Tag: Work Coaches

The ‘Intensive Personalised Employment Support’ programme & the problematic political application of Lewin’s theory of change

An ‘Intensive Personalised Employment Support’ programme is to be introduced which will “provide personalised employment support for long-term unemployed disabled people,” the new Work and Pensions Secretary Amber Rudd has announced.

“Disabled people will be able to work with a dedicated key worker to get and stay in employment,” she says.

The support comes from a new £40 million fund and is expected to benefit around 10,000 people.

The Intensive Personalised Employment Support programme will provide “highly personalised packages of employment support for people who are at least a year away from moving into work.”

People will be provided with coaching to help build their independence, confidence and motivation, as well as work experience to help boost their career prospects.

Rudd added: “Everyone, no matter what their background is, should have the opportunity to thrive in the workplace, and having the right support in place for disabled people is one of my greatest priorities.

“To truly help people transform their lives, there can be no one-size-fits-all approach.

“That’s why this new programme is designed to offer people, who may think they will never move into work, tailored support to help them overcome any personal barriers they may have in the first instance, and then to focus on boosting their skills.

“There are also huge economic benefits to improving disability employment rates. More than half of disabled people are in work, but in order to realise the full potential of disabled people in Britain we want to go further and see one million more disabled people in work by 2027.”

People on the scheme will be offered a dedicated key worker who will work with them to overcome complex barriers which may be preventing them from entering work, ensuring they have a personal support network in place.

The voluntary scheme will be rolled out across England and Wales in 2019, and applicants will receive support for up to 21 months, including 6 months of in-work support for those who get a job.

Neil Heslop, Chief Executive of Leonard Cheshire, said: “Many disabled people with complex needs face significant barriers in accessing the workplace. It’s crucial that specialised employment support is available and the government responds to the challenges people often encounter.

“A more tailored approach can help reach those who are not currently receiving any employment support or skills development. The experiences of disabled people must be central for this support to meaningfully build confidence in an ongoing way, reflecting their individual circumstances and aspirations.”

The Intensive Personalised Employment Support programme will support people living with a disability who are unlikely to move into work within the next year or longer and may need additional support. Other existing government support to help disabled people get into and stay in work includes the Disability Confident scheme, the Work and Health programme, the Access to Work grant and Jobcentre Plus services.

The pathfinder report that informed the Intensive Personalised Employment Support programme

The government has established a managerial type of policy context in which it is aiming to “provide support which could enable disabled people to undertake employment in the open market rather than in protected or segregated employment.” 

The government have in particular targeted those disabled people who have just started claiming Employment and Support Allowance, before they undergo a work capability assessement for ‘interventions’. This approach is founded on an entrenched belief that “the longer a disabled person or an individual with a health condition is unemployed, the harder it is for them to return to work.”  

However, an alternative explanation is that those who are not employed because of a health condition for longer periods are simply too ill to work. Nonetheless, the government has focused on notions of “work-readiness” as a means to “help” disabled people into work, which tends to sidestep the barriers that people face because they are unwell. 

Research was carried out by IFF Research Ltd on behalf of the Department for Work and Pensions, to evaluate the Personalisation Pathfnder trial, which was  introduced in April 2015 in three Districts: South West Wales, Surrey and Sussex and Greater Wessex. The report can be found here.  

In part, the research aimed to “establish whether the Pathfinder worked in moving out-of-work individuals with a disability and/or health condition closer to employment and, if so, how and why it achieved this. Specifcally, the objectives of the research were to understand:   

  • Take-up of the Pathfinder programme – detailing the profile of individuals who joined the scheme in terms of employment history, claimant group, nature of health condition etc., as well as exploring the reasons and motivations for taking part  
  • The impact on outcomes for claimants. This includes both ‘hard’ impacts such as claim status and employment outcomes as well as ‘soft’ impacts such as attitudes towards work, levels of job-seeking activities, and perceptions of ability to manage health conditions 
  • Value for money 
  • Any impacts on the reputation of DWP and/or Jobcentre Plus among claimants.

The chief purpose of the Personalisation Pathfinder was to help claimants to become “work ready” through offered tailored support to those with a disability or health condition who are unemployed and aimed to investigate the impacts of an approach focused on personalisation, flexibility, peer support, and integration with local support.  

The report discusses findings from two waves of a quantitative survey with claimants on the Personalisation Pathfnder as well as from qualitative interviews with claimants and Pathfnder stakeholders.  

Job seeker’s Allowance (JSA) claimants with a health condition or disability accounted for the greatest proportion of participants on the Pathfnder (50 per cent), followed by Employment and Support Allowance (ESA) pre-Work Capability Assessment (WCA) claimants (38 per cent). 

Only around one in eight (12 per cent) of the participants were ESA Work Programme completers (WP). The majority of participants had been in employment at some point before joining the Pathfnder (76 per cent). Six in ten had left their previous employment due to health related reasons and more than seven in ten regarded their health as a key barrier to returning to work. 

Perhaps unsurprisingly, participants claiming JSA were generally less likely to perceive their disability as impacting on their employment before joining the Pathfnder. They were also less likely to believe their health condition or disability limited their ability to return to work. They tended to report fewer barriers to returning to work and were therefore generally more positive about this prospect. Three in ten claimants were in work twelve months after joining the Personalisation Pathfinder. 

ESA pre-WCA claimants were most likely to have found work while on the trial. Nearly a third of this group had, however, returned to a previous employer or job.

ESA WP Completers were the least likely to have found work, but the ones who did were more likely than the other claimant groups to credit the support they received from the Pathfinder in moving them into work. ESA WP Completers were also more likely to feel they needed health related support that the Pathfinder could not offer and that this prevented them from moving closer to employment.

The authors clearly stated that it is not possible to assess from the research what proportion of claimants would have achieved these outcomes without the assistance of the Pathfinder. Although there are indications of “work-readiness” improving among those who did not find work – and I am not sure how one measures that – improvements in wellbeing and social isolation, it was concluded,  were “more modest”. 

Methodology: some first glance criticism

The research was framed by the political application of the theory of change – this is essentially a description of how and why a desired change is expected to happen in a particular context. It is focused in particular on mapping out or “filling in” what has been described as the “missing middle” between what a programme or change initiative does (its activities or interventions) and how these lead to desired goals being achieved.

It does this by first identifying the desired long-term goals and then works backwards from these to identify all the conditions (outcomes) that must be in place (and how these related to one another ‘causally’) for the goals to occur. Government sectors use the theory of change to promote various managed social and political changes, to define their long-term goals. 

So it is a model based on backcasting, which is a planning method that starts with defining a desirable future and then works backwards to identify policies and programmes that will connect that specified future to the present.

The outcomes in a theory of change must be coupled with indicators that guide and facilitate measurement. The measurement is often of changes in behaviours and perceptions.

However, any serious explanation of anything in the social world should be suspect if it only uses one theory – e.g. a theory of financial incentives, or peer influences. All successful models are assemblies of multiple elements and theories – and they are open to exploration. Anyone familiar with systems thinking will be dubious of linear explanations, especially where complex  phenomena like disability, emloyment, homelessness, poverty or social isolation are concerned.

On key problem with the theory of change is that it does not model how events happen; rather, it models how strategists believe things will happen. Theory of change is a forecast that shows what conditions they believe must exist for other conditions to come into being. It’s easy to see how the model may very easily accommodate assumptions, prejudices and channel bias. The model may confuse accountability with ambitions and hopes.

Often, theory of change is insular and parochial, too. It can fail to take the external context into account. This is an important criticism in the context of current government behaviour change programes, as the emphasis is entirely on individuals, who are somehow viewed as detached from their social, cultural, economic and policy contexts. 

Participation in the programme was voluntary. However, people decided not to engage with the programme, so the invitation letters were reworded, making the statement about the programme’s voluntary basis of participation less prominent, to nudge people into engaging. That is unethical, because it bypasses the important condition of fully informed consent. Yet later in discussion between job coaches and claimants, the voluntary aspect became important in retaining some participants:

The voluntary issue is quite interesting actually, because I have had people who have come back from the Work Programme, have sat down in front of me and you can tell have arrived expecting me to say, ‘Right, you’re going to do this/you’re going to do that/you’re going to do this’, and they’ve been quite defensive, and they’ve said, ‘You know I can’t work.

“So when I’ve said, you know, ‘That’s fne, you don’t have to. This is a voluntary programme’, they’ve almost said, ‘Oh don’t walk away. I’m interested’, you know. The voluntary thing has defnitely produced a different reaction from people.”

Nonetheless, some 11% of the participants still said they were unaware they had a choice in whether they participated. Nearly one-ffth (19 per cent) of claimants thought that the Personalisation Pathfnder was mandatory; this proportion rose to 36 per cent for ‘ESA WP Completers.’  And even those who understood that participation was voluntary nonetheless expressed fears that they may be sanctioned if they refused to engage (page 59):

“I did not feel I could say no to the Pathfnder, because if we don’t do what they say, they’ll stop our money.” (JSA Caseload claimant, Surrey and Sussex).

Another criticism of the pathfinder is that it does not seem to differentiate between perceived health-related barriers to work and actual health-related barriers to work. Part of the aim of the programme was to influence people’s perceptions of barriers, a strategy which had little impact overall.

Another problem with the theory of change approach is that it doesn’t confirm the plausibility of the theory. Also, to be able to test, refine, and improve a theory of change over time, you need to be able to accurately measure its key elements. Not differentiating between perceived and actual health-related barriers leads to measurement problems.

Another major criticism of applied behavioural scientist Kurt Lewins theory of change model is that it ignores the influence of organisational power, conflict and politics; it is “top-down” and management-driven. As such, it is rather an authoritarian approach to policy making.

This is down to a misuse of the original theory and its underpinning intents. This presents an irony given that Lewin’s original wish was to extend democratic values and resolve social conflicts. Even critics of Lewin’s work have drawn on his Field Theory to develop their own models of change. Including the government.

Any change that the Conservatives initiate is generally imposed on others and micromanaged. If prescribed, theory of change quickly becomes a compliance exercise and loses much of its original  value. Theory of change frameworks requires a commitment to anopen,  reflective and realistic approach. 

Assumptions reflect deeply held beliefs, norms and ideological perspectives. These inform the design and implementation of programmes. The quality of a theory of change process rests on ‘making assumptions explicit’ and making strategic thinking realistic and transparent. Power relations, both in the programme’s context and within organisations, limit the ability to challenge established ways of thinking and working. So a theory of change process often brings to the surface conflicts and tensions which require negotiation. 

It’s certainly true to say that some “politicians, like any other social group that is in a rarefied or tightly knit, small community, will frequently suffer from psychological ‘groupthink’.” Dr Paul Taffinder, Chartered psychologist.

Common pitfalls of using theory of change, and rules of thumb for taking a systemic approach: pitfall 1) neglect context. rule of thumb 1) understand context. pitfall 2) change others only. rule of thumb 2) know yourself. pitfall 3) think in linear terms. rule of thumb 3) think systemically. pitfall 4) seek safety in certainty. rule of thumb 4) learn and adapt. pitfall 5) change is technical. rule of thumb 5) recognise change is personal.


 

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

Thanks to  for the copy of a patient work coach letter to GPs.

One of the most worrying comments on the above letter is that despite claiming the work coach service is voluntary, and that if a patient refuses to engage “it won’t affect any benefit they get”, the letter then goes on to suggest that doctors may consider the issuing of subsequent fit notes conditional (“with the proviso that”) on their patient attending a meeting with the work coach. That one sentence simply makes a mockery of the claim that patient engagement with work coaches is voluntary. 

Illnesses don’t respond to provisos or caveats. People don’t suddenly recover when the Department for Work and Pensions decides that they are fit for work. When job centre staff tell GPs to stop issuing sick notes to patients it can have catastrophic consequences, from which the government never seem to learn. In fact they don’t even acknowledge the terrible costs that their deeply flawed policies are inflicting on citizens. 

Julia Savage is a manager at Birkenhead Benefit Centre in Liverpool. In 2016, she wrote a letter (an ESA65B notification form) 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 GP subsequently repeatedly refused to provide him with new fit notes, even as his health deteriorated, and he died months later.

James Harrison – the patient – had been declared “fit for work” and the letter stated that he should not get further medical certificates. The Department for Work and Pensions contacted his doctor without telling him, and ordered him to cease providing sick certification, James died, aged 55.

He was very clearly not fit for work.

It is very worrying that the ESA65B form is a standardised response to GPs from the Department for Work and Pensions following an assessment where someone has been found fit for work.  

The government as boardroom doctors: political jobsworths

The Department for Work and Pensions issued a new guidance to GPs in 2013, regarding when they should issue a Fit Note. This was updated in December 2016. 

In the dogma 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”

As a matter of fact, it isn’t clear at all.

The idea that people remain ill deliberately to avoid returning to work  – what Iain Duncan Smith and David Cameron 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 harmdistress and sometimes, in premature deaths.

Call me contrary, but whenever I am ill with my medical and not political illness, I generally trust my qualified GP or consultant to support me. I would never think of making an appointment to see the irrational likes of Esther McVey or Iain Duncan Smith for advice on lupus, or to address my health needs and treatment. 

The political de-professionalisation of medicine, medical science and specialisms (consider, for example, the ghastly 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 increasingly behaviourist-neoliberal 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 Department for Work and Pensions (DWP) as providing ‘scientific evidence’ that their policies are “verified” and “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 behaviourist 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 the dehumanising context of a night watchman, non-welfare state, absent of any notion of human rights. 

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 –  punishment – will cure’ ill health. 

It’s a completely slapstick rationale, hammered into shape by a blunt instrument – political ideology. People cannot simply be ‘incentivised’ (coercion is a more appropriate term) into not being ill. Punishing people for being poor by removing their support does not ‘help’ them to stop being poor, either, despite the  doublespeak and mental gymnastic pseudoscientific rubbish the government spouts.

Turning health care into a government work programme 

The government dogmatically assert “The idea behind the fit note is that individuals do not always need to be fully recovered to go back to work, and in fact it can often help recovery to return to work.” 

It was 2015 when I wrote a breaking article about the government’s Work and Health programme, raising concerns that the Nudge Unit team were 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.”

Of course the government hadn’t announced these ‘interventions’ in the lives of ill and disabled people. I found out about it quite by chance because I happened to read Matthew Hancock’s  conference speech: The Future of Public Services.

I researched a little further and found an article in Pulse – a publication for for medical professionals – which confirmed Hancock’s comment: GP practices to provide advice on job seeking in new pilot schemeI posted my own article on the Pulse site in October 2015, raising some of my concerns.

Many of us have warned that the programme jeopardises doctor-patient confidentiality, risks alienating patients from their doctors and perverts the primary role and ethical mission of the healthcare system, which is to help people to recover from illnesses. Placing job coaches in GP surgeries makes them much less inaccessible, because it turns tappointments potentially into areas of pressure and coercion. That is the very last thing someone needs when they become ill.

One worry was that the government may use the ‘intervention’ as a further opportunity for sanctioning ill and disabled people for ‘non-compliance’. People who are ill often can’t undertake work related tasks precisely because they are ill. Until recent years, this was accepted as common sense, and any expectation of sick people having to conform with such rigid welfare conditionality was quite properly regarded as both unfair and unrealistic.

I expressed concern that the introduction of  job coaches in health care settings, peddling the myth that ‘work is a health outcome’ would potentially conflict with the ethics and role of a doctor. I also stated my concern about the potential that this (then) pilot had for damaging the trust between doctors and their patients. 

In another article in 2016, titled Let’s keep the job centre out of GP surgeries and the DWP out of our confidential medical records, I outlined how GPs had 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) 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 ill 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 ‘business friendly’ government likes that or not. And regardless of the politically prescribed Orwellian renaming of sick notes, which show ‘paternalist’ linguistic behaviourism in action.

In 2017, the General Medical Council (GMC) – independent regulator for doctors in the UK – wrote a response to the government’s green paper: Improving Lives: The Work, Health and Disability Green Paper consultation. The authors of the document begin by saying ” Our purpose is to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine.”

The response continues: “Where doctors are expected to play a role in initiatives such as those set out in the Green paper, our concern is to ensure that any responsibilities that might be placed on doctors would be consistent with their professional obligations and would not risk damaging patients’ trust in their doctors. While we believe that many of the Green paper proposals are promising, we are concerned that key elements appear to present a conflict with the ethical responsibilities we place on doctors. The comments below are seeking clarification in these areas.”

And: “We understand from this Green paper, and from the Department of Work and Pensions’ published FOI response, dated 22 December 2016, that the work coaches who will conduct the mandatory health and work conversation with claimants will not be health professionals. There is a risk that claimants will not get the right support in setting health and work-related goals during this mandatory conversation if the work coach does not have clinical expertise.

“It would be helpful to know whether work coaches will be expected to have access to the claimant’s healthcare team and/or health records to inform these conversations. If so, we would appreciate reassurance that there will be a process for obtaining consent from the claimant, and providing assurance to the relevant health professionals that the individual has provided consent. Given that work coaches do not require medical expertise, we have some concerns about these conversations leading claimants to agree to health-related actions in a Health and Work ‘claimant commitment’. It seems possible that agreed actions might not be clinically appropriate for that individual or not the best course of action given their health condition. 

If a claimant commitment were reviewed by the claimant’s doctor (or other healthcare professional), and the doctor concluded that there was a health risk; then would the claimant be free to withdraw from the commitment without facing a benefits penalty? If not, then this would put the doctor and patient in a very difficult position, if it appeared that the patient had been poorly advised by the work coach and was not making an informed, voluntary decision in requesting a particular treatment or care regime from their doctor. 

We note the intention is for any agreement made in the Health and Work Conversation to be seen as voluntary. However, it seems to us that since the Conversation itself is mandatory and a Claimant commitment may influence subsequent handling of an individual’s Work Capability assessment, then in practice claimants may see these agreements as mandatory.

“As a result they may feel pressured to accept advice and make commitments which may not be appropriate in their case. This would place theirdoctors in a difficult ethical position, and we are concerned to ensure that this is not the case.

The authors add: “… we make it clear in our guidance that doctors must consider the validity of a patient’s consent to treatment if it is linked with access to benefits. Doctors should be aware that patients may be put under pressure by employers, insurers, or others to accept a particular investigation or treatment (paragraph 41, Consent: patients and doctors making decisions together).

“Difficulty could arise if a doctor does not believe that a patient is freely consenting to treatment and is instead only giving consent due to financial pressure. Doctors must be satisfied that they have valid consent before providing  treatment, which means they could be left with a difficult decision as to whether to refuse treatment in the knowledge that this could affect the patients benefit entitlements.” 

The GMC also raise concerns about how sensitive health data is collected and shared for purposes other for patients’ direct care, without patients being informed or giving consent. The government have simply proposed to access health care data to support “any assessment for financial support” and told GPs to assume consent has been given.

Promoting the myth that work is a ‘clinical outcome’ 

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. 

Of course it may 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. 

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.” 

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 all of a sudden successfully hold down a job for a minimum of six months.

Mind those large 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.

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 idea of the state persuading doctors and other professionals to “sing from the same [political] hymn sheet”, by promoting work outcomes in social and health care settings is more than a little Orwellian. Co-opting professionals to police the welfare system is very dangerous. 

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” as the government are urging, will invariably make accessing support conditional, and further isolate already marginalised social groups. Citizens’ safe spaces for genuine and objective support is shrinking as the state encroaches with strategies to micromanage those using public services. This encroachment 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.

State micromanagement of tenants

The GMC say in their response to the government’s proposals: “We are unclear about the evidence that might support a move to the position that ‘being in employment’ should be regarded as a ‘clinical outcome’ that healthcare professionals are expected to work towards with people of employment age seeking health-related advice and treatment. This is a highly contentious issue and indeed Dame Carol Black’s report certainly makes clear that there is limited support for this within the profession.” 

I’m not unclear. There is no evidence. In an era of small state neoliberalism and ideologically driven austerity, it is an act of sheer political expediency to claim that ‘worklessness’ is the reason for the poor health outcomes that are in fact correlated with increasing inequality, poverty and lower standards of living – higher mortality;  poorer general health, long-standing illness, limiting longstanding illness; poorer mental health, psychological distress, psychological/psychiatric morbidity; higher medical consultation, medication consumption and hospital admission rates.

Both social security and the National Health Service have been intentionally underfunded and run down by the Conservatives, who have planned and partially implemented a piecemeal privatisation process by stealth, to avoid a public backlash.

Unemployment (not ‘worklessness’ –  that’s part of the privileged discourse of neoliberalism, which serves to marginalise the structural aspects of persistent unemployment and poverty, by transforming these into individual pathologies of benefit ‘dependency ‘and ‘worklessness’) is undoubtedly associated with poverty, because welfare provision no longer meets the most basic living costs.

However to make an inferential leap and claim that work is therefore ‘good’ for health’ is incoherent, irrational and part of an elaborate political gaslighting campaign of an authoritarian government, who simply don’t want to address growing poverty and inequality caused by their own neoliberal policies.

The direction that government policy continues to be pushed in represents a serious threat to the health, welfare, wellbeing, basic human rights, democratic inclusionand lives of patients and the political independence of health professionals.


Related

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

Illustration by Jack Hudson

 


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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

 


 

Specialist Disability Employment Advisors in Jobcentres cut by over 60 per cent

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Full-time specialist disability employment advisors who are posted in jobcentres have been radically reduced since 2011. The full-time advisors are employed to help disabled people navigate the support system and find employment. Over the last four years, the number of specialist advisors fell by over 60 per cent, from 226 to just 90.

The government says that the advisors will be replaced by unqualified  non-specialist “work coaches” as part of its Universal Credit programme, which also extends welfare conditionality, entailing sanctions, to people in part-time and low paid work.

We reported last week that the work coach scheme is to extend from jobcentres to GP practices, to prevent sick and disabled people from “leaving the job market” and “claiming Employment Support Allowance” (ESA), with pilots already underway.

The latest figures on jobcentre advisors were released by ministers in response to a Parliamentary question by Labour MP Emily Thornberry.

A spokesman for the Department for Work and Pension said the fall in advisor numbers was consistent with Government policy.

“With the introduction of Universal Credit disabled people looking for work now have access to Work Coaches who are trained to provide tailored support specific to their individual needs. As we continue to make our mainstream services more accessible to disabled jobseekers it is expected that the number of Disability Employment Advisors will continue to decline.”

“The Government is committed to halving the disabled employment gap and the most recent disabled employment figures show that 226,000 more disabled people found work over the past year.”

Charities have responded, saying that the specialist advisors are absolutely crucial for people with disabilities who have to navigate the support system and that their reduction will undermine the Government’s own claim of “supporting people in to work.”

The government have also cut in work support for disabled people, such as the Access to Work fund, which helps people and employers cover costs of disabilities that may present a barrier to work. Under the Equality Act, employers are obliged to make “reasonable adjustments” to the workplace to support people with disabilities.

A coalition of 100 disability charities had warned that the government cuts threaten disabled people’s rights earlier this year, and last month, especially those with learning disability and mental health problems, charities also called for a halt in the government’s cuts to ESA, which will be reduced, removing the work-related activity component, so that people will receive the same amount as jobseekers with no disability, which will make it more difficult for disabled people to find work, and may have an adverse impact on people with health conditions.

The cuts to specialist employment support for people with disabilities flies in the face of  Iain Duncan Smith’s comments during the Tory conference – that sick and disabled people need to see work as their route out of poverty. It’s difficult to see how that can be achieved when the government is busy closing down the transport system, as it were.

Duncan Smith commented at the Conservative conference: “We don’t think of people not in work as victims to be sustained on government handouts. No, we want to help them live lives independent of the state.

“We won’t lift you out of poverty by simply transferring taxpayers’ money to you. With our help, you’ll work your way out of poverty.”

We can’t help wondering what “help” actually means to Conservatives, because there is every indication that they don’t use the word in a conventional sense. Usually when Tories use the word “help” or “support”, it indicates some sort of penalty or punishment: a reference to the extended draconian benefit conditionality and  sanctions regime

Elliot Dunster, group head of policy, research and public affairs at disability charity Scope, has said that the fall in specialist assistance was concerning:

“Disability employment advisors make a huge difference in supporting disabled people into work – providing expert, personalised advice and guidance.

“We’re very concerned to see this drop in the number of job centres that have fulltime specialist advisors for disabled people. Disabled people are pushing hard to find work, but continue to face huge barriers, ranging from inaccessible workplaces to employer attitudes. 

“Disability employment advisors help tackle these barriers. The Government has set out a welcome ambition to halve the disability employment gap. To do this disabled people must have access to specialist, tailored employment support.”

Dan Scorer, head of policy at Mencap, has warned that the replacement generalist advisors would “simply not have the training” required:

“People with a learning disability find the demands placed upon them difficult while claiming Job Seekers Allowance or Employment and Support Allowance.

“Some find them impossible and we are worried that there is not the right support in Jobcentres to help them. Families tell us that a lack of learning disability training and cuts to DEAs is leading to many people with a learning disability being unfairly sanctioned and receiving insufficient support to appeal decisions, or the right support to find employment.

“Even if the reduction in DEAs in some part of the country is due to the rolling out of Universal Credit and part of a strategic move to generic advisors, we are concerned that these advisors will simply not have the training to fully support claimants with a learning disability.

“The problems with the administration of benefits and changes in the benefits system, combined with future cuts to benefits and social care, is causing fear and anxiety among the 1.4 million people with a learning disability and their families in the UK who are scared they could be isolated in their local communities.”

Mind have already warned that the transition away from specialist help under Universal Credit would make the benefits system more difficult for people with mental health issues. Policy manager, Tom Pollard told the Independent:

“We’re pretty sceptical of the ability of those jobcentre advisors to be able to understand the barriers that people with mental health issues face.” 

Labour MP Debbie Abrahams recently challenged Priti Patel, the employment minister, during work and pensions questions in the Commons recently to raise concerns about the negative impacts of social security sanctions on the mental health of claimants.

During the session the Patel had claimed: “Our staff are trained to support claimants with mental health conditions and there is no evidence to suggest that such claimants are being sanctioned more than anybody else.”

Mrs Abrahams, Shadow minister for Disabled People, responded: “The minister may have inadvertently slipped up there. There is clear evidence from last year that 58 per cent, more than half, of people with mental health conditions on the employment and support allowance work-related activity group were sanctioned.”

A recent Freedom of Information request showed that between April, 2014, and March this year there were almost 20,000 benefit sanctions received by people who were out of work because of their mental health.

However, in this same period only 6,340 of the group were successfully supported into employment during the same period by the Work Programme.

Tom Pollard said: “Figures obtained by us show that people with mental health problems are more likely to have their benefits stopped than those with other conditions.

“Last year, the Department of Work and Pensions issued more sanctions to people with mental health problems being supported by Employment and Support Allowance than they did to those with other health conditions.

“Stopping somebody’s benefits, or threatening to stop them, is completely the wrong approach to help people with mental health problems find work — it’s actually counterproductive.

“In continually refusing to listen to calls for a review of the use of sanctions, the Government is not only undermining its ambition of helping a million more disabled people into work, but is also failing its duty of care for the health and wellbeing of hundreds of thousands of people with mental health problems.”

The Department of Work and Pension’s own research shows that the threat of sanctions does ensure that people who need support from social security comply with benefit rules, but that doesn’t actually help them to find work. It also tends to undermine confidence, and many jobcentre advisors have expressed concern that people with mental illness are more likely to be sanctioned simply because they would have greater difficulty meeting the strict conditionality criteria and because of the greater pressure to sanction “non-compliance” from government. (page 54)

But we deeply suspect that sanctions are precisely what the government are referencing when they use the phrase “helping people into work.”

This post was written for Welfare Weekly, which is a socially responsible and ethical news provider, specialising in social welfare related news and opinion.

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