional.” The causes are simply explained in terms of perceived effects, and conversely, the effects are explained in terms of perceived causes). 

Because of the highly gendered division of labour in the 1950s, the body in Parsons’ sick role is a male one, defined as controlled by a rational, purposive mind and oriented by it towards an income-generating performance. For Parsons, most illness could be considered to be psychosomatic.

This “mind over matter” dogma is not benign; there are billions of pounds and dollars at stake for the global insurance industry, which is set to profit massively to the detriment of sick and disabled people. And billions to be saved and redistributed to big business and to fund tax cuts for the wealthy from our increasingly rationed and rapidly disappearing social security and NHS.

The eulogised psychosocial approach is evident throughout the highly publicised UK PACE Trial on treatment regimes that entail Cognitive Behaviour Therapy (CBT) and graded exercise. By curious coincidence, that trial was also significantly about de-medicalising illnesses. Another curious coincidence is that Mansel Aylward – who co-authored the document I cited earlier – sat on the PACE Trial steering group. 

From 1996 to April 2005 Aylward was Chief Medical Adviser, Medical Director and Chief Scientist of the UK Department for Work and Pensions and Chief Medical Adviser and Head of Profession at the Veteran’s Agency, Ministry of Defence. He was on the board of the Benefits Agency Medical Service in the 1990s.

He was involved in the establishment of the Work Capability Assessment test. When he left the department he headed the UnumProvident Centre for Psychosocial and Disability Research, at Cardiff University,

Aylward has been heaviliy criticized for providing unwarranted academic credibility to the biopsychosocial model (with a heavy  emphasis on the “psychological” element) which became both the basis and justification for the Conservative government’s disability support cuts.

The government seem to have convinced themselves that for the poorest citizens, illness is all in the mind. Disability that entails additional needs and costs is really all about people simply conforming to roles, normative expectations, and academically constructed stereotypes.

For example, a contemporary interpretation of Parsons’ functionalist perspective of the sick role: “Diagnosis elicits the belief the patient has a serious disease, leading to symptom focusing that becomes self-validating and self-reinforcing and that renders worse outcomes, a self-fulfilling prophecy, especially if the label is a biomedical one like ME. Diagnosis leads to transgression into the sick role, the act of becoming a patient even if complaints do not call for it, the development of an illness identity and the experience of victimization”. Simon Wessely and Marcus S.J. Huibers: The act of diagnosis: pros and cons of labelling chronic fatigue syndrome. Psychological Medicine 2006: 36

In 1993, Mansel Aylward invited psychiatrist Simon Wessely to give a presentation on his biopsychosocial approach to Chronic Fatigue Syndrome before the then Minister for Social Security. Wessely claimed:As regards benefits:- it is important to avoid anything that suggests that disability is permanent, progressive or unchanging. Benefits can often make patients worse.” 

Benefits can often make patients worse.” Ensuring that people can meet their basic survival needs is apparently a bad thing. Have you ever heard such utter nonsense?

It’s much more likely that patients who become more severely ill require welfare support. Despite there being no empirical evidence whatsoever for Wessely’s claims, the Minister for Social Security was looking to cut spending, so self-styled “experts” like Wessely and Aylward were more useful to an expedient government than rigorous research, empirical evidence and common decency.

I think it would be true to say that without social security, many people who are disabled because of Chronic Fatigue Syndrome (CFS) and other chronic illnesses that cause disability would experience MUCH worse symptoms,  and many would undoubtedly die without lifeline support to enable them to meet the cost of their basic survival needs. 

And actually, that is precisely what is happening in the 6th wealthiest, so-called democratic nation in the world. 

Image result for sick roleImage result for disability cuts causing death

Image result for disability cuts causing death


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Man who had two heart attacks was forced to work resulting in another heart attack

Emily and Michael Bispham (Photo: cascadenews.co.uk)

A 44 year old man suffered his third heart attack after being refused disability benefits and being forced to work. Michael Bispham, who had already suffered two heart attacks, collapsed with a third on the day he started work as a delivery driver, just three hours into his shift.

He had been awarded zero points at his Work Capability Assessment (WCA), and was told he was not eligible to claim sickness benefit and must look for work.  

Michael was told he was found “fit for work” by the Department for Work and Pensions (DWP), despite 11 letters from consultants and other doctors that clearly stated he wasn’t.

Yet he received confirmation that he had won his Employment and Support Allowance tribunal – reversing the DWP decision – as he lay in hospital following his heart attack in work. 

Michael had been fitted with a cardiac defibrillator – a device that delivers electric shocks as a treatment for life-threatening cardiac dysrhythmias – before he started work on February 13.

As a delivery driver, Michael was forced into an unacceptable situation of risk, both to himself and to others, potentially, through no fault of his own. 

Anyone who has seen the film I, Daniel Blake will probably recognise parallels. It’s a work of art that really does imitate real life.

In February, the employer relationship manager at Jobcentre Plus in Tyne & Wear and Northumberland, who is based at the branch featured in the film I, Daniel Blake, said: “I, Daniel Blake is a representation … I hope people don’t think the film is a documentary, because it’s a story that doesn’t represent the reality we work in.”

“My team and I try to treat people as individuals, and we care about the work we do,” he told the Guardian. “There will be times when we get it wrong, but I don’t believe we are ever as wrong as how we are portrayed in this film.

“I remember talking about the film in the canteen. We were concerned about how it might affect our relationship with the people we were trying to help find work. How would they react to it?”

Ken Loach, however, defended the authenticity and realism of the film’s content. “I challenge anyone to find a single word in that film that isn’t true,” he said.

I, Daniel Blake tells the story of a joiner who has had a heart attack, and is no longer able to work. However, he becomes caught up in the nightmare bureacracy of the welfare state, is passed as “fit for work” at his Work Capability Assessment, and is told he has to look for work. He suffers a second attack just before his tribunal, as a consequence of the sustained psychological distress and strain he experiences because of the punitive Conservative welfare “reforms”. 

Damian Green, the work and pensions secretary, said the film was “monstrously unfair” – though he added he had not seen it. 

Michael’s wife, Emily, would disagree.

Emily has spoken out about the distress of helping Michael to recover, while having to fight the “horrendous and unfair” benefits system she says is designed to make “honest people feel worthless”.

She says: “My husband scored zero points when he was assessed for employment support allowance.

“He’d already had two heart attacks. That should have been it.

“We knew he was too poorly, we submitted 11 letters about his condition from consultants and the hospital, but they declared him fit to work.

“It nearly killed him. I’m so angry about it.

“Just when we needed help and support, we had to navigate the system with pages of forms.

“They stopped any money because he was no longer able to job seek and we were told to start from the beginning and apply again for the ESA he’d been turned down for in the first place.

“We had nothing for three weeks at what was the worst time of our lives. It was so difficult.”

Emily was forced to stop work herself last year after being diagnosed with Crohn’s disease. She is hoping to return to work as soon as she is well enough, though Crohn’s disease is a chronic illness.

She said: “We were just normal people with jobs. We’ve got a mortgage. This could happen to anyone. But the way you are treated by the government is appalling.

“Basically, it’s a case of guilty until proven innocent at these assessments. You are there to prove you’re not making it up.

A DWP spokesperson, giving what has become a standardised and somewhat meaningless response, said: The decision on whether someone is well enough to work is taken following a thorough assessment, including all available evidence from the claimant’s GP or medical specialist.

 “Anyone who disagrees with the outcome of their assessment can appeal.” 

However, recently a Freedom of Information (FoI) request showed that controversial targets exist within the DWP that prompt decision makers carrying out mandatory reconsiderations of DWP decisions to favour their original decision, regardless of the evidence submitted and the quality and appropriateness of the original decision. Appeals cannot go ahead until the mandatory reconsideration has been carried out.

The FoI response says:

The key measures which are used by the Department for Work and Pensions to monitor Mandatory Reconsideration (MR) Performance are: 
 
a) 90% to be cleared within target. 
         
b) 80% of the original decisions are to be upheld. 
 
The performance measures for April 2016 – March 2017 are: 
 
% MR Cleared within target = 70.2% 
 
% MR Original Decision Upheld = 87.5% 

This means that DWP “reconsiderations” are not objective, as they are likely to be favourable towards the original DWP decision.

 


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A few thoughts on the implications of the United Nations report

maslow-5
There is an important link between human needs and human rights that the Conservatives have dismally and persistently failed to recognise

The United Nations (UN) inquiry into the allegations many of us made regarding the systematic abuse of the human rights of disabled people in the UK has exposed the multiple injustices of targeted cuts and the disproportionate burden of austerity heaped on sick and disabled people, their carers and their families, evidencing and detailing the effects of a range of policy measures affecting them that have been introduced since 2010. These include the bedroom tax and cuts to disability benefits, funds to support independence and social care.

The report concludes that the overall effect of what is now an essentially punitive welfare regime, which has been based almost entirely on unevidenced political claims and assumptions, has had an extremely detrimental and regressive effect on the rights of disabled people, to live independently, to meet their basic needs, to seek and stay in work,  and to be able to live an ordinary life as citizens.

The UN report documented multiple violations of disabled people’s rights, including the way that they are politically portrayed as being lazy and a “burden on taxpayers”, the harm to health caused by unfair assessments, the cuts to legal aid and curtailed access to justice, the imposition of the bedroom tax and the ending of the Independent Living Fund.

I wrote a lengthy article about the unsurprising but nonetheless disquieting report findings and recommendations as I read it, here.

Predictably, the government responded to the damning contents of the report by denying a “causal link” between their policies and the evidenced accounts of the consequences being presented to them. Yet the government have never monitored the cumulative impact of their policies and successive cuts on disabled people, and they told the UN rapporteurs that it was “not possible or practical” to carry out an impact assessment on how reforms would affect disabled people. The UN disagreed, and stated that with the evidence and data already available, the government could have done this. 

The UN have called on the government to carry out a cumulative impact assessment. The government have refused to comply with any of the recommendations the UN has made. However, that means they cannot legitimately claim that there is “no causal link demonstrated” regarding the austerity measures and psychological distress, severe hardship, deteriorating health and death, as they have persistently refused to investigate the associations that academics, charities, disabled people’s organisations, individual campaigners and opposition MPs have consistently demonstrated. Denial isn’t empirical evidence or any kind of proof that your claims are valid. Nor does withholding evidence of correlation disprove causality.

It was also noted that the government failed to listen to the concerns of disabled people it had claimed to involve in policy making processes. Disabled people and their representative organisations “were not meaningfully taken into account in the decision-making and had little or no influence on policy decisions.”

The implication is that disabled people have not been democratically included. The government have persisted in treating us as objects of policies, rather than seeing us as democratic subjects and citizens. 

Also of note: “The [individual] impact assessments conducted by the State party prior to the implementation of several measures of its welfare reform expressly foresaw an adverse impact on persons with disabilities.”

The State party has not conducted a comprehensive human rights-based cumulative impact assessment even though reliable sources have indicated it is feasible.”

The UN stated that the Department for Work and Pensions (DWP) failed to properly investigate people’s deaths after their social security payments were stopped. t was noted that the government had made no “attempts at objective, thorough, open and impartial investigation(s)” to look at the alleged 90 deaths a month, despite being aware that there was widespread public concern about this.

Among other concerns, the committee said the UK government had used rhetoric to stigmatise disabled people, negatively influencing public perceptions. The report says that disabled people “have been… negatively portrayed as being dependent or making a living out of benefits; committing fraud as benefit claimants; being lazy and putting a burden on taxpayers, who are paying ‘money for nothing’. Persons with disabilities continue to experience increasing hostility, aggressive behaviour and sometimes attacks to their personal integrity.”

The committee said it found no evidence to support any of these ideas, especially the idea that disabled claimants were committing benefit fraud.

The committee were very critical of the legal aid cuts, which have created a significant barrier for people challenging benefits decisions and holding the government accountable:

“Evidence indicates that legal aid to challenge administrative decisions ending or curtailing their benefits before first-tier tribunals has been restricted. Legal aid for cases before those tribunals has also been curtailed. Similarly, access to review by an independent and impartial tribunal has been restricted by the introduction of mandatory reconsideration procedures before the same administrative entity that has ruled on benefits.”

I was pleased to see the United Nations report highlight a fundamental prejudice that informed the very basis of the “functional capacity approach” of the Work Capability Assessment (WCA), as well as commenting on the major flaws of the assessment process itself. The WCA is based on the assumption that a health condition or disability should not automatically be regarded as a “barrier” to work and that work itself can have health benefits. However these assumptions have been controversial from the outset.

The WCA places focus entirely on how we as individuals experience our illness and impairments. As such, this approach does not permit us to place our experiences of disadvantage in the context of how organisations, institutions, policy-makers and wider society interact with us. Despite the government claiming that they take a social model approach, eligibility for benefits and services is still being determined by assessment of how much our own bodies are affected by illness and impairment rather than the disabling social, cultural and political barriers that we experience.

The report said: Work Capability Assessments do not take into account the “support persons with disabilities need to perform a job or the complex nature of some impairments and conditions.” 

The inquiry also found that welfare assessors displayed a “lack of awareness and limited knowledge of disability rights and specific needs”, and disabled people experienced distress, “anxiety and psychological strain” as a result of this flawed process, and the financial insecurity that it generates.

“The committee observes that measures have caused financial hardship to persons with disabilities resulting in arrears, debts, evictions and cuts to essentials such as housing and food,” the report said.

The Government’s own research, published in June this year, revealed that one of the cornerstones of their austerity campaign – that cutting social security means recipients will be more likely to find work – is fundamentally flawed. 

Researchers found that cutting unemployed peoples’ benefits had the opposite effect to what is being claimed – something that many of us have also previously argued. The study, carried out by Oxford city council and the Department for Work and Pensions, found unemployed people become less likely to get a job when benefits are cut. Instead of looking for work, they are forced to devote their energies to surviving day-to-day. For every £1 in benefits cut per week, a person’s chance of getting a job drops by 2 per cent.

The government can no longer justify its narrative about benefit cuts, claiming that they are  “incentives” to “support” people into work.

Beyond the rhetoric – the hidden agenda

There is a wider agenda driving the welfare “reforms” and it is important to consider the hidden ideological dimension and the language references and signposts to that, as well as the superficial narratives and semantic shifts being deployed as a PR exercise, techniques of neutralisation and gaslighting to obscure political intentions and the consequences of policies.

The UN report effectively exposed the justification narratives presented by the government for their welfare “reforms” as unfounded and unsupported by empirical evidence. This report is just the beginning, it arms us with an invaluable weapon with which to continue our campaigning, and shape future challenges and debate to government policies and social injustice.  

The Conservatives have an ideological commitment to a “small state” and this is fueled by privatisation and an ever-expanding neoliberal competitive “market place.” The market place, private profit opportunities and neoliberal outcomes have been conflated with citizen’s interests and needs.

The welfare “reforms” have presented the opportunity to promote and deliver private income protection provision via profit making companies operating in free markets. Insurance companies and right-wing think tanks have been attempting to steer governments in this direction for many years. 

For example, Matthew Oakley, a senior researcher at the Social Market Foundation, and government advisor, recently published a report entitled Closing the gap: creating a framework for tackling the disability employment gap in the UK, in which he suggests considering a “role that a form of privately run social insurance could play in both increasing benefit generosity and improving the support that individuals get to manage their conditions and move back to work.

Oakley also proposes abolishing the ESA Support Group. To meet extra living costs because of disability, Oakley says that existing spending on PIP and the Support Group element of ESA should be brought together to finance a new extra costs benefit. Eligibility for this benefit should be determined on the basis of need, with an assessment replacing the WCA and PIP assessment. The Conservative definition of “the basis of need” seems to be an ever-shrinking category.

May’s new director of policy, John Godfrey, is a keen advocate of what in his last job, at financial services giant Legal and General, he called “Beveridge 2.0”: using technology to introduce new forms of “social insurance”.

Godfrey told a campaigning group, the Financial Inclusion Commission, last year that the systems used to deliver “auto-enrolment”, the scheme that ensures all low-income workers have a pension, could also be used to help the public insure themselves against “unexpected events”.

“There is a clear lesson from auto-enrolment that if you have a plumbing network or an infrastructure that works, that auto-enrolment infrastructure could be used for other things which would encourage financial inclusion: things like, for example, life cover, income protection and effective and very genuine personal contributory benefits for things like unemployment and sickness,” he said. “They can be delivered at good value if there is mass participation through either soft compulsion or good behavioural economics.”

Note the context shift in use of the term “inclusion”, which was originally deemed a democratic right, now it’s being discussed narrowly in terms of individual responsibility.

A report published by the Adam Smith Institute as far back as 1995 – The Fortune Account – also sets out proposals to replace “state welfare” with an insurance system “operated by financial institutions within the private sector”.

Mo Stewart has spent eight years researching the influence of the US insurance giant Unum over successive UK governments, and how it led to the introduction of the “totally bogus” work capability assessment (WCA), which she says was designed to make it harder for sick and disabled people to claim out-of-work disability benefits.Stewart’s book, Cash Not Care: The Planned Demolition Of The UK Welfare State, was published in September. She states that the assessment was modeled on methods used by the controversial company Unum to deny protection to sick and disabled people in the US who had taken out income protection policies.

She goes on to say that the WCA was “designed to remove as many as possible from access to [employment and support allowance]on route to the demolition of the welfare state”, with out-of-work disability benefits to be replaced by insurance policies provided by private companies like Unum.

Stewart warns us that the UK is now close to adopting a US-style model.  

The implications of the inquiry findings for Conservative welfare policies 

The government has announced further welfare measures which will affect disabled people including a four year freeze for most working-age benefits, reductions in the Benefit Cap, changes to tax credits and to Universal Credit, and abolishing the “Work-Related Activity Component” for new ESA claims from 2017.

As noted in the UN report: “The State party continues its policy of reducing social benefits of persons with disabilities as reflected in the Welfare Reform and Work Act 2016.” 

Article 28 of the Convention on the rights of persons with disabilities (CRPD) says: Adequate standard of living and social protection – This article affirms the rights of persons with disabilities to an adequate standard of living for themselves and their family, and to social protection without discrimination on the basis of disability. This right includes access to assistance from the state with disability-related expenses for persons with disabilities and their families.

The report reiterated something that many of us have noted and discussed in detail previously: that there is no evidence of a causal relationship between a reduction in social security and an increase in employment amongst disabled and sick people. Nor does welfare “dependency” “disincentivise” people seeking employment more generally. It was pointed out in UN report that these views are not evidenced. The two assumptions are embedded in justifications of Conservative welfare policies, and are prejudices that have been around since the Thatcher administration.

Bearing in mind these are key assumptions underpinning current policies and the proposals set out in the recent work, health and disability green paper –  for example, the recent decision to reduce the money paid to people who have been assessed as being unfit to work but able to undertake work related activity (those people in the Employment and Support Allowance work related activity group (WRAG)) is based on the same assumption- the Department for Work and Pensions have claimed  – that it will “remove the financial incentives that would otherwise discourage claimants from taking steps back to work”.

Particularly important in the current context and given the government’s recent work, health and disability green paper, the UN report says that: “Given the barriers that still prevent the full participation of persons with disabilities in the labour market and mean higher unemployment rates for them, income-maintenance social security schemes are particularly important for persons with disabilities. Such schemes allow them to maintain their autonomy and freedom of control and choice of their living arrangements and day-to-day activities. Without an adequate level of social protection, persons with disabilities run the risk of being isolated, segregated from the community and/or institutionalized. 

States parties should find an adequate balance between providing an adequate level of income security for persons with disabilities through social security schemes and supporting their labour inclusion. The two sets of measures should be seen as complementary rather than contradictory.

Measures aimed at facilitating the inclusion in the labour market of beneficiaries of social security should include transitional arrangements to ensure income protection while they reach a certain threshold and sustainability in their wages. They should become eligible again without delay if they lose their jobs.” 

Although many of us have been discussing these issues for a few years, the inquiry has consolidated a lot of valuable evidence and provided a concise rebuttal of government justification narratives for cuts in support for disabled people, which we really needed to be presented to the government formally, from an independent, official and international witness.

Though the government have tended to dismiss much evidence to date of the harm that their policies are causing, such as that which has been presented through case studies by shadow ministers, as “anecdotal”, it is rather more difficult to dismiss and ignore the substantial evidence presented as a result of rigorous international scrutiny.

The government response was founded on denials, more misdirectional rhetoric and techniques of neutralisation, defensive arrogance, authoritarian scorn and contrived outrage, rather than being about stepping up to democratic accountability, reasoned discussion and rationality. No sign of civilised conscience and decent concern regarding the impact of the prejudice and discrimination that is being intentionally and systematically embedded in Conservative policies, aimed at disabled people, at all. 

The government’s response to the UN report bears little resemblance to the lived experiences of disabled people, despite claims to the contrary. The government has justified systematic cuts to disabled people’s social security by claiming such cuts “incentivise” people to find work. The cuts are a form of punishment (apparently for our own “good”) designed to bring about “behaviour change” and this approach is founded on the wrongly perceived attitudes of disabled people, who this government consistently describes as being “parked on benefits” with the “misperception that they can’t work”. 

This does nothing at all to address the barriers disabled people face in finding and staying in work, nor does it address the acknowledged prejudiced attitudes of employers and Conservative ministers. It’s not long ago that Conservative welfare minister David Freud expressed the view that disabled people should work for less than the minimum wage. He wasn’t the only one, either. Philip Davies expressed the same view, claiming that disabled people “are the most disadvantaged by the national minimum wage,” so they should be “permitted” to work for less in order to “compete” in the labor market. Davies described criticism of his remarks that disabled people could work for less than minimum wage as “leftwing hysteria”.

It seems that Conservatives believe that the only way of “helping” disabled people in any way is by simply taking money from them. 

In their response to the UN report, the government say: “The United Kingdom is proud of its record in supporting disabled people to lead more independent lives and participate more fully in society. More than 20 years ago the UK legislated to protect disabled people’s rights. It now spends around £50 bn a year on benefits to support disabled people and people with health conditions, which is over £6 bn more than in 2010. That is around 5% of GDP, or over 6% of government spending. The UK spends more on disabled people and people with health conditions than the OECD average, and countries such as Germany, France and the USA.”

That’s definitely Conservatives being… conservative with the truth again.

The Institute of Fiscal Studies (IFS) report on spending on benefits for disabled people says the actual spend is £36,063 bn but this is partly in benefits that are not counted as working age disability benefits: War Pensions, Attendance Allowance for over 65s, Statutory Sick pay, Carer’s Allowance, Industrial Injuries Benefits and the ILF which the government has closed)

The total of those benefits not paid to working age disabled people is £7,908bn

That makes the actual spend on all working age benefits for disabled people £28,155 billion

The IFS report says: “The spending on DLA/PIP is only half what it was in 1995-96. Spending across Great Britain on disability benefits in 2014–15 was £13.5 billion. At 0.8% of national income this is half the level of disability benefit spending when it was at its peak in 1995–96.

The overall number of individuals receiving disability benefits has fallen slightly since the mid-1990s. But this is in the presence of underlying demographic change that would have tended to push UP the numbers receiving considerably – both overall population growth and the baby boomer generation reaching older working ages.”

It’s not clear if the spending figures include the massive costs of private companies that are contracted by the state, ironically, to cut welfare spending. 

The National Audit Office (NAO) report earlier this year scrutinised public spending for parliament, and is independent of government. The report indicates how public services are being appropriated for purely private benefit.

The audit report in January concluded that the Department for Work and Pension’s spending on contracts for disability benefit assessments is expected to double in 2016/17 compared with 2014/15. The government’s flagship welfare-cut scheme will be actually spending more money on the assessments conducted by private companies than it is saving in reductions to the benefits bill.

From the report:

£1.6 billion
Estimated cost of contracted-out health and disability assessments over three years, 2015 to 2018

£0.4 billion
Latest expected reduction in annual disability benefit spending.

This summary reflects staggering economic incompetence, a flagrant, politically motivated waste of tax payer’s money and even worse, the higher spending has not created a competent or ethical assessment framework, nor is it improving the lives of sick and disabled people. Private companies like Maximus are paid millions from our welfare budget, yet they are certainly not “helping the government” to serve even the most basic needs of sick and disabled people.

I will be challenging the government’s response to the UN report fully in due course. It would be good to see some collaborative effort from disabled campaigners and activists in addressing the government as comprehensively as possible. If anyone is interest in working together on this, just contact me here via the comment section.

The UN committee will meet to discuss the government’s comments and determine a response in Geneva, in March 2017. 

Meanwhile it’s crucial that we use the body of evidence collated by the UN and the conclusions drawn in the report effectively. For example, our responses to the consultation on the work, health and disability green paper must address the underpinning propositions and delve beneath the superficial rhetoric and glittering generalities, rather than permitting the DWP’s weighted and somewhat leading questions to shape the outcome of the consultation.

We must use the UN findings constructively to continue to challenge existing policies, and any which arise in the future to violate the human rights of disabled persons. 

We need to continue to coherently and collectively challenge the government’s assumptions on which their proposals for work, health and disability policy are based, none of which are not supported by a shred of solid empirical evidence.

 


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