Tag: Fit notes

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

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Abbie and her late father, James Harrison.

Julia Savage is a manager at Birkenhead Benefit Centre in Liverpool. She wrote a letter addressed to a GP regarding a seriously ill patient. It said:

“We have decided your patient is capable of work from and including January 10, 2016.

“This means you do not have to give your patient more medical certificates for employment and support allowance purposes unless they appeal against this decision.

“You may need to again if their condition worsens significantly, or they have a new medical condition.” 

The patient, James Harrison, had been declared “fit for work” and the letter stated that he should not get further medical certificates. 

However, 10 months after the Department for Work and Pensions (DWP) contacted his doctor without telling him, James died, aged 55, the Daily Record has reported.

He was clearly not fit for work.

His grieving daughter, Abbie, said: “It’s a disgrace that managers at the Jobcentre, who know nothing about medicine, should interfere in any way in the relationship between a doctor and a patient.

“They have no place at all telling a doctor what they should or shouldn’t give a patient. It has nothing to do with them.

“When the Jobcentre starts to get involved in telling doctors about the health of their patients, that’s a really slippery slope.”

Abbie said James had worked since leaving school at a community centre near his home. But his already poor health went downhill after the centre was shut down because of austerity cuts.

James had a serious lung condition and a hernia before the centre closed, and also developed depression and anxiety afterwards.

Abbie said: “He’d worked all his life. He wasn’t the kind of guy who knew anything about benefits.

“But as his health deteriorated, there wasn’t any chance he could do a job. He applied for employment and support allowance.”

James received Employment and Support Allowance (ESA), but only at the low rate of £70 a week, the same amount as jobseekers’ allowance. He was then sent to attend one of the DWP’s controversial Work Capability Assessments – and declared fit for work.

Despite that decision, Abbie said James remained in constant need of medical help and had to visit his doctor regularly.

However, the GP concerned repeatedly refused to give him a sick note, and James began to suspect the Jobcentre were to blame for this.

Abbie said: “He really needed a note. He was too ill to go to the constant appointments at the Jobcentre and he didn’t want to be sanctioned.

“He became convinced the DWP had been talking to his doctor behind his back.”

Although Abbie felt her father was confused, and didn’t think his explanation was right at the time, she later asked to see her father’s medical records. She found the letter in his file from Julia Savage, the manager at Birkenhead Benefit Centre, in James’s home city of Liverpool.

The letter was addressed to James’s GP.

Context: Government claims that work is a “health outcome”

James Harrison was very worried that his ill health interfered with his obligation to comply with the inflexible and constant conditions attached to his eligibility for welfare support, and that this would lead to sanctions – the withdrawal of his lifeline support, which was calculated to meet basic survival needs only.

The GP should have provided evidence that this was the case. The doctor was advised not to provide further fit notes by the DWP, however, unless James appealed. Yet the circumstances warranted that the GP provide a fit note. 

fit-note-guidance

Last year, the Department for Work and Pensions issued an ideologically directed new guidance to GPs regarding when they should issue a Fit Note. This was updated in December 2016.

In the document, doctors are warned of the dangers of “worklessness” and told they must consider “the vital role that work can play in your patient’s health”.  According to the department, “the evidence is clear that patients benefit from being in some kind of regular work”.

The biopsychosocial model, with a current political emphasis on the psychological element, has become a disingenuous euphemism for psychosomatic illness, which has been exploited by successive governments (and rogue insurance companies) to limit or deny access to social security, medical and social care.

Nobody would deny that illness has biological, psychological and social dimensions, however, the model has been adapted to fit a neoliberal “small state” ideology – one that rests almost entirely on Conservative individualist notions of citizen responsibility, as opposed to a rights-based approach and provision of publicly funded state support.

This approach to disability and ill health has been used by the government to purposefully question the extent to which people claiming social security bear personal responsibility for their own health status, rehabilitation and prompt return to work. It also leads to the alleged concern that a welfare system which was originally designed to provide a livable income to those with disabling health problems, may provide “perverse incentives” for perverse behaviours, entrenching “worklessness” and a “culture of dependency”. It’s worth pointing out at this point that there has never been any empirical evidence to support the Conservative notion of welfare “dependency”. 

Instead of being viewed as a way of diversifying risk and supporting those who have suffered misfortune and ill health, social and private insurance systems are to be understood as perverse incentives that pay people, absurdly, to remain ill and keep them from being economically productive.

The idea that people remain ill deliberately to avoid returning to work  – what Iain Duncan Smith and David Cameron have termed “the sickness benefit culture” – is not only absurd, it’s very offensive. This is a government that not only disregards the professional judgements of doctors, it also disregards the judgements of sick and disabled people. However, we have learned over the last decade that political “management” of people’s medical conditions does not make people healthier or suddenly able to work. Government policies, designed to “change behaviours” of sick and disabled people have resulted in harm, distress and sometimes, in premature deaths

The government have made it clear that there are plans to merge health and employment services. In a move that is both unethical and likely to present significant risk of harm to many patients, health professionals are being tasked to deliver benefit cuts for the DWP. This involves measures to support the imposition of work cures, including setting employment as a clinical outcome and allowing medically unqualified job coaches to directly update a patient’s medical record.

The Conservatives (and the Reform think tank) have also proposed mandatory treatment for people with long term conditions (which was first flagged up in the Conservative Party Manifesto) and this is currently under review, including whether benefit entitlements should be linked to “accepting appropriate treatments or support/taking reasonable steps towards “rehabilitation”.  The work, health and disability green paper and consultation suggests that people with the most severe illnesses in the support group may be subjected to welfare conditionality and sanctions.

Many campaigners have raised concerns about the DWP interfering with people’s medical care and accessing their medical files. I wrote an article last year about how the government plans to merge health and employment services and are now attempting to redefine work as a clinical outcome. I raised concerns about the fact that unemployment has been stigmatised and politically redefined as a psychological disorder, and that the government claims, somewhat incoherently, that the “cure” for unemployment due to illness and disability, and sickness absence from work, is work.

In a critical analysis of the recent work, health and disability green paper, I said: 

“And apparently qualified doctors, the public and our entire health and welfare systems have ingrained “wrong” ideas about sickness and disability, especially doctors, who the government feels should not be responsible for issuing the Conservatives recent Orwellian “fit notes” any more, since they haven’t “worked” as intended and made every single citizen economically productive from their sick beds.

It seems likely, then, that a new “independent” assessment and some multinational private company will most likely very soon have a lucrative role to ensure the government get the “right” results.”

The medical specialists are to be replaced by another profiteering corporate giant who will enforce a political agenda in return for big bucks from the public purse. Health care specialists are seeing their roles being incrementally and systematically  de-professionalised. That means more atrocious and highly irrational attempts from an increasingly authoritarian government at imposing an ideological “cure” – entailing the withdrawal of any support and imposing punitive “behavioural incentives” – on people with medical conditions and disabilities. Doctors, who are clever enough to recognise, diagnose and treat illness, are suddenly deemed by this government to be insufficiently clever to judge if patients are fit for work.

The political de-professionalisation of medicine, medical science and specialisms (consider, for example, the implications of permitting job coaches to update patient medical files), the merging of health and employment services and the recent absurd declaration that work is a clinical “health” outcome, are all carefully calculated strategies that serve as an ideological prop and add to the justification rhetoric regarding the intentional political process of dismantling publicly funded state provision, and the subsequent stealthy privatisation of Social Security and the National Health Service. 

“De-medicalising” illness is also a part of that process:

“Behavioural approaches try to extinguish observed illness behaviour by withdrawal of negative reinforcements such as medication, sympathetic attention, rest, and release from duties, and to encourage healthy behaviour by positive reinforcement: ‘operant-conditioning’ using strong feedback on progress.” Gordon Waddell and Kim Burton in Concepts of rehabilitation for the management of common health problems. The Corporate Medical Group, Department for Work and Pensions, UK. 

Waddell and Burton are cited frequently by the DWP as providing “evidence” that their policies are “evidence based.” Yet the DWP have selectively funded their research, which unfortunately frames and constrains the theoretical starting point, research processes and the outcomes with a heavy ideological bias. 

This framing simply shifts the focus from the medical conditions that cause illness and disability to the “incentives”, behaviours and perceptions of patients and ultimately, to neoliberal notions of personal responsibility and self-sufficient citizenship in a context of a night watchman, non-welfare state. 

Medication, rest, release from duties, sympathetic understanding – the remedies to illness – are being appallingly redefined as “perverse incentives” for ill health, yet the symptoms necessarily precede the prescription of medication, the Orwellian renamed (and political rather than medical) “fit note” and exemption from work duties. Notions of “rehabilitation” and medicine are being redefined as behaviour modification: here it is proposed that operant conditioning in the form of negative reinforcement – which the authors seem to have confused with punishment – will “cure” ill health. 

People cannot simply be “incentivised” into not being ill. 

The political use of the biopsychosocial model to cut costs at the expense of people who are ill will undoubtedly have further extremely serious implications. Such an approach, which draws on behaviourism and punishment (such as the threat and implementation of sanctions) is extremely unethical and makes the issue of consent to medical treatment very problematic if it is linked to the loss of lifeline support or the fear of loss of benefits.

This is clearly the direction that government policy is moving in and this represents a serious threat to the health, welfare, wellbeing and human rights of patients and the political independence of health professionals.

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The government’s in-work sanctions are incompatible with ‘halving the disability employment gap’ (and other ideological problems)

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The government have introduced in-work sanctioning for low paid and part-time workers to “incentivise” them to “progress” in work. Historically, wages and employment conditions were raised, and hours were often negotiated by Trade Unions. Now those decisions are entirely down to the executive decisions of employers not employees. Sanctioning employees is grossly unfair, because they have very little negotiating and bargaining power (especially since the raft of Conservative anti-collectivist and anti-Trade Union legislation) to improve their lot.

There is also a significant growing body of empirical evidence that informs us sanctions do not work as the government claim.

It’s not as if employees’ behaviour is at fault or that they would ever actually want poor pay, fewer rights and adverse working conditions – that’s down to exploitative employers who are primarily profit driven. It’s hardly fair to punish workers for the motivations and behaviour of their employers.

There are profoundly conflicting differences in the interests of employers and employees. The former are generally strongly motivated to purposely keep wages as low as possible so they can generate profit and pay dividends to shareholders and the latter need their pay and working conditions to be such that they have a reasonable standard of living. 

Clearly, the weight of favour in policy-making is heavily towards big business profiteering. Implying that the behaviours of workers are a problem in this context is simply another way justification is presented for the further erosion of state responsibility and support and ultimately, the long term plan is to remove such support completely.

Workplace disagreements about wages and conditions are now typically resolved neither by collective bargaining nor litigation but are left to management prerogative. This is because Conservative aspirations are clear. Much of the government’s discussion of legislation is preceded primarily with consideration of the value and benefit for big business and the labour market. They want a cheap labour  force and low cost workers, unable to withdraw their labour, unprotected by either Trade Unions or employment rights and threatened with destitution via benefit sanction cuts if they refuse to accept low paid, low standard work. Similarly, desperation and the “deterrent” effect of the 1834 Poor Law Amendment Act – the principle of less eligibility – also served to drive down wages.

In the Conservative’s view, trade unions distort the free labour market which runs counter to New Right and neoliberal dogma. Since 2010, the decline in UK wage levels has been amongst the very worst in Europe. The fall in earnings under the Coalition is the biggest in any parliament since 1880, according to analysis by the House of Commons Library, and at a time when the cost of living has spiraled upwards.

In-work conditionality enforces a lie and locates blame within individuals for structural problems – political, economic and social – created by those who hold power. Despite being a party that claims to support “hard-working families,” the Conservatives have nonetheless made several attempts to undermine the income security of a significant proportion of that group of citizens recently. Their proposed tax credit cuts, designed to creep through parliament in the form of secondary legislation, which tends to exempt it from meaningful debate and amendment in the Commons, was halted only because peers in the House of Lords have been paying attention to the game.

Sanctioning people in work flies in the face of the government’s previous “hard working families” mantra. But it also flies in the face of their aim to “help” disabled people into work. Many of disabled people would have to work part-time: reduced and flexible hours are also a reasonable adaptation, especially for people who are ill. Many of us also have to accommodate hospital appointments, often with a variety of specialists, as well as hospital based treatment regimes. All of which probably makes us much more likely to face in-work sanctioning in the future.

How does this address the “disability employment gap”? 

The government propose tax cuts and other rewards for employers who employ disabled people in their recent consultation on work, health and disability. However, it is against the law to treat someone less favourably than someone else because of a personal characteristic, such as being disabled.

Furthermore, disabled people have a legal RIGHT to work and to be included in the economy, and I think in light of this, employers should be fined for not employing a quota of disabled people instead. “Disability Confident” is supposed to be about supporting disabled people, not providing publicly funded handouts to employers, whilst at the same time, financially punishing the very people that the policy is supposedly designed to “support.”

There was some very worrying discussion in the recent work health and disability green paper about new mandatory “health and work conversations” in which work coaches will use “specially designed techniques” to “help” disabled Employment and Support Allowance (ESA) claimants “identify their health and work goals, draw out their strengths, make realistic plans, and build resilience and motivation.” Apparently these conversations were “co-designed with disabled people’s organisations and occupational health professionals and practitioners and the Behavioural Insights Teamthe controversial Nudge Unit, which is part-owned by the Cabinet Office and Nesta. 

It’s very evident that “disabled people’s organisations” were not major contributors to the design. It’s especially telling that those people to be targeted by this “intervention” were completely excluded from the conversation. Sick and disabled people are reduced to objects of public policy, rather than being seen as citizens and democratic subjects capable of rational dialogue.

Systematically reducing social security, and increasing conditionality, particularly in the form of punitive benefit sanctions, doesn’t “incentivise” people to look for work. It simply means that people can no longer meet their basic physiological needs, as benefits are calculated to cover only the costs of food, fuel and shelter. In fact sanctioning people make it less likely that they will find work.

Food deprivation is closely correlated with both physical and mental health deterioration. Maslow explained very well that if we cannot meet basic physical needs, we are highly unlikely to be able to meet higher level psychosocial needs. The government proposal that welfare sanctions will somehow “incentivise” people to look for work is pseudopsychology at its very worst and most dangerous. State imposed sanctions on sick and disabled people are known to have very harmful consequences. In fact sanctions create significant difficulties and distress for everyone subjected to them. (See also An example of in-work conditionality: when work doesn’t pay).

In the UK, the government’s welfare “reforms” have further reduced social security support, originally calculated to meet only basic physiological needs, which has had an adverse impact on people who rely on what was once a social safety net. Poverty is linked with negative health outcomes, but it doesn’t follow that employment will alleviate poverty sufficiently to improve health outcomes.

In fact record numbers of working families are now in poverty, with two-thirds of people who found work in 2014 taking jobs for less than the living wage, according to the annual report from the Joseph Rowntree Foundation a year ago.

Essential supportive provision is being systematically reduced by increasing conditionally; by linking support to such a narrow outcome – getting a job – and this will ultimately reduce every service to nothing more than a state behaviour modification programme based on punishment, with a range of professionals being politically co-opted as state enforcers of an ideology  which is perpetuating and accentuating socioeconomic problems in the first place.

Work is not a “health” outcome

The Government is intending to “signpost the importance of employment as a health outcome in mandates, outcomes frameworks, and interactions with Clinical Commissioning Groups.”

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.

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 “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 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”

The government made a political and a particularly partisan decision, rather than one that has any an evidence base, 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 potentially downright harmful and dangerous.

The government’s Work and Health programme involves a plan to integrate health and employment services, aligning the outcome frameworks of health services, Improving Access To Psychological Therapies (IAPT), Jobcentre Plus and the Work programme.

2020health – Working Together is a report from 2012 that promotes the absurd notion of work as a health outcome. This is a central theme amongst the ideas that are driving the fit for work and the work and health and programme. Developing this idea further, Dame Carol Black and David Frost’s Health at Work – an independent review of sickness absence was aimed at reviewing ways of “reducing the cost of sickness to employers, ‘taxpayers’ and the economy.”

Seems that the central aim of the review wasn’t a genuine focus on sick and disabled people’s wellbeing and “health outcomes,” then. Black and Frost advocated changing sickness certification to further reduce the influence of GPs in “deciding entitlement to out-of-work sickness benefits.”

The subsequent “fit notes” that replaced GP sick notes (a semantic shift of Orwellian proportions) were designed to substantially limit the sick role and reduce recovery periods, and to “encourage” GPs to disclose what work-related tasks patients may still be able to perform. The idea that employers could provide reasonable adjustments that allowed people who are on sick leave to return to work earlier, however, hasn’t happened in reality.

The British Medical Association (BMA) has been highly critical of the language used by the government when describing the fit for work service. The association said it was “misleading” to claim that fit for work was offering “occupational health advice and support” when the emphasis was on sickness absence management and providing a focused return to work.

The idea that work is a “health” outcome is founded on an absurd and circular Conservative logic: it’s an incorrect inference based on the fact that people in work are healthier than those out of work. It’s true that they are, however, the government have yet again confused causes with effects. Work does not make people healthier: it’s simply that healthy people can work and do. People who have long term or chronic illnesses most often can’t work. It has been historically  and empirically established that poverty is closely correlated with disproportionate levels of ill health, and it’s most probable that targeted austerity, leading to increasingly inadequate welfare provision, has made a significant contribution to poorer health outcomes, too.

The government’s main objection to sick leave and illness more generally, is that it costs businesses money. The government remain committed to a supply-side labour market model. However, as inconvenient as it may be, politically and economically, it isn’t ever going to be possible to cure people of serious illnesses by cruelly coercing them into work.The government’s aim to prompt public services to “speak with one voice” is founded on questionable ethics. This proposed multi-agency approach is reductive, rather than being about formulating expansive, coherent, comprehensive and importantly, responsive provision.

This is psychopolitics. It’s all about (re)defining the experience and reality of a social group to justify dismantling public services (especially welfare), and that is form of gaslighting intended to extend oppressive political control and 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.

However, unsatisfactory employment – low-paid, insecure and unfulfiling work – can result in a decline in health and wellbeing, indicating that poverty and growing inequality, rather than unemployment, increases the risk of experiencing poor mental and physical health.

People are experiencing poverty both in work and out of work. Moreover, in countries with an adequate social safety net, poor employment (low pay, short-term contracts), rather than unemployment, has the biggest detrimental impact on mental health. There is ample medical evidence to challenge the current political dogma, and to support this account. (See the Minnesota semistarvation experiment, for example. The understanding that food deprivation in particular dramatically alters cognitive capacity, emotions, motivation, personality, and that malnutrition directly and predictably affects the mind as well as the body is one of the legacies of the experiment.)

Systematically reducing social security, and increasing conditionality, particularly in the form of punitive benefit sanctions, doesn’t “incentivise” people to look for work. It simply means that people can no longer meet their basic physiological needs, as benefits are calculated to cover only the costs of food, fuel and shelter.Food deprivation is closely correlated with both physical and mental health deterioration. Maslow explained very well that if we cannot meet basic physical needs, we are highly unlikely to be able to meet higher level psychosocial needs.

The government proposal that welfare sanctions will somehow “incentivise” people to look for work is pseudopsychology at its very worst and most dangerous.In the UK, the government’s welfare “reforms” have further reduced social security support, originally calculated to meet only basic physiological needs, which has had an adverse impact on people who rely on what was once a social safety net.

Poverty is linked with negative health outcomes, but it doesn’t follow that employment will alleviate poverty sufficiently to improve health outcomes.In fact record numbers of working families are now in poverty, with two-thirds of people who found work in 2014 taking jobs for less than the living wage, according to the annual report from the Joseph Rowntree Foundation a year ago.

Essential supportive provision is being reduced by conditionally; by linking it to such a narrow outcome – getting a job – and this will reduce every service to nothing more than a political semaphore and service provision to a behaviour modification programme based on punishment, with a range of professionals being politically co-opted as state enforcers. 

I have pointed out previously that there has never been any research that demonstrates unemployment is a direct cause of ill health or that employment directly improves health, and the existing studies support the the idea that the assumed causality between unemployment and health may actually run in the opposite direction.It’s not that unemployment is causing higher ill health, but that ill health and discrimination are causing higher unemployment. If it were unemployment causing ill health, at a time when the government assures us that employment rates are currently “the highest on record,” why are more people becoming sick?

The answer is that inequality and poverty have increased, and these social conditions, created by government policies, have long been established by research as having a correlational relationship with increasing mental and physical health inequalities. For an excellent, clearly written and focused development of these points, the problem of “hidden” variables and political misinterpretation, see Jonathan Hulme’s Work won’t set us

– childhood immunisation
– antibiotics
– access to education, and particularly, improving female literacy
– increasing social equality

Given that, as statistics sadly show, the health of the poorest in the UK is again declining despite the first four factors mainly still being accessible to even the UK’s very poorest, one can only point at the worsening inequalities and social injustices as a significant cause. The Marmot review pretty much concludes the same. “

Addressing these issues is not consistent with the ideological thrust of Conservative policies, unfortunately, since the government insist that social problems such as poverty and ill health (the biopsychosocial model, with an emphasis on the “psychosocial” elements) are due to individual “behaviours.” Their approach to date has been to level punitive policies with an embedded core of behaviour modification techniques which usually entails the punitive removal of lifeline income at the poorest citizens – casually called “incentivising” and “supporting” – whilst addressing the behaviours of the wealthy with a system of publicly funded financial reward. This simply recreates, deepens, perpetuates and accentuates existing inequalities.

Empirical research published two years ago demonstrated the high a cost the country paid in terms of health and wellbeing for the Thatcher administration’s neoliberal economic and social policies. The study, which examined at material from existing research and data from the Office for National Statistics, illustrates that Thatcherism resulted in the unnecessary and unjust premature deaths of British citizens, together with a substantial and continuing burden of suffering and a widespread degradation of wellbeing.

Co-author and researcher Professor Clare Bambra from the Wolfson Research Institute of Health and Wellbeing said that deaths from violence and suicide all increased substantially during the Thatcher era in comparison with other countries. Regional inequalities in life expectancy between north and south were also exacerbated, as were health inequalities between the richest and poorest in British society.

Professor Bambra also says that the welfare cuts implemented by Thatcher’s governments led to a rise in poverty rates from 6.7% in 1975 to 12% by 1985; poverty is well known to be one of the major causes of ill health and mortality. Income inequality also increased in the Thatcher period, as the richest 0.01% of society had 28 times the mean national average income in 1978 but 70 times the average by 1990. Other research (The Spirit Level) indicates that income inequality is internationally associated with higher mortality and morbidity.

Yet earlier this year, the welfare reform minister, Lord Freud, refused to monitor the number of people who take their own lives as a result of the £120-a-month cut planned for those people in the work related activity group (WRAG), claiming employment and support allowance from April 2017. Concerns were raised in the House of Lords, when Baroness Meacher, amongst others, warned that for the most vulnerable citizens, the cut was “terrifying” and bound to lead to increased debt.

Condemning the truly callous and terrible actions of the Treasury, she urged ministers to monitor the number of suicides in the year after the change comes in, adding: “I am certain there will be people who cannot face the debt and the loss of their home, who will take their lives.”

Many people have died as a consequence of the welfare “reforms.”

Not only have the government failed to carry out an impact assessment regarding the cuts, Lord Freud said that the impact, potential increase in deaths and suicides won’t be monitored, apart from “privately” because individual details can’t be shared and because that isn’t a “useful approach”.

He went on to say “We have recently produced a large analysis on this, which I will send to the noble Baroness. That analysis makes it absolutely clear that you cannot make these causal links between the likelihood of dying – however you die – and the fact that someone is claiming benefit.”

However, a political refusal to investigate an established correlation between the welfare “reforms” and an increase in the mortality statistics of those hit the hardest by the cuts – sick and disabled people – is not the same thing as there being no causal link. Often, correlation implies causality and therefore such established links require further investigation. It is not possible to disprove a causal link without further investigation.

Whilst the government continue to deny there is a “causal link” between their punitive welfare policies, austerity measures and an increase in premature deaths and suicides, they cannot deny there is a clear correlation , which warrants further research and political accountability.

We have a government that provides disproportionate and growing returns to the already wealthy, whilst imposing austerity cuts on the very poorest. How the government possibly claim that inequality is falling, when inequality is so fundamental a prop to their ideology and when social inequalities are extended and perpetuated by all of their policies? It seems an Orwellian re-writing of language about inequality is being used to mislead us into thinking that the economy is far more “inclusive’ than it is. The number of vulture private businesses payrolled by the government to deliver increasingly ideologically biased and punitive welfare, health and social care “services” has risen dramatically this past six years, all of which has cost the UK taxpayer billions.

Meanwhile, those people who need essential supportive public services are facing severe cuts to their lifeline provision. Many of the multinationals contracted by the government are paid to cut the costs of public services, but are costing the public far more than they save.far more than they save. This brand of neoliberal crony capitalist is an entrenched mindset that needs to radically change, because the only beneficiaries are big businesses, and at the expense of those people with the highest level of need. The government’s policies are harming our most vulnerable citizens.

It seems that for wealthy people, “incentives” are always financial rewards, and for poor people, “incentives” simply involve grossly unfair financial punishments, which have too often challenged people’s  capacity to meet basic survival needs.

It’s time to challenge the class-based prejudice and blatant discrimination that is embedded in Conservative policies, which ultimately may only serve to deepen existing wealth and health inequality and increase social and economic division.

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Let’s keep the job centre out of GP surgeries and the DWP out of our confidential medical records

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Last year I wrote a critical article about the government’s new Work and Health Programme, I flagged up concerns regarding government plans to enlist GPs in prescribing work coaches for people who are sick and disabled, and in providing advice on job-seeking. The private and confidential patient-doctor relationship ought to be about addressing medical health problems, and supporting people who are ill, not about creating yet another space for an 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.

I also posted my article on the Pulse site for medical professionals last October, raising some of my concerns. I proposed that the government may use the “intervention” as a further opportunity for sanctioning sick and disabled people for “non-compliance”, and I expressed concern that this would conflict with the ethics and role of a doctor. I also stated my concern about the potential this pilot has for damaging the trust between doctors and their patients. I do support the idea of social prescribing in theory, but this scheme is certainly not that. This is plain state harrassment and coercion.

It’s interesting to see that amongst all those listed present at the various pilot-related meetings behind closed doors regarding the government’s new Work and Health programme, there isn’t a single sick and disabled person or relevant representative charity to be found. That’s telling, because it means that the provision is not founded on consultation, is not designed to be inclusive from the start, nor does it have a democratic or representative foundation. It’s another case of government policy that acts upon groups people, prescriptively, as if they were objects, rather than human subjects with identifiable needs and the capacity for democratic dialogue.

I discovered last October, almost by chance, 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.

Now GPs have raised their own concerns about sharing patient data with the Department for Work and Pensions – and quite properly so. Pulse reports that the Department for Work and Pensions (DWP) plans 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 work to 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 plans 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.

This is the kind of mentality that the new Work and Health programme is founded on: Dr Josephine Sauvage, the joint vice chair of NHS Islington CCG and a GP at City Road Medical Practice, where the programme is being trialed currently, said the programme can help patients.

She said: “When we become ill we often stop doing those things that get us out and about and bring fulfilment to our lives.”

Yes, that’s what being chronically ill means: we often become incapacitated and sometimes we can’t do all of the things we did before. But since when is working the only source of fulfilment? And how does forcing people who are ILL to look for ANY job, regardless of pay, security, terms and conditions and appropriateness lead to “fulfilment”? A patient is defined as:

  • A person who requires medical care.
  • A person receiving medical care or medical treatment.
  • A person under a physician’s care for a particular disease or condition.

There is no mention of a person’s employment status or the pressing need for a job prescription in that definition.

As part of the Work and Health programme, beginning next month, the DWP plans to access people’s medical information. Employment coaches will be able to directly “update” a patient’s medical record.

GPs will have to inform patients of the access to information and any extraction of confidential information from their medical files, but cannot withhold information unless their patient explicitly objects.

, a senior journalist at Pulse, says: GPs, as data controllers, will be required to tell patients in person, via notices in the practice and on the practice website of the impending extraction.”

Patients have the right to object to the use and disclosure of confidential information that isn’t used for their medical care.

Patients can explicitly refuse their consent to data sharing. The Data Protection Act 1998 covers personal information including health records. Further provision under Article 8 of the Human Rights Act 1998 establishes a right to respect for private and family life. This underscores the duty to protect the privacy of individuals and preserve the confidentiality of their health records.

There is also additional guidance from the British Medical Association (BMA) here – GPs as Data controllers guidance. (PDF)

You can:

Write your own letter to the GP health centre. Here is a basic letter template in 3 formats that you can download and use:

Opt out letter (PDF)

Opt out letter (MS Word)

Opt out letter (Rich Text)

Make sure you state clearly that don’t wish for any of your data and medical information, including details of your fit notes, to be shared with the DWP and any other third party. You can also:

In addition to sharing information with the DWP, due to changes in legislation, your GP can now be required to upload personal and identifiable information from the medical record of every patient in England to central servers at the Health and Social Care Information Centre (HSCIC).

Once this information leaves your GP practice, your doctor will no longer be in control of what data is passed on or to whom. This information will include diagnoses, investigations, treatments and referrals as well as other things you may have shared with your doctor including your weight, alcohol consumption, smoking and family history. Each piece of information will be identifiable as it will be uploaded with your NHS number, date of birth, post code, gender and ethnicity. NHS England – the body now in charge of commissioning primary care services across England – will manage and use the information extracted by HSCIC for a range of purposes, none of which are to do with your direct medical care.

Whenever I am ill, I don’t ever consider consulting Iain Duncan Smith or the government more generally for advice. There are very good reasons for this. I don’t want to be confronted with pseudoscientific Conservative anti-welfare dogma, I prefer instead to seek the expert, trusted medical opinion of a qualified doctor. I expect professional medical care, not brute state coercion and a punishment regime that is particularly reminiscent of the 1834 Poor Law amendment Act.

And despite assurances from those professionals currently trialing the Work and Health programme that all participation is (currently) voluntary, against the current backdrop of ever-increasing welfare conditionality, the political stigmatisation of people not in work, the frequent punitive deployment of benefit sanctions, the mandatory  welfare-to-work schemes, it’s difficult to imagine a Conservative scheme that will not entail exercising Conservative prejudice and pseudoscientific justifications of Tory economic Darwinist ideology.

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.

It’s not possible to make people who are ill better by punishing them, in just the same way as state coercion and using prejudiced language doesn’t “cure” poverty.  I don’t need more quack medicine on top of the current heavy doses of Conservative big state psychopolitics, traditional prejudices and subsequent quacking, slapstick psychobabble. It’s bad enough that Jeremy Hunt thinks he’s the all singing homeopathic Minister for magic and that Iain Duncan Smith thinks he can miraculously cure sick and disabled people by simply forcing them to work. The side-effects of five years of the Conservative’s ontologically insecure rhetoric, that’s been largely ranting, repetitive, incoherent monologue, are nauseating enough. Nobody should need to say any of this in 2016, but tragically, we seem to have a government that hasn’t yet escaped the feudal era. Or playing with their alchemy sets.

I’m in full agreement with Boycott Workfare, the Mental Health Resistance Network, and Disabled People Against the Cuts. I shared my original article with two of those groups and I’m pleased that they have since organised a protest for March 4, 3pm at the City Road Surgery, 190-196 City Road, London EC1V 2QH to raise public awareness of the issues and implications outlined. I just wish I was currently well enough to get to the protest.

They say: GP surgeries are for medical treatment, the job centre is for “employment coaching” and job-hunting.

And governments in first-world liberal democracies are for creating policies that actually meet public needs, rather than imposing totalitarian control, manipulating and micromanaging citizens to meet government needs and political outcomes.

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